Intravenous Midazolam should only be used in settings with equipment and skilled personnel for continuous monitoring of cardiorespiratory function and resuscitation procedures. Patients should be continuously monitored for early signs of under ventillation or apnea. Vital signs should continue to be monitored during the recovery period. During intravenous application of Midazolam respiratory depression, apnea, respiratory arrest and/or cardiac arrest have occurred. In some cases where this was not recognized promptly and treated, hypoxic encephalopathy or death has resulted. These life-threatening incidents may occur especially in elderly patients or patients with pre-existing respiratory insufficiency, especially if the injection is given too rapidly or with excessive dose. Particular care must be used in administering the drug by the I.V. route to the elderly to very ill patients, high risk surgical patients and to those with significant hepatic impairment, chronic renal insufficiency, or with limited pulmonary reserve because of the possibility that apnea or respiratory depression may occur. These patients require lower doses whether premedicated or not.
Dependence and Withdrawal: The development of dependence is common after regular use of Midazolam, even in the therapeutic doses for short periods.
Dependence is particularly likely in patients with a history of alcohol or drug abuse and in patients with marked personality disorders. Abrupt withdrawal of Midazolam should be avoided to prevent withdrawal symptoms. Therefore, a gradual reduction of Midazolam is recommended. The time needed for withdrawal can vary from about 4 weeks to a year or more. The extent to which tolerance occurs involves psychomotor performance more than anxiolytic effects. Drug-seeking behavior is uncommon with therapeutic doses of benzodiazepines.