Optimal Dose of Intranasal Midazolam for Procedural Sedation in Children

Importance Intranasal (IN) midazolam is commonly used for procedural sedation in children, but the optimal dose is unclear. Insufficient dosing may result in inadequate sedation, leading to short- and long-term consequences associated with poorly managed procedural pain and distress, whereas doses that are too high may be associated with more adverse events. Objective To determine the optimal dose of IN midazolam for procedural sedation in children undergoing laceration repair. Design, Setting, and Participants This prospective, double-blind, adaptive selection randomized clinical trial used the Levin-Robbins-Leu sequential selection procedure and was conducted between September 2021 and May 2024 at a tertiary care pediatric emergency department. Participants were children aged 6 months to 7 years with a simple laceration who required IN midazolam to facilitate the repair. The sequential selection procedure eliminated doses when they failed to achieve a prespecified rate of adequate sedation state compared with the best-performing dose. If more than 1 dose survived elimination, secondary outcomes of remaining doses were compared. Data were analyzed from June to August 2024. Interventions Doses of 0.2, 0.3, 0.4 or 0.5 mg/kg of IN midazolam. Main Outcomes and Measures The primary outcome was adequate sedation state, defined as Pediatric Sedation State Scale (PSSS) score of 2, 3, or 4 (of 5) for at least 95% of the procedure; no PSSS score of 0 or 1; procedure start within 17 minutes of IN midazolam administration; and procedure completion. Secondary outcomes included ideal sedation state (PSSS score of 2 or 3 for 100% of the procedure), time to onset of minimal sedation, adverse events, time to recovery, and clinician and caregiver satisfaction. Results Following the sequential selection procedure, a total of 101 children (38 [37.6%] female; median [IQR] age, 3 [2-4] years) were enrolled. The 0.2 and 0.3 mg/kg doses were eliminated, with 19 children receiving 0.2 mg/kg and 24 children receiving 0.3 mg/kg. The 0.4- and 0.5-mg/kg doses remained at enrollment completion, with 29 children receiving 0.4 mg/kg and 29 children receiving 0.5 mg/kg. There were no differences in secondary outcomes between the 2 remaining doses and no serious adverse events with any dose. Conclusions and Relevance In this randomized clinical trial, the optimal doses of IN midazolam for procedural sedation in children undergoing laceration repair were 0.4 and 0.5 mg/kg. This finding can inform clinical practice and future studies of IN midazolam for procedural sedation. Trial Registration ClinicalTrials.gov Identifier: NCT04586504