Training innovations buccal midazolam training slideshare

Buccal Midazolam
July 2015
Tutor: Patrick Doyle
© Training Innovations Ltd 2015 Last updated: 21.07.15

Learning Outcomes
By the end of the session candidates will:
• Be able to recognise prolonged and serial
seizures and respond appropriately
• Be able to describe the appropriate conditions
required to participate in the administration
of Buccal Midazolam
• Be able to demonstrate through simulation
the procedure for administering Buccal
Midazolam
LD ESN June 2009 2© Training Innovations Ltd 2015

National Institute for Clinical
Excellence(NICE)
• NICE recommends Buccal Midazolam as the
first-line treatment in children, young people
and adults with prolonged or repeated
seizures in the community and
• Only used in those people who have had a
previous episode of prolonged or serial
convulsive seizures NICE (2012)
© Training Innovations Ltd 2015

What is Midazolam?
• Is the pharmaceutical name for this drug, from a
family of similar drugs called Benzodiazepines
• Other names and formulations for Midazolam
include Hypnoval and most commonly Buccolam and
Epistatus
• Buccolam comes in pre-filled syringes
• Epistatus comes in a bottle with empty syringes
• Midazolam is licensed as a sedative and is used in
hospitals and clinics before clinical procedures.
• In the brain it acts as an effective anti epileptic

How was Midazolam developed
for use?
• Used as a sedative since 1988
• Used in epilepsy since 1997
• Community use developed in paediatric services/
school age children
• Gradual introduction in to adult learning disability
• Now the most common form of rescue medication
• Recommendations for use in NICE, included in most
formularies

Why do we use Midazolam?
• We know that early treatment for seizures is
more effective preventing SE
• We may be preventing brain damage even death
• We may be preventing other poor health (e.g
aspiration infection)
• Prevents disruption, decreasing hospitalisation
• Best outcomes for individual, family and carer
6© Training Innovations Ltd 2015

How Does Midazolam Work?
• Slowly dripped into nasal/buccal cavity
• Absorbed through mucosal skin surfaces
• Good blood supply to these areas
• Travels via the heart and lungs to the brain
• Dampens down seizure activity

Indications for use
• Midazolam is prescribed where the individual
has a history of seizures which are prolonged/
serial , most commonly with people who also
have LD
• Prolonged seizures are around 5 minutes for
tonic clonic seizures. Serial seizures occur one
after the other with no recovery between
LD ESN June 2009 8

Indications for Use contd.
• Midazolam is used as a rescue medication early
on in the development of the seizure/s to try to
prevent status epilepticus, improve outcome
from seizure/s and quality of life
• Status Epilepticus is a continued state of seizure
lasting for 30 minutes.

Care Plan
• Each individual should have an epilepsy care plan.
• Care plans should include details of individual such as:
• Type of epilepsy – if known
• Types of seizure
• Details of prescribed treatment
• Details of who is responsible for monitoring /reviewing
epilepsy
• Details of any known aura
• Known triggers
• Usual length of seizure
• Mental state during recovery etc

Protocol
The Prescribing doctor
must provide a clear protocol
for the use of rescue medication in prolonged
or repeated (serial) convulsive seizures

This Protocol must include:-
• Details of service user (name, DOB, age, address)
• Details of the prescribing doctor and start date.
• When to give medication (i.e. when seizure is prolonged , 5
minutes or more, repeated/cluster)
• The dose of medication prescribed and the route of
administration.
• Time to allow for drug to take effect (e.g.6 –10 minutes)
• Details of any second dose – when to give and time to allow
for drug to take effect.
• Time allowed between doses and maximum dose in 24
hours
• What to do if rescue medication is not effective

Protocol continued
• The protocol should be reviewed annually by
the prescribing doctor.
• The protocol should be kept with the
medication for the specific individual
• Consider copying / reducing / laminating the
protocol to make it easier to take out with
person.
• The protocol must be checked before each
administration of Midazolam

Buccolam
• Does not require special storage – do not
refrigerate or freeze
• Buccolam has a shelf life of 18 months (please
check expiry date)
• Buccolam is to be administered into the buccal
cavity
• Buccolam is prescribed off-license for over
18’s

Epistatus Midazolam Buccal Liquid
• 10mg (base) in 1ml sugar-free syrup
• Indication
• Treatment of prolonged or repeated (serial) seizures, which
are likely to progress to Status Epilepticus, by buccal
administration
• Presentation
• Box (with instructions for use on one panel) containing:
• 30ml amber glass bottle (large enough to hold firmly) with
a safety closure
• 5ml of liquid (sufficient to deliver 4 x 1ml doses)
• 4 x 1ml oral syringes (syringes without needles)
• Patient information leaflet

Epistatus Midazolam Buccal Liquid
16

Storage of the Pack
• Store the pack upright at 15-25°C.
• The cap must be replaced immediately after use
otherwise the liquid will evaporate and some of
the Midazolam will precipitate. (This will be
exhibited as white particles in the liquid.)
• The pack must be discarded if the solution is not
clear.
• The last 1ml of solution MUST NOT BE USED, the
pack should be returned to the pharmacist.
© Training Innovations Ltd
2014

Possible Adverse Effects
• Depression of respiratory effort
• Restlessness
• Severe drowsiness (possibly for several hours)
• Memory loss
• May irritate nasal passages or cause discomfort to
gums
• Over use can cause dependence and be ineffective
• Recovery rates vary
LD ESN June 2009 18

Contra-Indications & Precautions
• Hypersensitivity and acute narrow angle
glaucoma.
• The safety of Midazolam in pregnancy has not
been established.
• Dental Care
• The solution has a pH of 5.0 – 5.5 which is
mildly acidic
• (as acidic as vinegar), it is also sugar-free.

Buccal Midazolam: Following onset
• Note the time the seizure starts
• Follow the individuals protocol to see how
long to wait before giving Midazolam
• Decide to give Midazolam
• Check Midazolam package to ensure:
• Dose, expiry date, route, time interval, name
and correct medication

Buccal Midazolam: Drawing up
• Ensure syringe plunger is pushed all the way
down syringe
• Insert syringe into bottle and tip whole bottle
upside down
• Following the protocol draw the required
amount of liquid into syringe and replace the
cap on the bottle

• Point syringe to back of mouth on insertion then angle
downwards into the buccal cavity
• Administer approximately half the dose buccal cavity
on one side of the mouth.
• Then administer the residual liquid into the buccal
cavity on the other side of the mouth.
• If that is not possible, then administer the whole dose
to the buccal cavity on one side of the mouth
• Do not administer the dose below the tongue since the
teeth may clamp shut and break the syringe in the
mouth
22
Buccal Midazolam: Administration

The Buccal Cavity:
between cheek and gums

Buccal Midazolam: Post Administration
• Stay with the individual until the seizure has stopped
• Note the time the seizure stops
• Stay with the person until they have returned to usual
functioning
• Be aware that individual may be at risk of respiratory
depression, so will need close observation for several hours.
• Assist the person to dress or tidy themselves (remember: they
may have been incontinent)
• Document the seizure in the notes or care plan, etc
Consideration must be given to:
• Recording amount
• Recording use
• Recording outcome in the epilepsy care plan

Onset & Duration of Action
Onset of Action
• Initial effects become apparent after
approximately five minutes. About 80% of
seizures are terminated within ten minutes
Duration of Action
• The patient may be drowsy for several hours
after administration and may be protected
from recurring seizures for up to four hours

It is vital that Buccal Midazolam is administered
according to the Guidelines because
prolonged convulsive epileptic seizures are
potentially life threatening

Convulsive Status Epilepticus
• A continuous Tonic Clonic seizure or repeated
Tonic Clonic seizures lasting 30 minutes
• This can be life threatening and requires
medical attention

Non Convulsive Status Epilepticus
Any seizure can develop into status
• Complex partial status relatively common in
Learning disability.
• This condition can be difficult to diagnose,
consciousness is often impaired but not lost
completely.
• Can continue for long periods.
• Can adversely affect health in vulnerable people
28

29
Ethical Issues
• Duty Of Care
• Consent
• Invasive
• Fear of Legal Action

“When Midazolam is prescribed there should
be no unreasonable barriers to its use”
Joint Epilepsy Council for the UK and Ireland

• Any questions?
• Please take some time to complete the course evaluation - Thank
you…
• PowerPoint slides available at: www.slideshare.net/TInnovations
• patrickdoyle@traininginnovations.co.uk
• www.traininginnovtions.co.uk/news/gemmasstory
• Twitter: @Traininnovate
• Facebook: https://facebook.com/pages/Training-Innovations-Ltd

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