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Buccal Midazolam- The Administration. Sinéad Murphy Community Epilepsy Nurse Specialist Beaumont Hospital/Brainwave May 2008. Introduction. Status Epilepticus What is Buccal Midazolam (EPISTATUS) Why we use Buccal Midazolam When we use Buccal Midazolam How we use Buccal Midazolam.

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Buccal Midazolam- The Administration

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Buccal midazolam the administration l.jpg

Buccal Midazolam-The Administration

Sinéad Murphy

Community Epilepsy Nurse Specialist

Beaumont Hospital/Brainwave

May 2008


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Introduction

  • Status Epilepticus

  • What is Buccal Midazolam (EPISTATUS)

  • Why we use Buccal Midazolam

  • When we use Buccal Midazolam

  • How we use Buccal Midazolam


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What is status epilepticus?

  • In the past described as a condition characterised by a seizure or series of seizures that lasts for 30 minutes or more, without complete recovery of consciousness.

  • However, if a seizure lasts longer than 5mins it should be treated as if going to last greater than 30minutes(Lowenstein, 1999).

  • If a seizure continues for more than five minutes, it may be difficult to stop unless treatment is given.


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Midazolam

  • High potency, short duration benzodiazepine.

  • Effective via buccal, intranasal, IV & IM routes.

  • Mucosal absorption very good with peak blood concentration after 5-10 minutes.

  • Short half life (3 hours) and small volume of distribution.


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MidazolamUses and application

  • As effective as Diazepam for acute seizures

  • Administered via mucosal surfaces (mouth & nose) in various settings, but unlicensed (special) in ROI

  • Significant implications on impact of epilepsy as can be administered in public places

  • No hangover effect so therefore no significant loss of opportunities & improved QOL

  • Can be repeatedly administered with no significant problems as per patient information sheet.


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When should Buccal Midazolam be given?

  • Individual basis

  • Information leaflet suggests only give after 5mins

  • However if usual sz lasts more than 5mins then your doctor may advise you to administer Buccal Midazolam stat


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How is Buccal Midazolam given?

  • Some centres suggest giving a test dose under close supervision

  • Via the oral cavity

    • 10mg/ml

      • 5mg in each side

  • Via the nasal cavity

    • 10mg/ml

      • 5mg in each side


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Epistatus-The Product

  • Buccal Midazolam (Epistatus) is supplied in a bottle containing 5mls of medicine with a child resistant cap self drainage bung and 4 syringes of 1 ml capacity.

  • The extra 1 ml is to cover for spills or leaks that may occur.


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Epistatus-The Administration

  • Open the bottle by pressing down on the lid and twisting it in an anti-clockwise direction. Insert one of the syringes firmly into the opening (bung) on the top of the bottle, with the plunger of the syringe pressed fully in.


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Epistatus-The Administration

  • Holding the bottle firmly, turn it upside-down and slowly pull back on the plunger of the syringe to withdraw the prescribed amount of medicine. Replace the lid on the bottle to avoid accidental spillage and evaporation.


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Administration

  • If the individual has no head support, you can support their head by standing behind them and gently holding their chin. Take care not to press accidentally on their throat.


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Administration

  • Open the mouth gently by holding the chin and applying gentle downward pressure to the lower lip with your thumb. Wipe away any excess saliva etc. (there is no need to part the teeth)

  • If the individual is on the ground, gently hold the chin to keep the head steady


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Administration

  • Insert the syringe horizontally into the mouth between the lower gum and the cheek on one side

  • To locate the buccal cavity, gently tilt the syringe downwards and slowly squeeze half of the medicine into the buccal cavity.


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Administration

  • Repeat the same procedure on the other side.

  • If it is too difficult, or the patient is on the ground then it is OK to give all the medicine to one side (the lower side if they are on the ground).

  • Gently hold the lips together for a minute or so prevent leakage.

  • Can also be given via nose.


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PLACE THE INDIVIDUAL IN THE RECOVERY POSITION AS SOON AS YOU ARE SAFELY ABLE TO DO SO

Continue to monitor RECOVERY and Breathing


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How soon will it work

  • Most (80%) of sz will end 10mins after giving Buccal Midazolam

    Scott RC, Besag FMC, Neville BGR, The Lancet (1999) 353, 623-626


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Duration of Action

  • Patient will be drowsy for several hours


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Can I give more than one dose

  • Yes-you can repeat the dose after 10mins but the dose cannot be repeated again for a further 12 HOURS- see data sheet


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Side Effects

  • Respiratory problems if OD

  • Drowsiness

  • Agitation

  • Restlessness

  • Disorientation

  • Overdose treated with flumazenil


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Problems with administration

  • All doses are in one box

  • Impossible to get last 2 doses out of the bottle without removing bung

  • If cap not replaced immediately, then the liquid will evaporate and some of the Midazolam may precipate, the liquid will become milky-discard.


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Organisational Responsibilities

  • Individual care plan as per JEC Guidelines

  • Organisational policy on the use of Buccal Midazolam

    • Introduction-organisation’s position on the use of Buccal Midazolam;

    • Detailed written protocol

    • Individual care plan with guidelines from the Consultant &MDT

    • Named individuals appropriately trained every 2 years, tested locally and mentor mentioned

    • Aware of legal responsibilities


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Once care plan completed by service providers

  • Individual care plan signed off by Neurologist/Hospital

  • Prescribing Doctor

  • Family/carer

  • Staff member

  • Head of unit

  • Employer


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Unlicensed Drug

  • Unlicensed drugs are those that do not have a product licence from IMB or EMEA

  • May have product licence from another state

  • Doctors are free to prescribe unlicensed (special) drugs on their own responsibility

  • Unlicensed drugs can be dispensed by pharmacies and maybe administered by nurses

  • Doctor should make patients aware that the medicine is unlicensed


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Unlicensed Drug

  • Can now be ordered direct by phoning Allphar Services 01 4041640

  • Available on LTI on individual basis

  • Not available on Medical card

  • Available on Hardship Payment Scheme

    • Details as per local pharmacy


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Sources of further information

  • Brainwave www.epilepsy.ie

  • Epilepsy Action www.epilepsy.org.uk

  • JEC http://www.jointepilepsycouncil.org.uk/jecguidebm.asp

  • www.specialproducts.biz


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Thank you for listening!

  • The Community Epilepsy Nurse can be contacted on 087 7708702

  • Or through Brainwave on the Nurse Line Mondays and Wednesdays 0930hrs-1300hrs 01-4557500


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