Dose:  0.2 to 1.0 mg/kg/dose IV, PO, or PR

Frequency: Q 15 to 30 minutes for seizures           

Comments:    Diazepam is a benzodiazepine that has been used as both a sedative and an anticonvulsant in the newborn. It effective if given IV, PR, or PO. Due to variable serum levels and risk or tissue irritation/necrosis following IM administration, this route should be avoided.   Diazepam is primarily metabolized in the liver to a pharmacologically active compound, n-desmethyldiazepam. This metabolite has an extremely long half-life and is slowly excreted by the kidneys. There is some controversy as to the use of diazepam in the treatment of seizures in neonates. Long-term use of diazepam is limited because of accumulation of the drug and its metabolites leading to potential toxicity as well as the development of tolerance. The doses to treat acute seizures range from 0.20 to 2.7 mg/kg given IV, PO, or PR. The IV dose was administered as a slow infusion over several minutes, titrating the dose against the seizure activity. The majority of patients who did respond did so in less than 3 minutes from the onset of drug administration. Diazepam's long half-life (30 hours) makes it less likely to be used for sedation; lorazepam is a better alternative both for sedation and treatment of seizures. Diazepam is also painful when administered IV. The effects of the drug can be reversed with flumazenil, though its effects are often slow and incomplete. Avoid use of the IV solution in infants with hyperbilirubinemia since sodium benzoate competes with bilirubin for binding sites on albumin. More comments on diazepam.

Toxicity: Hypotension, brady-arrhythmias, and respiratory depression may occur following rapid infusion. As noted above, repeated administration may lead to hypotonia, CNS depression, and respiratory depression due to the accumulation of diazepam or its metabolites (Langslet, Acta Paediatr Scand, 67:699, 1978). IV administration is accompanied by a local burning sensation and may cause phlebitis. Withdrawal symptoms can occur if the drug is abruptly discontinued following the administration of large doses over an extended period of time. Withdrawal symptoms include convulsions, tremors, muscle cramps. vomiting, and sweating.

Preparation:
IV:Diazepam (Valium) is available in a 5 mg/ml concentration. If diazepam is diluted prior to use, add 1 ml to 9 ml of either NS or D5W to prepare a 0.5 mg/ml solution.  Add the diluting solution to the diazepam to avoid precipitation. Do not use the mixture if cloudy. Discard after a single use.  The manufacturer recommends that diazepam not be mixed with other drugs or added to IV infusion solutions.  Diazepam undergoes significant absorption into PVC IV bags and tubing. This is in part related to the length of time the drug is in contact with the bags. The IV preparation contains Propylene glycol-40%, Ethyl Alcohol-10%, Sodium Benzoate-5%, Benzyl Alcohol-1.5%.]

PO: Diazepam (Valium) is available in both 5 mg/5 ml and 5 mg/ml (Intensol) concentrations. Stable at room temperature. The Intensol may be better tolerated if mixed with liquids or semisolid foods such as apple sauce.

Diazepam is a CONTROLLED SUBSTANCE.  Records of its use are recorded in the Controlled Substances Log Sheet. Multiple entries into vial or bottle for repeated doses must be recorded.  The drug preparation must be stored in the locked narcotic drawer.

Compatibility: Not compatible with either TPN or filter.   Compatible with D5W, LR, and normal saline using concentrations less than 125 mg/ml.  It is also compatible with dobutamine, nafcillin, quinidine gluconate.  It is incompatible with atracurium, dobutamine, doxapram, fluconazole, furosemide, glycopyrrolate, heparin, meropenem, pancuronium, potassium chloride, propofol, ranitidine, and vecuronium.