Dose:  0.03 to 0.1 mg/kg/dose IV, IM, PO, or PR

Frequency: Q 15 to 30 minutes for seizures
                      Q 8 to 12 hours for sedation           

Comments: Lorazepam is a benzodiazepine that has been used as both a sedative and an anticonvulsant in the newborn.    Lorazepam may be useful in treating seizures refractory to conventional anticonvulsants such as can be seen with hypoxic-ischemic encephalopathy.   When used to treat status epilepticus the recommended dose is 0.03 to 0.05 mg/kg/dose which may be repeated one time in 15 to 30 minutes.  Lorazepam is thought to have a slower tissue distribution (compared to diazepam) accounting for its longer duration of seizure control. When used for sedation, a starting dose of 0.03 to 0.1 mg/kg should be given 2 to 3 times a day and the dose and interval titrated based on its effectiveness. Phenobarbital levels may increase following its administration. Lorazepam may be a better alternative for sedation than diazepam since it has a shorter half-life and is not metabolized to an active metabolite making accumulation less likely.  The effects of the drug can be reversed with flumazenil. The IV preparation contains 2% benzyl alcohol.    More comments on lorazepam.

Toxicity: As with all benzodiazepines, respiratory depression may occurs, especially when other potentially respiratory depressant medication have been used. In adults, the most common adverse effects were excessive sleepiness, confusion, and delirium. Skin rashes, nausea, and vomiting have also been reported when lorazepam was used along with anesthetic agents. Finally pain at the site of injection has also been occasionally noted.

Preparation:
IV:Lorazepam (Ativan) is available in a 2 mg/ml concentration. If diluted, do so immediately before use by adding 1 ml to 9 ml of either D5W or NS (D5W is preferred) to prepare a 0.2 mg/ml solution.  Add the diluting solution to the lorazepam to avoid precipitation. Do not use the mixture if cloudy. Discard after a single use.  The manufacturer recommends that lorazepam not be mixed with other drugs or added to IV infusion solutions.  Lorazepam 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 benzyl alcohol.

PO: Lorazepam (Ativan) is available as an Intensol oral concentrate (2 mg/ml). Protect from light, store under refrigeration. Though alcohol and dye-free, there are small amounts of polyethylene glycol and propylene glycol. May be mixed with other liquids such as water, juices, or applesauce.

An extemporaneous suspension of lorazepam can be prepared with a 0.5 mg/ml concentration. The product should be shaken well before use and stored under refrigeration. It is stable for 14 days. To prepare the suspension, crush 60 lorazepam 1-mg tablets into a fine powder. Add a small amount of water to form a paste and mix until smooth. Dilute the paste with water until pourable. Transfer the liquid to a suitable container, then add enough cherry syrup or a 1:1 ratio of Ora-Plus and Ora-Sweet (Paddock Laboratories) to bring the total volume to 120 mL. 

Lorazepam 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. Significant adsorption can occur to PVC containers of infusion solutions.  Compatible with sterile water for injection, D5W, LR, and normal saline.  It is also compatible with acyclovir, albumin, allopurinol, amikacin, amoxicillin, amoxicillin-clavulanate, atracurium, bumetanide, dexamethasone, dobutamine, dopamine, epinephrine, erythromycin, famotidine, fentanyl, filgrastim, fluconazole, furosemide, gentamicin, heparin, hydrocortisone, labetalol, metronidazole, midazolam, morphine, pancuronium, piperacillin, piperacillin-tazobactam, potassium chloride, propofol, trimethoprim-sulfamethoxazole, vancomycin, vecuronium, and zidovudine. It is incompatible with aztreonam, imipenem-cilastatin,  It is equivocally stable with ranitidine.