A multicentre survey of Australian intensivists on optimal use of midazolam for sedation

Midazolam is widely used for sedation in intensive care units (ICUs). Emerging evidence links benzodiazepines with prolonged mechanical ventilation, increased delirium, and longer ICU stays. Clear guidance defining the role of midazolam in modern practice remains limited, and its use is largely clinician dependent. The aim of this study was to describe contemporary Australian intensivist opinions regarding indications, patient and disease modifiers, titration, and weaning strategies for midazolam infusions. Australian ICU specialists and fellows were included. We conducted a national cross-sectional self-administered survey. A 73-item questionnaire using case vignettes and Likert-scale responses assessed first-line and second-line indications, modifiers influencing use, and cessation strategies for midazolam infusions. Strong Agreement/Disagreement was defined a priori as greater than 80% of respondents indicating a score of 4 or 5 (Strongly agree; Agree) or a score of 1 or 2 (Strongly disagree; Disagree). Sixty-one clinicians responded. No first-line indications for midazolam use reached strong agreement. Respondents strongly disagreed with midazolam use as first-line sedation in agitation (90.1%, n = 55/61), acute respiratory distress syndrome (81.6% n = 49/60), positional restrictions (83.6%, n = 51/61), and out-of-hospital cardiac arrest (91.6%, n = 55/60). Strong agreement supported discontinuing midazolam when commenced prior to ICU admission (82%, n = 50/61). Strong agreement supported midazolam use as second-line sedation in traumatic brain injury (90%, n = 54/60) and status epilepticus (98.3%). No agreement was achieved for patient or disease modifiers, demonstrating substantial practice variability. For weaning, there was strong agreement that midazolam should be the first sedative ceased when used with other agents (90%, n = 54/60) and that tapering was unnecessary with infusions shorter than 48 h (80%, n = 47/59). Australian ICU practitioners report being selective with the use of midazolam and convey it is primarily reserved for use as a second-line agent in traumatic brain injury and status epilepticus. Persistent heterogeneity highlights the need for clearer guidance on selective use and weaning in modern ICU practice.