Guidance on the usage of midazolam and other anaesthetic drugs has been modified to meet the pressures of the COVID-19 pandemic, highlighting the large quantities of the drugs being used to treat critically ill Covid patients.

The Royal College of Anaesthetists released guidance on “potential changes to anaesthetic drug usage and administration during pandemic emergency pressures” on 2 April 2020, stating that the demand for drugs such as midazolam to treat Covid patients has increased significantly.

Midazolam is labelled as a “first-line” sedative to treat critically ill COVID-19 patients, yet the dangers of the drug include potentially causing breathing difficulties or even halting breathing altogether. UK regulators state that midazolam can only be used in hospitals that have the equipment to monitor heart and lungs and to provide life-saving medical treatment.

Those who are treated with midazolam must have their vitals monitored closely by nurses and doctors to ensure that they are breathing properly as the drug can induce significant depression of respiration.

The drug is often used before minor surgery to relieve anxiety and induce drowsiness but can be used to put a patient in a state of unconsciousness. As stated previously, it is now being used as a primary treatment for critically ill COVID-19 patients, however, why would you treat a patient with a respiratory illness with a drug that has the potential to stop breathing altogether?

The guidance from the Royal College of Anaesthetists shows that midazolam and propofol are the primary drugs used for sedation and transfer, with midazolam being highlighted as a drug “which may be subject to demand pressure.” Midazolam has also been labeled as a drug which supplies have been retained “for use in critical care at times of increased demand during the COVID-19 crisis.”

This table highlights how midazolam and other drugs are being used for anaesthesia, and in the case of midazolam, appears to be in high demand – especially because it is being used to treat Covid patients. It also shows which drugs should be used as alternate anaesthesia medicines, for example, if midazolam is not readily available, lorazepam or diazepam can be used to achieve sedation.

It appears as though propofol and midazolam can be used interchangeably as if propofol is not available, then midazolam can be used instead.

Again, there is a point to sharing this information – it shows which drugs are currently being primarily used and are in high demand to treat critically ill COVID-19 patients. The same question must be raised: Why treat those suffering from a respiratory illness with a drug that can cause breathing difficulties, and in some cases, can be life-threatening?

What is also interesting about this table is the use of drugs such as fentanyl and ketamine, which again, have been highlighted as drugs that are in high demand, and in the case of fentanyl, actively being used to treat COVID-19 patients. Ketamine is being used to induce patients into a state of unconsciousness, whilst fentanyl is used as an analgesic – a painkiller that can affect sensation throughout the body, and in some instances, completely eliminate any feeling.

Additionally, when ketamine is not available an alternative drug of choice is midazolam.

Fentanyl is a strong opioid painkiller that is used to treat severe pain, often during an operation, serious injury, or alongside cancer treatment. It can be prescribed to patients as patches to be on the skin, nasal sprays, and also injections. However, it is most commonly given as an IV injection or an IV drip in hospital.

Karen S. Sibert, MD, a physician who has practiced anaesthesiology for over 25 years, wrote in a KevinMD, a medical journal, that fentanyl is very potent and works very fast, which makes it effective in treating surgical pain. However, she notes that the drug has a high abuse potential, not just among patients, but also medical personnel.

Like midazolam, one of the reported dangers of fentanyl is respiratory depression, whereby “the drive to breathe can be seriously diminished.” It is suggested that those who take fentanyl should either notify their doctor prior to being given a dose or avoid it altogether.

Furthermore, Ketamine – which has been used since the 1970s as an induction drug – can cause dangerously slowed breathing: yet another drug listed as being in high demand for treating critically ill COVID-19 patients.

Of course, it is worth noting that both fentanyl and ketamine are drugs known to be abused beyond medical treatment, – especially fentanyl, and its strong potency (50 times more potent than heroin) means the risk of overdose is incredibly high. In the UK, deaths related to fentanyl rose from only 8 in 2008 to 135 in 2017, and officials fear this number will only increase.

Whilst we may be repeating ourselves here, the question is: Why would drugs which can have a dangerous affect on a patient’s ability to breathe, be used as treatment for COVID-19 patients, who are suffering from a virus that can lead to complications such as pneumonia, and in the most severe cases, acute respiratory distress syndrome (ARDS)?

If there is a reasonable explanation as to why drugs such as midazolam are being used despite their impact on the respiratory system, we would love to hear it.

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