Question explored with the scientific record
What role did midazolam play during covid
Midazolam was a workhorse sedative in COVID ICUs, and the sickest, most heavily sedated patients were also the ones who died.
In the Naples ICU cohort, deep sedation was used for every patient on a ventilator, and midazolam was one of the four drugs in the mix alongside propofol, remifentanil, and dexmedetomidine [1]. That unit's ICU mortality was 92% among 72 patients [1]. That number tells you how sick this group was, not that midazolam killed them. It is a cohort of the dying, not a trial of the drug.
The more useful signal comes from the delirium study. Among 62 COVID ICU patients, those who developed delirium had received far more midazolam than those who did not, and the difference was statistically significant [2]. They also had longer comas, longer ventilation, and longer ICU stays [2]. This is an association, not proof of cause. Sicker patients get more sedation and also get more delirium, so the arrow can run either way.
| Measure | Delirium group | No delirium |
|---|---|---|
| Midazolam dose (median) | 3.82 mg/kg | lower (p=0.001) |
| Coma duration (median) | 12 days | 2 days |
| Ventilation (median) | 15 days | 5 days |
| ICU stay (median) | 20 days | 9 days |
What this retrieval does not show is the question that matters most: did sedation strategy change outcomes? No trial here compares deep versus light sedation in COVID. The pediatric and infant records [3][4] are about other settings entirely and say nothing about COVID.
My call: midazolam was used heavily to keep ventilated COVID patients unconscious, and heavier exposure tracked with worse delirium and longer illness, but no study here proves it caused harm. Confidence: low.
Sources used 4
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Sedation and analgesia in critically ill patients with COVID-19: a cohort retrospective study
Deep sedation was universally used for invasive ventilation in a Naples ICU COVID-19 cohort, with propofol, remifentanil, midazolam, and dexmedetomidine; ICU mortality was extremely high (92%) among 72 patients.
DOI: 10.22514/sv.2021.129 -
Unravelling the complex inflammatory landscape of COVID-19 infection: a pathway to biomarkers identification in infection-associated delirium in the ICU
A retrospective study in ICU COVID-19 patients identifies peripheral immune biomarkers (soluble factors and immune cell populations) associated with delirium, demonstrates that a small biomarker panel can predict delirium with high accuracy, and shows that synthetic data can enh…
DOI: 10.1186/s40635-025-00825-w -
Efficacy of Intranasal Dexmedetomidine as a Preoperative Anxiolytic in Children: A Systematic Review
This is a systematic review comparing intranasal dexmedetomidine to oral midazolam for preoperative anxiolysis in pediatric patients, finding mixed results across three RCTs with no definitive conclusion and a call for larger, standardized trials.
DOI: 10.18776/72vx2g19 -
Paravertebral nerve block catheters using chloroprocaine in infants with prolonged mechanical ventilation for treatment of long‐gap esophageal atresia
Retrospective pilot study indicating that short-term paravertebral nerve block (PVNB) catheters with chloroprocaine in infants undergoing long-gap esophageal atresia repair reduce opioid and benzodiazepine exposure and shorten ICU stay without major complications.
DOI: 10.1111/pan.12736