Acute dystonia by droperidol during intravenous patient-controlled analgesia in young patients

Patient-controlled analgesia (PCA) is an important means for postoperative analgesia with parenteral opioid. However, postoperative nausea and vomiting (PONV) remains a major problem with a PCA system. Droperidol is used in PCA to prevent PONV. Extrapyramidal reactions by droperidol are, however, occasionally induced. We describe two cases of severe extrapyramidal hypertonic syndrome with an intravenous administration of droperidol in PCA in young patients, following orthopedic surgery.

[The efficacy of droperidol, metoclopramide, propofol, and ondansetron for the prevention of nausea and vomiting following middle ear surgery]

OBJECTIVES

The efficacy and reliability of prophylactic antiemetic therapy with low dose propofol, droperidol, metoclopramide, and ondansetron were evaluated in a randomized, double-blind, and prospective design.

PATIENTS AND METHODS

A total of 101 ASA I-II patients (34 females, 67 males; age range 16 to 53 years) undergoing middle ear surgery for chronic otitis media or its sequelae were randomly assigned to receive prophylactic antiemetic therapy with propofol (n=21, 0.5 mg/kg), droperidol (n=19, 20 mg/kg), metoclopramide (n=23, 0.2 mg/kg), ondansetron (n=21, 4 mg), and placebo (n=20, 0.9% NaCl). All drugs were administered intravenously five minutes before extubation.

RESULTS

In the early postoperative period (0 to 3 hours), the percentages of patients free from nausea and vomiting were 100% with droperidol, 71.4% with ondansetron and propofol, 52.1% with metoclopramide, and 35% with placebo. Ondansetron (90.4%) was found the most effective to prevent and control nausea and vomiting during the postoperative 3 to 24 hours, followed by droperidol (84.2%), propofol (57.1%), metoclopramide (47.8%), and placebo (40%). Compared with controls, the number of patients without nausea and vomiting was significantly greater in each treatment group but metoclopramide (p<0.05). No significant differences were detected with respect to adverse effects.

CONCLUSION

Droperidol and ondansetron seem to exert the highest efficacy to prevent nausea and vomiting during the postoperative 0 to 3 hours and 3 to 24 hours, respectively.

Comparison of granisetron with granisetron plus droperidol combination prophylaxis in post-operative nausea and vomiting after laparoscopic cholecystectomy

The aim of this study was to evaluate the effects of granisetron and granisetron plus droperidol combination therapy on post-operative nausea and vomiting (PONV) in 60 patients who had undergone elective laparoscopic cholecystectomy. Induction of anaesthesia was achieved using 5 mg/kg thiopentone, 2 micrograms/kg fentanyl and 0.5 mg/kg atracurium, and anaesthesia was maintained with 2-2.5% sevoflurane. The patients were randomly assigned to two groups: group G (granisetron) (n = 30) patients received 3 mg granisetron and group GD (granisetron plus droperidol) (n = 30) patients received 3 mg granisetron and 1.25 mg droperidol shortly before the induction of anaesthesia. PONV incidence was recorded post-operatively at 15 min, 30 min, 60 min, 2 h, 4 h, 12 h and 24 h. While PONV prophylaxis provided almost complete emetic control in patients who received the granisetron plus droperidol combination, patients who received granisetron prophylaxis alone experienced PONV more frequently at 30 min and 60 min post-operatively. We conclude that addition of a low dose of droperidol to granisetron prophylaxis is more effective than granisetron prophylaxis alone for successful control of PONV.

The addition of antiemetics to the morphine solution in patient controlled analgesia syringes used by children after an appendicectomy does not reduce the incidence of postoperative nausea and vomiting

BACKGROUND

We studied the effect of intraoperative ondansetron 0.1 mg x kg(-1) or droperidol 0.01 mg.kg-1, followed by the same dose of the antiemetic agent added to the morphine solution during patient controlled analgesia (PCA) on the incidence of nausea and vomiting in children following an appendicectomy.

METHODS

Sixty children, aged 5-13 years, were recruited and randomly allocated to receive no prophylactic antiemetic, the control group (group C), ondansetron (group O) or droperidol (group D). The PCA pump was programmed to deliver a bolus dose of 20 microg x kg(-1) of morphine.with a 5-min lockout period and a background infusion of 4 microg x kg(-1) x h(-1).

RESULTS

Postoperatively, the three groups were compared for nausea, vomiting and sedation scores for 24 h. The incidence of postoperative nausea and vomiting was 33% for group C, 44% for group O and 41% for group D. There was no increase in sedation scores in the droperidol group.

CONCLUSIONS

We were unable to show any significant benefit from the prophylactic administration of ondansetron or droperidol to children using morphine PCA devices following appendicectomy in the doses we employed.

[Effect of droperidol and tramadol combination on the hemostasis in rabbits]

The effect of a combined administration of analgesic droperidol and neuroleptic tramadol (tramal) on the plasma coagulation and platelet aggregation was studied on awake rabbits. Both tramadol and droperidol, as well as their combination, enhance the coagulation of plasma proteins and suppress the thrombocyte deaggregation process.

The rise and withdrawal of droperidol

Predicting which patients will experience postoperative nausea and vomiting is difficult. Prophylactic antiemetic administration has been shown to reduce unplanned admission after day case surgery. In published comparative studies of antiemetic efficacy, droperidol has been considered to be the 'gold standard' against which other agents are measured. The recent withdrawal of droperidol due to reports of cardiac arrhythmias and the potential for sudden death has left a vacancy for a safe and effective antiemetic. This article explores the published literature for alternatives to droperidol as a single dose or prophylaxis in patient controlled analgesia devices.

Intramuscular droperidol versus intramuscular dimenhydrinate for the treatment of acute peripheral vertigo in the emergency department: a randomized clinical trial

OBJECTIVE

The emergency department (ED) treatment of acute peripheral vertigo (APV) has not been well studied. The purpose of this study was to determine the efficacy of intramuscular (IM) droperidol vs IM dimenhydrinate, in the treatment of ED patients with APV.

METHODS

The study was a randomized, double-blinded clinical trial, performed at a suburban, teaching ED. A convenience sample of adult patients with symptoms and signs consistent with rigid diagnostic criteria for APV were randomized to one of two treatment groups. Patients more than 65 years of age were excluded to reduce the likelihood of diagnostic misclassification. Demographic and historical features were recorded on a standardized data form. Patients recorded their initial level (t0) of discomfort on a 10-centimeter (cm) visual analog scale (VAS). Treatment group 1 received 2.5 mg droperidol IM, while treatment group 2 received 50 mg dimenhydrinate IM. After 30 minutes (t30), patients again recorded the severity of their symptoms on the VAS. Chi-square, t-tests, and Mann-Whitney were used for statistical comparison as appropriate. All tests were two-tailed, with alpha set at 0.05. Primary outcome parameters were the mean change in VAS score from t0 to t30, and the percentage of patients in each treatment group who felt well enough to go home after t30 without further ED intervention.

RESULTS

There were 20 patients in the droperidol group and 20 in the dimenhydrinate group. The two groups were similar with respect to mean age (40 +/- 13 years droperidol vs. 42 +/- 13 years dimenhydrinate; p = 0.6), female sex (60% vs. 50%; p = 0.7), and mean median duration of symptoms [3 (interquartile range 2-12) vs 9 (interquartile range 2-30) hours; p = 0.2]. Mean initial t0 VAS scores were 7.2 +/- 2.3 and 7.8 +/- 1.9 (p = 0.47). Both treatment groups had mean reductions in VAS scores at t30 of 3.3 [95% confidence interval (95% CI) = 2.3 to 4.3]. At t30, 42% of patients in the droperidol group and 45% of patients in the dimenhydrinate group felt well enough to go home without further ED intervention.

CONCLUSIONS

The authors found no difference between the therapeutic efficacies of IM droperidol and dimenhydrinate for the treatment of acute peripheral vertigo.

Effect of intravenous droperidol on intraocular pressure and retrobulbar hemodynamics

PURPOSE

Topically-applied dopamine antagonists reduce intraocular pressure (IOP) and inrease retinal blood flow in animal models. We examined the acute effects of intravenous infusion of a dopamine blocker (droperidol) on these parameters in healthy humans.

METHODS

Sixteen subjects free from ocular or systemic disease (mean age 33 +/- 10 yrs) received either 5 mg i.v. droperidol over 5 minutes, or i.v. saline placebo in double-masked fashion. IOP was determined 30 and 60 minutes later, while color Doppler imaging was used to determine flow velocities in the ophthalmic, central retinal, and nasal and temporal posterior ciliary arteries 60 minutes after drug infusion.

RESULTS

30 minutes after drug infusion, IOP was reduced 6.0 mmHg as compared with baseline (p<0.001); after 60 minutes, IOP remained reduced by 3.7 mmHg (p<0.001). Placebo had no effect on IOP. While droperidol slightly elevated blood pressure and increased the calculated ocular perfusion pressure, the drug reduced visual acuity and contrast sensitivity (p<0.05). Droperidol elevated peak systolic velocity in the central retinal and nasal posterior ciliary arteries, without changing end-diastolic velocity or the resistance index in either of these vessels. Droperidol had no effect on flow velocities in the ophthalmic artery or the temporal posterior ciliary artery.

CONCLUSIONS

The rapid and marked ocular hypotension resulting from intravenous droperidol suggests that this agent may prove useful in the management of acute ocular hypertension. The retrobulbar changes consequent to the ocular tension reduction likely represent autoregulatory responses to altered ocular perfusion pressure.

A placebo-controlled, randomized trial of droperidol versus metoclopramide for outpatients undergoing gynecological laparoscopy under conscious sedation

This study compared the prophylactic antiemetic efficacy and the adverse effects of 0.5 mg droperidol, 5.0 mg metoclopramide, and placebo for outpatients undergoing gynecological laparoscopy under conscious sedation. One hundred and fifty outpatients were randomly allocated, in a randomized double-blind manner, into three groups to receive intravenous normal saline, 0.5 mg droperidol, and 5.0 mg metoclopramide before operation. Conscious sedation using intravenous pethidine, midazolam and local infiltration were given to each patient during the operation. Emetic symptoms were graded twice by the patients, at discharge time and the 24th post-operative hour. The difference of antiemetic effect of both study drugs failed to reach statistical significance. There was also no statistical difference of intra-operative hypoxemia, sedation score, and discharge time among the groups. Therefore, using 0.5 mg droperidol or 5.0 mg metoclopramide is not effective in providing antiemetic prophylaxis for outpatients undergoing gynecological laparoscopy under conscious sedation.

Superior prolonged antiemetic prophylaxis with a four-drug multimodal regimen - comparison with propofol or placebo

BACKGROUND

The purpose of this study was to compare the effects of a low-dose propofol infusion with a four-drug multimodal regimen for prophylaxis of postoperative nausea and vomiting (PONV).

METHODS

: PONV was studied in two patient groups with a known high incidence. Through a stratified randomization, 60 patients undergoing breast surgery and 120 patients undergoing abdominal surgery were randomized to three groups of equal size: the propofol group (P), the multidrug group (M) and the control group (C). All patients received general anesthesia, induction with propofol and maintenance with sevoflurane. After induction, patients in the P group received a continuous infusion of propofol 1 mg/kg/h during the operation and the first 4 postoperative h. Patients in the M group received dexamethasone 4 mg and three antiemetics, ondansetron 4 mg, droperidol 1.25 mg and metoclopramide 10 mg i.v. In the control group no prophylaxis was given. Nausea and pain were evaluated by incidence and a visual analog scale (0-10 cm). All emetic episodes were noted by the staff during the first 4 h and by the patients during the next 20 h.

RESULTS

The overall incidence of PONV during the first 24 h postoperatively was significantly lower in the M group (24%) than in the P group (49%) (P<0.01) or the C group (70%) (P<0.001). The incidence of PONV increased significantly both in patients undergoing breast surgery and abdominal surgery after termination of propofol. The number of patients who vomited was significantly lower in the M group, both in breast surgery patients (5%) and abdominal surgery patients (3%) compared to patients in the propofol groups (breast 16% NS; abdominal 29%, P<0.05) and in the control groups (breast 37%, P<0.01; abdominal 29%, P<0.01).

CONCLUSION

The incidence of PONV is very high in patients undergoing breast and abdominal surgery. In the present study antiemetic prophylaxis with a combination of droperidol, ondansetron, metoclopramide and dexamethasone was more effective in preventing PONV, especially vomiting, than a postoperative low-dose infusion of propofol, which had a short lasting effect.

Continuous epidural, not intravenous, droperidol inhibits pruritus, nausea, and vomiting during epidural morphine analgesia

PURPOSE

To investigate whether continuous epidural droperidol and intravenous (IV) intraoperative droperidol inhibit pruritus and postoperative nausea and vomiting (PONV) during epidural morphine analgesia.

DESIGN

Randomized, double-blinded, controlled study.

SETTING

Metropolitan cancer center.

PATIENTS

120 ASA physical status I and II patients undergoing thoracic or abdominal surgery with general anesthesia combined with epidural anesthesia.

INTERVENTIONS

Patients received an intraoperative epidural injection of 2 mg morphine hydrochloride, followed postoperatively by a continuous epidural infusion of morphine hydrochloride 4 mg/day for 4 days. Patients were randomly allocated to four groups: Group A = control group, Group B = intraoperative single IV injection of droperidol (2.5 mg), Group C = postoperative continuous epidural droperidol infusion (2.5 mg/day), and Group D = intraoperative IV injection of droperidol (2.5 mg) and postoperative continuous epidural droperidol infusion (2.5 mg/day).

MEASUREMENTS AND MAIN RESULTS

The frequency and severity of pruritus and PONV in each group were evaluated during the postoperative period. Continuous epidural infusion of droperidol significantly reduced the frequency and severity of pruritus and PONV induced by epidural morphine without causing significant side effects. Intraoperative single IV injection of droperidol was effective for PONV (p < 0.05) but not for pruritus.

CONCLUSION

Postoperative epidural droperidol infusion significantly decreased both the frequency and severity of pruritus and PONV during postoperative continuous epidural morphine analgesia. IV intraoperative droperidol significantly reduced the frequency and the severity of PONV but not pruritus.

[Continuous epidural administration of droperidol to prevent postoperative nausea and vomiting]

This randomized double-blind trial was designed to evaluate the antiemetic effect of continuous epidural analgesia with droperidol mixed with bupivacaine and buprenorphine. We studied 78 patients for abdominal gynecological surgery under general-epidural anesthesia. After recovery from anesthesia, they received epidural administration of 0.25% bupivacaine 40 ml and buprenorphine 0.4 mg with or without droperidol 2.5-5.0 mg at a rate of 2 ml.h-1 for 24 hours. The addition of droperidol 5.0 mg led to serious undesirable effects. Droperidol 2.5 mg, however, showed not only significant antiemetic effect without any adverse action, but also the reduction of rescue analgesics. We conclude that the addition of a small dose of droperidol to epidural analgesics reduces the incidence of postoperative emesis and the requirement of rescue analgesics.

[Droperidol causes multifocal ventricular dysrhythmias]

We report a case of ventricular chaotic arrhythmia after droperidol administration. A 49-year-old woman with chronic renal failure receiving hemodialysis, was scheduled for total hysterectomy under general anesthesia. General anesthesia was induced with thiopental 200 mg, fentanyl 0.1 mg and vecuronium 5 mg for endotracheal intubation. Anesthesia was maintained with 1% isoflurane and 60% nitrous oxide in oxygen. Droperidol 10 mg was injected for neuroleptanalgesia. After two minutes, ventricular chaotic arrhythmia occurred. Lidocaine 80 mg was injected. General anesthesia was stopped. After two minutes, arrhythmia disappeared. Several reports suggest that patients with preexisting conduction defects or prolonged QTc interval may be at risk to develop ventricular arrhythmias after droperidol administration. Administration of droperidol may have exaggerated prolongation of QTc interval.

Prehospital sedation with intramuscular droperidol: a one-year pilot

OBJECTIVE

Combative patients pose a threat to themselves and prehospital personnel, and are at risk for sudden death. Droperidol is an antipsychotic and sedative agent that might be effectively utilized by paramedics to assist in the management of uncontrollably violent patients.

METHODS

A prospective observational study of patients requiring sedation was conducted in an urban third-service emergency medical services system (55,000 calls per year). Patients were scored by paramedics on a five-point agitation scale with 5 being extremely combative (continuous, vigorous fighting against restraints) and 1 being somnolent (sleeping or sleepy). Eligible (score 4-5) patients received 5 mg of intramuscular droperidol on direct physician order. Data including vital signs and agitation scores were recorded at 5-minute intervals until hospital arrival. Adverse effects were also recorded.

RESULTS

Fifty-three patients received droperidol (51 patients received 5 mg; two received 2.5 mg) during the study period. The average predrug agitation score was 4.7 (+/- 0.1 SD). The average 5-minute postdrug score was 3.9 (+/- 0.1 SD, 95% CI 3.7-4.1. The average 10-minute postdrug score was 3.3 (+/- 0.1 SD, 95% CI 3.1-3.6). The average hospital arrival score was 2.8 (+/- 0.1 SD, 95% CI 2.5-3.1). One patient became obtunded and required supplemental oxygen; no other patient experienced an adverse event after receiving droperidol. Sedation was ineffective in seven patients, three of whom had head injuries, and one of whom received 2.5 mg of droperidol per physician order. Paramedics sustained no needlestick exposures.

CONCLUSION

Intramuscular droperidol contributed to effective and rapid prehospital sedation in this observational series of 53 combative patients.

IM droperidol as premedication attenuates intraoperative hypothermia

PURPOSE

Perioperative hypothermia results largely from core-to-peripheral heat redistribution. Droperidol, which is often used for premedication, promotes vasodilation, and thus may affect redistribution of heat. Accordingly, we tested the hypothesis that preanesthetic droperidol would affect perioperative hypothermia.

METHODS

Twenty-three ASA physical status I patients scheduled for arthroscopic ligament reconstruction were randomly assigned to two groups to receive no premedication or im droperidol 0.1 mg x kg(-1) 30 min before anesthesia. Anesthesia was induced and maintained with propofol and fentanyl. We monitored core (tympanic) and peripheral (palm) temperatures, and skin (fingertip) blood flow for two hours after the induction of anesthesia during surgery.

RESULTS

Before the induction of anesthesia, patients given droperidol were more deeply sedated than those given no premedication. Core temperature, which was similar in both groups before induction, decreased significantly more in the control than in the droperidol patients (0.75 +/- 0.34 degrees C and 0.37 +/- 0.20 degrees C, respectively, at 75 min after induction; P <0.01). Preinduction peripheral temperature and skin blood flow were lower in the control group than in the droperidol group, but the two variables became similar in both groups after induction.

CONCLUSION

The results of the present study confirm our hypothesis that premedication with droperidol affects perioperative hypothermia. Droperidol may prevent core-to-peripheral heat redistribution after the induction of anesthesia.

Droperidol vs. prochlorperazine for benign headaches in the emergency department

OBJECTIVE

To compare the efficacy of droperidol with that of prochlorperazine for the treatment of benign headaches in emergency department (ED) patients.

METHODS

Prospective, randomized clinical trial in an urban ED. Patients were given either droperidol, 5 mg intramuscular (IM) or 2.5 mg intravenous (IV), or prochlorperazine, 10 mg IM or 10 mg IV. Measurements included side effects and the patient's pain perception as measured on a 100-mm visual analog scale (VAS) at baseline, 30, and 60 minutes after the medication was given. Data were analyzed using chi-square, two-tailed t-tests, and two-way analysis of variance (ANOVA) when appropriate.

RESULTS

During an eight-month period, 168 patients were enrolled. Eighty-two (48.8%) of the patients received droperidol; 86 (51.2%) received prochlorperazine. In the droperidol group, 49 (59.6%) received IM administration and 33 (40.4%) IV. In the prochlorperazine group, 57 (66.3%) received IM administration and 29 (33.7%) IV. Sixty minutes after the medication, the mean decrease in the VAS scores was 81.4% for droperidol and 66.9% for prochlorperazine (p = 0.001). At 30 minutes, 60.9% of the patients receiving droperidol and 44.2% of the patients receiving prochlorperazine had obtained at least a 50% reduction in their VAS scores (p = 0.09). At 60 minutes, 90.2% of the patients receiving droperidol and 68.6% of the patients receiving prochlorperazine had at least a 50% reduction in their VAS scores (p = 0.017). No difference between IM dosing and IV dosing was detected. Side effects, including dystonia, akathisia, and decreased level of consciousness, were seen in 15.2% of the patients receiving droperidol and 9.61% of the patients receiving prochlorperazine. No significant or persisting morbidity was detected.

CONCLUSIONS

Droperidol was more effective than prochlorperazine in relieving pain associated with benign headaches.

[Continuous epidural administration of droperidol for the prevention of postoperative nausea]

Continuous antiemetic effect of epidural droperidol was evaluated by prospective, double-blinded study using 145 ASA physical status I-II patients undergoing major gynecological surgery. All patients received bolus epidural infusion of buprenorphine at the end of the operation and continuous epidural infusion of buprenorphine for 48 hours. Patients were divided into 3 groups, 49 patients of Group I received placebo, 50 patients of Group II received only bolus doses of droperidol 2.5 mg and the remaining 46 patients of Group III received continuous epidural infusion of droperidol 10 mg in 48 hours. Visual analogue scales for nausea, the incidence of emetic episodes and side effects were evaluated at 3 hr, 24 hr and 48 hr postoperatively. The scores for nausea were significantly lower in Group III (P < 0.05) compared with Group I 24 hr after the operation. The incidence of emesis was significantly lower in Group III (P < 0.05) as compared with Group I and II 48 hr after the operation. Extrapyramidal side effects and sedative effects were not observed in any patients. The continuous epidural administration of droperidol is effective in prevention of postoperative nausea and vomiting and the effect lasts during its infusion with no side effects.

[Prophylaxis of nausea and vomiting after thyroid surgery: comparison of oral and intravenous dolasetron with intravenous droperidol and placebo]

OBJECTIVE

Postoperative nausea and vomiting (PONV) are among the most common complications in operative medicine. Especially thyroid surgery is frequently associated with PONV. It was the aim of this study to determine the efficacy of oral and intravenous dolasetron in comparison to intravenous droperidol (DHB) and placebo in the prevention of PONV.

METHODS

93 female and 43 male patients undergoing thyroid surgery were stratified according to gender and then randomised to receive double-blind one of four antiemetic regimes: 50 mg dolasetron given orally 45 minutes prior to induction of anaesthesia (group I), 12.5 mg dolasetron given intravenously during induction of anaesthesia (group II), 1.25 mg DHB given intravenously during induction of anaesthesia (group III) or placebo (group IV). General anaesthesia and preoperative management of the patients were standardised: premedication with chloracepate-dipotassium, induction with thiopentone, sufentanil and rocuronium, maintenance with N2O/O2, sevoflurane and repetitive doses of sufentanil and rocuronium, postoperative analgesia with metamizol and piritramide, antiemetic rescue-treatment with dimenhydrinate, metoclopramide and triflupromazine. Number of emetic episodes, the need for additional antiemetics and adverse events were recorded for 24 hours. Efficacy was measured by "complete-response" (CR = 0 emetic episodes or 1 emetic episode after 4 hours and no rescue-treatment) and "total-response" (TR = complete response plus no nausea, i.e., < 5 mm VAS rating of patients maximum nausea).

RESULTS

Men: Only Dolasetron given intravenously reduced nausea and vomiting significantly, Dolasetron given orally reduced nausea, but not vomiting, DHB had no significant effects: CR 72.7% (group I), 100% (group II), 80% (group III), 63.6% (group IV); TR 72.7% (group I), 81.8% (group II), 50% (group III), 36.4% (group IV). Women: In all three treatment groups significantly less patients suffered from PONV compared to the placebo group (p < 0.05). There were no differences between the treatment groups: CR 58.3% (group I), 45.8% (group II), 52.2% (group III), 18.1% (group IV); TR 37.5% (group I), 33.3% (group II), 39.1% (group III), 13.6% (group IV). There were no adverse events in any group.

CONCLUSIONS

Our results confirm the expected high incidence of PONV after thyroid surgery, especially in female patients. Single doses of oral and intravenous dolasetron and intravenous droperidol reduced PONV effectively in female patients undergoing thyroid surgery. Dolasetron seems to be the more effective substance in male patients. Both substances can be administered safely and are well tolerated.

[Droperidol and dimenhydrinate alone or in combination for prevention of postoperative nausea and vomiting]

BACKGROUND

Droperidol and dimenhydrinate are inexpensive antiemetic drugs. Droperidol, especially, has been studied extensively in the past, but there are no studies that used the combination of both drugs for prevention of postoperative nausea and vomiting (PONV). Thus, the aim of this randomised controlled and double-blinded study was to evaluate the antiemetic efficacy and the side effects of such a combination therapy.

METHODS

240 inpatients undergoing ENT surgery under general anaesthesia were randomised to receive one of four antiemetic regimes: placebo, dimenhydrinate (1 mg x kg-1), droperidol (15 micrograms x kg-1), or the combination of both drugs (droperidol 15 micrograms x kg-1 + dimenhydrinate 1 mg x kg-1) was administered after induction of anaesthesia and repeated 6 hours after the first administration. For general anaesthesia a standardised technique including benzodiazepine premedication, propofol, desflurane in N2O/O2, vecuronium, and a continuous infusion of remifentanil was used. Postoperative analgesia and antiemetic rescue medication were standardised. Episodes of vomiting, retching, nausea, and the need for additional antiemetics were recorded for 24 hours. The main goal of the study was to increase the number of patients who were completely free from PONV (chi 2-test with Fisher-Yates' correction). Furthermore, the severity of PONV was analysed using a standardised scoring algorithm.

RESULTS

Data of 227 patients could be analysed. The incidence of patients who suffered from PONV was 41.3% (95%-confidence interval: 29-55%) in the placebo-group. Dimenhydrinate alone reduced PONV to 34.5% (95%-CI: 22-48%). This marginal effect and the effect of droperidol (PONV: 26.4% (95%-CI: 15-40%)) could not be proven statistically, since the power of the study was too small. The combination of both drugs decreased PONV to 19.6% (95%-CI: 10-32%) and also reduced the severity of the symptoms to a clinically acceptable level.

CONCLUSION

Dimenhydrinate failed to reduce the incidence and severity of PONV. The efficiency of droperidol given alone was within the ranges previously known from metaanalytic data. The combination of both drugs showed a moderate synergistic effect.

Small doses of propofol, droperidol, and metoclopramide for the prevention of postoperative nausea and vomiting after thyroidectomy

OBJECTIVE

To evaluate the efficacy and safety of small doses of propofol, droperidol, and metoclopramide for the prevention of postoperative nausea and vomiting (PONV) after thyroidectomy.

STUDY DESIGN

Prospective, randomized, double-blinded study.

SETTING

University-affiliated teaching hospital.

METHODS

In a randomized, double-blinded study, 90 patients (75 females) received propofol 0.5 mg/kg, droperidol 20 microg/kg, or metoclopramide 0.2 mg/kg intravenously (n = 30 in each group) at the end of surgery. A standardized general anesthetic technique was used.

RESULTS

The incidence of PONV during the first 24 hours after anesthesia was recorded in 13%, 47%, and 50% of patients who had received propofol, droperidol, and metoclopramide, respectively (P < 0.05; overall Fisher exact probability test). No clinically important adverse events were observed in any of the groups.

CONCLUSION

Small dose (0.5 mg/kg) of propofol is more effective than droperidol or metoclopramide for the prevention of PONV after thyroidectomy.