[Dolasetron, droperidol and a combination of both in prevention of postoperative nausea and vomiting after extracapsular cataract extraction under general anesthesia]

BACKGROUND

Both, droperidol and the new 5-HT3-antagonist (e.g. dolasetron) are effective drugs in the prevention of postoperative nausea and vomiting (PONV). It was the aim of this prospective double blind placebo controlled study to determine the efficacy of low-dose droperidol, dolasetron, and a combination of both drugs in the prevention of PONV after extracapsular cataract extraction.

METHODS

148 inpatients undergoing cataract surgery were stratified according to gender and then randomised to receive one of four antiemetic regimens: placebo, droperiodol (10 micrograms x kg-1), dolasetron (12.5 mg), or the combination of both drugs (10 micrograms x kg-1 + 12.5 mg). The drugs were administered intravenously 5-10 minutes before the end of anaesthesia. General anaesthesia and the perioperative management of the patients were standardised: benzodiazepine premedication, induction with etomidate, alfentanil and mivacurium. Maintenance using desflurane in N2O/O2, and a continuous infusion of mivacurium was used. Postoperative analgesia (diclofenac or paracetamol) and antiemetic rescue medication (dimenhydrinate and metoclopramide) was standardised. Nausea, episodes of vomiting, retching and the need for additional antiemetics were recorded for 24-hours. The severity of PONV was categorised using a standardised scoring algorithm. The main aim of the study was the number of patients who stayed completely free from PONV.

RESULTS

There were no differences between the two groups with regard to biometric data, type of surgery, and distribution of risk factors for developing PONV. In all three treatment groups significantly less patients suffered from PONV (placebo: 66%; droperidol: 89%, dolasetron: 92%, combination: 89%; p = 0.011). Furthermore, the severity of PONV was reduced (p = 0.012).

CONCLUSION

Low-dose droperidol and dolasetron are equally effective to reduce the incidence of PONV after cataract surgery under general anaesthesia. The combination of both drugs revealed no additional effect.

Droperidol-induced neuroleptic malignant syndrome

A 21-year-old female was admitted to the general medical wards via casualty with a suspected overdose of unknown amounts of procyclidine, diazepam and alcohol. She had been a known intravenous drug addict for 3 years.

On examination she was drowsy, agitated and smelling of alcohol. She had venepuncture sites in her antecubital fossae. Her cardiorespiratory observations were normal and her abdomen was soft and non-tender. Glasgow Coma Score was 9 (E4, M4, V1). Her pupils were dilated but equal and reacting to light. Her tone was normal, as was her temperature. Investigations revealed a normal urea and electrolyte screen and a normal full blood picture. Drug screen was positive for benzodiazepines but negative for paracetamol, salicylates, opiates and amphetamines. Electrocardiography showed a sinus rhythm.

She was initially treated with flumazenil 500 μg intravenously and naloxone 1.6 mg intravenously with some improvement in her conscious state. She was given droperidol 10 mg intramuscularly (IM) for agitation and was admitted to a medical ward.

Two days after admission she was increasingly unmanageable, requiring two staff members to control her at all times. She was having auditory and visual hallucinations and was restless. Further droperidol 10 mg IM was given. At this stage, cardiorespiratory observations were still normal, as was temperature. Pupils were dilated, equal and slow to react. Tone was normal. She was reviewed by the psychiatrists who diagnosed drug-induced psychosis, secondary to procyclidine. She was given further droperidol 30 mg IM and transferred to the psychiatric ward for observation. She developed an acute dystonic reaction which was treated with a total of 20 mg of procyclidine IM.

By day 3 she was sweaty, rigid and psychotic. Her temperature was 37.4°C, with a pulse rate of 120 and arterial pressure of 140/90 mm Hg. She was noted to have extensive bruising over her arms and legs. Creatinine phosphokinase was elevated at 1597 mmol/litre (normal < 170 mmol/litre).

During that evening she became tachycardic (pulse 140 beats per minute), hypotensive (blood pressure 50/30 mmHg), tachypnoeic (respiratory rate 50 breaths per minute) and hyperpyrexial, and was found to have a rectal temperature of 42°C. Her pupils were dilated, equal and reacting but she had generalized increased tone and was vasoconstricted. An arrest call was put out and after initial resuscitation she was rapidly transferred to the surgical intensive therapy unit, with a presumed diagnosis of neuroleptic malignant syndrome.

She was intubated and ventilated with 100% oxygen, and received a total of 120 mg dantrolene intravenously. Active cooling measures were initiated. Over several hours her temperature dropped from 42°C to 36.1°C. She was noted to be oliguric (urine output ≈10 ml/hr) with blood-stained urine, positive for myoglobin. She was oozing from venepuncture sites and had a coagulation screen consistent with acute fulminant disseminated intravascular coagulation (prothrombin time 34 secs (normal 12–14 secs), fibrinogen level 1.8 g/litre (normal 2.5–4 g/litre), platelets 100x109/litre (normal 150–400×109/litre), D-Dimer >8 mg/litre (normal <0.5 mg/litre), haemoglobin 99 g/litre (normal 110–115 g/litre)). She had a marked metabolic acidosis (H+ 49 mmol/litre (normal 36–43 mmol/litre) (base excess -10)). Her potassium was normal. Her urea and creatinine were 10.6 mmol/litre and 259 μmol/litre respectively (normal 2.5–7.5 mmol/litre and 40–130 μmol/litre). An infective screen was normal. She continued to deteriorate rapidly, despite inotropic support, volume replacement, frusemide infusion and transfusion of fresh frozen plasma, platelets and concentrated red cells.

Early next morning (day 4) she was diagnosed as having multisystem organ failure and developed fixed dilated pupils, the latter presumed due to cerebral haemorrhage. Active treatment was withdrawn and she died shortly afterwards. A post-mortem showed pulmonary oedema but no apparent cerebral haemorrhage.

Droperidol-supplemented anaesthesia decreases post-operative nausea and vomiting but impairs post-operative mood and well-being

Post-operative nausea and vomiting is distressing for patients and can cause dissatisfaction and impaired well-being in the post-operative period. This study examined the question whether the reduced incidence of post-operative nausea and vomiting inevitably translates into improved clinical status and well-being. In this context high doses of droperidol were investigated. On the one hand, droperidol is known to be a powerful anti-emetic, but on the other hand there is concern about psychological effects, both in the pre- and the post-operative period. In this prospective randomized double-blinded study, droperidol (5-7.5 mg) was compared with midazolam (5-7.5 mg) used to supplement fentanyl-N2O based anaesthesia, with respect to post-operative mood and well-being using a psychological questionnaire (Bf-S-test). Furthermore, the incidence of post-operative nausea and vomiting was recorded. Out of 160 patients undergoing thyroidectomy and laparoscopic cholecystectomy, data from 150 patients were analysed. The administration of droperidol significantly lowered the incidence of post-operative nausea and vomiting from 77.8% to 55.1% compared with midazolam (P = 0.0059; chi 2-test). Although post-operative nausea and vomiting is an independent risk factor for post-operative discomfort and bad mood, patients receiving droperidol showed impaired well-being 6 h after surgery. Well-being scores returned to pre-operative base-line values and did not differ between the two groups 24 and 48 h post-operatively. The reduced incidence of post-operative nausea and vomiting achieved with high dose droperidol does not equate with increased post-operative well-being. It is an important point at issue to decide whether smaller doses of droperidol that are commonly used for anti-emetic therapy are free of these side effects.

Safety and ocular hypotensive efficacy of a single dose of metoclopramide or droperidol in healthy subjects

The purpose of this study was to evaluate the IOP lowering effect of two topical dopamine antagonists, metoclopramide or droperidol, in healthy subjects. Forty healthy volunteers were randomly assigned to receive, in double-masked fashion, topical administration of a single drop of 0.5% metoclopramide or 0.25% droperidol, with the fellow eye receiving isotonic saline as placebo. IOP was measured before and 1, 3, 5, and 7 hours after instillation of drugs. Ocular irritation and conjunctival congestion were also recorded at the time of each measurement. In the metoclopramide group, the maximal mean percentage change in IOP was -14.4% in tested eyes as compared with -10.8% in placebo-treated eyes 3 hours after instillation. All the changes were not significantly different between the metoclopramide-treated and the placebo-treated eyes at all time points. In the droperidol group, the maximal mean percentage change in IOP was -19.6% in tested eyes as compared with -17.7% in placebo-treated eyes at 3 hours after instillation. There was also no significant difference between the droperidol-treated and the placebo-treated eyes. None of the volunteers reported ocular irritation or conjunctival congestion after instillation of the drugs. In conclusion, while topical droperidol or metoclopramide tended to lower IOP in healthy subjects, the decrease in IOP did not differ significantly from that in placebo-treated eyes. Both drugs appear to be safe. Further studies with larger numbers of subjects at higher doses in glaucomatous subjects are needed before definite conclusions on drug efficacy can be drawn.

Combination of granisetron and droperidol in the prevention of nausea and vomiting after middle ear surgery

STUDY OBJECTIVES

To evaluate the efficacy and safety of granisetron-droperidol combination for the prevention of postoperative nausea and vomiting (PONV) after middle ear surgery.

DESIGN

Prospective, randomized, double-blind study.

SETTING

University hospital.

PATIENTS

150 ASA physical status I patients (108 females, 42 males) scheduled for elective middle ear surgery.

INTERVENTIONS

Patients received granisetron 40 micrograms/kg (n = 50), droperidol 20 micrograms/kg (n = 50), or granisetron 40 micrograms/kg plus droperidol 20 micrograms/kg (n = 50) intravenously immediately before induction of anesthesia.

MEASUREMENTS AND MAIN RESULTS

A standard general anesthetic technique and postoperative analgesia were used throughout the study. A complete response, defined as no PONV and no need for another rescue antiemetic, from 0 to 3 hours after anesthesia occurred in 78%, 56%, and 94% of patients who had received granisetron, droperidol, and granisetron plus droperidol, respectively. The corresponding incidence between 3 and 24 hours after anesthesia was 80%, 52% and 94%. Thus, a complete response within the first 24-hour postanesthetic period was greater in patients receiving granisetron-droperidol combination than in those receiving granisetron alone or droperidol alone (p < 0.05). No clinically adverse events were observed in any of the groups.

CONCLUSIONS

A combination of granisetron and droperidol is more effective than droperidol or granisetron alone for the prevention of PONV after middle ear surgery.

Malignant hyperthermia and neuroleptic malignant syndrome in a patient during treatment for acute asthma

Acute asthma is well known to provoke complications. We report the case of a patient who needed intubation and mechanical ventilation for acute asthma. Despite a treatment with corticosteroids, bronchodilators, neuromuscular blocking drugs and magnesium sulfate, the situation remained uncontrolled and as a last resort, halothane became necessary. The patient then developed an episode of malignant hyperthermia with fever at 40 degrees C and rhabdomyolysis. At this time, halothane could be stopped and all the symptoms disappeared without modifying the rest of the treatment. Eight days later, he presented with a neuroleptic malignant syndrome following an injection of droperidol. Temperature rose to 42 degrees C, associated with muscle rigidity, sweating, tachycardia and severe circulatory collapse. The use of dantrolene in association with a symptomatic treatment of the collapse led to a favourable outcome in. Unfortunately, in vitro contracture test could not be performed in this case. The links between malignant hyperthermia and neuroleptic malignant syndrome remain unclear. Although these two pathologies share the same physiopathology, symptomatology and treatment, they are clearly individualized. This case seems to be the first description of their occurrence in the same patient.

A granisetron-droperidol combination prevents postoperative vomiting in children

This study was performed to compare the efficacy of a granisetron-droperidol combination with each antiemetic alone to prevent postoperative vomiting after tonsillectomy with or without adenoidectomy in children. One hundred eighty pediatric patients, ASA physical status I, aged 4-10 yr, were enrolled in a prospective, randomized, double-blind investigation and assigned to one of three treatment regimens: granisetron 40 microg/kg (Group G), droperidol 50 microg/kg (Group D), or granisetron 40 microg/kg plus droperidol 50 microg/kg (Group GD) (n = 60 in each group). These drugs were administered i.v. after an inhaled induction. The same standard general anesthetic technique and postoperative analgesia were used throughout. The rate of complete response, defined as no emesis and no need for rescue antiemetic, 0-3 h after anesthesia was 83% in Group G, 60% in Group D, and 97% in Group GD (P = 0.029 versus Group G, P = 0.001 versus Group D). The corresponding rates 3-24 h after anesthesia were 83%, 55%, and 97% (P = 0.029 versus Group G, P = 0.001 versus Group D). No clinically important adverse events were observed in any of the groups. In conclusion, a granisetron-droperidol combination is superior to each antiemetic alone in complete response in children undergoing general anesthesia for tonsillectomy.

IMPLICATIONS

We compared the efficacy of granisetron plus droperidol with each antiemetic alone for the prevention of postoperative vomiting in children. The granisetron-droperidol combination was highly effective against postoperative emesis.

Prevention of nausea and vomiting with granisetron, droperidol and metoclopramide during and after spinal anaesthesia for caesarean section: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Nausea and vomiting during and after spinal anaesthesia for caesarean section are distressing to the patient. This study was undertaken to evaluate the efficacy and safety of granisetron, droperidol and metoclopramide for the prevention of nausea and vomiting in parturients undergoing caesarean section under spinal anaesthesia.

METHODS

In a randomized, double-blind, placebo-controlled trial, 120 patients received granisetron 3 mg, droperidol 1.25 mg, metoclopramide 10 mg or placebo (saline) (n = 30 of each) i.v. immediately after clamping of the foetal umbilical cord. Nausea, vomiting and safety assessments were performed during and after spinal anaesthesia for caesarean section.

RESULTS

The incidence of intraoperative, post-delivery nausea and vomiting was 13%, 17%, 20% and 63% after administration of granisetron, droperidol, metoclopramide and placebo, respectively; the corresponding incidence during 0-3 h after surgery was 7%, 27%, 27% and 43%; the corresponding incidence during 3-24 h after surgery was 7%, 20%, 23% and 37% (P < 0.05; overall Fisher's exact probability test). No clinically important adverse events were observed in any of the groups.

CONCLUSION

Granisetron is highly effective for preventing nausea and vomiting during and after spinal anaesthesia for caesarean section. Droperidol and metoclopramide are effective for the prevention of intraoperative, post-delivery emesis, but are ineffective for the reduction of the incidence of postoperative emesis.

High-dose ondansetron regimen vs droperidol for morphine patient-controlled analgesia

We have performed a randomized, double-blind study comparing droperidol and high-dose ondansetron mixed with morphine for patient-controlled analgesia (PCA). To detect a reduction in the incidence of postoperative nausea and vomiting from 55% to 20% with a power of 80% at the P < 0.05 level, 29 patients per group were required. We studied 60 healthy women undergoing abdominal hysterectomy, anaesthetized using a standard technique. Group D received a bolus dose of droperidol 1.25 mg at induction followed by droperidol 0.1 mg per 1 mg of morphine from the PCA system. Group O received a bolus dose of ondansetron 4 mg at induction followed by ondansetron 0.32 mg per 1 mg of morphine. This dose of ondansetron is more than double that studied previously. Mean nausea and vomiting scores at 4, 8, 12 and 24 h, mean time to first vomit, sedation scores, incidence of side effects, and doses of prochlorperazine did not differ between the groups. In group D, 24 patients did not vomit compared with 23 in group O. The only significant difference between the groups was increased morphine consumption in the ondansetron group up until 12 h after operation (P < 0.05), but by 24 h this difference was not significant. The ondansetron regimen was more expensive (at local prices) by a factor of 27, and our results suggested no clinical advantage over droperidol.

Torsade de pointes resulting from the addition of droperidol to an existing cytochrome P450 drug interaction

OBJECTIVE

To report a case of QT prolongation associated with concomitant cyclobenzaprine and fluoxetine administration followed by torsade de pointes potentiated by droperidol.

CASE SUMMARY

A 59-year-old white woman who had been receiving long-term fluoxetine and cyclobenzaprine therapy was admitted for Achilles tendon repair. Baseline QTc was prolonged at 497 msec. Prior to surgery, the patient received droperidol, an agent known to prolong the QT interval. During surgery the patient developed torsade de pointes, which progressed into ventricular fibrillation. On postoperative day 1, after cyclobenzaprine discontinuation, the QTc decreased toward normal (440 msec).

DISCUSSION

Cyclobenzaprine shares anticholinergic effects, tachycardia, and dysrhythmic potential with the tricyclic antidepressants (TCAs). Fluoxetine is a known inhibitor of the CYP2D6 isoenzyme (along with CYP3A4 and CYP2C) and has been shown to increase TCA serum concentrations. The combination of cyclobenzaprine and fluoxetine resulted in significant QT prolongation in our patient that progressed to torsade de pointes after preoperative droperidol administration. Resolution of QT abnormalities after cyclobenzaprine discontinuation provided further evidence of a drug-induced etiology. Other possible medical and drug-related causes of torsade de pointes are reviewed and ruled out.

CONCLUSIONS

Clinicians should be aware of the dysrhythmic potential of cyclobenzaprine and fluoxetine, monitor for other cytochrome P450 inhibitors, and avoid concomitant drugs known to prolong the QT interval.

Comparison of granisetron and droperidol in the prevention of vomiting after strabismus surgery or tonsillectomy in children

This prospective, randomized, double-blinded study evaluated the antiemetic efficacy of granisetron and droperidol in 80 ASA physical status I children, aged 4-10 years, undergoing strabismus surgery or tonsillectomy with or without adenoidectomy. After anaesthetic induction, the patients received either granisetron (40 micrograms.kg-1, n = 40) or droperidol (50 micrograms.kg-1, n = 40) intravenously. The incidence of vomiting during the first 24h after anaesthesia was 15% and 38% after administering granisetron and droperidol, respectively (P = 0.02). The requirement for rescue antiemetic therapy for the treatment of two or more episodes of vomiting was 0% with granisetron and 18% with droperidol (P = 0.001). In conclusion, granisetron was superior to droperidol in reducing the incidence and frequency of postoperative vomiting in paediatric patients.

Addition of droperidol to morphine administered by the patient-controlled analgesia method: what is the optimal dose?

Eighty patients were recruited into a double-blind, randomized trial to find the optimal dose of droperidol for addition to the patient-controlled analgesia (PCA) morphine infusate for female patients undergoing gynaecological surgery. A standardized anaesthetic technique was employed. Post-operative analgesia was provided by PCA morphine. Patients were allocated at random into one of four treatment groups receiving with each PCA morphine bolus: (1) droperidol 0.05 mg; (2) droperidol 0.10 mg; (3) droperidol 0.15 mg; and (4) droperidol 0.20 mg, respectively. The incidence of post-operative nausea and vomiting (PONV), requests for rescue anti-emetic medication, and incidence of side effects were recorded. The number of symptom-free patients in each group increased as the droperidol dose increased, but although there was a significant inverse association between the total dose of droperidol received and the severity of PONV (P < 0.05), there were no significant differences between individual groups. In each group, patients were significantly less sedated at 24 h compared with 12 h (P < 0.01). However, after 24 h, patients in group 4 were significantly more sedated than patients in groups 1 and 2 (P < 0.05). There were no significant differences between the groups in terms of the incidence of anxiety or other side effects attributable to droperidol. The present authors suggest that, although the results demonstrate few statistically significant differences between the four groups, a PCA bolus dose of droperidol of 0.10 mg mL-1 appears to provide the optimal balance between anti-emetic efficacy and an acceptable incidence of side effects.

A comparison of the efficacy, safety, and patient satisfaction of ondansetron versus droperidol as antiemetics for elective outpatient surgical procedures. S3A-409 and S3A-410 Study Groups

Two identical, randomized, double-blind, placebo-controlled studies enrolled 2061 adult surgical outpatients at high risk of postoperative nausea and vomiting (PONV) to compare i.v. ondansetron 4 mg with droperidol 0.625 mg and droperidol 1.25 mg for the prevention of PONV. The antiemetic drugs or placebo were administered i.v. 20 min before the induction of anesthesia with a barbiturate compound, followed by maintenance with N2O/isoflurane/enflurane. Nausea, emetic episodes, adverse events, and patient satisfaction were analyzed for the 0 to 2 h and 0 to 24 h postoperative periods. In the 0 to 2 h postoperative period, there was a complete response (no emesis or rescue antiemetic) in 46% of subjects given placebo (P < 0.05 versus antiemetic groups), in 62% given ondansetron, in 63% given droperidol 0.625 mg, and in 69% given droperidol 1.25 mg (P < 0.05 versus ondansetron). In the 0 to 24-h postoperative period, there were no significant differences in complete response between the ondansetron and droperidol 0.625 or 1.25 mg groups; all groups remained superior to placebo. The proportion of patients without nausea during the 0 to 24 h postoperative period was greater in the antiemetic groups compared with the placebo group; however, droperidol 1.25 mg was more effective than ondansetron 4 mg or droperidol 0.625 mg (43% vs 29% or 29%, respectively). Headache incidence was higher in the ondansetron group compared with either droperidol group. Patient satisfaction scores did not differ significantly among antiemetic treatment groups, although all were superior to placebo. In conclusion, all antiemetic treatment regimens were superior to placebo for the prevention of PONV in the immediate postoperative period; however, droperidol 1.25 mg was more efficacious than ondansetron during the early recovery period (0-2 h). There were no significant differences between ondansetron and either droperidol dose for emesis prevention during the 0 to 24 h postoperative period.

IMPLICATIONS

More than 2000 patients at high risk of postoperative nausea and vomiting were given either placebo, ondansetron 4 mg, or droperidol 0.625 mg or 1.25 mg i.v. before the administration of general anesthesia. After surgery, the incidence of nausea, vomiting, medication side effects, and patient satisfaction were evaluated for 24 h. Droperidol 0.625 or 1.25 mg i.v. compared favorably with ondansetron 4 mg i.v. for the prevention of postoperative nausea and vomiting after ambulatory surgery.

Neuroleptic malignant syndrome following autologous peripheral blood stem cell transplantation

Neuroleptic malignant syndrome (NMS) is a rare disorder characterized by hyperthermia, elevated creatine phosphokinase, extrapyramidal effects, autonomic instability, altered level of consciousness and leukocytosis associated with neuroleptic and other psychotropic medications. There are no cases of NMS reported following stem cell transplantation. We describe two patients receiving autotransplants who developed NMS. With the common use of neuroleptic and other related psychotropic medications in the peri-transplant period and the associated physiologic stress of the procedure, we believe that NMS may be unrecognized and account for significant morbidity in this setting.

Prevention of PONV with granisetron, droperidol or metoclopramide in patients with postoperative emesis

PURPOSE

A high incidence of postoperative nausea and vomiting (PONV) has been noted in patients with a history of postoperative emesis. This study was undertaken to compare the efficacy of granisetron, droperidol and metoclopramide, in the prevention of PONV in such patients undergoing general anaesthesia for major gynaecological surgery.

METHODS

In a randomised, double-blind study, 90 female patients received 2.5 mg granisetron, 1.25 mg droperidol or 10 mg metoclopramide (n = 30 of each) i.v. immediately before induction of anaesthesia. The same standard general anaesthetic technique, which consisted of isoflurane in nitrous oxide and oxygen, was used. Nausea, vomiting and safety assessments were performed continuously during the first 24 hr after anaesthesia.

RESULTS

The incidence of PONV was 20% with granisetron, 57% with droperidol and 60% with metoclopramide (P < 0.05; overall Fisher's exact probability test). No clinically adverse events were observed in any group.

CONCLUSION

Granisetron is more effective than droperidol or metoclopramide in preventing PONV in female patients with a history of postoperative emesis.

Dystonic movements following thalamonal and alfentanil induction--a case report

A 62 year old woman developed dystonic movements following induction of anesthesia with thalamonal and alfentanil. The patient remained awake during the episode. A small dose of thiopental sodium followed by succinylcholine aborted the unpleasant state. The case is being presented to emphasize the point that even small doses of opioid narcotic can cause tonic movements and frank seizures in some patients.

Comparison of tramadol and tramadol/droperidol mixture for patient-controlled analgesia

PURPOSE

To compare the analgesic efficacy and side effects of tramadol vs tramadol and droperidol for post-operative patient-controlled analgesia (PCA).

METHODS

Randomised, double-blind study. Thirty-four patients undergoing elective colorectal or head and neck surgery were allocated to Group 1 (n = 18, PCA bolus 10 mg tramadol) or Group 2 (n = 16, PCA bolus 10 mg tramadol + 0.1 mg droperidol). Anaesthesia was induced with fentanyl and thiopentone and maintained with O2, N2O plus enflurane or isoflurane with iv morphine at doses decided by the attending anaesthetists. Muscle relaxation was achieved with atracurium or vecuronium. Patients were observed four-hourly for pain using an 11-point verbal rating scale (VRS). Nausea and vomiting, and sedation were assessed using four-point scales post-operatively. Vital signs, request for rescue anti-emetic and analgesic, and overall satisfaction were recorded.

RESULTS

The mean nausea scores were lower in Group 2 (1.00 +/- 1.33 vs 0.06 +/- 0.25 at 0-8 hr, 1.22 +/- 1.93 vs 0.06 +/- 0.25 at 8-16 hr, P < 0.01; 0.81 +/- 1.68 vs 0 at 32-40 hr, P < 0.05; Group 1 vs Group 2). The vomiting scores were also lower (0.50 +/- 1.04 vs 0 at 0-8 hr, 0.67 +/- 1.50 vs 0, at 8-16 hr, P < 0.05; Group 1 vs Group 2). Seven (39%) patients in Group 1, but none in Group 2 requested rescue anti-emetic (P < 0.01). There were no differences in VRS, sedation score, overall satisfaction or vital signs.

CONCLUSION

Tramadol and droperidol combination is superior to tramadol alone for post-operative PCA. It provides a similar quality of analgesia with less nausea and vomiting and without an increase in sedation.

Ondansetron, droperidol and their combination for the prevention of post-operative vomiting in children

In this study the antiemetic effects of droperidol, ondansetron and their combination were evaluated in 160 ASA Grade I and II children undergoing surgery for strabismus, who were randomly assigned to one of four groups: Group D received droperidol 75 micrograms kg-1, group O ondansetron 0.1 mg kg-1, group D+O received both droperidol 75 micrograms kg-1 and ondansetron 0.1 mg kg-1, and group N NaCl as placebo. Emesis within the first 24 h occurred in 95.0% of the children with placebo medication, compared with 32.5% (D), 40.0% (O) and 45.0% (D+O) in the groups with antiemetic prophylaxis. The differences between group N and all other groups were significant (P < 0.001). However, there were no statistically significant differences between the groups D, O and D+O. It is concluded that droperidol (75 micrograms kg-1) and ondansetron (0.1 mg kg-1) both significantly reduce PONV in children undergoing surgery for strabismus. Neither ondansetron, nor the combination D+O were superior to droperidol alone.

Droperidol treatment of status migrainosus and refractory migraine

We conducted a pilot study of intravenous droperidol in 35 patients (32 women and 3 men; mean age 43 years) with status migrainosus (n = 25) or refractory migraine (n = 10) in an ambulatory infusion center. Headache was graded as severe in 21 patients and moderate in 14. An intravenous line was started and kept open. Droperidol (2.5 mg) was given intravenously every 30 minutes until either three doses were given or the patient was completely or almost headache-free prior to the next dose. Seven patients received one dose, 12 received two doses, and 16, three doses (mean 5.6 mg). Our success rate (headache-free or mild headache) was 88% (22 of 25) in patients with status migrainosus and 100% (10 of 10) in patients with refractory migraine. The average time to headache improvement was 40 minutes (n = 35), to mild headache--60 minutes (n = 32), and to headache-free--105 minutes (n = 28). Nausea, vomiting, and light and sound sensitivity resolved in all but 5 patients. Four patients had an asymptomatic systolic blood pressure drop > or = 20 mm Hg. Most patients were sedated (34 of 35). Five patients developed akathisia and 1 dystonia. At follow-up 24 hours after discharge, the recurrence rate (headache intensity from none or mild to moderate or severe) was 23% in status migrainosus and 10% in refractory migraine. Twenty-one patients were sedated, while 19 had extrapyramidal symptoms, mainly restlessness. Droperidol is effective and safe in treating status migrainosus or refractory migraine. Hypotension was uncommon. Patients should be warned of sedation and akathisia.

Conduction disturbances associated with administration of butyrophenone antipsychotics in the critically ill: a review of the literature

Droperidol and haloperidol have demonstrated efficacy and safety in the treatment of acute delirium in critically ill patients. We conducted MEDLINE and manual searches of literature published from 1966-1996 to identify articles describing conduction disturbances associated with the drugs. The objectives were to describe the proposed mechanisms of acquired long QTc interval syndrome and torsades de pointes, and to recommend how critically ill patients receiving these agents should be monitored. We found 11 published reports of conduction disturbances associated with intravenous administration of droperidol or haloperidol. The majority of cases occurred in critically ill patients prescribed more than 50 mg/24 hours of either agent. Of the 18 patients described, 13 (72%) had a history of cardiovascular disease. Based on the small number of available case reports, it seems reasonable to suggest that the incidence of adverse cardiovascular effects due to droperidol and haloperidol is small. The mechanism of butyrophenone-induced QTc interval prolongation is not known, but is presumed to involve abnormal ventricular repolarization and the development of early after-depolarizations. Before initiating therapy with droperidol or haloperidol in critically ill patients, a baseline QTc interval and serum magnesium and potassium concentrations should be measured. If the baseline QTc interval is 440 msec or longer, and they are receiving other drugs that may prolong the QTc interval or they have electrolyte disturbances, a butyrophenone antipsychotic should be prescribed with caution. All critically ill patients receiving droperidol or haloperidol should undergo electrocardiogram monitoring and QTc interval measurement; special attention should be given to those receiving doses greater than 50 mg/24 hours, as these patients appear to be at greatest risk for development of conduction disturbances. Based on the currently available literature, in any critically ill patient receiving droperidol or haloperidol therapy whose QTc interval lengthens by 25% or more over baseline, therapy should be discontinued or the dosage reduced.