Effectiveness and safety of droperidol in a United States emergency department

A Study of Cardiac Outcomes After Droperidol Administration in an Inpatient Psychiatric Cohort

PURPOSE/BACKGROUND

Droperidol is an antipsychotic medication used in psychiatric emergencies to manage acute behavioral disturbance. Droperidol use carries a risk of prolonged QT interval on the electrocardiogram and associated cardiac arrhythmias including torsades de pointes and ventricular fibrillation. This study aimed to evaluate the safety of droperidol in adults admitted to the psychiatric inpatient unit of a large Australian hospital.

METHODS/PROCEDURES

In this retrospective cohort study, psychiatric inpatients admitted between October 22, 2018, and March 1, 2021, who received at least 1 dose of intramuscular droperidol were consecutively included. Outcomes of interest were death, cardiac arrhythmias, and QT prolongation. QT prolongation was identified using the QT-interval nomogram.

FINDINGS/RESULTS

This study included 263 patients without exclusion. No deaths or cases of cardiac arrhythmia were recorded within 24 hours of droperidol administration. Electrocardiogram data were available for 41.1% of patients (n = 108) within 7 days of droperidol administration. Two cases of QT prolongation were identified using the QT-interval nomogram, but these patients were also prescribed other medications that may have contributed to QT prolongation.

IMPLICATIONS/CONCLUSIONS

This study contributes the first known large retrospective study of safety outcomes including QT prolongation after droperidol administration in a psychiatric inpatient setting. Our findings corroborate mounting evidence supporting the clinical safety of droperidol use in psychiatric settings. Nonetheless, we note that significant barriers remain with regard to timely electrocardiogram monitoring after droperidol use.

QT prolongation, torsades des pointes, and cardiac arrest after 4 mg of IV ondansetron

Ondansetron is a commonly used antiemetic in the emergency department despite a 2011 FDA warning regarding dose-related QTc prolongation and torsades des pointes (TdP). Cases of TdP from small ondansetron doses administered in the emergency department are lacking. A 41-year-old-woman with alcohol use disorder on no medications or supplements presented to an emergency department with one day of nausea, vomiting, and epigastric pain. Examination revealed a pulse of 77 beats/min and epigastric tenderness. The patient received 4 mg IV ondansetron, 30 mg IV ketorolac, and was placed on cardiac monitoring. ECG obtained one minute after ondansetron demonstrated premature ventricular contractions with QTc = 653 ms. Thirteen minutes after receiving ondansetron she suffered TdP and cardiac arrest. She received immediate CPR and IV epinephrine with successful defibrillation at one minute. She then received IV magnesium. Post-arrest ECGs demonstrated persistent QTc prolongation immediately and at three hours post-arrest. Laboratory studies, drawn prior to arrest, demonstrated hypokalemia (3.2 mEq/L), hypomagnesemia (1.3 mg/dL), and elevated lipase (4918 IU/L). She received no additional QT-prolonging agents. Transthoracic echocardiogram and troponins were normal; ECG intervals completely normalized within 12 h and she was discharged neurologically intact. The patient returned 18 months later with recurrent pancreatitis and similar electrolyte abnormalities; QT-prolonging drugs were avoided at that time and her course was uncomplicated. QT prolongation with subsequent torsades des pointes and cardiac arrest may occur in high-risk patients receiving small doses of ondansetron. Further studies are warranted to determine the safest antiemetic for use in the emergency department.

Retrospective evaluation of ketamine versus droperidol on time to restraint removal in agitated emergency department patients

PURPOSE

Acute agitation and violent behavior in the emergency department (ED) can lead to significant patient morbidity and contribute to the growing problem of workplace violence against health care providers. To our knowledge, there is no available literature directly comparing intramuscular ketamine to intramuscular droperidol in ED patients presenting with undifferentiated agitation. The purpose of this investigation was to compare the effectiveness and safety of these agents for acute agitation in the ED.

METHODS

This was a retrospective observational study conducted at an urban, academic ED. The primary endpoint was time from the first dose of study medication to restraint removal. Safety endpoints included incidence of bradycardia (heart rate < 60 bpm), hypotension (systolic blood pressure < 90 mmHg), hypoxia (oxygen saturation < 90% or need for respiratory support), and incidence of intubation for ongoing agitation or respiratory failure.

RESULTS

An initial 189 patients were screened, of which, 92 met inclusion criteria. The median time from initial drug administration to restraint removal was 49 min (IQR 30, 168) in the ketamine group and 43 min (IQR 30, 80) in the droperidol group (Median difference 6 min; 95% CI [-7, 26]). There was no significant difference in rates of bradycardia (3% vs 3%, 95% CI [-7%, 8%]), hypotension (0% vs 2%, 95% CI [-5%, 2%]), or hypoxia (7% vs 10%, 95% CI [-15%, 9%]) in the ketamine versus droperidol groups respectively. One patient in the ketamine group was intubated for ongoing agitation, and one patient in the droperidol group was intubated for respiratory failure.

CONCLUSIONS

Intramuscular droperidol and intramuscular ketamine were associated with similar times from drug administration to restraint removal in patients presenting to the ED with undifferentiated agitation. Prospective studies are warranted to evaluate IM droperidol and IM ketamine head-to-head as first line agents for acute agitation in the ED.

Droperidol Use in the Emergency Department: A Clinical Review

BACKGROUND

Droperidol is a butyrophenone, with antiemetic, sedative, anxiolytic, and analgesic properties. Although droperidol was once widely used in both emergency and perioperative settings, use of the medication declined rapidly after a 2001 U.S. Food and Drug Administration (FDA) boxed warning called the medication's safety into question.

OBJECTIVE

The purpose of this clinical review was to provide evidence-based answers to questions about droperidol's safety and to examine its efficacy in its various clinical indications.

DISCUSSION

Droperidol is an effective sedative, anxiolytic, analgesic, and antiemetic medication. As a sedative, when compared with haloperidol, droperidol has faster onset, as well as greater efficacy, in patients experiencing acute psychosis, with no increase in adverse events. As an antiemetic, droperidol has been found to have equal or greater efficacy in reducing nausea and vomiting than ondansetron and metoclopramide, with similar adverse effects and the added effect of reducing the need for rescue analgesia in these patients. As an analgesic, droperidol is effective for migraines and has opioid-sparing effects when used to treat abdominal pain. Droperidol is a particularly useful adjunct in patients who are opioid-tolerant, whose pain is often difficulty to manage adequately.

CONCLUSIONS

Droperidol seems to be effective and safe, despite the boxed warning issued by the FDA. Droperidol is a powerful antiemetic, sedative, anxiolytic, antimigraine, and adjuvant to opioid analgesia and does not require routine screening with electrocardiography when used in low doses in otherwise healthy patients before administration in the emergency department.

A systematic review of the effectiveness and safety of droperidol for pediatric agitation in acute care settings

OBJECTIVE

Agitation in children in acute care settings poses significant patient and staff safety concerns. While behavioral approaches are central to reducing agitation and oral medications are preferred, parenteral medications are used when necessary to promote safety. The goal of this systematic review was to evaluate the effectiveness and safety of an ultra-short-acting parenteral medication, droperidol, for the management of acute, severe agitation in children in acute care settings.

METHODS

A systematic review of randomized controlled trials, observational studies, and case series/reports examined the effectiveness and safety of parenteral droperidol for management of acute agitation in patients ≤21 years old in acute care settings. Effectiveness outcomes included time to sedation and need for a subsequent dose of medication. Safety outcomes were adverse effects such as QTc prolongation, hypotension, respiratory depression, and dystonic reactions.

RESULTS

A total of 431 unique articles were identified. Six articles met inclusion criteria: two in the prehospital setting, one in the emergency department, and three in the inpatient hospital setting. The articles included a prospective observational study, three retrospective observational studies, and two case reports. The largest study reported a median time to sedation of 14 min (interquartile range 10-20 min); other studies reported a time to sedation of 15 min or less. Across studies, 8%-22% of patients required a second dose of medication for ongoing agitation. The most frequent adverse effects were dystonic reactions and transient hypotension. One patient had QTc prolongation and another developed respiratory depression, but both had significant comorbidities that may have contributed. The risk of bias in included studies ranged from moderate to critical.

CONCLUSIONS

Existing data on droperidol for management of acute agitation in children suggest that droperidol is both effective and safe for acute, severe agitation in children. Data are limited by study designs that may introduce bias.

Non-opioid Intravenous Drugs for Pain Management in Patients Presenting with Acute Migraine Pain in the Emergency Department: A Comprehensive Literature Review

Context

Migraine is one of the most common causes of disability worldwide and the sixth cause of loss of life years due to disability. Migraine is reported mainly in young and middle-aged people, so it can cause a person to face many problems in doing daily tasks. The emergency department annually accepts 1.2 million patients with migraine. Therefore, timely diagnosis of the disease, knowledge of valuable drugs in an emergency, knowing how to use them, and finally, early treatment can play an essential and decisive role in improving patients' symptoms and reducing the disability caused by the disease. An essential and valuable drug category in the emergency department to manage pain is non-opioid intravenous (IV) drugs. Therefore, this study aimed to evaluate non-opioid IV drugs to manage pain in patients with acute migraines in the emergency department.

Method

This study conducted a comprehensive literature review to access the latest scientific studies and documents using keywords (acute migraine, non-opioid IV drugs, pain management) in reliable databases such as PubMed, Scopus, Web of Science, Cochrane, and Google Scholar. We reviewed 87 articles, 53 of which were evaluated and compared.

Results

A review study considers intravenous acetaminophen as a suitable option for the first-line treatment of acute migraine in the emergency department if the patient does not tolerate aspirin and non-steroidal anti-inflammatory drugs (NSAIDs). Various studies have obtained positive effects of NSAIDs and dihydroergotamine (DHE) in treating acute migraine. Prescribing anti-dopaminergic drugs can effectively reduce associated symptoms such as nausea and vomiting. Dexamethasone and magnesium sulfate are effective in preventing migraine and severe attacks. Intravenous sodium valproate is effective in moderate to severe migraine attacks or treatment-resistant migraines. In the emergency department, prescribing intravenous haloperidol, lidocaine, and propofol can help manage migraine and improve other associated symptoms, such as nausea or vomiting.

Conclusions

Non-opioid IV drugs are essential to manage pain and improve other migraine symptoms in the emergency setting. Knowing the above drugs and their optimal use has a decisive role in managing patients with acute migraine in the emergency department.

Prospective real-time evaluation of the QTc interval variation after low-dose droperidol among emergency department patients

OBJECTIVE

To assess the QTc interval variation after low-dose droperidol in a population of undifferentiated, stable, and non-agitated patients receiving droperidol in the emergency department.

METHODS

Prospective cohort study of patients aged ≥12 years of age who received low-dose droperidol (≤ 2.5 mg) for indications other than acute behavioral disturbances. QTc intervals were monitored in real-time during pre-specified observation periods in the ED. Primary outcome was variation of QTc interval after droperidol administration, defined as the maximum delta (change) of QTc interval. Other outcomes included proportion of patients with a QTc ≥ 500 ms after droperidol, delta ≥ +60 ms, and incidence of clinical adverse events. Patients were monitored up to 30 min after IV bolus and up to 46 min after infusion.

RESULTS

A total of 68 patients were included (mean age 42.1 years, 66.2% females). The median dose of droperidol was 1.875 mg (range 0.625 mg, 2.5 mg) and 94.1% received droperidol for headache management. Most patients received droperidol as a 2-min bolus (n = 41, 60.3%). The mean maximum delta of QTc interval after droperidol across all 68 patients was +29.9 ms (SD 15). A total of 12 patients (17.6%) experienced a QTc interval ≥ 500 ms during the observation period after droperidol, and 3 patients (4.4%) had a delta QTc ≥ +60 ms. There were no serious arrhythmias, such as TdP, or deaths among the 68 participants in this study (0/68). However, 13.2% (n = 9) had at least one non-serious adverse event including restlessness and/or anxiety.

CONCLUSION

The QTc interval slightly increased after droperidol administration, but these prolongations were brief, mostly below 500 msec and did not lead to serious arrhythmias. The yield of continuous cardiac monitoring in patients receiving low doses of droperidol is likely low.

Rapid tranquilization of the agitated patient in the emergency department: A systematic review and network meta-analysis

BACKGROUND

Safe and effective tranquilization of the acutely agitated patient is challenging, and head-to-head comparisons of medications are limited. We aimed to identify the most optimal agent(s) for rapid tranquilization of the severely agitated patient in the emergency department (ED).

METHODS

The protocol for systematic review was registered (PROSPERO; CRD42020212534). We searched MEDLINE, Embase, PsycINFO, and Cochrane Database/CENTRAL from inception to June 2, 2021. We limited studies to randomized controlled trials that enrolled adult ED patients with severe agitation and compared drugs for rapid tranquilization. Predetermined outcomes were: 1) Adequate sedation within 30 min (effectiveness), 2) Immediate, serious adverse event - cardiac arrest, ventricular tachydysrhythmia, endotracheal intubation, laryngospasm, hypoxemia, hypotension (safety), and 3) Time to adequate sedation (effect onset). We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2 tool. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effects model and vague prior distribution to calculate odds ratios with 95% credible intervals for dichotomous outcomes and frequentist NMA to calculate mean differences with 95% confidence intervals for continuous outcomes. We assessed confidence in results using CINeMA. We used surface under the cumulative ranking (SUCRA) curves to rank agent(s) for each outcome.

RESULTS

Eleven studies provided data for effectiveness (1142 patients) and safety (1147 patients). Data was insufficient for effect onset. The NMA found that ketamine (SUCRA = 93.0%) is most likely to have superior effectiveness; droperidol-midazolam (SUCRA = 78.8%) is most likely to be safest. There are concerns with study quality and imprecision. Quality of the point estimates varied for effectiveness but mostly rated "very low" for safety.

CONCLUSIONS

Available evidence suggests that ketamine and droperidol have intermediate effectiveness for rapid tranquilization of the severely agitated patient in the ED. There is insufficient evidence to definitively determine which agent(s) may be safest or fastest-acting. Further, direct-comparison study of ketamine and droperidol is recommended.

A Prospective Study of Intramuscular Droperidol or Olanzapine for Acute Agitation in the Emergency Department: A Natural Experiment Owing to Drug Shortages

STUDY OBJECTIVE

Intramuscular medications are commonly used to treat agitation in the emergency department (ED). The purpose of this study is to compare intramuscular droperidol and olanzapine for treating agitation.

METHODS

This was a prospective observational study of ED patients receiving intramuscular droperidol or olanzapine for acute agitation. The treating physician determined the medication and dose; however, over time drug shortages made either olanzapine (July to September 2019) or droperidol (November 2019 to March 2020) unavailable, creating a natural experiment. The primary outcome was time to adequate sedation, assessed by the Altered Mental Status Scale (AMSS), defined as time to AMSS score less than or equal to 0.

RESULTS

We analyzed 1,257 patients (median age 42 years; 73% men); 538 received droperidol (median dose 5 mg) and 719 received olanzapine (median dose 10 mg). The majority of patients (1,086; 86%) had agitation owing to alcohol intoxication. Time to adequate sedation was 16 minutes (interquartile range 10 to 30 minutes) for droperidol and 17.5 minutes (interquartile range 10 to 30 minutes) for olanzapine (absolute difference -0.7 minutes; 95% confidence interval -2.1 to 0.5 minutes). Adjusted Cox proportional hazard model analysis revealed no difference between groups in time to sedation (hazard ratio for adequate sedation for droperidol compared with olanzapine 1.12; 95% confidence interval 1.00 to 1.25). Patients receiving olanzapine were more likely to receive additional medications for sedation (droperidol 17%; olanzapine 24%; absolute difference -8% [95% confidence interval -12% to -3%]). We observed no difference between drugs regarding adverse effects except for extrapyramidal adverse effects, which were more common with droperidol (n=6; 1%) than olanzapine (n=1; 0.1%).

CONCLUSION

We found no difference in time to adequate sedation between intramuscular droperidol and olanzapine.

Reintegrating droperidol into emergency medicine practice

Purpose

After a long period of low utilization, droperidol has become easier to obtain in the US market. This comprehensive review discusses the safety, indications, clinical efficacy, and dosing of droperidol for use in the emergency department (ED) setting.

Summary

In 2001 the US Food and Drug Administration (FDA) mandated a boxed warning in the labeling of droperidol after reports of QT interval prolongation associated with droperidol use. Since that time, it has been difficult to access droperidol in the United States; as a result, many practicing clinicians lack experience in its clinical use. Multiple studies have been conducted to assess the clinical efficacy and safety of droperidol use in ED patients. Results consistently show the safety of droperidol and its clinical efficacy when used as an analgesic, antiemetic, and sedative. Now that droperidol is more widely available for use in the US market, pharmacists and prescribers need to reliably translate safety and efficacy data compiled since 2001 to help ensure appropriate and effective use of the medication.

Conclusion

Droperidol is an effective and safe option for the treatment of acute agitation, migraine, nausea, and pain for patients in the ED setting. Healthcare professionals can adopt droperidol for use in clinical practice, and they should become familiar with how to dose and monitor droperidol for safe and effective use.