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Li J, Zhu H, Wang Y, Chen J, He K, Wang S. Remifentanil is Superior to Propofol for Treating Emergence Agitation in Adults After General Anesthesia. Drug Des Devel Ther 2024; 18:341-350. [PMID: 38344258 PMCID: PMC10859049 DOI: 10.2147/dddt.s433155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 01/25/2024] [Indexed: 02/15/2024] Open
Abstract
Background Emergence agitation (EA) is one of the most common complications in clinical general anesthesia during recovery in adults. Remifentanil and propofol can reduce the incidence of EA, but with no randomized controlled trial to evaluate their effectiveness for treating EA. This study aims to compare the effectiveness of remifentanil and propofol for treating EA following general anesthesia. Patients and methods Among 152 randomized patients with a mean of 49.5 years, and 99 (65.1%) of them being male, 149 were divided into two groups for subsequent analysis. The remifentanil group (Group R, n = 74) received a 0.5μg kg-1 remifentanil infusion followed by a 0.05μg kg-1 min-1 infusion until 15 minutes, after the onset of agitation. The propofol group (Group P, n = 75) received a 1mg kg-1 propofol infusion once agitation occurred. Emergence agitation was assessed using the Riker Sedation Agitation Score, with a score of ≥5 defining emergence agitation. During the post-anesthesia care unit (PACU), the recurrence of emergence agitation, time to extubation, and discharge from PACU were evaluated. Results The incidence of reoccurring emergence agitation was lower in Group R (29.7%) compared with Group P (49.3%), with an odds ratio of 0.44 (95% CI 0.22-0.85; P=0.014). The time to extubation was shorter in Group R (mean 12min, range 8-15 min) compared with Group P (mean 17min, range 13-21 min) (P<0.001), as was the time discharge from the PACU (mean 30.5 min, range 25-40 min) vs Group P (mean 37.5 min, range 31-50 min) (P=0.001). Conclusion Treatment of emergence agitation in adults with remifentanil infusion is more effective than propofol, with a shorter time to extubation and discharge from PACU.
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Affiliation(s)
- Jun Li
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People’s Republic of China
| | - Hongrui Zhu
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People’s Republic of China
| | - Yu Wang
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Soochow, People’s Republic of China
| | - Jiaqi Chen
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People’s Republic of China
| | - Keqiang He
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People’s Republic of China
| | - Sheng Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People’s Republic of China
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Wolfe C, McCoin N. Management of the Agitated Patient. Emerg Med Clin North Am 2024; 42:13-29. [PMID: 37977745 DOI: 10.1016/j.emc.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
The acutely agitated patient should be managed in a step-wise fashion, beginning with non-coercive de-escalation strategies and moving on to pharmacologic interventions and physical restraints as necessary. Face-to-face examination, monitoring, and documentation by the physician are essential. The emergency physician should be familiar with multiple pharmaceutical options, tailored to the individual patient. Use of ketamine, benzodiazepines and antipsychotics should be considered. Patient autonomy, safety, and medical well-being are paramount.
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Affiliation(s)
- Carmen Wolfe
- Department of Emergency Medicine, Tristar Skyline Medical Center, 3443 Dickerson Pike, Suite 230, Nashville, TN 37207, USA.
| | - Nicole McCoin
- Department of Emergency Medicine, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA
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Sadlonova M, Beach SR, Funk MC, Rosen JH, Ramirez Gamero AF, Karlson RA, Huffman JC, Celano CM. Risk Stratification of QTc Prolongation in Critically Ill Patients Receiving Antipsychotics for the Management of Delirium Symptoms. J Intensive Care Med 2023:8850666231222470. [PMID: 38130132 DOI: 10.1177/08850666231222470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND Patients experiencing significant agitation or perceptual disturbances related to delirium in an intensive care setting may benefit from short-term treatment with an antipsychotic medication. Some antipsychotic medications may prolong the QTc interval, which increases the risk of potentially fatal ventricular arrhythmias. In this targeted review, we describe the evidence regarding the relationships between antipsychotic medications and QTc prolongation and practical methods for monitoring the QTc interval and mitigating arrhythmia risk. METHODS Searches of PubMed and Cochrane Library were performed to identify studies, published before February 2023, investigating the relationships between antipsychotic medications and QTc prolongation or arrhythmias. RESULTS Most antipsychotic medications commonly used for the management of delirium symptoms (eg, intravenous haloperidol, olanzapine, quetiapine) cause a moderate degree of QTc prolongation. Among other antipsychotics, those most likely to cause QTc prolongation are iloperidone and ziprasidone, while aripiprazole and lurasidone appear to have minimal risk for QTc prolongation. Genetic vulnerabilities, female sex, older age, pre-existing cardiovascular disease, electrolyte abnormalities, and non-psychiatric medications also increase the risk of QTc prolongation. For individuals at risk of QTc prolongation, it is essential to measure the QTc interval accurately and consistently and consider medication adjustments if needed. CONCLUSIONS Antipsychotic medications are one of many risk factors for QTc prolongation. When managing agitation related to delirium, it is imperative to assess an individual patient's risk for QTc prolongation and to choose a medication and monitoring strategy commensurate to the risks. In intensive care settings, we recommend regular ECG monitoring, using a linear regression formula to correct for heart rate. If substantial QTc prolongation (eg, QTc > 500 msec) is present, a change in pharmacologic treatment can be considered, though a particular medication may still be warranted if the risks of discontinuation (eg, extreme agitation, removal of invasive monitoring devices) outweigh the risks of arrhythmias. AIMS This review aims to summarize the current literature on relationships between antipsychotic medications and QTc prolongation and to make practical clinical recommendations towards the approach of antipsychotic medication use for the management of delirium-related agitation and perceptual disturbances in intensive care settings.
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Affiliation(s)
- Monika Sadlonova
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, Göttingen, Germany
- Department of Cardiovascular and Thoracic Surgery, University of Göttingen Medical Center, Göttingen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Margo C Funk
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Jordan H Rosen
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Andres F Ramirez Gamero
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Rebecca A Karlson
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jeff C Huffman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Christopher M Celano
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Allen PJ, Johanson KE, Reveles KR, Neff LA, Lock AE. Comparison of Droperidol and Midazolam Versus Haloperidol and Lorazepam for Acute Agitation Management in the Emergency Department. Ann Pharmacother 2023; 57:1367-1374. [PMID: 36999520 DOI: 10.1177/10600280231163192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Acute agitation accounts for up to 2.6% of visits to the emergency department (ED). To date, a standard of care for the management of acute agitation has not been established. Few studies have evaluated antipsychotic and benzodiazepine combinations. OBJECTIVE The purpose of this study was to evaluate effectiveness and safety of combination therapy for acute agitation with intramuscular (IM) droperidol and midazolam (D+M) compared with IM haloperidol and lorazepam (H+L) in patients in the ED. METHODS This was a single-center, retrospective medical record review of patients presenting to a large, academic ED with acute agitation from July 2020 through October 2021. The primary outcome was percentage of patients requiring additional agitation medication within 60 minutes of combination administration. Secondary outcomes included average time to repeat dose administration and average number of repeat doses required before ED discharge. RESULTS A total of 306 patients were included for analysis: 102 in the D+M group and 204 in the H+L group. Repeat dose within 60 minutes occurred in 7 (6.9%) and 28 (13.8%) patients in the D+M and H+L groups, respectively (P = 0.065). A total of 28.4% of D+M patients and 30.9% of H+L patients required any repeat dose during their ED visit. Time to repeat dose was 12 and 24 minutes in the D+M and H+L, respectively (P = 0.22). The adverse event rate was 2.9% in each group. CONCLUSION AND RELEVANCE IM D+M resulted in a lower rate of repeat doses of acute agitation medication compared with IM H+L, though this was not statistically significant. Both therapies were safe, and the adverse event rate was low.
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Affiliation(s)
- Patrick J Allen
- Department of Pharmacotherapy and Pharmacy Services, University Health, Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Kendra E Johanson
- Department of Pharmacotherapy and Pharmacy Services, University Health, Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Kelly R Reveles
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Luke A Neff
- Department of Pharmacotherapy and Pharmacy Services, University Health, Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Ashley E Lock
- Department of Pharmacotherapy and Pharmacy Services, University Health, Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Department of Emergency Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Tan JQ, Wu HL, Wang YC, Cata JP, Chen JT, Cherng YG, Tai YH. Antiemetic prophylaxis with droperidol in morphine-based intravenous patient-controlled analgesia: a propensity score matched cohort study. BMC Anesthesiol 2023; 23:351. [PMID: 37898746 PMCID: PMC10612161 DOI: 10.1186/s12871-023-02319-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/23/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND There are limited real-world data regarding the use of droperidol for antiemetic prophylaxis in intravenous patient-controlled analgesia (IV-PCA). This study aimed to evaluate the antiemetic benefits and sedation effects of droperidol in morphine-based IV-PCA. METHODS Patients who underwent major surgery and used morphine-based IV-PCA at a medical center from January 2020 to November 2022 were retrospectively analyzed. The primary outcome was the rate of any postoperative nausea and/or vomiting (PONV) within 72 h after surgery. Propensity score matching was used to match patients with and without the addition of droperidol to IV-PCA infusate in a 1:1 ratio. Multivariable conditional logistic regression models were used to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). RESULTS After matching, 1,104 subjects were included for analysis. The addition of droperidol to IV-PCA reduced the risk of PONV (aOR: 0.49, 95% CI: 0.35-0.67, p < 0.0001). The antiemetic effect of droperidol was significant within 36 h after surgery and attenuated thereafter. Droperidol was significantly associated with a lower risk of antiemetic uses (aOR: 0.58, 95% CI: 0.41-0.80, p = 0.0011). The rate of unintentional sedation was comparable between the patients with (9.1%) and without (7.8%; p = 0.4481) the addition of droperidol. Postoperative opioid consumption and numeric rating scale acute pain scores were similar between groups. CONCLUSIONS The addition of droperidol to IV-PCA reduced the risk of PONV without increasing opiate consumption or influencing the level of sedation. However, additional prophylactic therapies are needed to prevent late-onset PONV.
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Affiliation(s)
- Jia Qi Tan
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, 23561, New Taipei City, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, 11031, Taipei, Taiwan
| | - Hsiang-Ling Wu
- Department of Anesthesiology, Taipei Veterans General Hospital, 11217, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, 11221, Taipei, Taiwan
| | - Yi-Chien Wang
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, 23561, New Taipei City, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, 11031, Taipei, Taiwan
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 409, 77030, Houston, TX, USA
| | - Jui-Tai Chen
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, 23561, New Taipei City, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, 11031, Taipei, Taiwan
| | - Yih-Giun Cherng
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, 23561, New Taipei City, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, 11031, Taipei, Taiwan
| | - Ying-Hsuan Tai
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, 23561, New Taipei City, Taiwan.
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, 11031, Taipei, Taiwan.
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Bonfichi A, Ceresa IF, Piccioni A, Zanza C, Longhitano Y, Boudi Z, Esposito C, Savioli G. A Lethal Combination of Delirium and Overcrowding in the Emergency Department. J Clin Med 2023; 12:6587. [PMID: 37892725 PMCID: PMC10607343 DOI: 10.3390/jcm12206587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
Delirium is a common public health concern that significantly impacts older patients admitted to the Emergency Department (ED). This condition is linked to adverse outcomes such as reduced long-term functionality, higher mortality rates, extended hospital stays, and increased medical costs. The identification of risk factors is crucial for the early recognition and management of delirium in ED patients. Aging, cognitive decline, polypharmacy, and sensory impairment are some of the most common general risk factors described in the literature. Although validated delirium assessment tools already exist, they are not practical for the fast-paced ED environment because of their extended evaluation period or specialized training request. Moreover, clear guidance is needed to select the most suitable tool for detecting delirium, balancing between the accuracy and the swiftness required in an overcrowded, high-stress, and understaffed healthcare setting. This narrative review aims to analyze the updated literature on delirium risk factors in older ED patients and focuses on the methods for better screening, managing, and treating this condition in the ED.
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Affiliation(s)
- Alessandra Bonfichi
- Department of Internal Medicine, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
| | - Iride Francesca Ceresa
- Department of Emergency Medicine, Humanitas University-Research Hospital, 20089 Rozzano, Italy; (I.F.C.); (Y.L.)
| | - Andrea Piccioni
- Department of Emergency, Fondazione Policlinico Universitario A. Gemelli, IRCCS Fondazione Policlinico San Matteo, 00168 Roma, Italy;
| | - Christian Zanza
- Italian Society of Pre-Hospital Emergency Medicine (SIS-118), 74121 Taranto, Italy;
| | - Yaroslava Longhitano
- Department of Emergency Medicine, Humanitas University-Research Hospital, 20089 Rozzano, Italy; (I.F.C.); (Y.L.)
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15260, USA
| | - Zoubir Boudi
- Department of Emergency Medicine, Dr Sulaiman Alhabib Hospital, Dubai 2542, United Arab Emirates;
| | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri, University of Pavia, 27100 Pavia, Italy;
| | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
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Moura C, Vale N. The Role of Dopamine in Repurposing Drugs for Oncology. Biomedicines 2023; 11:1917. [PMID: 37509555 PMCID: PMC10377204 DOI: 10.3390/biomedicines11071917] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/04/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
Dopamine is a neurotransmitter that plays an important role within the brain by regulating a wide variety of cognitive and emotional processes. In cancer, its role is distinct and uncertain, but it is characterized by the interaction with its receptors that may be in the tumor cells; we have examples of different types of cancer with this characteristic, of which breast and colon cancer stand out. It is believed that dopamine and some of its receptors also influence other cellular processes such as cell proliferation, survival, migration, and invasion. The potential of these receptors has allowed the exploration of existing drugs, originally developed for non-oncological purposes, for the possible treatment of cancer. However, regarding the repurposing of drugs for cancer treatment, the role of dopamine is not so straightforward and needs to be clarified. For this reason, this review intends to present concepts associated with twelve drugs reused for oncology based on dopamine and its receptors. Some of them can behave as antagonists and inhibit tumor cell growth leading to cell death. Attention to this group of drugs may enhance the study of other pharmacological conditions such as signaling pathways related to cell proliferation and migration. Modulation of these pathways using drugs originally developed for other conditions may offer potential therapeutic opportunities in oncology. It is important to note that while the repurposing of oncology drugs based on dopamine signaling is promising, further studies are still needed to fully understand the mechanisms involved and determine the clinical efficacy and safety of these approaches.
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Affiliation(s)
- Catarina Moura
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- ICBAS-School of Medicine and Biomedical Sciences, University of Porto, Rua Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal
| | - Nuno Vale
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
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Orozco BS, Lee SC, Fuchs RT, Fushianes GD, Cole JB. QT prolongation, torsades des pointes, and cardiac arrest after 4 mg of IV ondansetron. Am J Emerg Med 2023; 68:214.e3-214.e6. [PMID: 37085406 DOI: 10.1016/j.ajem.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/01/2023] [Indexed: 04/08/2023] Open
Abstract
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.
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Affiliation(s)
- Benjamin S Orozco
- Minnesota Poison Control System, Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA; Department of Emergency Medicine, Gundersen Health System, La Crosse, WI, USA; Tomah Health, Tomah, WI, USA.
| | - Samantha C Lee
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA.
| | - Ryan T Fuchs
- Minnesota Poison Control System, Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA.
| | | | - Jon B Cole
- Minnesota Poison Control System, Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA.
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Krenz JR, Medeiros K, Lupez K. Retrospective evaluation of ketamine versus droperidol on time to restraint removal in agitated emergency department patients. Am J Emerg Med 2023; 69:23-27. [PMID: 37031618 DOI: 10.1016/j.ajem.2023.03.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
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.
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10
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Siegel RB, Motov SM, Marcolini EG. Droperidol Use in the Emergency Department: A Clinical Review. J Emerg Med 2023; 64:289-294. [PMID: 36925442 DOI: 10.1016/j.jemermed.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 11/21/2022] [Accepted: 12/13/2022] [Indexed: 03/17/2023]
Abstract
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.
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Affiliation(s)
- Rebecca B Siegel
- Department of Emergency Medicine, Brookdale University Hospital Medical Center, Brooklyn, New York
| | - Sergey M Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Evie G Marcolini
- Department of Emergency Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Department of Emergency Medicine, Brookdale University Hospital Medical Center, Brooklyn, New York.
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Curry A, Malas N, Mroczkowski M, Hong V, Nordstrom K, Terrell C. Updates in the Assessment and Management of Agitation. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:35-45. [PMID: 37205032 PMCID: PMC10172538 DOI: 10.1176/appi.focus.20220064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Agitated patients can be dangerous to themselves and others. In fact, severe medical complications and death can occur with severe agitation. Because of this, agitation is considered a medical and psychiatric emergency. Regardless of the treatment setting, identifying the agitated patient early is a necessary skill. The authors review relevant literature regarding the identification and management of agitation and summarize current recommendations for adults, as well as children and adolescents.
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Affiliation(s)
- Ashley Curry
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Nasuh Malas
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Megan Mroczkowski
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Victor Hong
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Kimberly Nordstrom
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Christina Terrell
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
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12
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Ramsden SC, Pergjika A, Janssen AC, Mudahar S, Fawcett A, Walkup JT, Hoffmann JA. A systematic review of the effectiveness and safety of droperidol for pediatric agitation in acute care settings. Acad Emerg Med 2022; 29:1466-1474. [PMID: 35490341 PMCID: PMC9622426 DOI: 10.1111/acem.14515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/14/2022] [Accepted: 04/27/2022] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
| | - Alba Pergjika
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Aron C. Janssen
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sukhraj Mudahar
- Department of Pharmacy, Children’s Hospital of Orange County, Orange, CA
| | - Andrea Fawcett
- Department of Clinical and Organizational Development, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL,Lurie Children’s Pediatric Research & Evidence Synthesis Center of Innovative Implementation Science & Engagement (PRECIISE): A JBI Affiliated Group, Chicago, IL
| | - John T. Walkup
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jennifer A. Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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Stern A, Munro A, King C, Knight A, Bruce E, Stacey J, Hammond S, Holland A. Patients treated for acute headache with intranasal droperidol spend less time in the emergency department: A retrospective observational study. Emerg Med Australas 2022; 34:818-821. [PMID: 35568501 DOI: 10.1111/1742-6723.14006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/27/2022] [Accepted: 04/10/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Headache is a common presenting complaint to the ED. Using time from the first provider to discharge as a surrogate for effectiveness, we aimed to determine if intranasal (IN) droperidol is as beneficial as usual treatment for acute headache in the ED. METHODS There were 1213 consecutive presentations of adults with acute headache over a 42-month period. Electronic records for each event were interrogated, 406 events met pre-determined exclusion criteria. Of the remaining 805 eligible patient events, 139 received IN droperidol, whereas 666 were given usual therapy. RESULTS There was a 20 min reduction of mean and median ED length of stay (LOS) for the group that got treated with IN droperidol. CONCLUSIONS IN droperidol reduced LOS in the ED. There are potential cost savings of this effective treatment via this novel route. A prospective multi-centre study of the use of IN droperidol for the treatment of acute headache in the ED is recommended.
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Affiliation(s)
- Ari Stern
- Nelson Hospital, Nelson, New Zealand
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14
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Rech MA, Griggs C, Lovett S, Motov S. Acute pain management in the Emergency Department: Use of multimodal and non-opioid analgesic treatment strategies. Am J Emerg Med 2022; 58:57-65. [DOI: 10.1016/j.ajem.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/05/2022] [Accepted: 05/14/2022] [Indexed: 12/01/2022] Open
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15
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Emergency medicine updates: Droperidol. Am J Emerg Med 2022; 53:180-184. [DOI: 10.1016/j.ajem.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/31/2021] [Accepted: 01/09/2022] [Indexed: 11/19/2022] Open
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Prospective real-time evaluation of the QTc interval variation after low-dose droperidol among emergency department patients. Am J Emerg Med 2022; 52:212-219. [PMID: 34959024 PMCID: PMC8761164 DOI: 10.1016/j.ajem.2021.12.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 02/03/2023] Open
Abstract
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.
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deSouza IS, Thode HC, Shrestha P, Allen R, Koos J, Singer AJ. Rapid tranquilization of the agitated patient in the emergency department: A systematic review and network meta-analysis. Am J Emerg Med 2021; 51:363-373. [PMID: 34823192 DOI: 10.1016/j.ajem.2021.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/29/2021] [Accepted: 11/04/2021] [Indexed: 10/19/2022] Open
Abstract
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.
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Affiliation(s)
- Ian S deSouza
- Department of Emergency Medicine, SUNY Downstate Health Sciences University and Kings County Hospital Center, Brooklyn, NY, USA.
| | - Henry C Thode
- Department of Emergency Medicine, Stony Brook University, NY, USA.
| | - Pragati Shrestha
- Department of Emergency Medicine, Stony Brook University, NY, USA.
| | - Robert Allen
- Department of Emergency Medicine, SUNY Downstate Health Sciences University and Kings County Hospital Center, Brooklyn, NY, USA.
| | - Jessica Koos
- Department of Emergency Medicine, Stony Brook University, NY, USA.
| | - Adam J Singer
- Department of Emergency Medicine, Stony Brook University, NY, USA.
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Cole JB, Stang JL, DeVries PA, Martel ML, Miner JR, Driver BE. A Prospective Study of Intramuscular Droperidol or Olanzapine for Acute Agitation in the Emergency Department: A Natural Experiment Owing to Drug Shortages. Ann Emerg Med 2021; 78:274-286. [PMID: 33846015 DOI: 10.1016/j.annemergmed.2021.01.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/23/2020] [Accepted: 01/04/2021] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Jon B Cole
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN.
| | - Jamie L Stang
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Paige A DeVries
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
| | - Marc L Martel
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
| | - James R Miner
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
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Kverno K, Mangano E. Psychiatric Emergencies and the Potential Role of Psychiatric-Mental Health Nurse Practitioners. J Psychosoc Nurs Ment Health Serv 2021; 59:7-12. [PMID: 33647157 DOI: 10.3928/02793695-20210212-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Emergency departments (EDs) are experiencing a worsening crisis of overcrowding, especially during the coronavirus pandemic. Persons experiencing psychiatric emergencies must be evaluated medically and screened for risks of harm to self or others before they can be cleared for transfer to inpatient units or discharged. Severe shortages of inpatient psychiatric beds can lead to hours or even days of costly boarding in the ED. The purpose of this article is to examine the potential role of psychiatric-mental health nurse practitioners in psychiatric ED care, from initial intake and medical clearance, screening for suicide risk, de-escalation, stabilization, and discharge. [Journal of Psychosocial Nursing and Mental Health Services, 59(3), 7-12.].
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Eagles D, Khoujah D. Rapid Fire: Acute Brain Failure in Older Emergency Department Patients. Emerg Med Clin North Am 2021; 39:287-305. [PMID: 33863460 DOI: 10.1016/j.emc.2020.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Delirium is common in older emergency department (ED) patients. Although associated with significant morbidity and mortality, it often goes unrecognized. A consistent approach to evaluation of mental status, including use of validated tools, is key to diagnosing delirium. Identification of the precipitating event requires thorough evaluation, including detailed history, medication reconciliation, physical examination, and medical work-up, for causes of delirium. Management is aimed at identifying and treating the underlying cause. Meaningful improvements in delirium care can be achieved when prevention, identification, and management of older delirious ED patients is integrated by physicians and corresponding frameworks implemented at the health system level.
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Affiliation(s)
- Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Danya Khoujah
- Emergency Medicine, MedStar Franklin Square Medical Center, 9000 Franklin Square Dr, Baltimore, MD 21237, USA; Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA. https://twitter.com/DanyaKhoujah
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21
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Kim HK, Leonard JB, Corwell BN, Connors NJ. Safety and efficacy of pharmacologic agents used for rapid tranquilization of emergency department patients with acute agitation or excited delirium. Expert Opin Drug Saf 2021; 20:123-138. [PMID: 33327811 DOI: 10.1080/14740338.2021.1865911] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Management of patients with acute agitation or aggressive behavior can pose a significant challenge to health-care providers in emergency departments. Areas covered: This article provides a comprehensive review of the pharmacologic properties, efficacy, and safety profiles of select intramuscular (IM) sedative agents (i.e., antipsychotics, benzodiazepines, and ketamine) for rapid tranquilization. Expert opinion: Using antipsychotics and benzodiazepines - whether a single agent or combined - will have similar efficacy in producing sedation. But there are differences in the time to sedation depending on which agent is used. Based upon the available studies, droperidol (5-10 mg IM) and midazolam (5-10 mg IM) have the fastest onset of sedation when either is used as a single agent. When combination therapy is used, using midazolam with an antipsychotic agent, instead of lorazepam, may result in faster sedative effect. QT prolongation and torsades de pointes are uncommon adverse drug effects of antipsychotic administration. Ketamine is often reserved as a second-line agent when antipsychotics and benzodiazepines fail to produce the desired tranquilization. However, ketamine (5 mg/kg IM) is more frequently associated with airway compromise requiring endotracheal intubation. A low-dose of ketamine (2 mg/kg IM) may reduce the risk of airway compromise while providing adequate sedation.
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Affiliation(s)
- Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - James B Leonard
- Maryland Poison Center, University of Maryland School of Pharmacy , Baltimore, MD, USA
| | - Brian N Corwell
- Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - Nicholas J Connors
- Department of Emergency Medicine, HCA Healthcare Trident Medical Center , Charleston, SC, USA
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Soghomonyan S, Stoicea N, Ackermann W, Bhandary SP. PONV management in patients with QTc prolongation on the EKG. Front Pharmacol 2021; 11:565704. [PMID: 33551794 PMCID: PMC7861054 DOI: 10.3389/fphar.2020.565704] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 11/25/2020] [Indexed: 11/15/2022] Open
Abstract
Postoperative nausea and vomiting (PONV) is a commonly encountered problem in surgical practice. It delays discharge from the post-anesthesia care unit, requires additional resources to treat, and may increase the morbidity in some patients. Many effective drugs are available to treat or prevent PONV, however many of these drugs have the potential to prolong the QTc on the electrocardiogram (EKG) and increase the risk of serious ventricular arrhythmias, in particular, torsade de pointes. The QTc prolongation may be a manifestation of a genetic mutation resulting in abnormal myocyte repolarization or it may be acquired and associated with the use of various medications, electrolyte disorders, and physiological conditions. Patients predisposed to QTc prolongation presenting for surgery constitute a challenging group, since many drugs commonly used for PONV management will put them at risk for perioperative serious arrhythmias. This is an important topic, and our mini-review is an attempt to highlight the problem, summarize the existing experience, and generate recommendations for safe management of PONV for patients, who are at increased risk of QTc prolongation and arrhythmias. Focused prospective studies will help to find definitive answers to the discussed problems and challenges and develop specific guidelines for clinical application.
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Affiliation(s)
- S Soghomonyan
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - N Stoicea
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - W Ackermann
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - S P Bhandary
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Muir-Cochrane E, Oster C, Grimmer K. Interrogating systematic review recommendations for effective chemical restraint. J Eval Clin Pract 2020; 26:1768-1779. [PMID: 32059065 DOI: 10.1111/jep.13363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 01/12/2020] [Accepted: 01/16/2020] [Indexed: 02/01/2023]
Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Candice Oster
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Karen Grimmer
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
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Muir-Cochrane E, Grimmer K, Gerace A, Bastiampillai T, Oster C. Safety and effectiveness of olanzapine and droperidol for chemical restraint for non-consenting adults: a systematic review and meta-analysis. Australas Emerg Care 2020; 24:96-111. [PMID: 33046432 DOI: 10.1016/j.auec.2020.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/24/2020] [Accepted: 08/27/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chemical restraint (CR) is emergency drug management for acute behavioural disturbances in people with mental illness, provided with the aim of rapid calming and de-escalating potentially dangerous situations. AIMS To describe a systematic review of Randomised Controlled Trials (RCTs) reporting on short-term safety and effectiveness of drugs used for CR, administered to non-consenting adults with mental health conditions, who require emergency management of acute behavioural disturbances. A meta-analysis was conducted of those RCTs with comparable interventions, outcome measures and measurement timeframes. METHOD Academic databases were searched for RCTs published between 1 January 1996 and 20th April 2020. Relevant RCTs were critically appraised using the 13-item JBI checklist. All RCTs were described, and step-wise filters were applied to identify studies suitable for meta-analysis. For these, forest and funnel plots were constructed, and Q and I2 statistics guided interpretation of pooled findings, tested using MedCalc Version 19.1. RESULTS Of 23 relevant RCTs, 18 (78.2% total) had excellent methodological quality scores (at least 90%). Eight RCTs were potentially relevant for meta-analysis (six of excellent quality), reporting 20 drug arms in total. Adverse events for 6-36% patients were reported in all 20 drug arms. Four drug arms from two homogenous studies of N = 697 people were meta-analysed. These RCTs tested two antipsychotic drugs (droperidol, olanzapine) delivered intravenously in either 5 mgs or 10 mg doses, with outcomes of time to calm, percentage calm within five or 10 min, and adverse events. There were no significant differences between drug arms for either measure of calm. However, 5 mg olanzapine incurred significantly lower risk of adverse events than 10 mg olanzapine (OR 0.4 (95%CI 0.2-0.8)), although no dose differences were found for droperidol. CONCLUSION 5 mg intravenous olanzapine is recommended for quick, safe emergency management of people with acute behavioural disturbances associated with mental illness.
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Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia.
| | - Karen Grimmer
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia
| | - Adam Gerace
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia; School of Health, Medical and Applied Sciences, Central Queensland University, 44 Greenhill Rd, Wayville, South Australia, Australia
| | - Tarun Bastiampillai
- College of Medicine & Public Health, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia
| | - Candice Oster
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia; College of Medicine & Public Health, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia
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25
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Kramer KJ. The Surprising Re-emergence of Droperidol. Anesth Prog 2020; 67:125-126. [PMID: 32992339 DOI: 10.2344/anpr-67-03-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Mattson A, Friend K, Brown CS, Cabrera D. Reintegrating droperidol into emergency medicine practice. Am J Health Syst Pharm 2020; 77:1838-1845. [DOI: 10.1093/ajhp/zxaa271] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Abstract
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.
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Affiliation(s)
| | | | | | - Daniel Cabrera
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
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Xiong GL, Pinkhasov A, Mangal JP, Huang H, Rado J, Gagliardi J, Demoss D, Karol D, Suo S, Lang M, Stern M, Spearman EV, Onate J, Annamalai A, Saliba Z, Heinrich T, Fiedorowicz JG. QTc monitoring in adults with medical and psychiatric comorbidities: Expert consensus from the Association of Medicine and Psychiatry. J Psychosom Res 2020; 135:110138. [PMID: 32442893 DOI: 10.1016/j.jpsychores.2020.110138] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/30/2020] [Accepted: 05/07/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Several psychiatric medications have the potential to prolong the QTc interval and subsequently increase the risk for ventricular arrhythmias such as torsades de pointes (TdP). There is limited guidance for clinicians to balance the risks and benefits of treatments. METHODS After a review of the existing literature, clinical-educators from the Association of Medicine and Psychiatry developed expert consensus guidelines for ECG monitoring of the QTc interval for patients with medical and psychiatric comorbidities who are prescribed medications with the potential to prolong the QTc interval. A risk score was developed based on risk factors for QTc prolongation to guide clinical decision-making. RESULTS A baseline ECG may not be necessary for individuals at low risk for arrythmia. Those individuals with a risk score of two or more should have an ECG prior to the start of a potentially QTc-prolonging medication or be started on a lower risk agent. Antipsychotics are not equivalent in causing QTc prolongation. A consensus-based algorithm is presented for the management of those identified at high (QTc >500 msec), intermediate (males with QTc 450-499 msec or females with QTc > 470-499 msec), or low risk. CONCLUSIONS The proposed algorithm can help clinicians in determining whether ECG monitoring should be considered for a given patient. These guidelines preserve a role for clinical judgment in selection of treatments that balance the risks and benefits, which may be particularly relevant for complex patients with medical and psychiatric comorbidities. Additional studies are needed to determine whether baseline and serial ECG monitoring reduces mortality.
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Affiliation(s)
- Glen L Xiong
- Department of Psychiatry and Behavioral Sciences, University of California at Davis School of Medicine, Sacramento, CA, United States of America.
| | - Aaron Pinkhasov
- Department of Behavioral Health, NYU Winthrop Hospital, Mineola, NY, United States of America
| | - Jed P Mangal
- Department of Behavioral Health, Martin Army Community Hospital, Ft Benning, GA, United States of America
| | - Heather Huang
- Departments of Psychiatry and Internal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
| | - Jeffrey Rado
- Psychiatry and General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Jane Gagliardi
- Departments of Psychiatry and Behavioral Sciences, and Internal Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Dustin Demoss
- Department of Psychiatry, University of North Texas Health Science Center, United States of America
| | - David Karol
- Department of Psychiatry and Behavioral Neuroscience, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | - Shannon Suo
- Department of Psychiatry and Behavioral Sciences, University of California at Davis School of Medicine, Sacramento, CA, United States of America
| | - Michael Lang
- Departments of Psychiatry and Internal Medicine, East Carolina University, Greenville, NC, United States of America
| | - Marsha Stern
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
| | - E Vanessa Spearman
- Departments of Internal Medicine and Psychiatry, Medical College of Georgia at Augusta University Medical Center, Augusta, GA, United States of America
| | - John Onate
- Department of Psychiatry and Behavioral Sciences, University of California at Davis School of Medicine, Sacramento, CA, United States of America
| | - Aniyizhai Annamalai
- Departments of Psychiatry and Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Zeina Saliba
- Department of Psychiatry & Behavioral Sciences and Department of Emergency Medicine, The George Washington University, Washington, D.C, Department of Obstetrics & Gynecology, Virginia Commonwealth University, Richmond, VA, United States of America
| | - Thomas Heinrich
- Departments of Psychiatry and Behavioral Medicine, Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Jess G Fiedorowicz
- Departments of Psychiatry, Epidemiology, and Internal Medicine, University of Iowa, Iowa City, IA, United States of America
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Cole JB, Lee SC, Martel ML, Smith SW, Biros MH, Miner JR. The Incidence of QT Prolongation and Torsades des Pointes in Patients Receiving Droperidol in an Urban Emergency Department. West J Emerg Med 2020; 21:728-736. [PMID: 32726229 PMCID: PMC7390553 DOI: 10.5811/westjem.2020.4.47036] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/13/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Droperidol carries a boxed warning from the United States Food and Drug Administration for QT prolongation and torsades des pointes (TdP). After a six-year hiatus, droperidol again became widely available in the US in early 2019. With its return, clinicians must again make decisions regarding the boxed warning. Thus, the objective of this study was to report the incidence of QT prolongation or TdP in patients receiving droperidol in the ED. METHODS Patients receiving droperidol at an urban Level I trauma center from 1997-2001 were identified via electronic health record query. All patients were reviewed for cardiac arrest. We reviewed electrocardiogram (ECG) data for both critically-ill and noncritical patients and recorded Bazett's corrected QT intervals (QTc). ECGs from critically-ill patients undergoing resuscitation were further risk-stratified using the QT nomogram. RESULTS Of noncritical patients, 15,374 received 18,020 doses of droperidol; 2,431 had an ECG. In patients with ECGs before and after droperidol, the mean QTc was 424.3 milliseconds (ms) (95% confidence interval [CI], 419.7-428.9) before and 427.6 ms (95% CI, 424.3-430.9), after droperidol (n = 170). Regarding critically-ill patients, 1,172 received droperidol and 396 had an ECG. In the critically-ill group with ECGs before and after droperidol mean QTc was 435.7 ms (95% CI, 426.7-444.7) before and 435.8 ms (95% CI, 427.5-444.1) after droperidol (n = 114). Of 337 ECGs suitable for plotting on the QT nomogram, 13 (3.8%) were above the "at-risk" line; 3/136 (2.2%; 95% CI, 0.05-6.3%) in the before group, and 10/202 (4.9%; 95% CI, 2.4%-8.9%) in the after group. A single case of TdP occurred in a patient with multiple risk factors that did not reoccur after a droperidol rechallenge. Thus, the incidence of TdP was 1/16,546 (0.006%; 95% CI, 0.00015 - 0.03367%). CONCLUSION We found the incidence of QTc prolongation and TdP in ED patients receiving droperidol to be extremely rare. Our data suggest the FDA "black box warning" is overstated, and that close ECG monitoring is useful only in high-risk patients.
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Affiliation(s)
- Jon B. Cole
- University of Minnesota Medical School, Department of Emergency Medicine, Minneapolis, Minnesota
- Minnesota Poison Control System, Minneapolis, Minnesota
- Hennepin Healthcare, Department of Emergency Medicine, Minneapolis, Minnesota
| | | | - Marc L. Martel
- University of Minnesota Medical School, Department of Emergency Medicine, Minneapolis, Minnesota
- Hennepin Healthcare, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Stephen W. Smith
- University of Minnesota Medical School, Department of Emergency Medicine, Minneapolis, Minnesota
- Hennepin Healthcare, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Michelle H. Biros
- University of Minnesota Medical School, Department of Emergency Medicine, Minneapolis, Minnesota
| | - James R. Miner
- University of Minnesota Medical School, Department of Emergency Medicine, Minneapolis, Minnesota
- Hennepin Healthcare, Department of Emergency Medicine, Minneapolis, Minnesota
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Gaw CM, Cabrera D, Bellolio F, Mattson AE, Lohse CM, Jeffery MM. Effectiveness and safety of droperidol in a United States emergency department. Am J Emerg Med 2020; 38:1310-1314. [DOI: 10.1016/j.ajem.2019.09.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/12/2019] [Accepted: 09/19/2019] [Indexed: 01/21/2023] Open
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Muir-Cochrane E, Oster C, Grimmer K. International research into 22 years of use of chemical restraint: An evidence overview. J Eval Clin Pract 2020; 26:927-956. [PMID: 31318109 DOI: 10.1111/jep.13232] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice. AIMS To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995. METHODS This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures. RESULTS This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%). DISCUSSION A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.
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Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing and Health Sciences, Flinders University, South Australia, Australia, 5042
| | - Candice Oster
- On-Line Education and Development, Flinders Human Behaviour and Health Research Unit (FHBHRU), College of Medicine and Public Health, Flinders University, South Australia, Australia, 5042
| | - Karen Grimmer
- College of Nursing and Health Sciences, Flinders University, South Australia, Australia, 5042.,Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Lu D, Wang Y, Zhao T, Liu B, Ye L, Zhao L, Zhao B, Li M, Ma L, Li Z, Niu J, Lv W, Zhang Y, Zheng T, Xue Y, Chen L, Chen L, Sun X, Gao G, Chen B, He S. Successful implementation of an enhanced recovery after surgery (ERAS) protocol reduces nausea and vomiting after infratentorial craniotomy for tumour resection: a randomized controlled trial. BMC Neurol 2020; 20:150. [PMID: 32321451 PMCID: PMC7175510 DOI: 10.1186/s12883-020-01699-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 03/26/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Infratentorial craniotomy patients have a high incidence of postoperative nausea and vomiting (PONV). Enhanced Recovery After Surgery (ERAS) protocols have been shown in multiple surgical disciplines to improve outcomes, including reduced PONV. However, very few studies have described the application of ERAS to infratentorial craniotomy. The aim of this study was to examine whether our ERAS protocol for infratentorial craniotomy could improve PONV. METHODS We implemented an evidence-based, multimodal ERAS protocol for patients undergoing infratentorial craniotomy. A total of 105 patients who underwent infratentorial craniotomy were randomized into either the ERAS group (n = 50) or the control group (n = 55). Primary outcomes were the incidence of vomiting, nausea score, and use of rescue antiemetic during the first 72 h after surgery. Secondary outcomes included postoperative anxiety level, sleep quality, and complications. RESULTS Over the entire 72 h post-craniotomy observation period, the cumulative incidence of vomiting was significantly lower in the ERAS group than in the control group. Meanwhile, the incidence of vomiting was significantly lower in the ERAS group on postoperative days (PODs) 2 and 3. Notably, the proportion of patients with mild nausea (VAS 0-4) was higher in the ERAS group as compared to the control group on PODs 2 or 3. Additionally, the postoperative anxiety level and quality of sleep were significantly better in the ERAS group. CONCLUSION Successful implementation of our ERAS protocol in infratentorial craniotomy patients could attenuate postoperative anxiety, improve sleep quality, and reduce the incidence of PONV, without increasing the rate of postoperative complications. TRIAL REGISTRATION ChiCTR-INR-16009662, 27 Oct 2016, Clinical study on the development and efficacy evaluation of Enhanced Recovery After Surgery (ERAS) in Neurosurgery.
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Affiliation(s)
- Dan Lu
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, China
| | - Yuan Wang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Tianzhi Zhao
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Bolin Liu
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, China
| | - Lin Ye
- Department of Nutrition, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Lanfu Zhao
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Binfang Zhao
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Mingjuan Li
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Lin Ma
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Zhengmin Li
- Department of Anesthesiology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Jiangtao Niu
- Department of Anesthesiology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Wenhai Lv
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yufu Zhang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Tao Zheng
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, China
| | - Yafei Xue
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Lei Chen
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, China
| | - Long Chen
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Xude Sun
- Department of Anesthesiology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Guodong Gao
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, China.,Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Bo Chen
- Department of Neurosurgery, Shaanxi Provincial People's Hospital, Xi'an, China.
| | - Shiming He
- Department of Neurosurgery, Xi'an International Medical Center, Xi'an, China. .,Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China.
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Page CB, Parker LE, Rashford SJ, Kulawickrama S, Isoardi KZ, Isbister GK. Prospective study of the safety and effectiveness of droperidol in elderly patients for pre-hospital acute behavioural disturbance. Emerg Med Australas 2020; 32:731-736. [PMID: 32216048 DOI: 10.1111/1742-6723.13496] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/06/2020] [Accepted: 02/19/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Acute behavioural disturbance in the elderly (≥65 years) is a significant issue for emergency medical services with increasing prevalence of dementia and aging populations. We investigated the pre-hospital safety and effectiveness of droperidol in the elderly with acute behavioural disturbance. METHODS This was a pre-hospital prospective observational 1-year study of elderly patients with acute behavioural disturbance. The primary outcome was proportion of adverse events (AEs) (airway intervention, oxygen saturation <90% and/or respiratory rate <12/min, systolic blood pressure <90 mmHg, sedation assessment tool score of -3 and dystonic reactions). Secondary outcomes included time to sedation, additional sedation, proportion with successful sedation. RESULTS There were 149 patients (males 78 [52%], median age 78 years; 65-101 years) presenting on 162 occasions. Dementia was the commonest cause (107/164 [65%]) of acute behavioural disturbance. There were six AEs in five patients (5/162 [3%]; 95% confidence interval 1-7). Three had hypotension, one with associated hypoxia (80%); and two had respiratory AEs (respiratory rate, 10/min [no hypoxia] and hypoxia [88%] which required oxygen). Median time to sedation was 19 min (interquartile range 12-29 min). Additional sedation was given in 2/162 patients during ambulance transfer and 16/162 within an hour of hospital arrival; 24/162 (15%) failed to sedate in the ambulance; 16 subsequently settled in ED and 8/24 received additional sedation. Of 162, 123 (76%) patients successfully sedated, without AEs or additional sedation. Of 162, 114 (70%) patients received 5 mg, 46 (29%) received two doses of 5 mg and two patients (1%) received three doses. CONCLUSIONS Droperidol appeared to be safe and effective for pre-hospital sedation of acute behavioural disturbance in elderly patients.
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Affiliation(s)
- Colin B Page
- Clinical Toxicology Research Group, The University of Newcastle, Newcastle, New South Wales, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Clincial Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | | | - Sanjeewa Kulawickrama
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Faculty of Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Katherine Z Isoardi
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Clincial Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, The University of Newcastle, Newcastle, New South Wales, Australia.,Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
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Page CB, Parker LE, Rashford SJ, Isoardi KZ, Isbister GK. A Prospective Study of the Safety and Effectiveness of Droperidol in Children for Prehospital Acute Behavioral Disturbance. PREHOSP EMERG CARE 2018; 23:519-526. [PMID: 30380965 DOI: 10.1080/10903127.2018.1542473] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Study objective: Although uncommon, children (<16 years) with acute behavioral disturbance are a significant issue for emergency medical service providers. In this study, we aimed to investigate the safety and effectiveness of droperidol in children with prehospital acute behavioral disturbance. Methods: This was a prospective observational study over 1 year investigating the use of droperidol (0.1-0.2 mg/kg) for children (< 16 years) with acute behavioral disturbance. Inclusion criteria for acute behavioral disturbance were defined by a sedation assessment tool score of ≥2 determined by the attending paramedic. The primary outcome was the proportion of adverse effects (need for airway intervention, oxygen saturation <90% and/or respiratory rate <12, systolic blood pressure <90 mmHg, sedation assessment tool score of -3 and dystonic reactions). Secondary outcomes included time to sedation (sedation assessment tool score decreased by 2 or more, or a score of zero), requirement for additional sedation, failure to sedate and proportion of sedation success defined as the number of patients successfully sedated who did not suffer any adverse events or receive additional sedation. Results: There were 96 patients (males 51 [53%], median age 14 years [range 7-15 years]) who presented on 102 occasions over the one year study period. Self-harm and/or harm to others was the commonest (74/105 [70%]) cause of acute behavioral disturbance followed by alcohol (16/105 [15%]). There were 9 adverse events in 8 patients (8/102 [8%]; 95% confidence intervals [CI]: 3-13%) Five patients had hypotension, all asymptomatic and only one required treatment; 2 dystonic reactions managed with benztropine and one patient with respiratory depression. Median time to sedation was 14 min (interquartile range (IQR): 10-20 min; range: 3-85 min). There was no requirement for prehospital additional sedation (0/102 [0%]; 95% CI: 0-4%) and additional sedation in the first hour of arrival to hospital was required by 4 patients (4/102 [4%]; 95% CI: 1-10%). Overall successful sedation was achieved in 89 (87%) patients. Conclusions: The use of droperidol in children for acute behavioral disturbance in the prehospital setting is both safe and effective.
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Lai PC, Huang YT. Evidence-based review and appraisal of the use of droperidol in the emergency department. Tzu Chi Med J 2018; 30:1-4. [PMID: 29643708 PMCID: PMC5883829 DOI: 10.4103/tcmj.tcmj_195_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Droperidol is a short-acting, potent dopamine D2 antagonist that can pass through the blood–brain barrier. A black box warning was issued for droperidol by the United States Food and Drug Administration in 2001 because of a risk of development of torsades de pointes induced by QT prolongation. Many experts feel that the incidence of arrhythmia is overestimated, and low-dose droperidol is almost always used by anesthesiologists for postoperative nausea and vomiting. In this review, we used evidence-based analysis to appraise high-quality studies with a low risk of bias published after 2001 on the use of droperidol in the emergency department (ED). Droperidol appears not only efficacious but also safe to treat patients with nausea/vomiting, acute psychosis, and migraine in the ED. For these conditions, droperidol may be an option for shared decision-making.
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Affiliation(s)
- Pei-Chun Lai
- Department of Pediatrics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yen-Ta Huang
- Division of Experimental Surgery, Department of Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Foundation, Hualien, Taiwan.,Department of Pharmacology, Tzu Chi University, Hualien, Taiwan
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Pourmand A, Mazer-Amirshahi M, Chistov S, Sabha Y, Vukomanovic D, Almulhim M. Emergency department approach to QTc prolongation. Am J Emerg Med 2017; 35:1928-1933. [PMID: 28855066 DOI: 10.1016/j.ajem.2017.08.044] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 08/13/2017] [Accepted: 08/19/2017] [Indexed: 01/08/2023] Open
Abstract
QTc prolongation has been associated with increased risk of developing ventricular tachydysrhythmias, particularly Torsades de Pointes (TdP). QTc prolongation is influenced by many factors including congenital causes, heart rate, metabolic imbalances, and pharmacotherapy. Several commonly used medications in the emergency department (ED), such as antipsychotics and antiemetics, are known to prolong the QT interval. In addition, ED patients may present with conditions that may predispose them to QTc prolongation, such as drug overdose or hypokalemia, which can further complicate management. ED providers should not only be aware of which medications have these effects, but must also thoroughly investigate any pertinent patient history that may contribute to QTc prolongation. This review discusses commonly encountered medications that are associated with QTc prolongation, the mechanisms by which they prolong the QTc interval, and other factors that may influence ED medication administration and management.
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Affiliation(s)
- Ali Pourmand
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC; Georgetown University School of Medicine, Washington, DC, United States
| | - Sonya Chistov
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Youssef Sabha
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Damir Vukomanovic
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Mohammed Almulhim
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
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Yap CYL, Taylor DM, Knott JC, Taylor SE, Phillips GA, Karro J, Chan EW, Kong DCM, Castle DJ. Intravenous midazolam-droperidol combination, droperidol or olanzapine monotherapy for methamphetamine-related acute agitation: subgroup analysis of a randomized controlled trial. Addiction 2017; 112:1262-1269. [PMID: 28160494 DOI: 10.1111/add.13780] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 12/19/2016] [Accepted: 01/26/2017] [Indexed: 01/10/2023]
Abstract
AIM To examine the efficacy and safety of (1) midazolam-droperidol versus droperidol and (2) midazolam-droperidol versus olanzapine for methamphetamine-related acute agitation. DESIGN AND SETTING A multi-centre, randomized, double-blind, controlled, clinical trial was conducted in two Australian emergency departments, between October 2014 and September 2015. PARTICIPANTS Three hundred and sixty-one patients, aged 18-65 years, requiring intravenous medication sedation for acute agitation, were enrolled into this study. We report the results of a subgroup of 92 methamphetamine-affected patients. INTERVENTION AND COMPARATOR Patients were assigned randomly to receive either an intravenous bolus of midazolam 5 mg-droperidol 5 mg combined, droperidol 10 mg or olanzapine 10 mg. Two additional doses were administered, if required: midazolam 5 mg, droperidol 5 mg or olanzapine 5 mg, respectively. MEASUREMENTS The primary outcome was the proportion of patients sedated adequately at 10 minutes. Odds ratios with 95% confidence intervals (ORs, 95% CI) were estimated. FINDINGS The baseline characteristics of patients in the three groups were similar. At 10 minutes, significantly more patients in the midazolam-droperidol group [29 of 34 (85.3%)] were sedated adequately compared with the droperidol group [14 of 30 (46.7%), OR = 6.63, 95% CI = 2.02-21.78] or with the olanzapine group [14 of 28 (50.0%), OR 5.80, 95% CI = 1.74-19.33]. The number of patients who experienced an adverse event (AE) in the midazolam-droperidol, droperidol and olanzapine groups was seven of 34, two of 30 and six of 28, respectively. The most common AE was oxygen desaturation. CONCLUSION A midazolam-droperidol combination appears to provide more rapid sedation of patients with methamphetamine-related acute agitation than droperidol or olanzapine alone.
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Affiliation(s)
- Celene Y L Yap
- Centre for Medicine Use and Safety, Monash University, Parkville, Australia
| | | | - Jonathan C Knott
- Emergency Department, Royal Melbourne Hospital, Parkville, Australia
| | | | | | - Jonathan Karro
- Emergency Department, St Vincent's Hospital, Fitzroy, Australia
| | - Esther W Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong
| | - David C M Kong
- Centre for Medicine Use and Safety, Monash University, Parkville, Australia.,Pharmacy Department, Ballarat Health Services, Ballarat, Central, Australia
| | - David J Castle
- St Vincent's Hospital and The University of Melbourne, Fitzroy, Australia
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37
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Antiemetic Use in the Emergency Department. Adv Emerg Nurs J 2017; 39:97-105. [PMID: 28463865 DOI: 10.1097/tme.0000000000000141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Nausea and vomiting are 2 of the most common complaints of patients presenting to the emergency department (ED). In addition, antiemetics are the most commonly prescribed medications in the ED behind analgesics. Treating these conditions can be complex, especially as one considers that nausea and/or vomiting could be the primary presenting illness or simply a symptom of a more complex etiology. Although there is a wide variety of pharmacotherapeutic options in the armamentarium to treat these conditions, very few consensus recommendations exist to help guide the use of antiemetic agents in the ED, leading to wide variability in medication use. Contributing to these variations in practice is the extended spectrum of etiologies and potential physiological factors that contribute to the development of nausea or vomiting. A thorough understanding of the pharmacology and administration of these agents can help practitioners devise tailored antiemetic regimens based upon the underlying etiology.
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38
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Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A Randomized Clinical Trial. Ann Emerg Med 2017; 69:318-326.e1. [DOI: 10.1016/j.annemergmed.2016.07.033] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/25/2016] [Accepted: 07/27/2016] [Indexed: 11/18/2022]
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39
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Zhang H, Huang D, Wang KH, Li J, Su Y, Hu Y. Synthesis of Benzimidazolones via One-Pot Reaction of Hydroxylamines, Aldehydes, and Trimethylsilyl Cyanide Promoted by Diacetoxyiodobenzene. J Org Chem 2017; 82:1600-1609. [DOI: 10.1021/acs.joc.6b02781] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Huaiyuan Zhang
- College
of Chemistry and Chemical Engineering, Northwest Normal University, 967 Anning East Road, Lanzhou 730070, P. R. China
| | - Danfeng Huang
- College
of Chemistry and Chemical Engineering, Northwest Normal University, 967 Anning East Road, Lanzhou 730070, P. R. China
| | - Ke-Hu Wang
- College
of Chemistry and Chemical Engineering, Northwest Normal University, 967 Anning East Road, Lanzhou 730070, P. R. China
| | - Jun Li
- College
of Chemistry and Chemical Engineering, Northwest Normal University, 967 Anning East Road, Lanzhou 730070, P. R. China
| | - Yingpeng Su
- College
of Chemistry and Chemical Engineering, Northwest Normal University, 967 Anning East Road, Lanzhou 730070, P. R. China
| | - Yulai Hu
- College
of Chemistry and Chemical Engineering, Northwest Normal University, 967 Anning East Road, Lanzhou 730070, P. R. China
- State
Key Laboratory of Applied Organic Chemistry, Lanzhou University, Lanzhou 730000, P. R. China
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40
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Carubia B, Becker A, Levine BH. Child Psychiatric Emergencies: Updates on Trends, Clinical Care, and Practice Challenges. Curr Psychiatry Rep 2016; 18:41. [PMID: 26932516 DOI: 10.1007/s11920-016-0670-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Over the past 15 years, the number of pediatric patients presenting to the emergency room in psychiatric crisis has nearly doubled. Suicidality and aggression are among the most common presenting problems, making it important for providers to have up-to-date knowledge about the assessment and management of these frequently encountered clinical issues. Psychometrically sound suicide risk assessment tools are available for use in the emergency room setting, which can be administered efficiently with minimal provider training. Rates of off-label medication use in the pediatric population continue to increase and are often used in the management of acute agitation in the pediatric population. The current literature will be reviewed and summarized for application in emergent treatment settings. Overall, evidence to inform best practice is limited, leading to opportunities for innovation in health care delivery, the development of new research aims, and discussion of challenging clinical dilemmas.
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Affiliation(s)
- Beau Carubia
- Department of Psychiatry, University of Colorado, Aurora, CO, USA. .,B. Harrison Levine, MD, Inc., Denver, CO, USA.
| | - Amy Becker
- Department of Psychiatry, University of Colorado, Aurora, CO, USA.,Psychiatric Emergency Service, Children's Hospital Colorado, Aurora, CO, USA
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41
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Newman DH. Training the Mind, and the Food and Drug Administration, on Droperidol. Ann Emerg Med 2015; 66:243-5. [PMID: 26116221 DOI: 10.1016/j.annemergmed.2015.05.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Indexed: 10/23/2022]
Affiliation(s)
- David H Newman
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
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