Effect of low-dose propofol combined with dexamethasone on the prevention of postoperative nausea and vomiting in gynaecological day surgery under remimazolam-based general anesthesia

BACKGROUND

To observe the effect of low-dose propofol combined with dexamethasone on the prevention of postoperative nausea and vomiting (PONV) in gynaecological day surgery under remimazolam-based general anesthesia.

METHODS

A total of 120 patients, aged from 18 to 65 years old, American Society of Anesthesiologists grade I or II, were scheduled to undergo hysteroscopy under total intravenous anesthesia. The patients were divided into 3 groups (n = 40 each): dexamethasone plus saline group (DC group), dexamethasone plus droperidol group (DD group) and dexamethasone plus propofol group (DP group). Dexamethasone 5 mg and flurbiprofen axetil 50 mg were given intravenously before induction of general anesthesia. Anesthesia induction: remimazolam 6 mg/kg/hours was continuously pumped until sleep and slow intravenous injection of alfentanil 20 ug/kg and mivacurium chloride 0.2 mg/kg was given. Anesthesia maintenance: remimazolam 1 mg/kg/hour and alfentanil 40 ug/kg/hours were continuously pumped. After the start of surgery, DC group was given 2 mL saline, DD group was given droperidol 1 mg, and DP group was given propofol 20 mg. Primary outcome: incidence of PONV in the postanesthesia care unit (PACU). Secondary outcome: incidence of PONV in patients within 24 hours after surgery, as well as general patient data, duration of anesthesia, the recovery time of patients, dose of remimazolam and alfentanil, etc.

RESULTS

In PACU, patients of group DD and DP showed less PONV than those in group DC (P < .05). Within 24 hours after operation, there was no significant difference in the incidence of PONV among the 3 groups (P > .05), but the incidence of vomiting in DD group and DP group was significantly lower than that in DC group (P < .05). There was no significant difference in general data, anesthesia time, the recovery time of patients and dosage of remimazolam and alfentanil among the 3 groups (P > .05).

CONCLUSION

The effect of low-dose propofol combined with dexamethasone to prevent PONV under remimazolam-based general anesthesia was similar to that of droperidol combined with dexamethasone, both of which significantly reduced the incidence of PONV in the PACU compared to dexamethasone alone. However, low-dose propofol combined with dexamethasone had little effect on the incidence of PONV within 24 hours compared to dexamethasone alone and only reduced the incidence of postoperative vomiting in patients.

The Incidence of QT Prolongation and Torsades des Pointes in Patients Receiving Droperidol in an Urban Emergency Department

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.

[Involuntary Movement of Bilateral Lower Limbs Caused by Epidural Anesthesia: A Case Report]

Regional anesthesia, especially epidural anesthesia, rarely causes involuntary movement Here we present a case of a patient who demonstrated myoclonus-like involuntary movement of the lower limbs during continuous infusion of ropivacaine, fentanyl, and droperidol through the thoracic epidural catheter. This movement disappeared when the epidural infusion was stopped, but reappeared when the epidural infusion was restarted. Naloxone did not eliminate the movement The patient was thereafter discharged uneventfully. This case and other reports in the literature suggest that involuntary movement associated with regional anesthesia is rare and self-limiting. However, careful consideration should be given to exclude other, potentially dangerous complications.

[Catatonic syndrome after single low dose of droperidol]

BACKGROUND

Patients find postoperative nausea and vomiting extremely unpleasant. If nausea persists despite initial treatment, droperidol, a butyrophenone with anti-dopaminergic activity, can be very effective. Side-effects, albeit rare, can occur and are potentially serious.

CASE DESCRIPTION

A 75-year-old postoperative patient was given a single low dose of droperidol to treat persistent nausea. Subsequently, the patient developed catatonic syndrome. The psychiatrist treated the patient with benzodiazepine and electroconvulsive therapy. Within four weeks the patient had completely recovered.

CONCLUSION

Catatonic syndrome is a serious condition; morbidity and mortality are mainly influenced by disease duration and early initiation of appropriate treatment. Physicians are not familiar with this syndrome. Since other syndromes and diseases may display similar symptoms, the condition is difficult to diagnose. Even after a single, low dose of droperidol, patients can be at risk of developing catatonic syndrome.

Droperidol for treatment of nausea and vomiting in palliative care patients

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 10, 2010, on droperidol for the treatment of nausea and vomiting in palliative care patients. Nausea and vomiting are common symptoms in patients with terminal illness and can be very unpleasant and distressing. There are several different types of antiemetic treatments that can be used to control these symptoms. Droperidol is an antipsychotic drug and has been used and studied as an antiemetic in the management of postoperative and chemotherapy nausea and vomiting.

OBJECTIVES

To evaluate the efficacy and adverse events (both minor and serious) associated with the use of droperidol for the treatment of nausea and vomiting in palliative care patients.

SEARCH METHODS

We searched electronic databases including CENTRAL, MEDLINE (1950-), EMBASE (1980-), CINAHL (1981-) and AMED (1985-), using relevant search terms and synonyms. The basic search strategy was ("droperidol" OR "butyrophenone") AND ("nausea" OR "vomiting"), modified for each database. We updated the search on 2 December 2009. We performed updated searches of MEDLINE, EMBASE, CENTRAL and AMED 2009 to 2013 on 19 November 2013 and of CINAHL on 20 November 2013. We also searched trial registers (metaRegister of controlled trials (www.controlled-trials.com/mrct), clinicaltrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (http://apps.who.int/trialsearch/)) on 22 November 2013, using the keyword "droperidol".

SELECTION CRITERIA

Randomised controlled trials (RCTs) of droperidol for the treatment of nausea or vomiting, or both, in adults receiving palliative care or suffering from an incurable progressive medical condition.

DATA COLLECTION AND ANALYSIS

We judged the potential relevance of studies based on their titles and abstracts, and obtained studies that we anticipated might meet the inclusion criteria. Two review authors independently reviewed the abstracts for the initial review and four review authors reviewed the abstracts for the update to assess suitability for inclusion. We discussed discrepancies to achieve consensus.

MAIN RESULTS

The 2010 search strategy identified 1664 abstracts (and 827 duplicates) of which we obtained 23 studies in full as potentially meeting the inclusion criteria. On review of the full papers, we identified no studies that met the inclusion criteria.The updated searches carried out in November 2013 identified 304 abstracts (261 excluding duplicates) of which we obtained 18 references in full as potentially meeting the inclusion criteria. On review of the full papers, we identified no studies that met the inclusion criteria, therefore there were no included studies in this review.We found no registered trials of droperidol for the management of nausea or vomiting in palliative care.

AUTHORS' CONCLUSIONS

Since first publication of this review, no new studies were found. There is insufficient evidence to advise on the use of droperidol for the management of nausea and vomiting in palliative care. Studies of antiemetics in palliative care settings are needed to identify which agents are most effective, with minimum side effects.

Comparison of droperidol and haloperidol for use by paramedics: assessment of safety and effectiveness

BACKGROUND

Since the 2001 "black box" warning on droperidol, its use in the prehospital setting has decreased substantially in favor of haloperidol. There are no studies comparing the prehospital use of either drug. The goal of this study was to compare QTc prolongation, adverse events, and effectiveness of droperidol and haloperidol among a cohort of agitated patients in the prehospital setting.

METHODS

In this institutional review board-approved before and after study, we collected data on 532 patients receiving haloperidol (n = 314) or droperidol (n = 218) between 2007 and 2010. We reviewed emergency department (ED) electrocardiograms when available (haloperidol, n = 78, 25%; droperidol, n = 178, 76%) for QTc length (in milliseconds), medical records for clinically relevant adverse events (defined a priori as systolic blood pressure (SBP) <90 mmHg, seizure, administration of anti-dysrhythmic medications, cardioversion or defibrillation, bag-valve-mask ventilation, intubation, cardiopulmonary arrest, and prehospital or in-hospital death). We also compared effectiveness of the medications, using administration of additional sedating medications within 30 minutes of ED arrival as a proxy for effectiveness.

RESULTS

The mean haloperidol dose was 7.9 mg (median 10 mg, range 4-20 mg). The mean droperidol dose was 2.9 mg (median 2.5 mg, range 1.25-10 mg.) Haloperidol was given i.m. in 289 cases (92%), and droperidol was given i.m. in 132 cases (61%); in all other cases, the medication was given i.v.. There was no statistically significant difference in median QTc after medication administration (haloperidol 447 ms, 95% CI: 440-454 ms; droperidol 454 ms, 95% CI: 450-457). There were no statistically significant differences in adverse events in the droperidol group as compared to the haloperidol group. One patient in the droperidol group with a history of congenital heart disease suffered a cardiopulmonary arrest and was resuscitated with neurologically intact survival. There was no significant difference in the use of additional sedating medications within 30 minutes of ED arrival after receiving droperidol (2.9%, 95% CI: -2.5-8.4%).

CONCLUSIONS

In this cohort of agitated patients treated with haloperidol or droperidol in the prehospital setting, there was no significant difference found in QTc prolongation, adverse events, or need for repeat sedation between haloperidol and droperidol.

[Extrapyramidal reactions in three patients due to droperidol infusion for intravenous patient-controlled analgesia]

Intravenous patient-controlled analgesia (iv-PCA) has a great advantage for pain control in the postoperative period with occasional disadvantages of postoperative nausea and vomiting, which should be treated appropriately. Droperidol is commonly used as anti-emetic drug, but it also has a potential risk to induce extrapyramidal reactions. We report three patients who showed extrapyramidal reactions among 589 patients after droperidol administration. Although this complication is rare, we should be aware of the possible extrapyramidal reactions due to droperidol.

[Droperidol for the treatment of acutely agitated patients: still an option]

BACKGROUND

In Flemish emergency psychiatry droperidol is still an option for the treatment of agitation. However, its efficacy and safety are contested.

AIM

To find out whether the continuing use of droperidol to treat agitation is justified on scientific grounds.

METHOD

Randomised controlled trials of droperidol (intramuscular or intravenous) were traced via a systematic search of the literature. These data were supplemented with a description of the drug’s most important pharmacological properties and a survey of the literature on cardiac side-effects and of the place accorded to droperidol in some guidelines.

RESULTS

The efficacy and safety of droperidol (IM/IV) were studied in 8 randomised control-led trials: 352 patients treated with droperidol. Droperidol was compared with benzodiazepines, antipsychotics and combination treatment. A single injection of droperidol was successful in 64-92% of patients. Droperidol tended to act faster and be more effective than haloperidol and lorazepam. There were very few side-effects. No clinically important cardiac side-effects were reported; this is also in keeping with evidence revealed in systematic reviews on the subject. The ecological validity of the trials was high.

CONCLUSION

In spite of a decline in the popularity of droperidol in most guidelines, the drug still seems to play a valuable role in the treatment of the agitated patient. Because it acts rapidly over a short period of time and is safe to use in patients with high (co)morbidity, it is still in favour with many health professionals.

[Dyskinesia after treatment with droperidol for preventing postoperative nausea and vomiting]

This case presents a young woman with extrapyramidal reactions after the use of a small dose (0.625 mg) of droperidol. In combination with dexamethason (8 mg) droperidol was given as the patient underwent laparoscopic cholecystectomy in order to prevent postoperative nausea and vomiting. The patient presented characteristic signs of ataxia. The signs lasted for 36 hours. We believe that droperidol was the cause. She had previously experienced similar signs after taking metoclopramide.

[Evaluation of the side effects of intravenous patient controlled analgesia after spine surgery]

BACKGROUND

We have adopted intrravenous patient controlled analgesia (IV-PCA) for spine surgery. We could not find reports about detailed examinations of the side effects of IV-PCA using morphine after spine surgery, so we investigated retrospectively side effects in cases using morphine IV-PCA.

METHODS

Eighty-five patients underwent IV-PCA after spine surgery. The contents of PCA pump were morphine 20 mg (= 2 ml), droperidol 2 mg (= 0.8 ml), and saline 77 ml. We fixed continuous infusion at 2 ml x hr(-1), bolus infusion at 2 ml x hr(-1), and lockout time at 15 minutes. Respiration time, SpO2, blood pressure, pulse rate, nausea and vomiting, and VAS were monitored while IV-PCA was in use. When severe side effects were noticed, IV-PCA was discontinued by physician in charge. We judged discontinuation of IV-PCA as occurrence of severe side effects.

RESULTS

IV-PCA was discontinued in seven patients. The causes of discontinuation were nausea and vomiting, hypotension, and bradycardia. Nausea and vomiting was the most common cause and found mostly in women.

CONCLUSIONS

Because IV-PCA was discontinuated in 8.2% of patients, it was thought that its management depending on patients' personal state was necessary to utilize IV-PCA as a method of postoperative analgesia.

Droperidol for treatment of nausea and vomiting in palliative care patients

BACKGROUND

Nausea and vomiting are common symptoms in patients with terminal illness and can be very unpleasant and distressing. There are several different types of antiemetic treatments which can be used to control these symptoms. Droperidol is an antipsychotic drug and has been used and studied as an antiemetic in the management of post-operative and chemotherapy nausea and vomiting.

OBJECTIVES

To evaluate the efficacy and adverse events (both minor and serious) associated with the use of droperidol for the treatment of nausea and vomiting in palliative care patients.

SEARCH STRATEGY

We searched electronic databases including CENTRAL, MEDLINE, EMBASE, CINAHL and AMED, using relevant search terms and synonyms. The basic search strategy was ("droperidol" OR "butyrophenone") AND ("nausea" OR "vomiting"), modified for each database. The search was updated on 2 December 2009.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of droperidol for the treatment of nausea or vomiting, or both, for adults receiving palliative care or suffering from an incurable progressive medical condition.

DATA COLLECTION AND ANALYSIS

We judged the potential relevance of studies based on their titles and abstracts, and obtained studies which we anticipated might meet the inclusion criteria. We both read these to assess suitability for inclusion. Discrepancies were discussed to achieve consensus.

MAIN RESULTS

The search strategy identified 1664 abstracts (and 827 duplicates) of which 23 studies were obtained in full as potentially meeting the inclusion criteria. On review of the full papers, no studies were identified which met the inclusion criteria, therefore, there were no included studies in this review.

AUTHORS' CONCLUSIONS

There is insufficient evidence to advise on the use of droperidol for the management of nausea and vomiting in palliative care. Studies of antiemetics in palliative care settings are needed to identify which agents are most effective with a minimum of side effects.

[Case of acute dystonia during epidural droperidol infusion to prevent postoperative nausea and vomiting]

We report a case of bilateral ocular deviation due to droperidol-induced acute dystonia that was initially undiagnosed. A 22-year-old, 72 kg, parturient at 42 weeks' gestation underwent emergency cesarean section for pregnancy-induced hypertension under combined spinal-epidural analgesia. The epidural catheter was inserted through the T11-12 interspace, followed by intrathecal hyperbaric bupivacaine with adjunctive fentanyl. The patient complained of nausea shortly after delivery, which subsided with intravenous droperidol 1.25 mg and metoclopramide 10 mg. After surgery, epidural infusion with a mixture of ropivacaine, fentanyl, and droperidol was started. Around 25 hours postoperatively, both of the patient's eyes rotated upwards, although she was fully conscious. Brain CT/MRI did not show any abnormalities. An ophthalmologist and a neurosurgeon were consulted but there was no definitive diagnosis. On subsequent consultation with anesthesiologists, it was assumed that the symptom was related to external ophthalmoplegia secondary to spinal anesthesia. Thereafter, a "wait and see" approach was adopted. After 8 hours, she gradually developed torticollis and increased muscle tone of the lower extremities, which facilitated a diagnosis based on extrapyramidal signs. Epidural infusion was discontinued without further treatment. Her symptoms completely disappeared within 5 hours. The estimated cumulative dose of intravenous and epidural droperidol was 4.6 mg over 34 hours.

[Case with difficulty in differentiating between transient neuroleptic malignant syndrome and catatonia after neuroleptic analgesia]

An 18-year-old woman was treated with neuroleptic analgesia using fentanyl, morphine, droperidol and haloperidol for general anesthesia and pain control for her knee operation. Postoperatively, she showed emotional unstableness, following dyspnea, tachycardia, fever, hyperhydrosis, muscle rigidity and myoclonus like involuntary movement. She received infusion of 140 mg dantrolene in total under suspicion of having neuroleptic malignant syndrome, but her symptoms improved slightly. After being transferred to our hospital, she exhibited immobility, mutism, rigidity, and catalepsy, and she was suspected of having lethal catatonia. Infusion of diazepam 10 mg resulted in dramatical improvement of her symptoms. Differential diagnosis between neuroleptic malignant syndrome and catatonia is difficult; however, a first line therapy is differential diagnosis. Thus, physician should consider catatonia when treating neuroleptic malignant like syndrome.

Heart block and prolonged Q-Tc interval following muscle relaxant reversal: a case report

Heart block and Q-Tc interval prolongation have been reported with several agents used in anesthesia, and the US Food and Drug Administration mandates evaluation of the Q-T interval with new drugs. Drug-induced Q-T interval prolongation may precipitate life-threatening arrhythmias, is considered a precursor for torsades de pointes, and may predict cardiovascular complications. In the patient described in this article, heart block occurred and the Q-Tc interval became prolonged after muscle relaxant reversal with neostigmine; both were considered to be related to the combination of agents used in the case, as well as to other predisposing factors such as morbid obesity. The agents used that affected cardiac conduction were neostigmine, desflurane, droperidol, dolasetron, and dexmedetomidine. Although the heart block was resolved after 2 doses of atropine, prolonged P-R and Q-Tc intervals persisted into the immediate postoperative period but returned to baseline within 4 hours. Clinical implications of this report include increasing awareness of the multitude of factors affecting Q-T interval prolongation during anesthesia.

Does low-dose droperidol administration increase the risk of drug-induced QT prolongation and torsade de pointes in the general surgical population?

BACKGROUND

The US Food and Drug Administration issued a black box warning regarding the use of droperidol and the potential for torsade de pointes (TdP).

METHODS

The primary objective of this retrospective study was to determine whether low-dose droperidol administration increased the incidence of TdP in the general surgical population during a 3-yr time period before and after the Food and Drug Administration black box warning. A random sample of 150 surgical patients during each time interval was selected to estimate the droperidol use for each time period.

RESULTS

During the time period before the black box warning (July 1, 1998 to June 30, 2001), 2,321/139,932 patients (1.66%) had QT prolongation, TdP, or death within 48 h after surgery. We could identify no patients who clearly developed TdP before the black box warning. There was one patient for whom the cause of death could not positively be ruled out as due to TdP. In the time period after the black box warning (July 1, 2002 to June 30, 2005), 2,207 patients (1.46%) had documented QT prolongation, TdP, or death within 48 h after surgery, including only two cases (<0.1%) of TdP. The incidence of droperidol exposure was approximately 12% (exact 95% confidence interval, 7.3-18.3%) before the black box warning and 0% after placement of the black box warning on droperidol. Therefore, we estimate that approximately 16,791 patients (95% confidence interval, 10,173-25,607) were exposed to droperidol, none of whom experienced documented TdP.

CONCLUSIONS

This indicates that the Food and Drug Administration black box warning for low dose droperidol is excessive and unnecessary.

Evidence-based review of the black-box warning for droperidol

PURPOSE

Data collected from the Food and Drug Administration (FDA) under the Freedom of Information Act are presented to help clinicians understand the data prompting the black-box warning for droperidol and to make educated decisions regarding the use of droperidol and alternative agents.

SUMMARY

A written request was submitted to FDA to provide a report of any and all reports of cardiovascular adverse events related to droperidol that were part of the decision to add a black-box warning to the label of droperidol. The report listed 277 cases of adverse effects associated with droperidol since its introduction to the market in 1970. Many of the reports were duplicates, leaving a total of 65 individual cases. Of these cases, only 2 described adverse effects possibly caused by droperidol in dosages commonly used in the United States. In addition to these reports, the results of two European studies prompted FDA to make the decision for the black-box warning. Both studies used droperidol doses 50-100 times higher than those used in the United States.

CONCLUSION

Studies show that there is a dose-dependent increase in the rate of adverse cardiovascular events when droperidol is used either alone or in combination with other medications that cause Q-T interval prolongation. At this time, there does not appear to be significant evidence to suggest that serotonin type 3-receptor (5-HT(3)) antagonists are safer than droperidol with regard to Q-T interval prolongation. More studies are needed to determine the safety and efficacy of droperidol when used in doses of 0.625-1.25 mg compared with the 5-HT(3) antagonists.

Postoperative impairment of cognitive function in rats: a possible role for cytokine-mediated inflammation in the hippocampus

BACKGROUND

Postoperative cognitive dysfunction is being increasingly reported as a complication. The authors investigated the role of cytokine-mediated inflammation within the central nervous system in the development of cognitive dysfunction in a rat model.

METHODS

Adult rats were subjected to neuroleptic anesthesia (20 microg/kg fentanyl plus 500 microg/kg droperidol, intraperitoneal) for splenectomy or no surgery. On postanesthetic days 1, 3, and 7, cognitive function was assessed in a Y maze. To evaluate the immune response in the hippocampus, the authors measured glial activation, as well as transcription and expression of key proinflammatory cytokines interleukin 1beta and tumor necrosis factor alpha. To determine propensity for apoptosis, they measured expression of Bax and Bcl-2.

RESULTS

Cognitive function in splenectomized animals was impaired at days 1 and 3 after surgery compared with cognitive function in nonanesthetized rats. At all times, anesthetized rats that were not subjected to surgery were no different from control rats. Glial activation was observed in the hippocampus only in splenectomized rats at postsurgery days 1 and 3. Interleukin-1beta messenger RNA (mRNA) was significantly increased at postsurgery days 1 and 3, with an increase in protein expression detected on day 1. There was a significant increase in tumor necrosis factor-alpha mRNA on day 1 after surgery, although this was not associated with an increase in protein expression. The ratio of Bcl-2:Bax was significantly decreased in the splenectomized animals.

CONCLUSION

These results suggest that splenectomy performed during neuroleptic anesthesia triggers a cognitive decline that is associated with a hippocampal inflammatory response that seems to be due to proinflammatory cytokine-dependent activation of glial cells.

Intravenous droperidol: a review of its use in the management of postoperative nausea and vomiting

Droperidol (Dehydrobenzperidol, Dehidrobenzoperidol, Dridol, Droleptan, Inapsine) is a dopamine D(2) receptor antagonist that has been widely used in adults and children for the prevention and treatment of postoperative nausea and vomiting (PONV) over several decades and, more recently, for the prevention of opioid-induced PONV during patient-controlled analgesia (PCA) in adults. In well controlled clinical trials of patients undergoing surgery, the efficacy of single-dose intravenous (IV) droperidol in preventing PONV was similar to that of ondansetron and dexamethasone. Droperidol significantly reduced opioid-induced PONV in adults during PCA and had a morphine-sparing effect. Droperidol is generally well tolerated and the incidence of adverse effects is similar to that observed with placebo and the serotonin 5-HT(3) receptor antagonists (setrons). Guidelines recommend that, in adults, droperidol monotherapy be considered for those at moderate risk of PONV, and droperidol in combination with a setron and/or dexamethasone be considered for patients at moderate or high risk of PONV. In children with moderate or high risk of PONV, droperidol is recommended for first-line use in some countries, and second-line use in others.

A comparison of intravenous-based and epidural-based techniques for anesthesia and postoperative analgesia in elderly patients undergoing laparoscopic cholecystectomy

PURPOSE

We wished to compare the effectiveness of intravenous-based (IV) and epidural-based (EPI) techniques for anesthesia and postoperative analgesia in elderly patients undergoing laparoscopic cholecystectomy. Effectiveness was compared in terms of reduction of postoperative pain and adverse events, and achieving a high level of patient satisfaction.

METHODS

Thirty American Society of Anesthesiologists (ASA) physical status I-II patients aged more than 65 years, scheduled for laparoscopic cholecystectomy, were enrolled in this study. The patients in the IV group (n = 15) received modified neurolept anesthesia with droperidol 0.2 mgxkg(-1) and pentazocine 0.15-0.3 mgxkg(-1) (maximum dose of 1.0 mgxkg(-1)) and 60% nitrous oxide in oxygen, followed by postoperative intravenous infusion of 20 microgxml(-1) buprenorphine, provided with a patient-controlled analgesia pump programmed to deliver a bolus of 0.5 ml with a lockout interval of 15 min and a background infusion of 0.5 mlxh(-1). The patients in the EPI group (n = 15) had combined epidural analgesia and general anesthesia with sevoflurane and 60% nitrous oxide in oxygen, followed by the epidural infusion of a 0.125% bupivacaine and 5 microg x ml(-1) buprenorphine mixture by means of an on-demand analgesic system (bolus of 2 ml, lockout interval of 60 min, and background infusion of 2 mlxh(-1)).

RESULTS

The quality of postoperative analgesia was similar in the two groups. The incidences of intraoperative hypotension and bradycardia and postoperative hypotension were significantly lower in the IV group than in the EPI group (P < 0.05). A significantly higher level of patient satisfaction was found in the IV group compared with that in the EPI group (P < 0.05). The major contributor to dissatisfaction in the EPI group was anxiety or discomfort associated with the epidural procedures.

CONCLUSION

Modified neurolept anesthesia with pentazocine and postoperative i.v. analgesia with buprenorphine were superior to epidural-based techniques, in terms of hemodynamic stability and patient satisfaction, in elderly patients undergoing laparoscopic cholecystectomy.

Meta-analysis of the safety of 5-HT3 antagonists with dexamethasone or droperidol for prevention of PONV

BACKGROUND

Antiemetic guidelines recommend a combination of serotonin (5-HT3) with a second agent such as droperidol or dexamethasone. Physicians have been reluctant to employ these guidelines due to concerns over the black-box warning of droperidol and safety concerns with a steroid.

OBJECTIVE

To assess the safety profiles of 5-HT3 receptor antagonist (5-HT3RA) monotherapy and combination therapy with a steroid or droperidol for prophylaxis of postoperative nausea and vomiting (PONV).

METHODS

A MEDLINE search of English-language reports of randomized controlled trials (RCTs) was conducted (1966-September 2005) using the key terms 5-HT3, granisetron, ondansetron, dolasetron, tropisetron, PONV, postoperative, vomiting, emesis, and nausea. RCTs with treatment arms comparing 5-HT3RA monotherapy (granisetron, ondansetron, dolasetron, or tropisetron) with dexamethasone or droperidol or 5-HT3RA combinations and providing incidence data on adverse events were identified and reviewed. Within-study odds ratios with 95% confidence intervals were calculated to determine the incidence rates of all adverse events in RCTs using 5-HT3RA monotherapy and combination therapies. Overall effect sizes for frequently reported adverse events were estimated by pooling ORs using fixed- and random-effect models.

RESULTS

Pooled ORs (OR(pooled)) for adverse events with 5-HT3RA/dexamethasone versus 5-HT3RA for PONV prophylaxis were not significant for any reported adverse events or the overall incidence of adverse events; 5-HT3RA/droperidol versus 5-HT3RA was significant only for decreased headache incidence (fixed model: OR(pooled) 0.35; 95% CI 0.18 to 0.69). The OR(pooled) for 5-HT3RA/dexamethasone versus dexamethasone was not significant for any reported adverse events except headaches (fixed model OR(pooled) 1.75; 95% CI 1.01 to 3.03), none of which was serious. OR(pooled) for 5-HT3RA/droperidol versus droperidol was not significant for any reported adverse events. Avascular necrosis, occult infection, and delayed wound healing were not observed with either combination therapy. Cardiac abnormalities were observed with 5-HT3RA/droperidol therapy.

CONCLUSIONS

This meta-analysis indicates that either therapy has a safety profile similar to that of dexamethasone, droperidol, or 5-HT3RA.

Droperidol’s Effect on QT Interval

The Food and Drug Administration (FDA) issued a letter to health care providers on December 4, 2001, concerning the medication, droperidol. The purpose of the warning was to alert health care providers to the possible role of droperidol in the development of torsades de pointes (TdP) in susceptible patients. The purpose of this article is to explore the role of droperidol in the development of TdP in susceptible patients and current recommendations for the use of droperidol as an antiemetic.

Antipruritic and antiemetic effect of epidural droperidol

BACKGROUND AND OBJECTIVES

This study was designed to investigate whether single epidural droperidol or continuous epidural droperidol inhibit pruritus and postoperative nausea and vomiting induced by postoperative continuous epidural fentanyl administration, and to identify the optimal method of administering epidural droperidol.

METHODS

120 ASA I-II patients undergoing subtotal gastrectomy with general anaesthesia combined with epidural anaesthesia were randomly allocated into three groups: control (no droperidol), single injection (droperidol 2.5 mg) and continuous group (droperidol 2.5 mg 2 day(-1)). Postoperatively the frequency and severity of pruritus and postoperative nausea and vomiting in all groups were compared during 48 h.

RESULTS

The frequency and severity of pruritus was significantly lower in both single injection and continuous groups than control group after epidural fentanyl administration (P < 0.05). The frequency and severity of postoperative nausea and vomiting was significantly lower in single injection group than control group after epidural fentanyl administration (P < 0.05).

CONCLUSION

Epidural continuous droperidol is effective for reducing pruritus, and single epidural droperidol injection is effective for reducing pruritus and postoperative nausea and vomiting induced by postoperative continuous epidural fentanyl analgesia.

Randomized Clinical Trial Comparing Intravenous Midazolam and Droperidol for Sedation of the Acutely Agitated Patient in the Emergency Department

STUDY OBJECTIVE

We compare intravenous midazolam and droperidol for the onset of sedation of acutely agitated patients in the emergency department (ED).

METHODS

This was a double-blind, randomized, clinical trial set in the ED of a university teaching hospital. Subjects were adults, acutely agitated because of mental illness, intoxication, or both, who received midazolam or droperidol, 5 mg intravenously, every 5 minutes until sedated. We analyzed time to sedation using survival analysis, median times to sedation, and proportions sedated at 5 and 10 minutes.

RESULTS

Seventy-four patients received midazolam; 79 patients, droperidol. Survival analysis showed no difference in time to sedation (hazard ratio 0.86; 95% confidence interval [CI] 0.61 to 1.23), P=.42. Median time to sedation was 6.5 minutes for midazolam (median dose 5 mg) and 8 minutes for droperidol (median dose 10 mg), P=.075 (effect size 1.5 minutes; 95% CI 0 to 4 minutes). At 5 minutes, 33 of 74 (44.6%) patients from the midazolam group were adequately sedated compared with 13 of 79 (16.5%) patients from the droperidol group, a difference of 28.1% (95% CI 12.9% to 43.4%; P<.001). By 10 minutes, 41 of 74 (55.4%) from the midazolam group were sedated compared to 42 of 79 (53.2%) from droperidol, a difference of 2.2% (95% CI -14.9% to 19.3%; P=.91). Eleven adverse events occurred in the midazolam group and 10 in the droperidol group. Three patients required active airway management (3 patients with assisted ventilation and 1 patient intubated); all received midazolam.

CONCLUSION

There is no difference in onset of adequate sedation of agitated patients using midazolam or droperidol. Patients sedated with midazolam may have an increased need for active airway management.

Interaction between tramadol and two anti-emetics on nociception and gastrointestinal transit in mice

BACKGROUND

Clinical studies suggest that tramadol-induced analgesia is partially antagonized by ondansetron.

AIMS

To investigate the type of interaction between tramadol and two anti-emetics on antinociception and gastrointestinal transit in mice.

METHODS

We assessed the antinociceptive (acetic acid writhing test, plantar test) and antitransit (charcoal meal) effects of tramadol individually, and combined with ondansetron or droperidol in female Swiss CD-1 mice. Isobolograms and analysis of variance were used to determine the type of interaction.

RESULTS

In the writhing test, tramadol, ondansetron and droperidol, each induced dose-related inhibition of nociception. The ED(50)'s were: tramadol 4.2+/-0.33 mg kg(-1); ondansetron 1.03+/-0.05 mg kg(-1), and droperidol 1.00+/-0.14 mg kg(-1). Dose-response curves were also obtained with tramadol combined with ondansetron or droperidol at 1:1 fixed ratios. The isobolographic analysis demonstrated antagonism for both combinations. In the plantar test, the ED(50) for tramadol was 51.4+/-2.3 mg kg(-1), but no dose-response curves could be obtained with ondansetron or droperidol individually. The interaction was assessed from dose-response curves to tramadol in the presence of a fixed dose of ondansetron (0.1 mg kg(-1)) or droperidol (0.05 mg kg(-1)). The results show antagonism between tramadol-ondansetron (p<0.05) and no interaction for the tramadol-droperidol combination. Both anti-emetics antagonized the antitransit effects of tramadol.

CONCLUSIONS

The interaction of tramadol with ondansetron or droperidol on antinociception can be antagonistic or additive, depending on the type of stimuli. Both anti-emetics antagonize the anti-transit effects of tramadol. The results demonstrate antagonism between tramadol and the two anti-emetics for analgesia and inhibition of gastrointestinal transit, supporting previous clinical studies.

Haloperidol: an alternative butyrophenone for nausea and vomiting prophylaxis in anesthesia

Droperidol has been an efficacious, inexpensive butyrophenone used since the early 1970s to prevent or treat postoperative nausea and vomiting. Because of reports of sudden cardiac death in patients receiving droperidol, the US Food and Drug Administration (FDA) recently placed significant restrictions on its administration. These restrictions have essentially removed droperidol from use. Haloperidol is another butyrophenone with antiemetic properties but without the FDA restrictions. This article reviews the literature regarding haloperidol and supports its use as a safe substitute for droperidol in the prevention and treatment of postoperative nausea and vomiting.

[Four cases of extrapyramidal reactions to epidural droperidol administration]

Continuous epidural administration of droperidol at 2.5 mg x day(-1) or less was performed in 837 patients after surgery. In 4 of these patients, an extrapyramidal reaction occurred. Patient 1 was a 10-year-old girl who developed the symptom 29 hours after the start of administration, with a total dose of 3.0 mg. Patient 2 was a 16-year-old girl in whom the symptom occurred 24 hours after the start, with a total of 5.3 mg. Patient 3 was a 22-year-old female with the symptom occurring 26 hours after the start, with a total of 5.2 mg. Patient 4 was a 74-year-old female in whom the symptom occurred 24 hours after the start, with a total of 1.3 mg. With respect to the age distribution, the total of 837 patients consisted of 16 patients aged 10 to 19 years, 85 patients aged 20 to 29 years, 91 patients aged 30 to 39 years, 90 patients aged 40 to 49 years, 77 patients aged 50 to 59 years, 148 patients aged 60 to 69 years, 240 patients aged 70 to 79 years, 97 patients aged 80 to 89 years, and 9 patients aged 90 to 99 years. Extrapyramidal reactions related to epidural administration may readily develop at younger ages.

Prolongation of QTc interval after postoperative nausea and vomiting treatment by droperidol or ondansetron

BACKGROUND

At dosages above 0.1 mg/kg, droperidol induces a dose-dependent QTc interval prolongation. Although subject to controversy, low-dose droperidol has recently been suspected to induce cardiac arrhythmias. Hence, 5-hydroxytryptamine type 3 antagonists have become the first-line drug for management of postoperative nausea and vomiting. These drugs are also known to prolong the QTc interval at high dosages. This study describes QTc interval changes associated with postoperative nausea and vomiting treatment by droperidol or ondansetron at low doses.

METHODS

Eighty-five patients with postoperative nausea and vomiting were included in this prospective, single-blind study. Patients received either 0.75 mg intravenous droperidol (n = 43) or 4 mg intravenous ondansetron (n = 42). Electrocardiographic recordings were obtained before administration of antiemetic drug and then 1, 2, 3, 5, 10, and 15 min after. Electrocardiographic monitoring was maintained for 3 h in eight patients in each group.

RESULTS

The QTc interval was prolonged (> 450 ms in men, > 470 ms in women) in 21% of the patients before antiemetic drug administration. This was significantly correlated with lower body temperature and longer duration of anesthesia. Compared with predrug QTc measurement, both antiemetics were associated with a significant QTc interval prolongation (P < 0.0001). The mean maximal QTc interval prolongation was 17 +/- 9 ms after droperidol occurring at the second minute and 20 +/- 13 ms after ondansetron at the third minute (both P < 0.0001). Compared with predrug measurement, the QTc interval was significantly lower after the 90th minute in both groups.

CONCLUSIONS

Droperidol and ondansetron induced similar clinically relevant QTc interval prolongations. When used in treatment of postoperative nausea and vomiting, a situation where prolongation of the QTc interval seems to occur, the safety of 5-hydroxytryptamine type 3 antagonists may not be superior to that of low-dose droperidol.

Morphine sparing with droperidol in patient-controlled analgesia

STUDY OBJECTIVE

To determine if droperidol has a morphine-sparing effect when coadministered with morphine via patient-controlled analgesia (PCA) for postoperative pain management.

DESIGN

A randomized, double-blind clinical study.

SETTING

Department of Anesthesiology, Kaohsiung Veterans General Hospital, Taiwan.

PATIENTS

One hundred seventy-nine American Society of Anesthesiologists physical status 1 and 2 female patients undergoing abdominal hysterectomy.

INTERVENTIONS

At the end of surgery, patients in the droperidol group received PCA, with the device programmed to deliver a bolus dose of 1 mg morphine and 50 mug droperidol on demand. Patients in the control group received 1 mg morphine on demand. For both groups, PCA lockout was 5 minutes between boluses, with a 4-hour morphine limit of 30 mg.

MEASUREMENTS AND MAIN RESULTS

Pain intensity at rest or on movement and relative sedation score were evaluated and recorded at 6, 12, 24, 48, and 72 hours after surgery. Related side effects were also evaluated and recorded on postoperative days 1, 2, and 3. Morphine use was significantly lower for the droperidol group than the control group during the postoperative 72-hour period (33.9 +/- 9.8 and 54.9 +/- 12.1 mg, respectively), with significantly decreased pain intensity levels for the former relative to the latter at 48 hours (pain intensity on movement: 3.9 +/- 1.2 vs 4.3 +/- 0.9, respectively; P = .049) and 72 hours (pain intensity on movement: 3.0 +/- 1.1 vs 3.6 +/- 0.5, respectively; P = .003; pain intensity at rest: 1.3 +/- 1.0 vs 1.6 +/- 0.7, respectively; P = .033) subsequent to surgery. Control subjects demonstrated a greater frequency of postoperative nausea and vomiting than did their droperidol counterparts on postoperative day 1.

CONCLUSION

Coadministration of 50 mug droperidol and 1 mg morphine on demand via PCA provides a morphine-sparing effect and reduces the frequency of postoperative nausea and vomiting.

Effect of Low-dose Droperidol on the QT Interval during and after General Anesthesia

Background

Since the effects of antiemetic doses of droperidol on the QT interval have not been previously studied, the authors designed a randomized, double-blind, placebo-controlled study to evaluate the intraoperative and postoperative effects of small-dose droperidol (0.625 and 1.25 mg intravenous) on the QT interval when used for antiemetic prophylaxis during general anesthesia.

Methods

One hundred twenty outpatients undergoing otolaryngologic procedures with a standardized general anesthetic technique were enrolled in this study. After anesthetic induction and before the surgical incision, 60 patients were given either saline or 0.625 or 1.25 mg intravenous droperidol in a total volume of 2 ml. A standard electrocardiographic lead II was recorded immediately before and every minute after the injection of the study medication during a 10-min observation period. The QTc (QT interval corrected for heart rate) was evaluated from the recorded electrocardiographic strips. In 60 additional patients, a 12-lead electrocardiogram was obtained before and at specific intervals up to 2 h after surgery to assess the effects of droperidol and general anesthesia on the QTc. Any abnormal heartbeats or arrhythmias during the operation or the subsequent 2-h monitoring interval were also noted.

Results

Intravenous droperidol, 0.625 and 1.25 mg, prolonged the QT interval by an average of 15 +/- 40 and 22 +/- 41 ms, respectively, at 3-6 min after administration during general anesthesia, but these changes did not differ significantly from that seen with saline (12 +/- 35 ms) (all values mean +/- SD). There were no statistically significant differences among the three study groups in the number of patients with greater than 10% prolongation in QTc (vs. baseline). Although general anesthesia was associated with a 14- to 16-ms prolongation of the QTc interval in the early postoperative period, there was no evidence of droperidol-induced QTc prolongation after surgery. Finally, there were no ectopic heartbeats observed on any of the electrocardiographic rhythm strips or 12-lead recordings during the perioperative period.

Conclusion

Use of a small dose of droperidol (0.625-1.25 mg intravenous) for antiemetic prophylaxis during general anesthesia was not associated with a statistically significant increase in the QTc interval compared with saline. More importantly, there was no evidence of any droperidol-induced QTc prolongation immediately after surgery.

Safety of droperidol in behavioural emergencies

By the year 2000, droperidol had become a standard drug for the treatment of behavioural emergencies in both psychiatric and medical settings. In 2001, the US FDA issued a 'black box' warning, citing cases of QT prolongation and/or torsades de pointes. As a result, the use of droperidol has been sharply circumscribed. The authors will review the literature on antipsychotic medications in general, focusing on droperidol in particular, with regard to QT interval prolongation, dysrhythmia, and sudden death. In addition, the mechanism of drug-induced QT interval prolongation will be discussed. The authors will then review their extensive experience with droperidol. The authors conclude that, while in theory droperidol may prolong the QT interval to an extent similar to thioridazine, its long history of clinical use has shown no pattern of sudden deaths analogous to those that provoked the FDA warning. Although the numbers presented by the FDA initially appear alarming, after further evaluation it is clear that more definitive studies should have been carried out. Droperidol is safe, extremely effective, and now underused as a treatment for severely agitated or violent patients.

The efficacy of the 5-HT3 receptor antagonists combined with droperidol for PONV prophylaxis is similar to their combination with dexamethasone. A meta-analysis of randomized controlled trials

PURPOSE

The aim of this quantitative systematic review is to compare the efficacy and side effects of combining one of the 5-HT(3) receptor antagonists (5-HT) with droperidol or dexamethasone for postoperative nausea and vomiting (PONV) prophylaxis.

METHODS

We performed a systematic search (Medline, Embase, and the Cochrane Library) for randomized controlled trials that compared the antiemetic efficacy of combining one of the 5-HT with droperidol or dexamethasone vs 5-HT alone. Relevant endpoints were prevention of early (0 to 6 hr), and overall (0 to 24 hr) PONV, and side effects. The articles that could meet the inclusion criteria were scored for inclusion and methodological validity using the three-item, five-point, Oxford-scale. Relative risk and numbers needed-to-treat with 95% confidence intervals were calculated for each combination vs 5-HT alone. The two combinations were then indirectly compared. A random effects model was used.

RESULTS

We considered 41 trials for analysis but subsequently excluded eight. Thirty-three trials with data from 3,447 patients were analyzed. Except for early nausea with the 5-HT plus droperidol, both combinations were significantly more effective than 5-HT in preventing early and overall PONV. There was no difference in antiemetic efficacy between the two combinations. The incidence of commonly reported side effects was also similar in the two combination groups.

CONCLUSION

We conclude that there is no statistically significant difference in antiemetic efficacy or side effects profile when one of the 5-HT is combined with either droperidol or dexamethasone and that both combination regimens are significantly more effective than 5-HT alone.

Droperidol for perioperative sedation causes a transient prolongation of the QTc time in children under volatile anesthesia

BACKGROUND

Droperidol is useful for postoperative sedation in infants and children after cardiac surgery because it provides sedation and akinesia with minimal respiratory depression. However, droperidol has been associated with QT prolongation and ventricular arrhythmias. We investigated, if neuroleptanalgesic doses of droperidol led to QT prolongation and cardiac arrhythmias in children undergoing cardiac surgery.

METHODS

We retrospectively analysed electrocardiogram rhythm strips that were obtained before and in time increments after a 100 microg x kg(-1) intravenous bolus of droperidol in 20 children undergoing cardiac surgery. The longest QT interval was determined in each ECG and corrected for heart rate (QTc). All arrhythmias were recorded.

RESULTS

Droperidol led to a significant increase in QTc time that was still present at 15 min but had resolved within 30 min after the bolus. No associated arrhythmias were observed.

CONCLUSIONS

The statistically significant prolongation of QTc time after a sedative dose of droperidol is of concern because it may increase the risk for malignant cardiac arrhythmias. A large, prospective study is necessary to identify the true risk for arrhythmias after droperidol in this patient population, but our study suggests that any arrhythmogenic risk, if present, will be very transient, since the increase in QTc time was limited to a period of less than 30 min after the bolus.

Droperidol and dolasetron alone or in combination for prevention of postoperative nausea and vomiting after vitrectomy

PURPOSE

Droperidol and the new serotonin-3 antagonists are effective drugs for the prophylaxis of postoperative nausea and vomiting (PONV). The aim of this trial was to evaluate whether dolasetron could be a substitute for droperidol, because the Food and Drug Administration has required a Black Box warning on the droperidol package insert.

DESIGN

Randomized, placebo-controlled, double-blinded trial.

PARTICIPANTS

Inpatients undergoing vitreoretinal surgery (standard 3-port pars plana vitrectomy for proliferative diabetic vitreoretinopathy, complicated retinal detachment, or macular disease, such as macular pucker, macular hole, or choroidal neovascularization).

INTERVENTION

Two hundred forty patients (3x80) receiving droperidol (10 microg. kg(-1)), dolasetron (12.5 mg), or the combination of both drugs administered 5 to 10 minutes before the end of surgery.

CONTROL

Eighty patients received saline placebos as controls.

METHODS

Standardized general anesthesia was performed, including benzodiazepine premedication, propofol, atracurium or vecuronium, desflurane in N(2)O/O(2), and a continuous infusion of remifentanil. Postoperative analgesia and antiemetic rescue medication were standardized. Episodes of vomiting, retching, nausea, and the need for additional antiemetics were recorded for 24 hours.

MAIN OUTCOME MEASURES

Severity of PONV (rated by a standardized scoring algorithm) was analyzed as the main end point of the study using the Kruskal-Wallis test.

RESULTS

Data of 304 patients could be analyzed. Mean severity scores in the placebo, dolasetron, droperidol, and combination groups were 1.21, 0.76, 0.47, and 0.30. Incidences of PONV of any severity were 56%, 40%, 28%, and 18%, respectively. The reduction of the incidence of PONV and its severity was statistically significant in the droperidol group and in the combination group relative to the placebo. Dolasetron alone failed to reduce the incidence of PONV. The combination of dolasetron and droperidol showed an additive antiemetic efficacy.

CONCLUSION

Low-dose droperidol (10 microg. kg(-1)) but not dolasetron (12.5 mg) reduced postoperative nausea and vomiting after vitreoretinal surgery. Dolasetron (12.5 mg) is not an equivalent substitute for droperidol.

Effects of droperidol dosage on postoperative emetic symptoms following pediatric strabismus surgery

STUDY OBJECTIVE

To compare the frequency of postoperative emetic symptoms and side effects in pediatric strabismus surgery using four doses of droperidol.

DESIGN

Randomized, blinded study.

SETTING

University eye institute.

PATIENTS

82 ASA physical status I and II pediatric patients, aged 1 to 16 years, undergoing outpatient strabismus surgery.

INTERVENTIONS

Patients were assigned to one of four doses of droperidol (10, 20, 40, or 80 microg.kg(-1)) (Groups 1, 2, 3, and 4, respectively). All patients received the same anesthetic management, with droperidol administered intravenously immediately after induction of anesthesia.

MEASUREMENTS AND MAIN RESULTS

Postoperatively, patients were evaluated for emetic symptoms (nausea, retching, and/or vomiting) and side effects (postoperative sedation or extrapyramidal symptoms). There was a dose-dependent reduction of emetic symptoms seen with increasing droperidol dose. Predischarge emetic symptoms were 50%, 15%, 15%, and 5% in Groups 1, 2, 3, and 4, respectively (p < 0.009). Peak emetic symptoms were observed after discharge: 75%, 40%, 35%, and 15% in Groups 1, 2, 3, and 4, respectively (p < 0.003). Convalescence times, including awakening, extubation, recovery, and hospitalization, were unaffected by increasing droperidol dose. Sedation was similar in all groups and no patient exhibited any side effects. However, when patients exhibited emetic symptoms, discharge time increased from 207 +/- 57 minutes to 283 +/- 128 minutes (p < 0.001).

CONCLUSIONS

Prophylactic administration of droperidol 80 microg.kg(-1) is most effective in reducing postoperative emetic symptoms without increasing time to discharge. In those patients with emetic symptoms who also received prophylactic droperidol, time to discharge was significantly delayed.

Randomized, double-blind trial of dolasetron versus droperidol for prophylaxis of postoperative nausea and vomiting in patients undergoing TRAM flap breast reconstruction surgery

Clinical observation indicates that patients undergoing transverse rectus abdominus musculocutaneous (TRAM) flap breast reconstruction surgery frequently experience postoperative nausea and/or vomiting (PONV). No controlled trials have evaluated the role of pharmacologic prophylaxis of PONV in this population. A prospective randomized, double-blinded, active-controlled trial comparing intraoperative intravenous droperidol 1 mg with dolasetron 50 mg was conducted. Seventy-one patients were included in the intention-to-treat analysis. The incidence of the primary end point of PONV within 24 hours after surgery was 81.8% versus 78.9% for droperidol and dolasetron, respectively (p = 0.8). No significant differences were detected in the time to onset of PONV, incidence of severe nausea or emesis, or incidence of emesis alone. Time to rescue antiemetic use was longer in the droperidol group (7.1 vs. 1.3 hours, p = 0.002). Adverse effects were similar between the two groups. No PONV-related complications occurred during the trial period. The incidence of PONV in TRAM flap breast reconstruction surgery patients remains high despite prophylactic intraoperative antiemetic administration.