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.

Physicochemical stability of ternary admixtures of butorphanol, ketamine, and droperidol in polyolefin bags for patient-controlled analgesia use

BACKGROUND

Delivery of drug admixtures by intravenous patient-controlled analgesia is a common practice for the management of postoperative pain; however, analytical confirmation of the compatibility and stability of butorphanol tartrate, ketamine hydrochloride, and droperidol combined in ternary admixtures is not available.

METHODS

Butorphanol tartrate, ketamine hydrochloride, and droperidol have been examined for compatibility and stability when combined with 0.9% sodium chloride injection stored at 4°C and 25°C with light protection for a total of 14 days. Concentrations were 0.067 mg/mL, 1.33 mg/mL, and 0.033 mg/mL for butorphanol tartrate, ketamine hydrochloride, and droperidol, respectively. Drug concentrations were determined using high-performance liquid chromatographic analysis.

RESULTS

All three drugs were very stable (>97%) at 4°C and 25°C for 14 days. The ternary admixtures were initially clear and colorless throughout the observation period, and the pH value did not change significantly.

CONCLUSION

The results confirm that the ternary admixture of butorphanol tartrate 0.067 mg/mL, ketamine hydrochloride 1.33 mg/mL, and droperidol 0.033 mg/mL in 0.9% sodium chloride injection were stable for 14 days when stored in polyolefin bags at 4°C and 25°C and protected from light.

Successful protocol of anaesthesia for measuring transepithelial nasal potential difference in spontaneously breathing mice

Numerous difficulties arise during in vivo measurements of transepithelial nasal potential difference (PD) in mice, such as inadequate duration and depth of anaesthesia, bronchoaspiration of solutions perfused in the nose, and respiratory and/or cardiovascular depression.

Anaesthesia was induced in adult C57 mice with intraperitoneal injection of a combination of fentanyl, droperidol and medetomidine, each of these at either a small dose (0.20, 10 and 0.33 mg/kg, respectively) or at a large dose (0.40, 20 and 0.40 mg/kg, respectively), combined with a fixed dose of 0.375 μg clonidine. In order to establish a pharmacokinetic–pharmacodynamic relationship, blood concentrations of the first three drugs were measured in 24 animals by liquid-chromatography tandem mass spectrometry. At the end of the experiment, naloxone, a competitive morphinic antagonist, and atipamezole, an α-2 adrenergic antagonist, were administered. Bronchoaspiration was prevented by tilting the animal head downwards and by absorbing the excess fluid from the opposite nostril and from the oral cavity. Optimal assessment of anaesthesia associated with regular respiration, loss of blink, pupillary and pedal withdrawal reflexes was obtained with doses of fentanyl, droperidol and medetomidine corresponding to 0.20, 20 and 0.40 mg/kg, respectively. Blood concentrations of fentanyl around 17 ng/mL induced loss of respiratory efforts and were followed by death during the experiment. Integrity of ion transport was demonstrated under continuous perfusion by successive depolarization after amiloride and repolarization after chloride-free solution.

The combination investigated in this study lead to adequate surgical anaesthesia (stage III, plane 2) for prolonged nasal PD measurements in spontaneously breathing mice.

[The Effectiveness of Epidural Droperidol for Prophylaxis of Postoperative Nausea and Vomiting: A Comparative Study of Droperidol and Adrenaline]

BACKGROUND

Intravenous droperidol has strong evidence for antiemetic efficacy in high risk patients for prevention of postoperative nausea and vomiting (PONV). However it is not clear whether continuous epidural administration of doroperidol prevent PONV. It has been reported that epidural adrenaline decreases PONV; therefore we prospectively compared the effectiveness of epidural droperidol and adrenaline for prophylaxis of PONV.

METHODS

Eighty-six patients were scheduled for abdominal gynecological surgery under general-epidural anesthesia in the study. Patients were randomly assigned to droperidol group or adrenaline group. We investigated the incidences of PONV, the frequency of using the antiemetics.

RESULTS

There was no statistical difference between the groups. The incidences of PONV were 27.9% (doropeidol group) and 58.1% (adrenaline group), respectively (P = 0.0046). The frequency of the anti-emetics use were 18.6% and 41.9%, respectively (P = 0.0189). There was one patient who needed cancellation of continuous epidural administration for vomiting in adrenaline group, but no patient in doropeidol group.

CONCLUSIONS

The results suggest that epidural droperidol effectively decreases PONV in high risk patients. However epidural adrenaline might be ineffective.

[The Interaction of Low-dose Droperidol, Propofol, and Sevoflurane on QTc Prolongation]

BACKGROUND

Droperidol is an effective antiemetic, but its use is limited because of the warning of drug-induced QT prolongation. Some reports showed that low-dose droperidol does not significantly probing QT interval. This study was aimed to determine the effect of low-dose droperidol (1.25 and 2.5 mg) on QTc interval, and the interaction among droperidol, propofol and sevoflurane.

METHODS

Patients received either 1.25 mg (group L : n = 25) or 2.5 mg (group H : n = 25) droperidol, and fentanyl (3 μg x kg(-1)) was administered 2.5 min later. One minute after fentanyl administration, anesthesia was induced using propofol (1.5 mg x kg(-1)) and vecuronium. One minute after propofol administration, sevoflurane (3%) was started. Tracheal intubation was performed 3 min after propofol administration, and then sevoflurane was reduced to 1%.

RESULTS

Compared to baseline, the QTc interval in group L was unchanged by droperidol. In group H, the QTc interval was significantly prolonged after droperidol injection, but recovered after propofol injection. After tracheal intubation, QTc interval was significantly prolonged in both groups.

CONCLUSIONS

Droperidol's effect on QTc prolongation was shown at the dose of 2.5 mg but not 1.25 mg. This prolongation effect was offset by propofol, and was unchanged by sevoflurane.

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.

[Prophylaxis of intraoperative nausea, vomiting and abdominal discomfort due to spinal anaesthesia for caesarian operation]

The article deals with data of comparison of different antiemetic drugs used for prophylactics of intraoperative nausea and vomiting (IONV) during caesarian operation. 150 women included in the study were divided into three groups. Patients of the group-1 (80 women) received dproperidol 0.08-0.12 mg kg(-1) intravenously and atropine 0.006-0.009 mg kg(-1). Patients of the group-2 (50 women) received dexamethasone 0.04-0.1 mg kg(-1) intravenously. In the group-3 (20 women) patients received methoklopramide 0.1-0.2 mg kg(-1) intravenously. Intravenous administration of low doses of atropine and dproperidol provides the most effective prophylactics of IONV.

[Influence of acupoint injection with small dose of fentanyl-droperidol mixed liquor on labor analgesia and level of stress hormone in parturient]

OBJECTIVE

To observe the clinical effect of acupoint injection with small dose of fentanyl-droperido mixed liquor at different time stages on labor analgesia, and explore its function mechanism.

METHODS

One hundred and fifty cases of full-term primiparas who were intended to take vaginal delivery were randomly divided into 3 groups, 50 cases in each one. The acupoint injection with fentanyl-droperido mixed liquor at different time stages was applied in the group I, where Shenshu (BL 23) was selected in active phase and Ciliao (BL 32) was selected in the 2nd stage of labor. The subcutaneous injection with fentanyl-droperido mixed liquor was adopted in group II. The group III, which was considered as a control group, was treated with subcutaneous injection of 0.9% NaCl at the same time stage as group I and II. The blood pressure, VAS score and level of norepinephrine and adrenaline were observed at different time stages.

RESULTS

Compared before the injection, the blood pressure of group III in the active phase and 2nd stage of labor was significantly increased (P < 0.05), and that in group II and III was obviously higher than that in the group I (P < 0.05). The VAS score of group I in the active phase and 2nd stage of labor was significantly lower than that in the group II and III (P < 0.01). After the injection, the level of NE and E was significantly decreased (P < 0.05), which was lower than that in the group II and III (P < 0.05).

CONCLUSION

The acupoint injection with small dose of fentanyl-droperido mixed liquor at different time stages has positive effect on labor analgesia, and it could significantly relieve stress reaction of parturient during the labor. Its mechanism could be related to the reduction of stress hormone in parturient.

[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.

Long-term use of intrathecal droperidol as an excellent antiemetic in nonmalignant pain--a retrospective study

Over the past five years our pain practice encountered eight patients (5 female, 3 male) with chronic non-malignant pain syndromes, in whom any meaningful pain reduction via opioid analgesics (either by oral or systemic and/or intraspinal route) had resulted in profound nausea and/or vomiting despite generous use of available and/or affordable anti-emetics. After obtaining proper consents, small, incremental doses of intrathecal droperidol were added to these patients having implanted intrathecal narcotic drug delivery system. Significant reduction of nausea and vomiting without any side effects from droperidol was obtained while adequate pain reduction is achieved.

PROCEDURE

All patients had implanted programmable Medtronic Synchromed pumps with intrathecal access catheters. The intrathecal catheter tip placement varied depending on the pain pathology of the patient. Six of eight patients were started and remained on morphine sulfate intrathecally for their opioids. Two patients with contraindications to morphine had fentanyl and hydramorphone as their intrathecal opioid respectively. The intrathecal dose of droperidol was started low (22.7 +/- 18.6 micrograms/day). All patients were on simple continuous pump dosing during the study.

RESULTS

All patients achieved statistically significant antiemesis (77 +/- 10% P < 0.001) as well as statistically significant pain relief (84 +/- 7% P < 0.005) early on (within two pump refills). As the intrathecal dose/day of droperidol was increased to 124.7 +/- 114.8 micrograms/day as well as their intrathecal pain medication use, the degree of significance of antiemesis improved to 86 +/- 9% (P < .001) which was a statistically significant improvement of P < or = 0.05 level from the starting dose of droperidol in each patient. For the six patients on morphine the antiemesis improved to 88 +/- 10% (P < or = .003), also statistically significantly different at P < or = 0.05 level from the starting antiemesis level. During this period the intrathecal morphine dose was doubled from 4.76 +/- 2.43 mg/day to 9.5 +/- 6.5 mg/day (P < or = .001). Patients had no adverse effects from the use of droperidol at these doses (no sedation, changes in mental status, no signs or symptoms of arachnoiditis, no new sensory or motor disturbance, or any other indications of nerve toxicity detected.). Serial neurological studies involving MRI and CT, with contrast, EMG every 6-12 month showed no intrathecal catheter tip irritation sequelae in our patients either.

CONCLUSIONS

We find droperidol in microgram doses of 5-300/day intrathecally a safe antiemetic to use along with opioid analgesics. We did not use droperidol intrathecally alone as its use systemically without an opioid companion base is fraught with concern in anesthesia literature ("calm looking on the outside-agitated on the inside"). We would suggest a minimal starting dose of 20-30 micrograms/day of droperidol, adjust most probably upwards by 25-50% on subsequent pump refills until the desired effect is established. The scientific literature is rich with references to the brainstem chemoreceptor trigger zone, the floor of the fourth ventricle, and other nausea center locations (area postrema, the circumventricular organ, etc.). We would like to suggest that droperidol's direct actions on these centers are involved with antiemesis at these small doses.

[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.

To add or not to add? An empirical study on droperidol and intravenous patient-controlled analgesia

BACKGROUND

Droperidol is commonly added to intravenous patient-controlled analgesia (IVPCA) regimens as an antiemetic agent. Although some studies have demonstrated its safety and efficacy, it is not clear whether adding droperidol to IVPCA infusate without an extra loading dose can effectively reduce the incidence and severity of postoperative nausea and vomiting (PONV) in real-life clinical settings.

METHODS

Patients receiving IVPCA in this retrospective survey were classified into two groups based on their IVPCA regimens. The droperidol group used morphine 1mg/mL with droperidol 50 μg/mL, and the non-droperidol group was given morphine 1 mg/mL alone. The incidence and severity of PONV were compared between the two groups during the 3-day course of IVPCA treatment using logistic regression and ordinal logistic regression. Propensity score methodology was applied to adjust for potential confounders.

RESULTS

Among the 186 patients enrolled, 94 patients received IVPCA with droperidol, and 92 patients received a pure morphine solution. There was no significant difference in patient attributes between the two groups. On the 1st postoperative day, there was no significant difference in incidence or severity of PONV between the two groups. From the 2nd day onward, the patients in the droperidol group had significantly fewer and less severe episodes of PONV (relative risk 0.34 and 0.31, respectively). The overall effects of droperidol on PONV and its severity during the whole IVPCA course were also statistically significant, whether or not adjustment for propensity score was made. However, although a statistically significant decrease in nausea was observed in the droperidol group after the 1st day, no significant difference in the incidence of vomiting between the two groups was noted during the study.

CONCLUSION

A loading dose should be considered on the 1st postoperative day. Our study suggests just how beneficial droperidol can be to IVPCA users in practical clinical settings, showing that droperidol can reduce with some significance the amount and severity of nausea suffered by patients postoperatively, even if the frequency of patient vomiting remains unchanged.

[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.

[Intravenous patient-controlled analgesia (IV-PCA) for relief of postoperative pain]

Intravenous patient-controlled analgesia (IV-PCA) using opioids such as morphine and fentanyl can be an effective analgesic method for post-operative pain that is resistant to conventional administration of narcotic analgesics and nonsteroidal anti-inflammatory drugs, and where epidural block and peripheral nerve block are not feasible. In addition to post-operative pain relief, IV-PCA can facilitate early ambulation, reduce respiratory complications, and increase patient satis-faction. However, respiratory and circulatory depression, and post-operative nausea and vomiting (PONV) often occur as side effects of IV-PCA with opioids. Administration of droperidol can be an effective treatment for PON.

[Effectiveness of low dose PCEA for postoperative pain after laparoscopic gynecological surgeries--a comparison of laparoscopic ovarian cystectomy and myomectomy]

BACKGROUND

We evaluated the effectiveness of low-dose patient-controlled epidural analgesia (PCEA) in the patients undergoing laparoscopic gynecological surgery, and investigated the difference of postoperative pain between patients for laparoscopic ovarian cystectomy and those for myomectomy.

METHODS

Thirteen patients (ASA PS 1 or 2), scheduled for laparoscopic surgery, were enrolled in this study. They were divided into two groups of ovarian cystectomy (group C, n=17) and myomectomy (group M, n=13). After administering epidural bolus of 0.2% ropivacaine 6 ml, droperidol 2.5 mg, and buprenorphine hydrochloride 0.1 mg, PCEA was started: 1 ml x hr(-1) background infusion; 0.2% ropivacaine 54 ml, droperidol 5 mg, and buprenorphine hydrochloride 0.3 mg; 1 ml epidural bolus with a 30-minute lockout interval. We evaluated postoperative pain using visual analogue scale (VAS) at rest and on movement, adverse effects such as respiratory and cardiovascular depression, nausea and vomiting for 48 hours after surgery.

RESULTS

VAS at rest with group M was significantly higher than that of group C (11 +/- 2 vs. 6 +/- 2, P=0.048), and VAS on movement of group M was also higher than that of group C (25 +/- 3 vs. 18 +/- 2, P=0.023): however, we found good analgesic effect of less than VAS 3 in both groups. Severe adverse effects were not observed.

CONCLUSIONS

These findings suggest that low dose PCEA is effective for patients who undergo laparoscopic gynecological surgery.

[Control of postoperative nausea and vomiting by preventive administration of dexamethasone]

BACKGROUND

Postoperative nausea and vomiting (PONV) are the most frequent side effects after anesthesia. Patients with persistent PONV continue to be impaired in performing their normal daily activities. We studied the controlling effect of dexamethasone (4 mg) before the induction of general anesthesia in the prevention of PONV.

METHODS

Ninety-one patients were divided into respiratory surgery group (dexamethasone N=22, none N=23) and gynecology group (dexamethasone N=22, none N=24), respectively. Dexamethasone group received dexamethasone 4 mg before the induction of general anesthesia. PONV and antiemetic requirements were recorded.

RESULTS

In the dexamethasone group (respiratory surgery, gynecology), the incidences of PONV during the initial 24 hour postoperative period were 36.4% (N=8), and 18.2% (N=4), respectively. In the none group, the incidences were 43.5% (N=10), and 41.7% (N=10), respectively Antiemetic requirements were 22.7% (N=5), 9.1% (N=2), 39.1% (N=9), and 20.1% (N=5), respectively (NS). In gynecology group, in almost all the patients droperidol was used in epidural anesthesia. Combination of dexamethasone and droperidol may have greater antiemetic action than a single drug.

CONCLUSIONS

Combination therapy with dexamethasone and droperidol may reduce PONV in patients undergoing surgery.

Discomfort, delirium, and PONV in infants and young children undergoing strabismus surgery

This article presents the results of a retrospective analysis of anesthesia care and perioperative outcomes in children up to 2 years of age who underwent strabismus surgery during a five-year period at the University of Minnesota Amplatz Children's Hospital. We reviewed the charts of 74 children to determine perioperative outcomes--namely discomfort, emergence agitation/delirium, and postoperative nausea and vomiting (PONV).We found that although PONV was not an issue in this age group, as it was with older children, discomfort and emergence agitation/delirium do need to be considered during their care.

[Preoperative intravenous administration of droperidol (1.25 mg) reduced postoperative nausea and vomiting after intrathecal morphine administration]

BACKGROUND

Intrathecal morphine (ITM) is an excellent postoperative analgesic, but may often cause postoperative nausea and vomiting (PONV). We designed this prospective, randomized and controlled study to evaluate the antiemetic efficacy of low-dose droperidol for the treatment of PONV caused by ITM.

METHODS

Two hundred female patients undergoing elective total hip arthroplasty were enrolled. They received spinal anesthesia with isobaric bupivacaine and 0.08 mg ITM, and 100 patients were randomly administered with 1.25 mg droperidol intravenously before operation. We observed the incidence of PONY and pain score until 24 hr after operation, and investigated the doses of anti-hypotensive drugs (ephedrine and phenylephrine) and fluid administered intraoperatively.

RESULTS

The incidence of PONV was lower in the droperidol group within 6 hr after operation (control group 47%, droperidol group 15%), and especially lower within 2 hr (43% vs. 3%), but was not different 6 hr after operation. The pain score was very low throughout the observation period in both groups and especially within 12 hr. The respective doses of the anti-hypotensive drugs and fluid administered intraoperatively during the operation were higher in the droperidol group. Severe arrhythmia was not observed in any patient throughout the observation period.

CONCLUSIONS

Single intravenous administration of 1.25 mg droperidol before operation showed prophylactic efficacy in early PONV caused by ITM. The duration of droperidol action was shorter than that of ITM. Hence we recommend that droperidol should be administered more frequently or continuously in the postoperative period.

Comparison the effects of metoclopramide and dropridol associated with dexamethasone on post operative nausea and vomiting

The aim of study was, comparison of effects of Metoclopramide and Dropridol associated with Dexamethasone on prevalence of nausea and vomiting after operation was considered. In this study 160 patients ASA physical status I were divided into two groups. In both groups, premedication and induction of anesthesia were given equally according to weight. To the first group, Metoclopramide associated with Dexamethasone and to the second group, Dropridol associated with Dexamethasone was ordered. At the end of the operation, after removing tracheal tube, prevalence of nausea and vomiting in both groups was considered after 2 h and results were analyzed with t-test and Chi-square. Ratio of nausea and vomiting after operation in the first group was 24% and in the second 8%. So results show that prevalence of nausea and vomiting in the second group was considerably lower than the first group (p < 0.004). According to the results of this study our conclusion, Dropridol with dexamethasone given at the before of general anesthesia was more effective in decreasing the prevalence of nausea and vomiting in patients compared with metoclopramide with dexamethasone.

[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.

[Preventive effect of acupoint injection at neiguan (PC 6) on postoperative nausea and vomiting after laparoscopic gynecologic surgery]

OBJECTIVE

To investigate the method for preventing the postoperative nausea and vomiting (PONV) after laparoscopic gynecologic surgery.

METHODS

One hundred and twenty patients being for laparoscopic gynecologic surgery at I- II grade as American Society of anesthesiologists (ASA) were randomly divided into three groups, 40 cases in each group. Twenty minutes before the operation, the mixture of 2. 5 mg Droperidol (1 mL) and 1 mL 0. 9% sodium chloride solution was injected into the bilateral Neiguan (PC 6) in group I , and an intravenous injection with 1 mL Droperidol was used in group II , while there was no treatment carried out in group Ill'. Twenty four hours after the operation, the frequency and degree of nausea and vomiting were observed and scored according to the criteria standard.

RESULTS

The incidence rate of nausea was 10. 0% (4/40) in group I , 57. 5% (23/40) in group II , which was significantly different from 80. 0% (32/40) in group III (P<0. 01, P<0. 05, respectively), while it was lower in group I than in group II (P<0. 01). The incidence rate of vomiting was 7. 5% (3/40) in group I , 52. 5% (21/40) in group II , which was significantly different from 75.0% (30/40) in group III (P<0.01, P<0.05 respectively), while it was lower in group I than in group II (P<0.01). No complication, such as obvious drowsiness, anxiety and extracorticospinal tract reaction, was observed among the three groups.

CONCLUSION

Acupoint injection at Neiguan (PC 6) with a small dose of Droperidol can effectively prevent the PONV after laparoscopic gynecologic surgery without other adverse effects.

T HE I NCIDENCE AND T REATMENT OF P REHOSPITAL M OTION S ICKNESS

OBJECTIVES

The authors' objectives were: 1) to determine the incidence of motion sickness during ambulance transport on a mountainous route in healthy volunteers, and 2) to determine if droperidol alleviated the signs and symptoms of motion sickness in those volunteers who developed it.

METHODS

This was a prospective, randomized, double-blind, placebo-controlled trial. Subjects were healthy volunteers over age 18 and not currently taking an antiemetic. Participants were transported in the back of an ambulance over a mountainous road. Those who developed motion sickness rated their nausea on a 100-mm visual analog scale (VAS) and were randomized to receive placebo (saline) or 2.5 mg droperidol intravenously. Symptoms were recorded on a VAS every 5 minutes until the end of the transport. Incidence of motion sickness was calculated as a percentage with 95% confidence intervals (CIs). Pretreatment characteristics were compared with chi-square tests, and mean VAS scores were compared using t-tests.

RESULTS

Thirty-seven subjects completed the study. Sixteen (43%, 95% CI=27%-59%) developed motion sickness. Fifteen were randomized and completed data collection. Eight received droperidol (mean baseline VAS, 45) and seven received placebo (mean baseline VAS, 40). Droperidol trended toward a greater mean reduction of nausea than placebo at 5 minutes (20 versus 4, p=0.077).

CONCLUSIONS

The incidence of motion sickness during ambulance transport in a mountainous setting is substantial. There was a strong trend toward a positive treatment effect with droperidol. Further prospective study in an actual patient setting is warranted.

[Postoperative inconveniences after breast cancer surgery]

The most common postoperative inconveniences after breast cancer surgery are pain, nausea and vomiting, which contribute to reduced patient satisfaction, prolonged hospital stays and delayed courses of rehabilitation. This article summarizes the literature regarding available procedure-specific evidence for prophylactic nausea, vomiting and pain treatment supported by transferable evidence from similar types of surgery. We propose a prophylactic combination of Dexametason, Ondansteron, Paracetamol, Celecoxib, Gabapentin and Detromethorphan as future treatment.

[Multimodal treatment of pain and nausea in breast cancer surgery]

INTRODUCTION

Every year 4000 women in Denmark undergo surgery for breast cancer. According to published literature approximately 50% suffer from post-operative nausea and vomiting (PONV) and moderate pain. No national guidelines are available regarding the treatment or prevention of pain and PONV associated with surgery for these patients.

MATERIALS AND METHODS

116 consecutive patients scheduled for breast cancer surgery were prospectively scored according to pain, PONV and sedation after being introduced to a combined evidence-based, empiric multimodal opioid-sparing prevention and treatment regime consisting of Paracetamol, Celecoxib, Dextromethorphan, Gabapetin, Dexamethason and Ondansetron.

RESULTS

In the recovery room, 75% of the patients scored either no or light pain at rest compared to 68% under mobilization. In the department, 94% of the patients scored no or light pain at rest as well as under mobilization on the evening of the operation and the next morning. Morphine consumption in the recovery room was, on average, 2 mg per patient. Only 1.5% of the patients were given morphine in the department. Five patients were troubled by light PONV, one by moderate PONV and another suffered from severe PONV and vomiting resistant to treatment. Upon arrival at the recovery 15% of the patients were in a state of moderate to severe sedation. This number was 1.5% 75 minutes later.

CONCLUSION

It is possible with a multimodal opioid-sparing prevention and treatment regime for pain and PONV to gain optimal postoperative pain and nausea control without significant problems with respect to sedation.

Low-dose haloperidol prevents post-operative nausea and vomiting after ambulatory laparoscopic surgery

BACKGROUND

We evaluated the prophylactic effect of low-dose haloperidol (1 mg) on post-operative nausea and vomiting (PONV) in women undergoing ambulatory laparoscopic surgery. Droperidol (0.625 mg) and saline were controls.

METHODS

One hundred and fifty women undergoing ambulatory laparoscopic surgery under general anaesthesia were enrolled in this randomized, double-blind, and placebo-controlled study. After tracheal intubation, the haloperidol group (n=50) received intravenous haloperidol (1 mg), the droperidol group (n=50) received intravenous droperidol (0.625 mg), and the saline group (n=50) received intravenous saline.

RESULTS

Haloperidol- and droperidol-group patients reported a lower incidence of PONV [24% and 23% vs. 49% (saline group); P<0.05] and requested fewer doses of rescue antiemetics [13% and 16% vs. 38% (saline group); P<0.05] during the first four post-operative hours. During the 24-h post-operative period, haloperidol- and droperidol-group patients also reported a lower incidence of PONV [31% and 32% vs. 62% (saline group); P<0.01]. No differences were found between the haloperidol and droperidol groups.

CONCLUSION

Like droperidol (0.625 mg), prophylactic intravenous haloperidol (1 mg) significantly reduced the incidence of PONV in women undergoing ambulatory laparoscopic surgery.

Ondansetron or droperidol for prophylaxis of nausea and vomiting after intrathecal morphine

BACKGROUND AND OBJECTIVE

There is a controversy regarding the best drug for prevention of nausea and vomiting in patients receiving intrathecal morphine. The aim of this study was to examine efficacy and tolerability of droperidol compared with ondansetron for the prevention of morphine-induced nausea and vomiting.

METHODS

In a randomized, placebo-controlled trial, 120 women undergoing Caesarean section under spinal anaesthesia with intrathecal morphine 0.1 mg received intravenous ondansetron 4 mg (n = 40), droperidol 1.25 mg (n = 40) or saline (n = 40) immediately after umbilical-cord clamping. Nausea and vomiting were graded according to intensity at 1, 2, 4, 6, 12 and 24 h.

RESULTS

Nausea or vomiting occurred in 14 patients (35%) in the placebo group, 4 (10%) in the ondansetron group and 10 (25%) in the droperidol group; the difference between ondansetron and placebo was statistically significant (P = 0.007). Eleven of the 14 placebo patients (27.5%) vomited, compared with none of the 4 ondansetron patients (vs. placebo, P = 0.0004) and 5 of the droperidol patients (vs. placebo, P = 0.18). Three of the 14 placebo patients (7.5%) were nauseous, compared with 4 (10%) receiving ondansetron and 5 (12.5%) receiving droperidol.

CONCLUSIONS

Ondansetron was effective in reducing the incidence of nausea and vomiting in patients receiving intrathecal morphine for Caesarean section.

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.

The Antipruritic and Antiemetic Effects of Epidural Droperidol: A Study of Three Methods of Administration

BACKGROUND

In this study, we compared rates of postoperative nausea and vomiting (PONV) and pruritus after using different protocols for administering epidural droperidol.

METHODS

Using the same dose of droperidol, we evaluated the effectiveness of three different methods of administration (single, continuous, and combined) on the frequency of PONV and pruritus induced by continuous infusion of epidural fentanyl for 48 h postoperatively. One hundred sixty ASA physical status I and II patients who underwent surgical resection for colorectal cancer under general anesthesia combined with epidural anesthesia were randomly allocated into four groups: (a) control group (no droperidol), (b) single injection group (droperidol 2.5 mg), (c) continuous group (droperidol 1.25 mg/day) and (d) combined single (droperidol 1.25 mg) and continuous (droperidol 0.625 mg/day) group.

RESULTS

Pruritus and PONV were significantly less frequent in all droperidol groups, when compared with the control group (P < 0.05). The incidence and the incidence over time of PONV were similar among all groups who received epidural droperidol.

CONCLUSION

Epidural droperidol is effective for reducing pruritus and PONV, regardless of the method of administration.

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.

[Clinical application of brain hypothermia therapy for acute brain insults]

Brain hypothermia therapy has been expected to lead to good neurological outcome in acute brain insults. There are a few positive results which have been proven by multicenter randomized clinical trials (RCT) in the cardiopulmonary arrest (CPA) in patients with ventricular fibrillation. Among these clinical trials, early application of hypothermia, maintenance of cerebral blood flow during hypothermia therapy and prevention of quick rewarming are pointed out to result in good outcome from clinical experiences. For brain hypothermia therapy to become an effective method for acute brain insults, indications, brain oriented intensive cares and biomarkers for the therapy must be established. RCT in acute brain insults beside CPA victims are needed in the near future.

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.

The additive interactions between ondansetron and droperidol for preventing postoperative nausea and vomiting

Prophylactic ondansetron or droperidol reduces the incidence of postoperative nausea and vomiting (PONV). Previous studies showed that the combination of these two drugs produced better antiemetic effect than either drug alone. We present a nonparametric method to determine the pharmacologic interaction between ondansetron and droperidol and compared the observed response of the drug combination with that predicted from additivity. This is calculated as the product of the individual drug response, normalized to that of the controls. Five minutes before induction of anesthesia, 400 patients scheduled for laparoscopic gynecologic surgery were randomly assigned to receive 1) saline IV; 2) ondansetron 4 mg IV; 3) droperidol 1.25 mg IV; or 4) a combination of droperiodol 1.25 mg and ondansetron 4 mg IV. A standardized anesthetic technique and postoperative analgesic regimen were used. Patients were reviewed regularly for 48 h. Changes in the heart rate adjusted QT (QTc) interval were measured from electrocardiograms recorded before and 5 min after study drug administration. In a subgroup of 160 patients, QTc intervals were measured again at 2-3 h after surgery. During the first 48 h after the surgery, the proportion of patients experiencing PONV was 68% (95% CI 58-77) in the control group. A single dose of ondansetron or droperidol decreased the incidence of PONV to 30% (95% CI 21-40) and 28% (95% CI 20-38), respectively. The predicted incidence of PONV after drug combination, 11.8% (7.1-11.9), was similar to that observed, 12.1% (6.4-20.2), P = 0.94. The corresponding predicted and observed treatment responses in the combination group were 88.2% and 87.9%, respectively. There was a modest and transient increase in QTc interval after administration of ondansetron, droperidol, or their combination. The changes were however similar among groups. We conclude that the interaction between ondansetron and droperiodol was additive. Both drugs acted independently of each other through their specific mechanisms of action. The incidence of QTc prolongation did not increase with the drug combination.

The Effects of Droperidol in Perforating Keratoplasty

PURPOSE

To evaluate the intraoperative and postoperative effects of droperidol administered with general anesthesia during perforating keratoplasty.

METHODS

A prospective, randomized, double-masked clinical trial. Twenty-seven patients undergoing penetrating keratoplasty under general anesthesia were included. Patients were assigned randomly to two groups. Fifteen subjects received droperidol during induction of general anesthesia. Twelve control patients received general anesthesia without droperidol.

RESULTS

Droperidol significantly reduced fellow eye intraocular pressure (p < 0.0001). Intraoperative anterior chamber depth was significantly deeper with droperidol (p = 0.0002). Iris bulging was observed in 25% of the control group and 0% with droperidol. There was significantly less postoperative nausea in the droperidol group (p = 0.038). There was less postoperative vomiting in the droperidol group, although the difference was not significant (p = 0.07). Postoperative wound gaping was observed in 2 patients; both of them did not receive droperidol.

CONCLUSIONS

Droperidol effectively reduces intraoperative and postoperative complications in keratoplasty surgery.

Droperidol, when used for sedation during ERCP, may prolong the QT interval

BACKGROUND

Droperidol is a known effective adjunctive agent for sedation/analgesia during endoscopic procedures, particularly in patients who are difficult to sedate with narcotics and benzodiazepines alone. However, the Food and Drug Administration (FDA) warning about potential droperidol-related fatal cardiac arrhythmias, issued in December 2001, led to concern about its safety in current clinical practice.

OBJECTIVE

In this study, we evaluated the effects of droperidol on the Bazett's corrected QT interval (QTcB) administered to patients undergoing ERCP and frequency of cardiac arrhythmias.

DESIGN

We retrospectively reviewed the medical records of patients who, at our institute, underwent ERCP while under sedation/analgesia and who received droperidol. Our protocol for patients who are considered to be candidates for droperidol use includes obtaining an ECG before and 1 to 3 hours after the procedure.

RESULTS

From April 2002 to October 2004, 6292 ERCPs were performed, of which 3113 patients with normal baseline QTcB (2001 women, 1112 men) received droperidol. Mean dosages were 4.3 mg (range, 1.25-10 mg) in women and 4.5 mg (range, 1.25-13.75 mg) in men. A total of 233 patients (7.48%; 133 women, 100 men) developed QTcB prolongation. Mean increases of the QTcB above the upper limit of normal were 16 milliseconds in women (range, 1-194 milliseconds) and 22 milliseconds in men (range, 1-310 milliseconds). Of these, 15 patients (0.48%; 8 women, 7 men) had marked prolongation of the QTcB (defined QTcB, >500 milliseconds). No serious dysrhythmias occurred.

CONCLUSIONS

Droperidol at usual doses during sedation/analgesia may precipitate QTcB prolongation above the normal range. However, no QT-related arrhythmias were noted in this study. Clinically significant cardiac events are probably rare with droperidol, despite documented QTcB effects. Baseline electrocardiogram for excluding patients with prolonged baseline QTcB and 1 to 3 hours afterward monitoring appears adequate when using droperidol. The study is still too small to detect very infrequent arrhythmia events.

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.

Anesthesia for an adult with mucopolysaccharidosis I

We describe the anesthetic management difficulties of a man with mucopolysaccharidosis I. We also briefly review the anesthesia literature related to this disease.

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.

[Prophylactic use of droperidol for postoperative nausea and vomiting following gynecological laparoscopic surgery under total intravenous anesthesia]

BACKGROUND

Propofol and droperidol decrease the incidence of postoperative nausea and vomiting (PONV). We investigated the incidence of PONV after total intravenous anesthesia (TIVA) with propofol alone versus combined use of droperidol and propofol.

METHODS

Eighty three patients, who had undergone laparoscopic gynecologic surgery with TIVA using propofol and fentanyl, were retrospectively evaluated whether droperidol had affected the incidence of early (up to six hours postoperatively) and late (6-24 hours postoperatively) PONV. Group D (46 patients) received droperidol intravenously at the end of surgery. Group N (37 patients) received no droperidol.

RESULTS

The incidences of early nausea were 27% in Group N and 4% in Group D (P<0.01). The incidences of early vomiting were 0% in Group N and 8% in Group D. The incidences of late nausea were 14% in Group N and 13% in Group D. The incidences of late vomiting were 3% in Group N and 7% in Group D.

CONCLUSIONS

Droperidol was useful in reducing the incidence of early nausea and vomiting after total intravenous anesthesia with propofol and fentanyl in the patients undergoing laparoscopic surgery.

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.