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American Journal of Health-system... Oct 2020After a long period of low utilization, droperidol has become easier to obtain in the US market. This comprehensive review discusses the safety, indications, clinical... (Review)
Review
PURPOSE
After a long period of low utilization, droperidol has become easier to obtain in the US market. This comprehensive review discusses the safety, indications, clinical efficacy, and dosing of droperidol for use in the emergency department (ED) setting.
SUMMARY
In 2001 the US Food and Drug Administration (FDA) mandated a boxed warning in the labeling of droperidol after reports of QT interval prolongation associated with droperidol use. Since that time, it has been difficult to access droperidol in the United States; as a result, many practicing clinicians lack experience in its clinical use. Multiple studies have been conducted to assess the clinical efficacy and safety of droperidol use in ED patients. Results consistently show the safety of droperidol and its clinical efficacy when used as an analgesic, antiemetic, and sedative. Now that droperidol is more widely available for use in the US market, pharmacists and prescribers need to reliably translate safety and efficacy data compiled since 2001 to help ensure appropriate and effective use of the medication.
CONCLUSION
Droperidol is an effective and safe option for the treatment of acute agitation, migraine, nausea, and pain for patients in the ED setting. Healthcare professionals can adopt droperidol for use in clinical practice, and they should become familiar with how to dose and monitor droperidol for safe and effective use.
Topics: Dose-Response Relationship, Drug; Droperidol; Drug Labeling; Drug Monitoring; Drug Utilization; Emergency Service, Hospital; Emergency Treatment; Humans; Long QT Syndrome; Migraine Disorders; Nausea; Pain; Practice Patterns, Physicians'; Psychomotor Agitation; Treatment Outcome; United States
PubMed: 32839811
DOI: 10.1093/ajhp/zxaa271 -
Journal of Education & Teaching in... Oct 2020This scenario was developed to educate emergency medicine residents about the diagnosis and management of the agitated psychiatric patient.
AUDIENCE
This scenario was developed to educate emergency medicine residents about the diagnosis and management of the agitated psychiatric patient.
INTRODUCTION
The prevalence of agitation among patients in the emergency department is increasing, with an estimated 1.7 million events occurring annually in the United States.1 There are various methodologies for de-escalation, including verbal and chemical de-escalation and physical restraints. Chemical and/or physical restraints are sometimes necessary to ensure patient and staff safety when verbal de-escalation is ineffective, particularly since agitation is the leading cause of hospital staff injuries.2 Chemical restraints have been shown to be less physically traumatizing to patients.3 4 Adverse events associated with physical restraints include persistent psychological distress, blunt chest trauma, aspiration, respiratory depression, and asphyxiation leading to cardiac arrest.5 In regards to chemical restraints, adverse event reporting has been heterogeneous among studies, but the most consistent reported events involve respiratory compromise such as desaturation, airway obstruction, and respiratory depression.3 A study measuring QTc (corrected QT interval) after high-dose intramuscular ziprasidone or haloperidol did not demonstrate any QTc longer than 480 msec.6 Other events linked to chemical restraints include uncommon cardiovascular events and extrapyramidal side effects from medications.3 The main classes of medications utilized for chemical restraint include first-generation antipsychotics (eg, haloperidol and droperidol), second-generation antipsychotics (olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone), benzodiazipenes (eg, lorazepam and midazolam), and N-methyl-D-aspartic acid (NMDA) receptor antagonists (eg, ketamine).7,8 It is important to exclude other medical causes of agitation, consider the differential diagnoses, and then select a medication that is tailored to address underlying etiologies while remaining cognizant of the side effect profiles of these chemical agents.: At the conclusion of the simulation session, learners will be able to: 1) Obtain a relevant focused history and physical examination on the agitated psychiatric patient. 2) Develop a differential for the agitated psychiatric patient, including primary psychiatric conditions and other organic pathologies. 3) Discuss the management of the agitated psychiatric patient, including the different options available for chemical sedation. 4) Prioritize safety of self and staff when caring for an agitated psychiatric patient.
EDUCATIONAL METHODS
This session was conducted using simulation with a standardized patient, followed by a debriefing session and lecture on the presentation, differential diagnosis, and management of the agitated psychiatric patient. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board examination case.
RESEARCH METHODS
The residents are provided a survey at the completion of the debriefing session to rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. This survey is specific to the local institution's simulation center.
RESULTS
Feedback from the residents was overwhelmingly positive, although many stated that they felt some degree of intimidation or stress from the standardized patient who did not break from their role throughout the scenario.The local institution's simulation center feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form9 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. This session received mostly 7 scores (extremely effective/outstanding).
DISCUSSION
This is a physically safe method for reviewing management of the agitated psychiatric patient. There are multiple potential presentations of the agitated psychiatric patient, as well as varying underlying etiologies. These scenarios may be tailored to the needs of the learner, including identifying agitation, pharmacologic review, and de-escalation techniques.
TOPICS
Medical simulation, agitated psychiatric patient, chemical sedation, verbal de-escalation, emergency medicine, psychiatry.
PubMed: 37465334
DOI: 10.21980/J85352 -
The American Journal of Emergency... Mar 2022Droperidol is a butyrophenone that has recently been reintroduced after a United States Food and Drug Administration (US FDA) black box warning in 2001. Evidence...
INTRODUCTION
Droperidol is a butyrophenone that has recently been reintroduced after a United States Food and Drug Administration (US FDA) black box warning in 2001. Evidence demonstrates utility in a variety of clinical conditions.
OBJECTIVE
This paper provides evidence-based updates concerning the use of droperidol for the emergency clinician.
DISCUSSION
Droperidol received a black box warning by the US FDA in 2001 due to concerns for QT prolongation and torsades de pointes; however, reevaluation of the available data suggests droperidol is a safe and efficacious medication. It can be used in the emergency department (ED) setting for many conditions, including acute agitation, headaches, vertigo, nausea, and vomiting. Extensive literature supports that the QT-prolonging effects are transient and that the risk of torsades de pointes is rare with doses utilized in the ED. An electrocardiogram does not need to be routinely obtained before droperidol use but should be considered in patients at high risk for QT prolongation.
CONCLUSIONS
Current evidence suggests that droperidol is a safe and effective medication for treating nausea and vomiting, headache, vertigo, and agitation in the ED setting.
Topics: Droperidol; Emergency Medicine; Headache; Humans; Long QT Syndrome; Nausea; Torsades de Pointes; United States; Vertigo; Vomiting
PubMed: 35063889
DOI: 10.1016/j.ajem.2022.01.011 -
Best Practice & Research. Clinical... Dec 2020Postoperative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV) are frequent unpleasant complaints that patients and clinicians report after... (Review)
Review
Postoperative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV) are frequent unpleasant complaints that patients and clinicians report after surgery. PONV and PDNV have been associated with postoperative complications and hospital discharge delays. Despite the extensive evidence describing the use of several regimens in different surgical populations, the ideal regimen has not been established. Several antiemetic drugs have been evaluated in more than 1000 clinical controlled trials for management of this complex emetogenic pathway, including the 5-hydroxytryptamine (5-HT) receptor antagonists, dopamine receptor antagonists, neurokinin-type receptor antagonists, antihistaminics, anticholinergics, and corticosteroids, with the 5-HT receptor antagonists being the most commonly used for PONV prophylaxis. Because of the complex emetogenic pathway and multifactorial etiology of PONV, a multimodal approach using two or more drugs that act at different neuro-receptor sites is suggested in patients with one or more risk factors to successfully address PONV and reduce its incidence. Nevertheless, the most studied regimens in randomized clinical trials (RCTs) are the combination of serotonin 5-HT3 receptor antagonists with dexamethasone or dopamine receptor antagonists (droperidol). Therefore, the safest and more effective combination regimen appears to be the use of serotonin 5-HT3 receptor antagonist antiemetic drugs with dexamethasone.
Topics: Aftercare; Antiemetics; Dopamine Antagonists; Drug Therapy, Combination; Histamine Antagonists; Humans; Meta-Analysis as Topic; Patient Discharge; Postoperative Nausea and Vomiting; Risk Factors; Serotonin 5-HT3 Receptor Antagonists; Sex Factors; Systematic Reviews as Topic
PubMed: 33288120
DOI: 10.1016/j.bpa.2020.10.009 -
The Journal of Emergency Medicine Mar 2023Droperidol is a butyrophenone, with antiemetic, sedative, anxiolytic, and analgesic properties. Although droperidol was once widely used in both emergency and... (Review)
Review
BACKGROUND
Droperidol is a butyrophenone, with antiemetic, sedative, anxiolytic, and analgesic properties. Although droperidol was once widely used in both emergency and perioperative settings, use of the medication declined rapidly after a 2001 U.S. Food and Drug Administration (FDA) boxed warning called the medication's safety into question.
OBJECTIVE
The purpose of this clinical review was to provide evidence-based answers to questions about droperidol's safety and to examine its efficacy in its various clinical indications.
DISCUSSION
Droperidol is an effective sedative, anxiolytic, analgesic, and antiemetic medication. As a sedative, when compared with haloperidol, droperidol has faster onset, as well as greater efficacy, in patients experiencing acute psychosis, with no increase in adverse events. As an antiemetic, droperidol has been found to have equal or greater efficacy in reducing nausea and vomiting than ondansetron and metoclopramide, with similar adverse effects and the added effect of reducing the need for rescue analgesia in these patients. As an analgesic, droperidol is effective for migraines and has opioid-sparing effects when used to treat abdominal pain. Droperidol is a particularly useful adjunct in patients who are opioid-tolerant, whose pain is often difficulty to manage adequately.
CONCLUSIONS
Droperidol seems to be effective and safe, despite the boxed warning issued by the FDA. Droperidol is a powerful antiemetic, sedative, anxiolytic, antimigraine, and adjuvant to opioid analgesia and does not require routine screening with electrocardiography when used in low doses in otherwise healthy patients before administration in the emergency department.
Topics: Humans; Analgesics; Analgesics, Opioid; Anti-Anxiety Agents; Antiemetics; Droperidol; Emergency Service, Hospital; Hypnotics and Sedatives; Ondansetron; Pain
PubMed: 36925442
DOI: 10.1016/j.jemermed.2022.12.012 -
The Medical Letter on Drugs and... Oct 2020
Topics: Acupuncture Therapy; Adult; Analgesics; Anti-Inflammatory Agents, Non-Steroidal; Antiemetics; Calcitonin Gene-Related Peptide Receptor Antagonists; Drug Interactions; Ergot Alkaloids; Female; Humans; Migraine Disorders; Pregnancy; Serotonin 5-HT1 Receptor Antagonists; Tryptamines
PubMed: 33434187
DOI: No ID Found -
Journal of Anesthesia Dec 2023Perioperative shivering is common and can occur as a result of hypothermia or changes in the threshold of thermoregulation. Droperidol usage for anesthesia is currently...
PURPOSE
Perioperative shivering is common and can occur as a result of hypothermia or changes in the threshold of thermoregulation. Droperidol usage for anesthesia is currently limited to its sedative and antiemetic effects. We investigated the effects of high and low doses of droperidol on the shivering threshold in rabbits.
METHODS
Forty-two male Japanese white rabbits were anesthetized with isoflurane and randomly assigned to the control, high-dose, or low-dose group. Rabbits in the high-dose group received a 5 mg/kg droperidol bolus followed by continuous infusion at 5 mg/kg/h, those in the low-dose group received a 0.5 mg/kg droperidol bolus, and those in the control group received the same volume of saline as the high-dose group. Body temperature was reduced at a rate of 2-3 °C/h, and the shivering threshold was defined as the subject's core temperature (°C) at the onset of shivering.
RESULTS
The shivering thresholds in the control, high-dose, and low-dose groups were 38.1 °C ± 1.1 °C, 36.7 °C ± 1.2 °C, and 36.9 °C ± 1.0 °C, respectively. The shivering thresholds were significantly lower in the high-dose and low-dose groups than in the control group (P < 0.01). The thresholds were comparable between the high-dose and low-dose groups.
CONCLUSIONS
Droperidol in high and low doses effectively reduced the shivering threshold in rabbits. Droperidol has been used in low doses as an antiemetic. Low doses of droperidol can reduce the incidence of shivering perioperatively and during the induction of therapeutic hypothermia.
Topics: Animals; Rabbits; Male; Shivering; Droperidol; Body Temperature; Isoflurane; Hypothermia
PubMed: 37566231
DOI: 10.1007/s00540-023-03240-1 -
The Annals of Pharmacotherapy Feb 2015To evaluate the safety and efficacy of droperidol for the relief of acute migraine headaches. (Review)
Review
OBJECTIVE
To evaluate the safety and efficacy of droperidol for the relief of acute migraine headaches.
DATA SOURCES
A MEDLINE search (1946 to August 2014) was performed using the following keywords and associated medical subject headings: droperidol, inapsine, headache, migraine, and migraine disorder.
STUDY SELECTION AND DATA EXTRACTION
The search was conducted to identify randomized controlled trials comparing droperidol with placebo or an active control in adult patients with acute migraine headaches that were published in English. Primary end points included acute headache improvement after the intervention. Safety end points included the frequency of extrapyramidal symptoms, somnolence, and cardiac adverse effects.
DATA SYNTHESIS
In all, 5 manuscripts are included in this review. Patients presenting to the emergency department with acute headache desire rapid pain relief, which was the primary objective in each of the evaluated studies. Droperidol was better than placebo and at least as effective as comparator drugs such as prochlorperazine, meperidine, or olanzapine using droperidol doses of 2.5 to 5 mg, given either intramuscularly (IM) or intravenously (IV). The most commonly reported adverse effects were extrapyramidal symptoms and sedation. Cardiac adverse effects were not reported in any of the studies; however, only 2 articles described using cardiac monitoring.
CONCLUSIONS
Parenteral droperidol is an effective option for the treatment of acute migraine. The minimum effective dose is 2.5 mg given IM or IV. Clinicians must be aware of the risk for adverse events, select appropriate patients, perform EKG monitoring for patients at risk of QTc prolongation, and institute treatment if necessary.
Topics: Acute Disease; Dopamine Antagonists; Droperidol; Humans; Migraine Disorders; Randomized Controlled Trials as Topic
PubMed: 25416184
DOI: 10.1177/1060028014554445 -
Ci Ji Yi Xue Za Zhi = Tzu-chi Medical... 2018Droperidol is a short-acting, potent dopamine D2 antagonist that can pass through the blood-brain barrier. A black box warning was issued for droperidol by the United... (Review)
Review
Droperidol is a short-acting, potent dopamine D2 antagonist that can pass through the blood-brain barrier. A black box warning was issued for droperidol by the United States Food and Drug Administration in 2001 because of a risk of development of torsades de pointes induced by QT prolongation. Many experts feel that the incidence of arrhythmia is overestimated, and low-dose droperidol is almost always used by anesthesiologists for postoperative nausea and vomiting. In this review, we used evidence-based analysis to appraise high-quality studies with a low risk of bias published after 2001 on the use of droperidol in the emergency department (ED). Droperidol appears not only efficacious but also safe to treat patients with nausea/vomiting, acute psychosis, and migraine in the ED. For these conditions, droperidol may be an option for shared decision-making.
PubMed: 29643708
DOI: 10.4103/tcmj.tcmj_195_17 -
Annals of Emergency Medicine Jan 2016
Topics: Conscious Sedation; Dangerous Behavior; Droperidol; Emergency Service, Hospital; Female; Humans; Hypnotics and Sedatives; Male
PubMed: 26707529
DOI: 10.1016/j.annemergmed.2015.09.029