Does Low-dose Droperidol Increase the Risk of Polymorphic Ventricular Tachycardia or Death in the Surgical Patient?

Abstract

Background:The Food and Drug Administration issued a black box warning regarding the use of droperidol and the potential for torsade de pointes. Methods: The primary objective of this retrospective study was to determine if low-dose (0.625 mg) droperidol administration was associated with episodes of torsade de pointes in the general surgical population during the 3-yr period following the reinstitution of droperidol to our institutional formulary. Results:The authors identified 20,122 surgical patients who received 35,536 doses of droperidol. These patients were cross-matched with an electrocardiogram database and an adverse outcome database. The charts of 858 patients were reviewed, including patients with documentation of prolonged QTc (>440 ms) from March 2007 to February 2011, polymorphic ventricular tachycardia (VT) within 48 h of receiving droperidol, or death within 7 days of receiving droperidol. Twelve surgical patients had VT (n = 4) or death (n = 8) documented within 48 h of droperidol administration. No patients developed polymorphic VT or death due to droperidol administration (n = 0). The eight patients that died were on palliative care. The four patients with documented VT had previous cardiac conditions: two had pre-existing implantable cardiac defibrillators, three had episodes of VT before receiving droperidol, and another had pre-existing hypertrophic obstructive cardiomyopathy.The authors found 523 patients with a documented QTc >440 ms before receiving droperidol. No patients developed VT or death as a direct result of droperidol administration. Conclusions: Our evidence suggests that low-dose droperidol does not increase the incidence of polymorphic VT or death when used to treat postoperative nausea and vomiting in the surgical population. POsTOperATiVe nausea and vomiting (pONV) results in an increased length of hospital stay and decreases patient satisfaction. Droperidol, is used as an antiemetic and for treatment of agitation and delirium in critically ill patients.1 Lowdose droperidol, in the dose range of 0.625-1.25 mg, has been used successfully by anesthesia providers for the treatment and prevention of pONV in millions of patients for over 30 yr. 2,3Droperidol acts centrally by antagonizing one of the pathways causing nausea and vomiting. 4 in December 2001, The U.s. Food and Drug Administration issued a black box warning for droperidol based on safety reports of adverse cardiac events believed to be associated with QTc prolongation and the development of torsades de pointes (Tdp), a form of polymorphic ventricular tachycardia (VT).3 Before issuing the warning, there was accumulating evidence of QT prolongation and risk for Tdp and the Food and Drug Administration was called upon to review 22 cases of QT prolongation or Tdp, including five deaths. 5 The droperidol package

Pathophysiological and neurochemical mechanisms of postoperative nausea and vomiting

“…Its ability to prolong the QT interval has been attributed to its action to block the rapid component of the delayed rectifier potassium current within myocytes (Drolet et al, 1999). However, recent studies have shown that the low doses of droperidol used for PONV prophylaxis do not increase the risk for arrhythmia formation or cardiac death (Nuttall et al, 2007; Nuttall et al, 2013). This recent data suggests that the low doses used to potentially prevent PONV are likely safe.…”

Small doses of droperidol do not present relevant torsadogenic actions: a double‐blind, ondansetron‐controlled study

“…That study included 20 122 persons receiving a total of 35 536 doses of 0.625 mg of droperidol intravenously. Eight hundred and fifty‐eight of those individuals had ECG charts that could be analyzed and no one developed polymorphic ventricular tachycardia or death as a direct result of droperidol administration . On the other hand, TdP has clearly been reported associated with droperidol in cases published in the literature.…”

Agitation Crisis Control

“…Despite a black box warning on droperidol, there are many studies demonstrating its safety. [7][8][9][10][11][12] Adverse effects to be aware of are extrapyramidal syndrome and QT-interval prolongation. The QT-interval effects are unlikely to be clinically significant and rarely precipitate torsades de pointes.…”

“…The QT-interval effects are unlikely to be clinically significant and rarely precipitate torsades de pointes. 7,10 Benzodiazepines have relatively quick onset, are safe, and can be rapidly titrated to effect. They can be used alone or in combination with antipsychotics.…”