Droperidol Use in the Emergency Department: A Clinical 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.

Neuroleptanalgesia for acute abdominal pain: a systematic review.

BACKGROUND: Acute abdominal pain (AAP) comprises up to 10% of all emergency department (ED) visits. Current pain management practice is moving toward multi-modal analgesia regimens that decrease opioid use. OBJECTIVE: This project sought to determine whether, in patients with AAP (population), does administration of butyrophenone antipsychotics (intervention) compared to placebo, usual care, or opiates alone (comparisons) improve analgesia or decrease opiate consumption (outcomes)? METHODS: A structured search was performed in Cochrane CENTRAL, CINAHL, Database of Abstracts of Reviews of Effects, Directory of Open Access Journals, Embase, IEEE-Xplorer, Latin American and Caribbean Health Sciences Literature, Magiran, PubMed, Scientific Information Database, Scopus, TÜBITAK ULAKBIM, and Web of Science. Clinical trial registries (ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and Australian New Zealand Clinical Trials Registry), relevant bibliographies, and conference proceedings were also searched. Searches were not limited by date, language, or publication status. Studies eligible for inclusion were prospective randomized clinical trials enrolling patients (age ≥18 years) with AAP treated in acute care environments (ED, intensive care unit, postoperative). The butyrophenone must have been administered either intravenously or intra-muscularly. Comparison groups included placebo, opiate only, corticosteroids, non-steroidal anti-inflammatory drugs, or acetaminophen. RESULTS: We identified 7,217 references. Six studies met inclusion criteria. One study assessed ED patients with AAP associated with gastroparesis, whereas five studies assessed patients with postoperative AAP: abdominal hysterectomy (n=4), sleeve gastrectomy (n=1). Three of four studies found improvements in pain intensity with butyrophenone use. Three of five studies reported no change in postoperative opiate consumption, while two reported a decrease. One ED study reported no change in patient satisfaction, while one postoperative study reported improved satisfaction scores. Both extrapyramidal side effects (n=3) and sedation (n=3) were reported as unchanged. CONCLUSION: Based on available evidence, we cannot draw a conclusion on the efficacy or benefit of neuroleptanalgesia in the management of patients with AAP. However, preliminary data suggest that it may improve analgesia and decrease opiate consumption.

Dexmedetomidine use during epiduroscopy reduces fentanyl use and postoperative nausea and vomiting: A single-center retrospective study.

OBJECTIVES: Minimally invasive epiduroscopy has recently been reported as an effective treatment procedure for chronic and intractable low back pain. However, no study has determined safe anesthetics for monitored anesthesia care during epiduroscopy. We aimed to compare and evaluate conventional monitored anesthesia care drugs with dexmedetomidine. METHODS: A retrospective study including all patients who underwent epiduroscopy at the JR Tokyo General Hospital from April 2011 to March 2016 was designed. The epiduroscopy procedures were performed under anesthesia with dexmedetomidine plus fentanyl (dexmedetomidine group) or droperidol plus fentanyl (neuroleptanalgesia group). Patients who received analgesics other than fentanyl, another analgesic combined with fentanyl, any sedative other than dexmedetomidine or droperidol, or who had incomplete data were excluded. We compared (1) the type and dose of medication during the epiduroscopy and (2) the incidence of postoperative nausea and vomiting. RESULTS: We identified 45 patients (31 and 14 in the dexmedetomidine and neuroleptanalgesia groups, respectively) with a mean age of 69.0 years. The two groups had comparable characteristics, such as age, sex, body mass index, the American Society of Anesthesiologists Physical Status, analgesics used in the clinic, comorbidities, history of smoking, and the duration of anesthesia. The dexmedetomidine group received a significantly lower fentanyl dose during surgery (126 ± 14 vs 193 ± 21 µg, mean ± standard deviation, p = 0.014) and exhibited a significantly lower incidence of postoperative nausea and vomiting (1 vs 3, p = 0.047) than the neuroleptanalgesia group. CONCLUSION: This study involved elderly patients, and the use of dexmedetomidine in monitored anesthesia care during epiduroscopy procedures in these patients may reduce the required fentanyl dose during surgery and the incidence of postoperative nausea and vomiting. This strategy may help prevent respiratory depression and aspiration.

Effects of three methadone doses combined with acepromazine on sedation and some cardiopulmonary variables in dogs.

OBJECTIVE: To evaluate the sedative and cardiopulmonary effects of three methadone doses, combined with acepromazine, in dogs. STUDY DESIGN: Prospective, randomized, complete block study. ANIMALS: Six healthy, adult, cross-bred dogs weighing 17.2±4.4 kg (mean±standard deviation). METHODS: Each dog was administered four treatments: acepromazine (0.05 mg kg-1) alone or acepromazine (same dose) in combination with methadone (0.25, 0.50 or 0.75 mg kg-1). All drugs were administered intramuscularly. Sedation was scored by a numeric descriptive scale (NDS, range 0-3) and a simple numerical scale (SNS, range 0-10). Heart rate, invasive blood pressure, arterial blood gases and rectal temperature were measured at 15 to 30 minute intervals for 120 minutes. RESULTS: According to NDS scores, mild to moderate sedation (NDS=1-2) was observed in most dogs in the acepromazine treatment, with only one out of six dogs scored as exhibiting intense sedation (NDS=3). All treatments with methadone resulted in significantly higher SNS scores compared with acepromazine alone. In these treatments, most dogs exhibited intense sedation (NDS=3). Increasing the dose of methadone from 0.25 to 0.50 or 0.75 mg kg-1 prolonged sedation in a dose-related manner, but did not influence the degree of sedation. The main adverse effects following administration of acepromazine-methadone treatments were decreased blood pressure, mild respiratory acidosis and decreased rectal temperature. These effects were well tolerated and resolved without treatment. CONCLUSIONS AND CLINICAL RELEVANCE: In this study in six dogs, acepromazine-methadone administration resulted in intense sedation in most dogs. The results are interpreted to indicate that a low dose of methadone (0.25 mg kg-1) administered in combination with acepromazine (0.05 mg kg-1) will induce short-term sedation in dogs, whereas higher doses of methadone should be administered when prolonged sedation is desired.

Preliminary assessment of midazolam, fentanyl and fluanisone combination for the sedation of rhesus macaques ( Macaca mulatta).

This study was undertaken to assess the suitability of fentanyl/fluanisone ('Hypnorm', VetaPharma; 0.315 mg/mL of fentanyl citrate and 10 mg/mL of fluanisone) alone or combined with midazolam in rhesus macaques. Fifteen rhesus macaques requiring sedation for veterinary procedures received an intramuscular (IM) dose range of Hypnorm from 0.01 mL/kg to 0.3 mL/kg either alone or combined with 0.5 mg/kg of midazolam. To reverse the sedation, flumazenil in combination with either naloxone, buprenorphine or butorphanol was administered intravenously (IV) or IM. Rhesus macaques were successfully sedated with 0.1 mL/kg of Hypnorm and 0.5 mg/kg of midazolam, and sedation was partially reversed by the administration of flumazenil and either naloxone or buprenorphine. However the primates remained slightly sedated and were only released into their home cage several hours post recovery. Butorphanol failed to induce recovery and caused marked respiratory depression. The neuroleptanalgesic combination, Hypnorm and midazolam, effectively immobilized rhesus macaques and was reversible with a combination of flumazenil and either naloxone or buprenorphine.

The application effect of sufentanil and dexmedetomidine on blind intubation in 88 patients with difficult airway / 重庆医学

Objective To explore the application effect of sufentanil or dexmedetomidine on blind intubation in 88 patients with difficult airway .Methods Eighty eight cases of patients with difficult airways in our hospital were divided into treatment group and control group depending on different preoperative sedation .There were 44 cases in each group .Patients in the treatment group were treated with dexmedetomidine anesthesia treatment ,and patients in the control group were treated in clinical routine application of sufentanil anesthesia ,both groups were taken blind intubation after anesthesia treatment .The heart rate ,systolic arterial pressure , diastolic arterial pressure and respiratory rate of patients before anesthesia ,after anesthesia ,when the intubation tube reached uvu‐la ,epiglottis ,when the intubation finished and 5 minutes after the intubation were recorded .Cases of nausea ,dysphoria ,bucking and respiratory depression during the intubation were also recorded .Results From the induction of anesthesia to 5 min after intubation , the respiratory rate of the treatment group was higher than the control group (P<0 .05);the systolic blood pressure ,diastolic blood pressure and heart rate of treatment group were significantly lower than the control group since intubation tube arrive uvula until the completion of systolic (P<0 .05);The arterial oxygen pressure was (98 .52 ± 9 .18) mm Hg in the treatment group 5 min after intubation ,which was significantly higher than the control group which was (93 .46 ± 10 .81) mm Hg (P<0 .05);cases of nausea , dysphoria ,bucking and respiratory depression in the treatment group were significantly lower than that of control group(P<0 .05) , and the average intubation time of the treatment group were significantly shorter than that of control group (P<0 .05) .Conclusion Dexmedetomidine could effectively improve the condition of the patients with difficult airways ,achieve effective anesthesia ,reduce cardiovascular reactivity in patients ,and ensure the smooth progress of intubation for the difficult airway patients .

Influence of electroacupuncture on thermal changes in a soft tissue defect.

This study investigated thermal changes in the skin at locations where soft tissue defects existed and acupuncture needles stimulated by using bipolar electroacupuncture (EA) had been inserted. Under general anesthesia (GA), experimental defects were made at the dorsum site of five New Zealand rabbits. Bipolar EA was used for 20 minutes to stimulate the experimental defects, and the skin temperature was monitored at the sites where the acupuncture needles had been inserted and the soft tissue defects existed. The initial thermography of those defects had the same trend as that of the negative pole of EA stimulation at the first acupoint. Skin thermography during the first 3 minutes of bipolar EA indicated a centrifugal vasoconstriction and a vasodilatation at the negative and positive poles, respectively. After that, the thermal change in soft tissue undergoing EA stimulation was not modified by a different EA polarity. The local temperature at the defect and its surroundings under both positive and negative electric loads was increased by 0.2-0.3 °C for vasodilatation. This study indicates that EA influences sympathetic modulation of soft tissue defects and that selective sympathetic modulation caused by bipolar EA is responsible for the clinical perception.

Psychiatric agents and implications for perioperative analgesia.

The use of antidepressants, anxiolytics, mood stabilizers, anticonvulsants, and major tranquilizers introduces neurochemical, behavioral, cognitive, and emotional factors that increase the complexity of medical and surgical tasks. Increasingly, various classes of psychotropic medications are being prescribed in the perioperative setting for their analgesic properties in patients with or without a psychiatric diagnosis. In many cases, the precise mechanisms of action and dose-response relationships by which these agents mediate analgesia are largely unclear. An appreciation of the side effects and adverse-effect profiles of such medications and familiarity with the clinically relevant drug interactions that may occur in the perioperative setting are imperative to ensure the best possible outcome in dealing with patients on these medications. This review focuses on various classes of psychotropic agents, which are addressed individually, with particular focus on their analgesic properties. The latest published research is summarized, deficiencies in our current collective knowledge are discussed, and evidence-based recommendations are made for clinical practice.

Randomized clinical trial of the effects of a combination of acepromazine with morphine and midazolam on sedation, cardiovascular variables and the propofol dose requirements for induction of anesthesia in dogs.

The present study evaluated the effects of acepromazine combined with midazolam and morphine on sedation and cardiovascular variables as well as the propofol dose required for induction of anesthesia in dogs compared with acepromazine-morphine or midazolam-morphine. Dogs were randomly assigned to receive an intramuscular administration of (1) acepromazine (0.05 mg/kg) with 0.5mg/kg of morphine (group AM, n=10), (2) midazolam (0.5mg/kg) with 0.5mg/kg of morphine (group MM, n=9), or (3) acepromazine with midazolam and morphine at the same doses (group AMM, n=10). After 30 min, sedation was assessed by a numeric descriptive scale (NDS, range 0-3) and a simple numerical scale (SNS, range 0-10). Dogs were then administered IV propofol to allow endotracheal intubation. NDS and SNS scores were significantly higher in the AMM than in the MM group (P<0.05). There was a trend towards more dogs presenting with intense sedation (NDS=3) in AMM (6/10 dogs) compared with AM (1/10 dogs) and MM (1/9 dogs) (P=0.057). The propofol dose required for induction of anesthesia was significantly lower in AMM (4.0mg/kg) compared with MM (6.0mg/kg, P<0.01) but not AM (4.6 mg/kg). Heart rate decreased in AM after treatment and after intubation. Blood pressure decreased in groups AM and AMM following treatment and in all groups after intubation. The combination AMM resulted in intense sedation more frequently than AM and MM, and provided the greatest sparing effect in the propofol dose. Administration of AM and AMM but not MM decreased blood pressure although hypotension was not recorded in healthy dogs.

Electroacupuncture analgesia in a rabbit ovariohysterectomy.

This study investigated the effectiveness of electroacupuncture analgesia (EAA) at local and paravertebral acupoints for a rabbit undergoing an ovariohysterectomy. Twelve clinically healthy New Zealand white rabbits were chosen and divided into two groups: the control group (5 rabbits) and the experimental group (7 rabbits). A neuroleptanalgesic (ketamine + xylazine) was administered to the control group (NLA group); the experimental group received EAA treatment (EAA group). The EAA treatment includes one acupuncture formula for local stimulation at the incision site and systemic stimulation. Results of clinical research have shown postoperative analgesia using EAA treatment to be superior to that using NLA. The average postoperative recovery time was 5.2 times longer in the NLA group than in the EAA group. Because consciousness was maintained, EAA presented an advantage in thermoregulation. Animals administered NLA had prolonged thermal homeostasis because of neurovegetative disconnection. For the EAA group, the operative times were characterized as excellent (28%, p = 0.28) or good (72%, p = 0.72). Local stimulation at the incision site provided excellent analgesia of the abdominal wall (100%). In conclusion, EA can provide general analgesia with a considerable analgesic effect for a rabbit undergoing an ovariohysterectomy, resulting in a short postoperative recovery time.

The safety of the application of dexmedetomidine in patients with heart failure / 中国医师杂志

Objective To investigate the safety of the application of dexmedetomidine in patients with heart failure .Methods The selective cardiac surgery 80 patients with heart failure were randomly divided into two groups ( n =20 each):group I:0.5 μg/kg dexmedetomidine intravenous injection in 10 min;and group II:control group.Systolic blood pressure (SBP), diastolic blood pres-sure (DBP), heart rate (HR), oxygen saturation (SpO2), and bispectral index (BIS) were recorded at 10, 20, 30 min after injec-tion.Cardiac output (CO) and stroke volume variation (SVV) were also recorded at the time after radial artery and internal jugular vein puncture , and Ramsay and visual analogue scale ( VAS) score were also given to each patients of two groups at 30 min.Results The SBP, DBP, HR, and BIS of group I were lower than group II at 10 and 20 min after injection ( P <0.05 ); the SBP, DBP, HR, and BIS of group I were also lower than group II at the time after radial artery and internal jugular vein puncture [ SBP:(124.9 ± 15.5)mmHg vs (138.7 ±17.8)mmHg;(128.9 ±17.8)mmHg vs (140.3 ±19.3)mmHg, P <0.05;DBP:(69.4 ±10.2)mmHg vs (80.1 ±11.2)mmHg;(70.5 ±11.8)mmHg vs (87.7 ±13.6)mmHg, P <0.05;HR:(65.3 ±9.4)bpm vs (78.8 ±10.9)bpm;(68.2 ±10.8)bpm vs (80.9 ±13.3)bpm, P <0.05;BIS:84.5 ±5.7 vs 95.4 ±3.7;87.8 ±7.7 vs 95.3 ±4.7, P <0.05]; The CO, SVV, and SpO2 were no difference between two groups;the Ramsay(3.4 ±1.5 vs 1.2 ±0.4;3.9 ±1.7 vs 1.4 ±0.5) and VAS (2.1 ±0.7 vs 3.8 ±2.1;1.9 ±1.5 vs 4.1 ±2.1)score of group I were lower than group II ( P <0.05).Conclusions A amount (0.5 μg/kg) of dexmedetomidine intravenous injection can be safely used in patients with heart failure .

Efeitos antinociceptivos e sedativos da buprenorfina, da acepromazina ou da associação buprenorfina e acepromazina em gatos / Antinociceptive and sedative effects of buprenorphine, acepromazine, or combination of both, in conscious cats

O efeito antinociceptivo da buprenorfina tem sido relatado em cães e gatos. No presente estudo, avaliou-se o limiar nociceptivo mecânico em felinos tratados com buprenorfina, acepromazina ou ambas associadas e foram comparados os efeitos antinociceptivos e sedativos da associação em relação ao uso isolado desses fármacos determinados pelo mesmo observador, por meio de analgesiômetro e da escala analógica visual dinâmica interativa (DIVAS), respectivamente. Os oito animais empregados no estudo foram previamente familiarizados com os procedimentos utilizados. Após quatro mensurações basais, foram administrados, por via intramuscular, 0,02mg kg-1 de buprenorfina, 0,06mg kg-1 de acepromazina ou 0,01mg kg-1 de buprenorfina associada a 0,03mg kg-1 de acepromazina, em um estudo cego, com delineamento em quadrado latino e tratamento semanal. Os efeitos antinociceptivos e sedativos foram avaliados aos 15, 30, 45 minutos e uma, duas, três, quatro, seis, oito e 12 horas após a administração do tratamento. O limiar nociceptivo mecânico se elevou significativamente apenas no grupo tratado com a associação buprenorfina-acepromazina (entre 45 minutos e uma hora). Em relação à sedação, nos grupos tratados com acepromazina e com a associação, os valores da DIVAS foram significativamente maiores, respectivamente, de 15 minutos até quatro horas e de 15 minutos até três horas pós-tratamento, não apresentando elevação desses valores com a buprenorfina. Concluiu-se que não foi possível verificar a superioridade da neuroleptoanalgesia em relação ao uso dos fármacos isoladamente.

The antinociceptive effects of buprenorphine have been reported in dogs and cats. This study evaluated changes in the mechanical nociceptive threshold and the sedative effects of buprenorphine, acepromazine and its combination in cats, determined by the same observer using a nociceptive threshold testing device and DIVAS, respectively. Eight animals were previously conditioned to the procedures. After four baseline measurements, 0.02mg kg-1 of buprenorphine, 0.06mg.kg-1 of acepromazine, or 0.01mg kg-1 of buprenorphine with 0.03mg kg-1 of acepromazine were administered intramuscularly in a blinded and experimental study using a Latin square design within a one week interval between treatments. The antinociceptive and sedative effects were evaluated at 15, 30, 45 minutes and 1, 2, 3, 4, 6, 8 and 12 hours post treatment. The nociceptive threshold increased significantly only after the combination buprenorphine-acepromazine (between 45 minutes and 1 hour). Regarding sedation, the use of acepromazine and the combination of both were associated with significantly higher DIVAS values from 15 minutes to 4 hours and 15 minutes to 3 hours post treatment, respectively. No increase in these values was noted with the use of buprenorphine. It was concluded that it could not be verified the superiority of neuroleptanalgesia over the use of drugs alone.