Question & Answers Re: Droperidol

Thanks to Delia for requesting information regarding the correct route of Droperidol administration. As per the following emails, the end result is that Anesthesiologists should not be ordering Droperidol for PONV until it has been passed through the P&T committee.

Question:
Hi Helen (Zhong) and John (Iazzetta)
Recently there have been anesthesiologists ordering Droperidol for post-op nausea and vomiting in the PACU. I can’t seem to find it in the Sunnybrook formulary, nor under the IV authorization for Nurses. Is this a new medication being used at SB? If it is, the trend seems to be that we will be using it more frequently in PACU as drug of choice for PONV and it should be added to the above pharmacy sections.
Can you find out how it is meant to be given ie: can the RN’s push it (like gravol) or does it need to be hung in a minibag?
Thanks for clarifying, I look forward to your response!
Ramona


(email from John Iazzetta, Pharm.D.Drug Information Service)
As you may be aware, Jason is proposing revising the PONV algorithm, especially the rescue antiemetics. One change is the routine use of IV droperidol in the PACU. A major for this change are that it is considered by many to be the most effective antiemetic in the PONV setting.

The reason for it’s lack of use over the years is that case reports published years ago had associated it’s use with prolonged QT-interval and rarely, Torsade de Pointe. As a result of these reports the FDA required a black box to be included in the product monograph, warning of the potential for this arrhythmia. Because of the black box most anesthesiologists stopped using it because medical-legal concerns.

However, over the past few years the initial reports implicating droperidol have been critically reviewed by many experts in this area and concluded that the warning was unfounded because in the majority of cases there were other contributing factors and the doses used greatly exceeded the usual antiemetic doses used in PONV.

Many experts and consensus guidelines have concluded that droperidol is an effective and relatively safe antiemetic when used in low doses (eg 1mg) and for one or two doses. As safeguards, the anesthesiologists/APS should still screen patients who might be at risk for QT-prolongation and patients should undergo ECG monitoring during and for a brief period following the dose. In recalling my discussion with Jason, we agreed to administer the dose via a minibag, at least initially.

The plan is to take the revised PONV algorithm to P&T for approval, at which time we would request that the PACU nurses be authorized to administer droperidol IV. My suggestion is that the anesthesiologists be requested to not prescribe the drug with the expectation that the PACU nurses will administer until it is officially approved by P&T (pharmacy cannot add droperidol to the authorized IV list without P&T approval). In the interim, although it may not be practical, the physicians are free to administer droperidol IV at their discretion.

(From John)
Dr. Morningstar has responded to the email and has offered to review the literature on the efficacy and safety of IV droperidol for PONV and propose a protocol for its administration in the PACU. Unfortunately, because of scheduling conflicts the earliest we can present this issue at the P&T Committee is in April.

Until there is an approved protocol we would ask that that you please refrain from prescribing the drug.

Thank you for your cooperation.

John