An ode to Droperidol

[Angry Birds]

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I remember when I was in residency all the old timers would talk about how they miss droperidol. Now I know why.

What doses do you guys use? I often go for the full 5 mg IV. Too much?

 

[BoardingDoc]

I remember when I was in residency all the old timers would talk about how they miss droperidol. Now I know why.

What doses do you guys use? I often go for the full 5 mg IV. Too much?

Depends on circumstances.

Cannabinoid hyperemesis: 2.5mg IV unless they're a peanut in which case I do 1.25.
Agitated psych patient who needs to chill out: IM 5 of drop with 5 of versed.
Very agitated or large psych patient who needs to go the F*** to sleep: IM 10 of drop with 5 of versed.

Acutely dangerous agitated psych patient: 5mg/kg IM ketamine.

 

[AlmostAnMD]

Depends on circumstances.

Cannabinoid hyperemesis: 2.5mg IV unless they're a peanut in which case I do 1.25.
Agitated psych patient who needs to chill out: IM 5 of drop with 5 of versed.
Very agitated or large psych patient who needs to go the F*** to sleep: IM 10 of drop with 5 of versed.

Acutely dangerous agitated psych patient: 5mg/kg IM ketamine.

I was the system leader of droperidol usage per pharmacy review for quite a while. once that label came off it was my go-to for quite a few situations.

I agree with above, and will add it's actually a VERY good nausea medication for people that aren't crazy at 0.625 mg iv.

EDIT: My "agitated trauma patient" cocktail was 2.5 or 5 mg IV (depending on patient size/agitation) and 50 mcg fentanyl iv. This cocktail would go from "we gotta intubate to assess this guy" to "good job ed doctor" in 3 min

 

[Groove]

I love the stuff and have wholeheartedly and enthusiastically started using it until the recent shortage. I usually give 2.5mg IV max and/or 1.25mg. I rarely need more than 2.5 and feel like 5 is actually counterproductive and increases my LOS because it's too much sedation at that point. I mainly use it on the gastroparetics or the supratentorial agitated (non hostile) pts. If they are hostile and trying to fight people I still go straight to ketamine. If they are 100% psych and extremely agitated...close to hostile. I'm usually using Geodon. Drop might work on that pt population too but I just don't have much experience using the stuff up until a couple years ago. However, all the glory talk from my attendings way back in residency was apparently justified.

 

[BJJVP]

I saw it used in some of my med school rotations for nausea/vomiting and then never again. Why did it fall out of favor and then return into our good graces?

 

[Groove]

I saw it used in some of my med school rotations for nausea/vomiting and then never again. Why did it fall out of favor and then return into our good graces?

Here's the history:

The Surprising Re-emergence of Droperidol - PMC

pmc.ncbi.nlm.nih.gov

 

[southerndoc]

Agree with the dosages people have mentioned above.

For simple vomiting that Zofran isn't helping, 0.625-1.25 mg IV.

It is an excellent migraine medication... 0.625 mg IV. Rarely, if ever, does someone still have a migraine after that.

I used up the last vial in the hospital the other day. My colleagues have aggravated me about it. LOL Hopefully we get more soon! Vitamin D!

 

[TooMuchResearch]

Agree with the dosages people have mentioned above.

For simple vomiting that Zofran isn't helping, 0.625-1.25 mg IV.

It is an excellent migraine medication... 0.625 mg IV. Rarely, if ever, does someone still have a migraine after that.

I used up the last vial in the hospital the other day. My colleagues have aggravated me about it. LOL Hopefully we get more soon! Vitamin D!

I routinely use it at 2.5 mg IV for headaches in young, healthy people.

It's a great add on medication for severe abdominal pain not responding well to the usual suspects. I recently had a patient with ischemic sigmoid volvulus still writhing after 3 mg Dilaudid and suddenly better after 2.5 mg droperidol.

 

[Tiger26]

Without it, I'm not sure I would continue doing emergency medicine (half serious ...)

Our health system makes our own, so we've been using it for years, even when all the not-shady-at-all black box stuff happened.

I find it about 98% effective for the pan-positive review of systems patient (i.e. "my hair hurts and I get elbow numbness every leap year")

 

[Jabbed]

It just went on shortage for us. I use 2.5 mg IV for most things. 5 mg droperidol IM with 5 mg versed IM is by far my favorite chemical takedown. It’s quick onset, they’re not totally snowed 2 hours later, and I haven’t had many issues with respiratory depression.

 

[xaelia]

I usually use it at 1.25mg IV as my floor-wax-and-a-dessert-topping dose, with a reduction to 0.625mg in the somewhat frail.

Since it's an old drug the literature behind it is Real Old, with all the warts the data gathered in that generation might have. I feel like 1.25mg is the sweet spot between sedation and efficacy, but there are a lot of Right ways to use droperidol.

Efficacy, dose-response, and adverse effects of droperidol for prevention of postoperative nausea and vomiting - PubMed

Droperidol is anti-emetic in the surgical setting. The effect on nausea is short-lived but more pronounced than the effect on vomiting. Sedation and drowsiness are dose-dependent, extrapyramidal symptoms are rare, and there is a protective effect against headache.

pubmed.ncbi.nlm.nih.gov

 

[Groove]

floor-wax-and-a-dessert-topping

My memory just completely jolted some cobwebs. Chevy Chase SNL skit from way back when?

 

[xaelia]

My memory just completely jolted some cobwebs. Chevy Chase SNL skit from way back when?

It's new Shimmer.

Same generation as "Wow, that's terrific bass!"

 

[EMhawkeye]

It's new Shimmer.

Same generation as "Wow, that's terrific bass!"

Halloween costumes: johnny human torch and johnny invisible pedestrian

 

[Janders]

Halloween costumes: johnny human torch and johnny invisible pedestrian

bag of glass! It’s a great children’s toy

 

[thegenius]

Does anybody who uses droperidol work in California?

 

[BJJVP]

Does anybody who uses droperidol work in California?

Why does it matter? Genuine question

 

[Jabbed]

Why does it matter? Genuine question

Droperidol is known to cause cancer in the state of California.










😉

 

[RustedFox]

Why does it matter? Genuine question

The laws of physics apply differently in CA. Droperidol may result in weird side effects like those we saw in "Charlie and the Chocolate Factory" (the good one, not the remake). Patients would turn blue and need to be rolled away by Oompah Loompahs, broken down into a "million tiny pieces" and then put back together on the TV screen, etc.

 

[thegenius]

Why does it matter? Genuine question

I asked my pharmacist here in CA and he said there is some state law preventing its use or some such. I can’t remember what he said but it was frustrating that he said we basically can’t use it.

 

[EctopicFetus]

I asked my pharmacist here in CA and he said there is some state law preventing its use or some such. I can’t remember what he said but it was frustrating that he said we basically can’t use it.

California is great in many ways but so completely stupid in perhaps many more…

 

[BoardingDoc]

I asked my pharmacist here in CA and he said there is some state law preventing its use or some such. I can’t remember what he said but it was frustrating that he said we basically can’t use it.

CA makes some bananas laws sometimes, but I would be more surprised if the answer was that there was in fact some law banning droperidol as opposed to the answer being that your pharmacist is confused / actually talking about the recent shortage / referring to the original black box warning etc etc....

 

[serosanguinous]

I asked my pharmacist here in CA and he said there is some state law preventing its use or some such. I can’t remember what he said but it was frustrating that he said we basically can’t use it.

I use this medication just about every shift in CA.

 

[Tiger26]

It's been about a decade since I worked in California, but that state could use a lot more droperidol

 

[Rockinacoustic]

I asked my pharmacist here in CA and he said there is some state law preventing its use or some such. I can’t remember what he said but it was frustrating that he said we basically can’t use it.

CA pharmacist here. CDPH is archaic and will audit your droperidol orders to ensure you followed the boxed warning to a tee.... some hospitals are okay assuming the risk you'll document accordingly.

Didn't document the patient failed or can't have other agents? Hospital Fine

Didn't get a baseline EKG or monitor the patient on tele for 2-3 hours after a dose? Hospital Fine

It's insane.

 

[AlmostAnMD]

CA pharmacist here. CDPH is archaic and will audit your droperidol orders to ensure you followed the boxed warning to a tee.... some hospitals are okay assuming the risk you'll document accordingly.

Didn't document the patient failed or can't have other agents? Hospital Fine

Didn't get a baseline EKG or monitor the patient on tele for 2-3 hours after a dose? Hospital Fine

It's insane.

Baseline ekg on the least qtc prolonging agent of all antipsychotics

Sad

 

[thegenius]

CA pharmacist here. CDPH is archaic and will audit your droperidol orders to ensure you followed the boxed warning to a tee.... some hospitals are okay assuming the risk you'll document accordingly.

Didn't document the patient failed or can't have other agents? Hospital Fine

Didn't get a baseline EKG or monitor the patient on tele for 2-3 hours after a dose? Hospital Fine

It's insane.

That's what it was. I wanted to tell the pharmacist that we are the ones assuming the risk, but now remember it was more complicated than that.

totally insane

 

[TooMuchResearch]

CA pharmacist here. CDPH is archaic and will audit your droperidol orders to ensure you followed the boxed warning to a tee.... some hospitals are okay assuming the risk you'll document accordingly.

Didn't document the patient failed or can't have other agents? Hospital Fine

Didn't get a baseline EKG or monitor the patient on tele for 2-3 hours after a dose? Hospital Fine

It's insane.

That's nuts...

I routinely give droperidol without cardiac monitoring in patients who have never had an ECG.

 

[southerndoc]

CA pharmacist here. CDPH is archaic and will audit your droperidol orders to ensure you followed the boxed warning to a tee.... some hospitals are okay assuming the risk you'll document accordingly.

Didn't document the patient failed or can't have other agents? Hospital Fine

Didn't get a baseline EKG or monitor the patient on tele for 2-3 hours after a dose? Hospital Fine

It's insane.

Whoa, that's really excessive for an FDA warning not justified. Very few patients had deaths due to prolonged QT. The vast majority were deaths confounded by trauma, multisystem organ failure, and/or sepsis. Plus, NO cardiac-related deaths were reported in patients receiving <10 mg. Those that died from prolonged QT had dosages 25+ mg.

Another reason I don't live and practice in California.

I don't even check EKGs on the majority of patients. Cardiac monitoring and they get the droperidol.