clinical thoughts: droperidol?

[amyl]

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So I was having an issue w a pt. tachycardic and BIS was running a little high. wasn't volume or anything else. was pain (chronic pain pt). nice dose of dilaudid would bring him down for a little while but the narcs were adding up! staff I was working with said give 1mg of droperidol (young pt btw) as an adjunct to the narcotics. i had never heard of this. but it worked. got NSR and BIS improved for about an hour... better and longer response than the narcs alone...saved me giving a bunch more narcs, pt woke up beautifully actually. just wondering what anyone heres thoughts are on the subject of droperidol used like this.

 

[DrRobert]

Cardiac cases used to be done with massive amounts of narcotic (morphine, fentanyl) and droperidol back in the day. Droperidol is a very effective sedative medication - in fact sedation is one of the side effects if you are administering it for nausea/vomiting.

 

[huktonfonix]

neuroleptanesthesia. Nitrous, narcs, drop. Coulda used ketamine also.

 

[jwk]

neuroleptanesthesia. Nitrous, narcs, drop. Coulda used ketamine also.

Damn, beat me by 40 minutes.

25 years+ years ago, a combo drug called INNOVAR was widely available and used - the formulation was droperidol 2.5mg + fentanyl 50mcg per cc. Interesting drug, but some of these patients had some pretty significant dysphoric effects on emergence, and a lot of patients would tell you "never again". It's also a mild alpha blocker.

 

[Jeff05]

giving drop to improve bis? that's one way to do it.

drop doesn't have any analgesic properties.

turn up the vapor and give more narcotic. there is no max dose for narcotics, so they can't really "pile up." or titrate in some ketamine.

 

[dfk]

benadryl helps as an adjunct, provided no contraindications. i also agree with ketamine. good times indeed.

 

[2ndyear]

Nothing wrong with what you guys did. Just be aware of what you are treating and why. If your BIS number is high despite adequate agent, ask why. Is your patient on the upper end of the bell curve of MAC? Is there EMG contamination? Have you given any drugs that give erroneuous BIS readings? BIS is a great tool, but be careful in treating the number alone. If you do give ketamine, BIS becomes less than useful.

As for the tachycardia, there is nothing wrong with treating it with short acting beta blockers either. Or even long ones depending on how you view POISE. If you end up treating every HR increase with narcs you will get burnt at some point. Some procedures are profoundly stimulating for brief periods with little post op pain. Pulling teeth comes to mind, as does tunnelling VP shunts.

The droperidol may or may not have a valid cause for concern, but as a private practitioner in todays medicolegal climate, I've got to have a real strong reason to use it.

 

[coprolalia]

Amy,

Did you consider trying a smaller dose at first? The dose you gave, 1mg, seems pretty high. When using it, we often give 0.125 mg and also see good effects. No experience with it modifying BIS, though. In fact, I rarely use the BIS (and when I do only in specific situations such as TIVA).

-copro

 

[climbingdocs]

I was told by one attending that BIS numbers corespond to MAC pretty closely. Anyone know any studies that proove that BIS actually make any difference?

 

[nutmegs]

We gave 2.5mg to a patient with a history of severe emergence delerium during her previous 32 surgeries. 😱 She did great, and the surgeon said it was the calmest she'd ever been. 👍 Snoozed a bit in the PACU and went on her way.

 

[jetproppilot]

Dexmetatomidine is great for cases like this with a chronic pain patient.

Dramatically reduces intraoperative opioid/volatile requirement, and postoperative opioid requirement too if patient is going to the ICU and you keep it running, albeit at a lower dose than during the procedure.

 

[2ndyear]

I was told by one attending that BIS numbers corespond to MAC pretty closely. Anyone know any studies that proove that BIS actually make any difference?

There have been several studies showing reduced anesthetic concentrations used when the anesthetic is titrated to BIS. I don't feel like googling right now but they're there. Really not huge differences in outcome though. I think that as the technology becomes more refined some form of anesthetic effect monitor (BIS or otherwise) will become more commonly used than the BIS. It really is more than just a tool to 'prevent' awareness.

 

[OB1🤙]

Dexmetatomidine is great for cases like this with a chronic pain patient.

Dramatically reduces intraoperative opioid/volatile requirement, and postoperative opioid requirement too if patient is going to the ICU and you keep it running, albeit at a lower dose than during the procedure.

👍 Definitely love dex in this spot.

 

[jetproppilot]

We gave 2.5mg to a patient with a history of severe emergence delerium during her previous 32 surgeries. 😱 She did great, and the surgeon said it was the calmest she'd ever been. 👍 Snoozed a bit in the PACU and went on her way.

Thats awesome.

One of my mentors back in residency, Dr Mack Thomas, showed me the coolest way to do an awake fiberoptic...we did it in the holding area to expedite stuff:

1) Dope up patient with fentanyl and up towards 5mg droperidol....funny thing about this neurolept-anesthetic-state....patient is totally buzzed out but will follow commands when needed.... Do nerve blocks and transtracheal.

2)Insert cool white or pink oral-airway-for-fiberoptics, or numb up the nose, your choice.

3)Insert scope, find the two white thinghys, and drive thru them.

4) Seldinger the ETT over the scope thru the cords, inflate balloon, remove scope.

5) Wheel the patient-on-the-stretcher-with-the-ETT-sticking-comfortably-outta-their-mouth (or nose) into the OR since...uhhhhh....patient is still breathing normally like they're watching a Saints game on TV.

6)Say to the patient: "Mr Smith, please move over to the OR bed."

7)Patient scoots self over to OR bed and lays down. With ETT in place.😱😱

8) Hook up circuit to ETT, turn gas-of-choice-vaporizer counterclockwise.

9) Push some IV medicines if you feel like it. Otherwise just wait a few minutes until patient breathes in enough gas, then switch over to controlled ventilation.

DOCTOR MACK THOMAS.

Anesthesiologist extrordinairre. (btw, how do ya spell extrordinairre?)

 

[2win]

👍👍👍👍👍👍👍

Thats awesome.

One of my mentors back in residency, Dr Mack Thomas, showed me the coolest way to do an awake fiberoptic...we did it in the holding area to expedite stuff:

1) Dope up patient with fentanyl and up towards 5mg droperidol....funny thing about this neurolept-anesthetic-state....patient is totally buzzed out but will follow commands when needed.... Do nerve blocks and transtracheal.

2)Insert cool white or pink oral-airway-for-fiberoptics, or numb up the nose, your choice.

3)Insert scope, find the two white thinghys, and drive thru them.

4) Seldinger the ETT over the scope thru the cords, inflate balloon, remove scope.

5) Wheel the patient-on-the-stretcher-with-the-ETT-sticking-comfortably-outta-their-mouth (or nose) into the OR since...uhhhhh....patient is still breathing normally like they're watching a Saints game on TV.

6)Say to the patient: "Mr Smith, please move over to the OR bed."

7)Patient scoots self over to OR bed and lays down. With ETT in place.😱😱

8) Hook up circuit to ETT, turn gas-of-choice-vaporizer counterclockwise.

9) Push some IV medicines if you feel like it. Otherwise just wait a few minutes until patient breathes in enough gas, then switch over to controlled ventilation.

DOCTOR MACK THOMAS.

Anesthesiologist extrordinairre. (btw, how do ya spell extrordinairre?)

 

[dhb]

extraordinaire

 

[Planktonmd]

Neuroleptics are great drugs and they are unfortunately under-utilized in our daily practice because most of them are old and there is no money to do research on them.

 

[nutmegs]

With ETT in place.😱😱

Must. Try. This.

 

[huktonfonix]

Must. Try. This.

If your blocks/topicalizaton is good and it is a COOPERATIVE patient. You can do this with just about any sedation med or none at all. Versed/Fentanyl, Dex, ketamine, whatever... its all about the blocks.

 

[Planktonmd]

If your blocks/topicalizaton is good and it is a COOPERATIVE patient. You can do this with just about any sedation med or none at all. Versed/Fentanyl, Dex, ketamine, whatever... its all about the blocks.

True, but Droperidol makes them so obedient that they actually would do anything you say without being too sedated and without even objecting to having to breath through 7-8 mm tube.
No other drug does that.

 

[jetproppilot]

If your blocks/topicalizaton is good and it is a COOPERATIVE patient. You can do this with just about any sedation med or none at all. Versed/Fentanyl, Dex, ketamine, whatever... its all about the blocks.

I humbly disagree with you.

All the combinations you list make the patient much more SEDATED...or with your ketamine suggestion, unreachable on planet earth...

the fentanyl(minimal dose) + droperidol (big dose) leaves the patient BUZZED BUT REACHABLE WITH EARTHLING COMMUNICATION.

I agree with you the blocks are very important....probably the most important part as you correctly stated...and of course the more cooperative the patient the easier the procedure will be...

but the neuroleptanesthetic technique induces a sedation level that seems deep but the patient is still able to follow commands.

I've done all the above combinations you suggested, with the exception of ketamine, for fiberoptic intubation.

None compared to the stuff I did with Mack Thomas.

 

[jetproppilot]

True, but Droperidol makes them so obedient that they actually would do anything you say without being too sedated and without even objecting to having to breath through 7-8 mm tube.
No other drug does that.

You must've posted this while I was typing since I didnt see it until after the post below this one.....NOTICE THE SIMILARITIES OF OUR POSTS.

Plank's observation is the ABSOLUTE TRUTH.

 

[nutmegs]

I humbly disagree with you.

All the combinations you list make the patient much more SEDATED...or with your ketamine suggestion, unreachable on planet earth...

the fentanyl(minimal dose) + droperidol (big dose) leaves the patient BUZZED BUT REACHABLE WITH EARTHLING COMMUNICATION.

I agree with you the blocks are very important....probably the most important part as you correctly stated...and of course the more cooperative the patient the easier the procedure will be...

but the neuroleptanesthetic technique induces a sedation level that seems deep but the patient is still able to follow commands.

I've done all the above combinations you suggested, with the exception of ketamine, for fiberoptic intubation.

None compared to the stuff I did with Mack Thomas.

Do they remember it?
I did my last awake fiberoptic with small versed, small fentanyl, moderate boluses of 10mcg/mL Precedex and managed to get an eyes-open thumbs up out of him after the tube was in. Remembered JACK about the experience afterwards.

 

[Planktonmd]

Do they remember it?
I did my last awake fiberoptic with small versed, small fentanyl, moderate boluses of 10mcg/mL Precedex and managed to get an eyes-open thumbs up out of him after the tube was in. Remembered JACK about the experience afterwards.

If you don't use any Midazolam there is a chance they might remember it.
It's always a good idea to use some Midazolam if you are doing Neuroleptanesthesia to avoid the occasional fear reaction and to improve amnesia.

 

[dfk]

If you don't use any Midazolam there is a chance they might remember it.
It's always a good idea to use some Midazolam if you are doing Neuroleptanesthesia to avoid the occasional fear reaction and to improve amnesia.

while i don't disagree with you, do you know this by experience? i only ask b/c i don't use drop enough.
FWIW, people remember on midaz as well. in any event, drop is hopefully making a comeback in my neck of the woods.

 

[fakin' the funk]

So I was having an issue w a pt. tachycardic and BIS was running a little high. wasn't volume or anything else. was pain (chronic pain pt). nice dose of dilaudid would bring him down for a little while but the narcs were adding up! staff I was working with said give 1mg of droperidol (young pt btw) as an adjunct to the narcotics. i had never heard of this. but it worked. got NSR and BIS improved for about an hour... better and longer response than the narcs alone...saved me giving a bunch more narcs, pt woke up beautifully actually. just wondering what anyone heres thoughts are on the subject of droperidol used like this.

We knew this already, but 2 dead giveaways you're at CCF

Sidenote: I've been emphatically told multiple times that BIS is a hypnosis meter, so isn't it unsurprising that it doesn't respond much to opioids?

 

[Planktonmd]

while i don't disagree with you, do you know this by experience?

Yes

 

[bluewater]

I did a sedation case with 15 mg of droperidol, 2 mg of versed and 100 mcg of fentanyl. Large abscess drainage on the right side of the chest.

Did not remember a thing and did not move during the procedure. "Mental handcuffs" (as described by one of my senior faculty members.)

 

[jetproppilot]

I did a sedation case with 15 mg of droperidol, 2 mg of versed and 100 mcg of fentanyl. Large abscess drainage on the right side of the chest.

Did not remember a thing and did not move during the procedure. "Mental handcuffs" (as described by one of my senior faculty members.)

That description needs to go into our forum's HALL OF FAME.👍

 

[dhb]

"Mental handcuffs" (as described by one of my senior faculty members.)

I like to call it the chemical restrainer 😀

 

[amyl]

We knew this already, but 2 dead giveaways you're at CCF

Sidenote: I've been emphatically told multiple times that BIS is a hypnosis meter, so isn't it unsurprising that it doesn't respond much to opioids?

i should have been more clear, i really didn't give a damn what the bis said. what i was concerned about was that the pt was experiencing pain and while i was okay narcing him out it just didn't last very long and the narcs were adding up. all in all okay, but the dilaudid bought me minutes at a time while the drop fixed it for much longer. this was a very interesting approach that worked well and wanted to hear some thoughts about it here as sometimes the clinical content is..., well lets just say, you can kind of never have enough -- thanks everyone! and to copro on the 1mg dose: was a young BIG guy... would have been a little more cautious w old or average build...

i don't follow the ccf-dead-giveway comment and the stuff you highlighted -- what did you mean by that?

 

[huktonfonix]

i should have been more clear, i really didn't give a damn what the bis said. what i was concerned about was that the pt was experiencing pain and while i was okay narcing him out it just didn't last very long and the narcs were adding up. all in all okay, but the dilaudid bought me minutes at a time while the drop fixed it for much longer. this was a very interesting approach that worked well and wanted to hear some thoughts about it here as sometimes the clinical content is..., well lets just say, you can kind of never have enough -- thanks everyone! and to copro on the 1mg dose: was a young BIG guy... would have been a little more cautious w old or average build...

i don't follow the ccf-dead-giveway comment and the stuff you highlighted -- what did you mean by that?

Im not sure what your goals were for this case. Was this a MAC case, a GA case? If you are concerned the patient was experiencing "pain" then droperidol isnt really a great drug to use. If you are worried about level of anesthesia, then droperidol may be a good adjunct. There is an old thread about "pain" with Tenesma which might be a good read. If it was a minimally stimulating procedure with likely minimal post op pain then it is probably better to deepen level of anesthesia (which you did with droperidol) or control hemodynamics with alternative drugs. If it is a MAC case and the patient is truly having pain. Then more narcs, local, dex, etc... may be neccesary. Or a peripheral/central block may have been a good idea especially in a chronic pain pt.

 

[Jeff05]

i have an attending in my program that used to be the program director at tulane. initials CS.

he loves using drop for awake FO. while it is not necessary, it certainly smoothes out even the smoothest AFOI.

 

[jetproppilot]

i have an attending in my program that used to be the program director at tulane. initials CS.

he loves using drop for awake FO. while it is not necessary, it certainly smoothes out even the smoothest AFOI.

You mean initials CF?

 

[dfk]

I did a sedation case with 15 mg of droperidol, 2 mg of versed and 100 mcg of fentanyl. Large abscess drainage on the right side of the chest.

Did not remember a thing and did not move during the procedure. "Mental handcuffs" (as described by one of my senior faculty members.)

how big was the patient? is this your standard cocktail?

 

[OB1🤙]

Im not sure what your goals were for this case. Was this a MAC case, a GA case? If you are concerned the patient was experiencing "pain" then droperidol isnt really a great drug to use. If you are worried about level of anesthesia, then droperidol may be a good adjunct. There is an old thread about "pain" with Tenesma which might be a good read. If it was a minimally stimulating procedure with likely minimal post op pain then it is probably better to deepen level of anesthesia (which you did with droperidol) or control hemodynamics with alternative drugs. If it is a MAC case and the patient is truly having pain. Then more narcs, local, dex, etc... may be neccesary. Or a peripheral/central block may have been a good idea especially in a chronic pain pt.

Agree 100%.

Patients under GA do not "experience pain."

amyl- we know you know this, but it's a point worth mentioning for anyone reading this thread who isn't familiar with these concepts.

The Tenesma thread is an excellent one, though I'm too lazy right now to search for it.

Also: 15mg seems like a metric $hit-ton of droperidol. Wowzers. Kinda like the 1mg of spinal morphine that I think Noy brought up at one point. Then again- if it works, it works.