Interesting points. I have used droperidol before and it's a good drug, but it's not formulary at this particular hospital. Being someone who likes pharm and using 'offbeat' drugs (when appropriate), I actually did think of giving olanzapine but ultimately decided not to because I think I would have gotten even stranger looks the following day ('Zyprexa is not a drug for nausea...' etc etc). Everyone around here seems to be afraid of IV Compazine, which results in a lot of IV promethazine being given (which I prefer not to use as it's a badass vesicant and I've seen the consequences). I've seen a fairly surprising amount of akathesia from both prochlorperazine or promethazine as well.
One interesting option for n/v in the right patient is Remeron (potent 5-HT3 antagonist with a super long half life...available in ODTs...minimal QT prolongation too). It seems to have worked pretty well when I've used it.
great points, especially about watching out for akathisia from atypicals and prochlorperazine or promethazine
in fact, I saw a case of agitation attributed to delirium (they were delirious in any case, but you can be both or one or the other) that was continually being treated with more and more quetiapine, when it fact we were just giving the patient worse and worse akathisia
I didn't look this up, but I was taught that Zofran shouldn't be thought of as an anti-emetic per se but as anti-nausea, for prophylaxis of emesis, but that once the patient goes status vomitus it's too late for Zofran to be really effective in terminating the cycle and it's actually better to reach for an motility slowing agent like Ativan or promethazine
essentially I was taught to think of these drugs as being 3 categories, anti nausea, anti-emetic terminating, and drugs that can do both like Ativan
I do remember being taught in medical school that the sensation of nausea is distinct and has a distinct mechanism from the vomiting reflex itself, they just usually go together, much as orgasm and ejaculation in men, so I never really questioned this wisdom much further
in our ICU, we actually held Zofran until emesis was under control than used it prophylactically, and I remember we got in trouble just as the OP did, only from the head of the unit not the senior
last point I thought of here, is that you don't really use olanzapine or quetiapine to "treat" or "clear" delirium, in fact they can bring it about themselves
I was taught that the best treatment for delirium is resolution of the primary cause, avoidance of *any* centrally acting med as much as possible including ones mentioned, and my favorite; time, normalization of day/sleep cycle, and re-orientation. I know this is obvious, I state it so I can state the primary purpose of those centrally acting meds, the role of olanzapine or quetiapine is to calm agititation so the patient can be more easily and safely treated for the primary cause, and to help normalize day/sleep. You have to recognize at what point those sedating meds are doing more to prolong the delirium than to promote the conditions for resolution. Pearl: Drugs don't treat delirum. Drugs treat the symptoms.
DISCLAIMER: I did not quote primary or secondary literature, therefore none of the above is evidence based and is purely anecdotal in every way
