Is a droperidol (antiemetic) infusion recommended?

Droperidol Infusion for Antiemesis: Not Recommended

Droperidol infusion is not recommended for antiemetic use due to safety concerns, particularly the risk of QT prolongation and potential fatal cardiac arrhythmias. 1, 2 Instead, intermittent bolus dosing should be used when droperidol is indicated as an antiemetic.

FDA-Approved Use and Administration

• Droperidol is FDA-approved to reduce the incidence of nausea and vomiting associated with surgical and diagnostic procedures 2
• The FDA-approved administration is via intermittent dosing, not continuous infusion:
  • Maximum recommended initial dose is 2.5 mg IM or slow IV for adults 2
  • Additional 1.25 mg doses may be administered to achieve desired effect, but with caution 2
• For children 2-12 years, maximum initial dose is 0.1 mg/kg 2

Safety Concerns and Black Box Warning

• In 2001, the FDA added a black box warning to droperidol due to concerns about:
  • QT prolongation 1
  • Risk of torsades de pointes 1
  • Potential for sudden cardiac death 1
• Droperidol is contraindicated in patients with:
  • Prolonged QTc interval (>440 ms in males, >450 ms in females) 1
  • Risk factors for QT prolongation including history of congestive heart failure, bradycardia, diuretic use, cardiac hypertrophy, hypokalemia, hypomagnesemia, age ≥65 years, and alcohol abuse 1

Appropriate Use in Clinical Practice

• Droperidol should be used only when first-line antiemetics are unsuccessful 1
• When used, it should be administered as intermittent boluses rather than continuous infusion 2
• Onset of action is 3-10 minutes with duration of effect of 2-4 hours 1
• Vital signs and ECG should be monitored routinely during administration 2

Recent Evidence on Safety

• Recent research suggests droperidol may be safer than initially thought:
  • A 2022 review found QT-prolonging effects are transient and risk of torsades de pointes is rare with ED doses 3
  • A 2020 observational study of 6,353 ED patients receiving droperidol found no deaths within 24 hours of administration 4
• Despite this reassuring evidence, the black box warning remains in effect, and continuous infusion is not an FDA-approved administration method 2

Alternative Antiemetics

• If antiemetic therapy is needed, consider alternatives such as:
  • Promethazine (most cited alternative to droperidol in surveys) 5
  • 5-HT3 antagonists (ondansetron, granisetron)
  • Metoclopramide
  • Prochlorperazine

Clinical Impact of FDA Warning

• The FDA warning has significantly reduced droperidol use in emergency settings 5
• Many emergency departments have removed droperidol from formularies 5
• Some clinicians believe there are no other antiemetics with greater efficacy and improved safety profiles 5

In summary, while droperidol is effective as an antiemetic, it should be administered as intermittent boluses per FDA guidelines rather than as a continuous infusion. The safety concerns that prompted the black box warning, particularly regarding QT prolongation and cardiac arrhythmias, make continuous infusion an unnecessarily risky administration method despite some recent evidence suggesting better safety than initially thought.