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Great Wall of China - Photo by JoAnn Sturman
by Scott Sturman MD
I trained when neuroleptic anesthesia was in vogue and droperidol was one of its mainstays. The doses were robust, to say the least: 0.1mg/kg. I continued to use droperidol at more modest doses for prophylactic treatment of PONV on approximately 20,000 patients from 1984 until 2001, when the FDA issued a Black Box Warning about QT interval prolongation and torsades de pointes. Controversy has surrounded the warning, and I have never witnessed such an event.
Nearly all TKA and THA cases in our practice are conducted under spinal anesthesia with intrathecal narcotics. Other than pruritis, PONV is the major side effect. This unpleasant symptom continues to occur in some patients despite treatment with dexamethasone, ondansetron, metochlopramide, H2 blockers, and IM hydroxyzine/ephedrine.
I consider all patients receiving spinal narcotics to be at high risk for PONV and administer a one time dose of droperidol 1.25mg IV when arriving in OR. Fortuitously, all total joint patients receive a routine preop EKG where the QT interval is measured. The two to three hour post injection monitoring requirement is satisfied, since an EKG is observed continuously throughout the case and in the recovery room. An added advantage of using droperidol with intrathecal spinal anesthesia is fewer antiemetics of other drug classes are required, which theoretically reduces potential adverse interactions.
