Showing posts with label droperidol. Show all posts
Showing posts with label droperidol. Show all posts

Saturday, January 5, 2013

Emergency Medicine - Variations on a Theme

The Gist:  Although emergency medicine has a reputation for being algorithmic, there's a good amount of variation in thinking and practice.  This is necessary (variable resources, different patient populations) and can be excellent (promoting growth, change, and innovation).  The foundation for our practice is built in the training we receive, both in text and from our local educational community.  FOAM has played a role in laying the foundation to what will become my EM practice and I think that FOAM has the ability to lead to improved patient care through discourse on evidence based medicine, updates on current practice, and insight into the thought process and practice of others (shared learning!).  

After spending my third year of medical school in rural Alabama and absorbing a good bit of EM FOAM, I thought I should experience the cutting edge, academic side of EM.  Realizing, through heated Twitter debates, that emergency physicians actually approach many situations rather differently, I wanted to lay a broad foundation of practice...knowing I would probably practice most similarly to wherever (and with whomever) I train.  Over the past six months, I had the privilege of training in seven excellent EDs in five states with the smartest people I've met.  Below is a smattering of bread and butter things I found...(limitation: this is clearly a small sampling of each institution due to my limited time).

Apneic oxygenation/high flow nasal cannula during intubation (NODESAT - nasal oxygen during efforts securing a tube).  One institution had adopted and implemented this by the time I rotated through, another started this after a virtual grand rounds lecture with Dr. Scott Weingart.  Pulse ox lag is real and few people talked about it in airway situations.  Check out this EMCrit podcast and this PHARM post on the subject.  
Use of droperidol.  Places either use it liberally or refuse to use the drug, as I discussed in this post.  At an institution that no longer uses droperidol, an attending went through the paucity of evidence behind the black box warning as well as the political/economic factors that likely played a role in the downfall of droperidol.
Use of ketamine.  FOAM teams with enthusiasm for ketamine (see any tweet by @embasic or @MDAware, this multi-national podcast, or one of many EMRAP episodes), but I saw this drug rarely used outside of pediatrics in all institutions, the most notable exception was to intubate asthmatic patients.  Why does this matter?  Procedural sedation can be tricky and I witnessed some that were executed well and others that were less than ideal.  In addition to the amnestic properties, ketamine confers some analgesia and has less respiratory depression (clinically relevant, that's uncertain).  Furthermore, one ED I rotated through had zero etomidate available.  We used whatever was available for RSI and thus, needed to be familiar with a cornucopia of agents.  This includes ketamine, which has showed excellence in induction for RSI, including in this recent study. 
Quantitative capnography (ETCO2).  Not routinely used after intubation or for procedural sedation in 5 of 7 institutions, although infrastructure was the limiting issue at one institution, which has since been rectified.  However, the FOAM community has referred to it as a 'standard of care," including Dr. Scott Weingart in his review of NAP4. 
Treatment of an abscess.  At nearly all institutions, antibiotics were prescribed following an I&D of an abscess, although almost all attendings mentioned that one could "probably get away without them"  A minority of cases had significant surrounding cellulitis or immunosuppressed states.  Three of six places had me pack abscesses, although this was more attending dependent than institution dependent.  The Skeptics Guide to Emergency Medicine's podcast #13 is a great review (free registration required) of the evidence base behind packing and antibiotics.  Freeemergencytalks.net also has a great talk on the subject.  
  • Antibiotics - a review, demonstrating that most abscesses don't need antibiotics.  Antibiotics also carry harm, from resistance to Steven-Johnson and diarrhea and this recent article in Pediatrics shows that TMP-SMX adverse effects are on the rise, likely secondary to profound administration for skin and soft tissue infections.  
    • What about MRSA abscesses?  Here are some EBM guidelines. 
      • 90% of patients with MRSA abscesses will do just as well without antibiotics (Rajendren).
    • What about recurrence? Less recurrence by day 10 but no change at 30 days. 
  • Packing - The NNT summary of a small study, demonstrating no benefit to packing abscesses. Confirmed in this Kessler et al study.  During ICEM 2012, there was much tweeting on packing in an era in which some abscesses undergo primary closure (across the Atlantic).  
  • Use of ultrasound for drainage.  We did this at two of five institutions.  In fact, at a community hospital that was not very ultrasound keen, an attending suggested that we ultrasound first. We saved that patient an incision as she had no discrete pockets to drain.  SonoSpot post, Adhikari, Blaivas article 
  • NB:  Much of the literature on this topic is from the surgical literature, which is not exactly equivalent; however, the ED literature base on the topic is growing.  
Central lines.  Sterility is key and, with the exception of code lines, was excellent at all sites.  Line placement varied quite a bit.  In 2012, the femoral line seemed to make a comeback in some literature and in the FOAM sphere (PHARM podcast, EMCrit). For the problems (DVT, infection rate) attributed to femoral lines, I saw (and placed) a surprisingly high number.  There was one in-ED IO insertion during all of my rotations.  Beneath the clavicles, ultrasound hadn't captured the attention of many.
  • Code line of choice:  Subclavian-4, Femoral-3.  
  • Use of ultrasound in code lines: 0.  
  • Use of ultrasound in femoral lines: 0.  
    • Small study: not slower than landmark approach and had better success.  It's a small study, but I've seen non-code femoral lines in awake, conversant patients, take many attempts from multiple people prior to establishing a successful line.  Ultrasound, if one practices, actually speeds things up (and may save the patient multiple sticks).
  • Use of ultrasound in subclavian lines: 0.
  • Use of ultrasound in the IJ: 7.
Ultrasound.  Each academic center used ultrasound heavily but the community hospital used ultrasound solely for FAST scans and placement of internal jugular central lines.  At the community institution, they often laughed as I dragged the single SonoSite Titan from room to room and enthusiastically discussed what I could do with a linear array probe.  It speeded things up, though, when I presented my patient noting that I had already visualized the IUP and documented a fetal heart rate (or not, as was the unfortunate case sometimes) or documented a normal caliber aorta, B-lines, etc.  When I diagnosed an SBO in mere seconds, one of the doctors was sold and disposition was easy.  Billing for scans and the practice of ordering confirmation scans seemed to vary the most. Also, utilization of ultrasound seemed more attending dependent than necessarily institution dependent since training and credentialing are still being worked out in many settings.  Listening to this episode may have been beneficial.

Observation units.  All but one place I rotated at had an observation/clinical decision unit (CDU) and the one place that did not have one, incorporated one by the time I returned a few months later.  These units provided a monitored setting where patients could have cardiac enzymes drawn for rule-out protocols, receive antibiotics, or receive rehydration, etc.  Anecdotally, these seemed to improve workflow and allow easier disposition, something supported by literature (Trzeciak, Schneider, Gordon).  In the cardiac setting, use of these seemed to buy most people either a stress test or CCTA on the spot, depending on the institution.  Although this practice is supported by the AHA, evidence seems to be mounting that this may be unnecessary and costly (See EMRAP November 2012 with Dr. Scott Weingart and SMART EM summary and podcasts on this topic).

Endotracheal intubation.
  • FOAM conversations often revolve around direct laryngoscopy (DL) versus video laryngoscopy (VL) (ex: PHARM podcast 51 and post, EMRAP 9/12).  DL served as the primary means of intubation across the board and residents and attendings preferred this modality.  Each institution had at least one VL in the ED, predominantly the glidescope (although one had one in the 'resuscitation area,' a slight trek in an unpredictably difficult intubation).  Two of seven places had combined VL/DL devices available but I didn't see these used during my rotations.  
  • Post-intubation sedation (vital!) was not always ordered, but was not an institutionally dependent thing.  Attendings at one institution seemed to consistently stress ordering sedation at the time one was ordering the paralytic and induction agents versus waiting until afterward.

In EM, there are constants as well:
  • The physicians were incredibly smart, motivated, and passionate
  • Emergency physicians know how to have fun

(EM clerkship wakeboarding and hiking days)

Personal thought:  FOAM levels the playing field with regard to access to information, something that can be amazing for community physicians removed from the academic setting, busy physicians, or those in more remote locations.  I am incredibly excited to see how FOAM can continue to evoke dialogue about (and create) variations in practice to achieve better quality of medicine - on individual, community, and international levels.
Posted by at 2 comments:
Labels: , , , ,

Thursday, December 13, 2012

Black Boxed? Droperidol as an Anti-emetic

The Gist:  Droperidol is a safe and effective anti-emetic at low doses (0.625-2.5 mg) and, as of September 2013, its use is supported in the ED with recommendations against routine EKG/telemetry monitoring by this AAEM Clinical Practice Statement (evidence based review of droperidol safety).

The background:  From EMCrit's podcast on chemical restraints to EM Lit of Note reviews of ondansetron, FOAM teams with support for droperidol.  My experience in the ED, however, has varied widely.  Over the past six months, I've rotated through seven emergency departments in the Eastern US.  I've discovered that people have very strong feelings about droperidol.  In some places, droperidol flowed freely yet judiciously and in others, the drug was a dirty word.  As part of a recent rotation, I gave a presentation on the use of droperidol as an anti-emetic so I figured I'd share my slide set.

Why do we care?  There are so many anti-emetics!
  • Drug shortages.  Hospitals across the nation are experiencing shortages of many drugs, including anti-emetics such as ondansetron, promethazine, prochlorperazine, and metoclopramide.  Nausea and vomiting is a "bread and butter" issue in the ED and it's vital that we're equipped to take care of patients, even when we don't have our favorite drugs. 
    • This database review found a statistically significant increase in adverse events after switching from droperidol to promethazine after the black box warning, when a shortage of prochlorperazine existed as well.  
  • Intolerance to other medications. The charts of many patients with migraines list allergies to promethazine, prochlorperazine, and metachlopramide.  
    • I recently had a patient with an intractable migraine who typically received relief from meperidine from his neurologist.  Unfortunately, on a long weekend, the neurologist's office was closed and the hospital didn't stock meperidine.  Opioid analgesics didn't mitigate the pain but droperidol did the trick (at 2.5 mg). 
  • Cost.  Droperidol has been around for decades and is cheap.  Ondansetron became generic in the US a few years ago, but remains more expensive than droperidol.  
  • Effective.  Droperidol 0.625 mg is as  effective as 4mg of ondansetron as demonstrated by Kriesler et al (this looked at post-operative nausea and vomiting).  Braude et al demonstrated that this effectiveness translates into the ED setting in a double-blind RCT comparing droperidol 1.25 mg, metoclopramide 10 mg, prochlorperazine 10 mg, and saline placebo.
  • These drugs often end up in our "migraine cocktails" and low-dose droperidol appears to work in migraines as well, representing a cheap intervention for ill patients (1)
The basics:
  • Butryophenone (like haloperidol)
  • D2 agonist, anti-emetic effect is likely secondary to effects in the chemoreceptor trigger zone.
  • Short-acting, works in 3-10 minutes
Safety
  • Side Effects:  Drowsiness, dysphoria, dystonia, akasthisia but these effects are easily fixed with diphenhydramine and aren't the reason that hospitals and physicians are sometimes reticent to embrace droperidol...The Prolonged the QT interval
    • Mechanism:  It's thought that droperidol blocks the rapid component of the delayed K+ and current depolarizing targets: L-type Ca2+ current, Na+-Ca2+ exchanger, and the Na+-K+ adenosine triphosphatase.  This mechanism may explain the susceptibility of individuals with Type I Long QT syndrome (2).
2001 Black Box Warning
Based on two studies (Lischke and White) and MedWatch reports.  I won't rehash all of the data here, but it's found in my slideset and in this summary.  Applies to FDA approved doses (2.5 mg and above).

MedWatch Reports
  • 271 unique, spontaneous adverse cardiovascular events from 93 individuals
  • Most cases were reported to the FDA between 1999-2001 (events dated 1970-2001)
    • 71 cases reported on July 9, 2001 by an unknown number of sources that occurred on a variety of dates.  This is a bizarre smattering of cases and trends that have led many to conclude that the FDA black box made room for ondansetron (then on-patent) to gain a larger portion of the nausea/vomiting market share.  I won't comment on this since it's more speculation than evidence based.
  • 10 of these cases were associated with doses of droperidol 2.5 mg or less.  Is this really a significant number of cases given the thousands of doses of droperidol administered each year in the decades it's been on the market?
    • Individuals in these cases were not your typical healthy individuals (see Table below from Habib et al). There are some individuals for whom droperidol is probably not the safest drug.  Think arrythmias or predisposing cardiac conditions.
    More recent evidence  Studies fail to demonstrate that inidviduals receiving droperidol have adverse clinical events secondary to the QTc prolongation.  Thus, is the minimal, transient QTc prolongation a clinically relevant marker?
    • Charbit et al (2005) prospective, single blind study where patients (n=85) received 0.75 mg droperidol OR 4 mg ondansetron. Demonstrated no difference in QTc prolongation and demonstrated zero adverse effects
      • QTc prolonged before administration in 21% of subjects 
      • Maximum Increases in QTc: Droperidol 17 +/- 9 ms, Ondansetron  20 +/- 13 ms
    • In 2008, Rappaport of the FDA stated that the FDA warning for droperidol did not apply to doses below 2.5 mg, as they had not evaluated that data (3).  
    • Ondansetron has been found to prolong the QTc for up to 120 minutes and has been associated with torsades de pointes, as in this paper by Hafermann et al.  In fact, this month, the 32 mg dose of ondansetron was pulled from the market. 

    • Treating primary headaches in the ED: can droperidol regain its role?

    Experts' take on the droperidol black box warning
    Posted by at No comments:
    Labels: , , , ,
    Subscribe to: Posts (Atom)