Reduction of nausea and vomiting from epidural opioids by adding droperidol to the infusate in home-bound patients

Abstract

In 184 adult patients with severe nonmalignant low back pain from postlaminectomy syndrome, temporary lumbar epidural catheters were infused with either 0.25% bupivacaine 92 mL, fentanyl 600 micrograms, and droperidol 5 mg (Group A), or 0.25% bupivacaine 92 mL, fentanyl 600 micrograms, and NaCl 0.9% 2 mL (Group B). Infusion rates ranged from 0.5 to 2 mL per hour, with an option for turning the infusion off when the patient had no pain and turning it on when the pain returned. Infusions were continued from 2 to 55 days, during which time the patient was at home. In Group A, only two patients had nausea without emesis, while in Group B, nausea occurred in 18 patients (P < 0.04) and four vomited (P < 0.05). The number of patients with headache, pruritus, somnolence, and/or numbness was minimal and without statistically significant group differences. During treatments, pain levels were 2 or less on a 10-cm visual analogue scale. Added to the epidural infusate, droperidol appears to significantly reduce nausea and vomiting in ambulatory patients receiving fentanyl and bupivacaine in extended epidural infusions. The possibility that droperidol potentiates analgesic effects could not be evaluated.

Nausea and Vomiting Side Effects with Opioid Analgesics during Treatment of Chronic Pain: Mechanisms, Implications, and Management Options

“…From the clinician's perspective, it is important to identify the underlying cause of nausea and vomiting from among the multiple causative mechanisms for each patient so that effective treatment can be chosen (Table 1). Opioid stimulation of the CTZ leading to nausea and vomiting can be treated with dopamine receptor antagonists such as phenothiazines (e.g., prochlorperazine) or butyrophenones (e.g., haloperidol and droperidol), though dopamine antagonism with these agents can cause a range of side effects such as drowsiness, constipation, dystonia, parkinsonism, tardive dyskinesia, torsades de pointes, and neuroleptic malignant syndrome [20,42,43]. Serotonin receptor antagonists (e.g., dolasetron, granisetron, and ondansetron) are also effective for the prevention of nausea and vomiting caused by opioid stimulation of the CTZ, and are associated with a good tolerability profile [17,20].…”

Dialogues on complex analgesic strategies for difficult pain syndromes

“…Previous experience in non-malignant patients with severe low back pain demonstrated that adding 5 mg of droperidol to epidural bupivacaine-fentanyl mixture was efficacious in reducing the incidence of these gastrointestinal symptoms [1]. The mechanism of these actions could involve agonist activity at the spinal and supraspinal levels and also dopamine antagonism.…”

Management of Opioid‐Induced Gastrointestinal Effects in Patients Receiving Palliative Care

“…Side effects, including drowsiness, constipation, dystonia, and parkinsonism, are largely dose dependent. 6,10,24 Tardive dyskinesia, torsades de pointes, and neuroleptic malignant syndrome are other adverse effects that may occur with butyrophenones and are considered to be dose independent.…”

“…4 In a study of 260 patients with cancer pain receiving opioids, nausea was rated as moderate to severe in 8. [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18].3%, regardless of the drug. This suggests that patients receiving palliative care frequently experience nausea and constipation, and opioids contribute significantly to these symptoms.…”

“…It is estimated that 6-12% of these patients may experience nausea, with some studies reporting its occurrence as high as 29%. 10,11 Often it may be difficult to differentiate the cause of opioid-induced nausea due to various comorbidities, conditions, and concomitant drugs, thus skewing an accurate estimate of its true frequency. 2 Patients often may associate nausea with a recent opioid analgesic, creating potential barriers to effective pain management in the form of anticipatory nausea, anxiety, or adherence problems.…”