Can We Use Droperidol for Pediatric Agitation?

July 8, 2022

Written by Davin Brar

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This systematic review suggests that droperidol is both safe and effective for treating agitation in the pediatric population.

Why does this matter?
Agitation is a common problem in the acute care setting. Behavioral approaches and verbal de-escalation are the preferred initial management for agitation. However, for the safety of our patients and staff, we sometimes need parental pharmacotherapy for severely agitated patients. It is important to understand the efficacy and risks associated with these medications, especially in the pediatric population where data can be limited.  As droperidol regains popularity, it is important to understand what role it can play in the management of acute pediatric agitation.

You get droperidol, you get droperidol, everybody gets droperidol!
This was a systematic review of 6 studies reporting effectiveness and safety outcomes of patients less than 21 years old who received parenteral droperidol for acute agitation. In total, there were 241 doses of droperidol administered to 198 patients ranging from 7 to 21 years old. The majority of patients received IM injections (185/241 administrations) and the remainder received IV droperidol (56/241 administrations).  Dosing was variable across studies and ranged from 1 mg to 10 mg.  Markers of drug effectiveness included time to sedation, depth and duration of sedation, and need for redosing. Safety outcomes included adverse effects such as arrhythmias, hemodynamic changes, airway intervention, and extrapyramidal symptoms (EPS).

Overall, the studies showed time to sedation of approximately 10-20 minutes and duration of sedation around 1 hour. Most patients were able to return to normal activities by 2 hours. A majority of patients achieved adequate sedation from a single dose. 

Reported risks of droperidol include QT prolongation, respiratory depression, dystonic reaction, and hypotension. Overall, the included studies found that these risks were exceedingly rare in pediatric patients. The two most common adverse effects were hypotension (~5%) and dystonic reaction (~2.5%). However, 4/5 patients with droperidol associated hypotension were asymptomatic, and their hypotension resolved without intervention. The other patient with reported hypotension improved after IV fluid bolus. The patients with dystonic reactions all improved after administration of diphenhydramine or benztropine. There was only one case of respiratory depression which occurred in the setting of alcohol intoxication and resolved after supplemental oxygen administration.

In 2001,the FDA issued a black box warning for QT prolongation¹. However, subsequent studies have shown that while droperidol can increase the QT interval in a dose-dependent fashion, adverse events and arrhythmias are rare². This review found only one patient who developed prolonged QT. Additionally, this patient had overdosed on lamotrigine which may have contributed to the prolonged QT interval. There were no observed arrhythmias in any patients across the 6 studies.

This systematic review had several limitations. Most of the included studies were not blinded and had moderate to critical risk of bias. Furthermore, no studies directly compared droperidol to other sedative medications. However, given these limitations, droperidol appears to be a safe and effective option to treat pediatric patients with acute agitation.

Edited and Peer-Reviewed by Sam Parnell

Source
A Systematic Review of the Effectiveness and Safety of Droperidol for Pediatric Agitation in Acute Care Settings. Acad Emerg Med. 2022 May 1. doi: 10.1111/acem.14515. Online ahead of print.

Works Cited

1. “Black Box” Warning on Droperidol: A Report of the FDA Convened Expert Panel, Anesthesia & Analgesia: June 2004 – Volume 98 – Issue 6 – p 1809 doi: 10.1213/01.ANE.0000121199.16379.A0
2. Perkins J, Ho JD, Vilke GM, Demers G. American Academy of Emergency Medicine position statement: Safety of droperidol use in the emergency department. J Emerg Med 2015;49(1):91-7