The prophylactic effect of haloperidol plus dexamethasone on postoperative nausea and vomiting in patients undergoing laparoscopically assisted vaginal hysterectomy

Anesth Analg 2008;106:1402-1406

Chu CC, Shieh JP, Tzeng JI, Chen JY, Lee Y, Ho ST, Wang JJ

 

 

Abstract

Purpose            The aim of this study was to evaluate the prophylactic effect of haloperidol plus dexamethasone on postoperative nausea and vomiting (PONV). The hypothesis was that prophylactic haloperidol plus dexamethasone would provide a greater reduction in the incidence of PONV than either drug used alone, placebo, or droperidol.

Background            Droperidol, a major tranquilizer with dopamine 2 (D2) receptor antagonist effect, has often been tested in combination with other antiemetics for treating PONV. The FDA “black-box warning” announcement led to a marked reduction in the use of droperidol for PONV prophylaxis and has led to a search for a substitute. Haloperidol, was considered a possible substitute for droperidol. Haloperidol has been used in palliative care as an antiemetic for nausea and vomiting. Recently, haloperidol was further found to have an effect on PONV.

Methodology            This was a randomized, double-blind, placebo, and positive-control study in 400 patients undergoing laparoscopic-assisted vaginal hysterectomy (LAVH). Patients were randomly assigned to one of five groups: (1) S, saline; (2) D, droperidol 1.25 mg; (3) H, haloperidol 2 mg; (4) Dx, dexamethasone 5 mg; (5) H + Dx, haloperidol 2 mg plus dexamethasone 5 mg. Anesthesia was standardized for all patients. After surgery, all patients were observed for 24 h. Pain and sedation scales were used for 24 h.

Result            Three hundred and seventy two patients completed the study. When compared with the S group, the D, H, Dx and H + Dx groups had a lower incidence of PONV at 2-24 h and 0-24 h. The H + Dx group had the lowest incidence of PONV and the highest incidence of complete response. During anesthesia, the QTc interval after the administration of the test medication in all groups was not different from their preinjection values. Three patients (two in the droperidol and one in the haloperidol group) reported motor restlessness.

Conclusion            A combination of haloperidol 2 mg plus dexamethasone 5 mg produced a greater reduction in the incidence of PONV than did either drug used alone, without increasing the following perioperative risks: QT prolongation, intensity of postoperative pain, level of sedation, or occurrence of motor restlessness. This study demonstrated that haloperidol alone offers no significant advantages over droperidol or dexamethasone for routine antiemetic prophylaxis. The use of a combination (i.e., haloperidol + dexamethasone) was better than any single drug alone, without increasing adverse perioperative outcomes.

 

Comment

The study confirmed that combination therapy with haloperidol 2 mg plus another anti-emetic dexamethasone 5 mg produced a greater reduction in the incidence of PONV. This study adds to the literature in support of multi-modal therapy for high risk patients and also adds another drug from the D2 family that can be used as a rescue medication.

 

Joseph F. Burkard, DNSc, CRNA