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What Can We Learn From Two Consecutive Cases? Droperidol May Abolish TcMEPs./Art Arda Gelen Iki Vaka Hakkinda Ne Dgrenebiliriz? Droperidol TcMEP'i Engelleyebilir mi?

Abstract / Oz

Droperidol is a D2 receptor antagonist currently used in Europe for preventing postoperative nausea and vomiting. It was used to perform neurolept anaesthesia in combination with fentanyl until a Food and Drug Administration (FDA) 'black box' warning restricted its use due to cardiovascular side effects in 2001. Tere is no literature regarding the effects of droperidol on transcranial motor evoked potentials (TcMEPs) elicited by electrical stimulation. Our aim was to report two cases of spine surgery in which TcMEPs were lost due to droperidol administration. We report the cases of a 4-year-old male with scoliosis undergoing correction and a 58-year-old woman with metastasis on the D8 vertebrae undergoing kyphosis correction. Intraoperative neurophysiological monitoring was achieved through TcMEPs and somatosensory evoked potentials (SEPs). Intraoperative neurophysiological monitoring (IONM) showed a temporal loss of TcMEPs without SEPs changes coinciding with the administration of droperidol. TcMEP stimulation parameters were changed to double train of pulses, with the aim to elicit them, obtaining responses. Five minutes after droperidol administration, Tc-MEPs were equal to those at baseline. Droperidol used as prophylaxis for postoperative nausea abolishes TcMEPs. Changing stimulation parameters to double train of pulses, it allows to bypass droperidol central action, achieving monitorable TcMEPs.

Keywords: Droperidol, intraoperative neurophysiological monitoring, transcranial motor evoked potentials, double train Droperidol postoperatif bulanti ve kusmayi onlemek amaciyla Avrupa'da su an kullanilan bir D2 reseptor antagonisttir. 2001 yilinda kardiyovaskuler yan etkilerinden dolayi FDA kara kutu uyarisi ile kullanimi engellenene kadar fentanil ile kombine edilerek norolept anestezi icin kullanildi. Droperidolun elektriksel stimulasyonun neden oldugu TcMEP uzerindeki etkileriyle ilgili literatur verisi bulunmamaktadir. Bu calismada TcMEP'in droperidol uygulamasindan dolayi yok oldugu iki omurga cerrahisi vakasi sunulmaktadir. Ilk olarak, duzeltme ameliyati olan 4 yasindaki skolyoz hastasi bir erkek cocugu vakasini ve sonra da D8 vertebralara metastazi olan ve kifoz duzeltme ameliyati geciren 58 yasindaki bir bayan hastayi sunduk. Transkraniyel motor uyarilmis potansiyeller (TcMEP) ve somatosensoriyel uyarilmis potansiyeller (SEP) ile, intraoperatif norofizyolojik monitorizasyon gerceklestirildi. Intraoperatif norofizyolojik monitorizasyon (IONM), SEP degisiklikleri olmaksizin, droperidol uygulamasiyla ayni zamanda meydana gelen gecici bir TcMEP kaybi ortaya koydu. TcMEP stimulasyonu parametreleri, cift nabiz atimlariyla degistirildi, yanitlar alindi. Droperidol uygulamasindan 5 dakika sonra TcMEP degeri baslangic degeriyle esitti. Postoperatif bulanti icin profilaksi olarak kullanilan droperidol TcMEP'i engeller. Stimulasyon parametrelerinin cift diziyle degistirilmesi ile problem cozulebilir.

Anahtar Kelimeler: Droperidol, intraoperatif norofizyolojik monitorizasyon, TcMEP, cift dizi

Introduction

Intraoperative neurophysiological monitoring in spine surgeries is a basic tool to assess the functional integrity of the spinal cord (1). To grant optimal intraoperative neurophysiological monitoring (IONM), an anaesthetic regime free of muscle relaxants as well as agents that do not suppress evoked potentials is essential. The gold standard is total intravenous anaesthesia (TIVA) with propofol and remifentanil.

Before TIVA was standardised, many other drugs were used to allow IONM. Neurolept anaesthesia was one of the regimens used, which combined droperidol, a butyrophenone acting by blocking D2 receptors, and fentanyl, an opioid. It was popular during conscious sedation for seizure focus identification and ablation and had minor effects on EEG and cortical somatosensory evoked potential monitoring (2).

In 2001, a Food and Drug Administration (FDA) 'black box' warning restricted droperidol use because of QT-interval prolongation and torsade de pointes in patients following antipsychotic treatment. However, these side effects might be dose dependant. No cardiovascular events have been reported in the literature due to droperidol at doses used for neurolept anaesthesia or as prophylaxis for postoperative nausea and vomiting (3).

Although droperidol is not currently used in the USA, it is still used by anaesthesiologists in 19 of 24 European countries as an antiemetic drug (0.625 to 1.25 mg IV) (4). It is more effective when administered at the end of surgery.

Case Presentation

The first patient's legal guardian and the second patient were informed on IONM modalities and the anaesthetic protocol; they signed the informed consent form, and their permission was taken for this case report. A 4-year-old male weighing 16kgs was operated for correction of scoliosis which he presented with. The patient underwent a TIVA regime with propofol (4-6 mg [kg.sup.-1 h.sup.-1)] and remifentanil (0.15-0.25 meg [kg.sup.-1 min.sup.-1)], and his scoliosis was corrected by placing unilateral pedicle screws from T10 to L1 on the right side. IONM was performed with a Cadwell Cascade IONM 32 channel device (Kennewick, WA, USA). Motor evoked potentials were elicited by transcranial stimulation (corkscrew electrodes on C1-C2, train of five stimuli, duration: 0.05 ms, interstimulus interval: 4 ms, intensity: 380 V) and were bilaterally recorded by needle electrodes (12 mm) on the abductor pollicis brevis, tibialis anterior and abductor hallucis muscles. Somatosensory evoked potentials were elicited by bilateral stimulation of the posterior tibial and median nerves (paired surface disk electrodes on each nerve, single stimulus, duration: 0.2 ms, interstimulus interval: 5.1 Hz, intensity: 20-40 mA) and were recorded by corkscrew electrodes on Cz-Fz for the lower limbs and C3'-C4' for the upper limbs. During the procedure, the depth of anaesthesia was assessed with BIS monitoring that maintained values between 40 and 60 and the body temperature was stable at 35.5[degrees]C. A blood gas sample was obtained each hour, and capnography was continuously performed.

Intraoperative neurophysiological monitoring continued without any disturbances, until the surgeons started to close the surgical wound, when a sudden bilateral loss of TcMEPs was noted (Figure 1) while the somatosensory evoked potentials were stable. Any potential cause that could explain this finding, such as surgical damage, hypotension, anaemia, hypercapnia or hypoxemia, was dismissed as TcMEPs were lost in the lower and upper extremities and no changes in the blood pressure, blood gas sample, or capnography were seen. The anaesthe-siologist adverted that 1-mg IV droperidol [(50 mcg kg.sup.-1)] was administered to the patient to avoid postoperative nausea 2 min before the TcMEPs were lost. After changing the parameters to elicit TcMEP by a double train of pulses (5) (first train: two stimuli, second train: five stimuli, duration: 0.05ms, interstimulus interval: 4ms, intertrain interval: 30ms, intensity: up to 400 V), low-amplitude TcMEPs were bilaterally obtained. Five minutes later, TcMEPs recovered. Surgery continued until the end without any further disturbance. The patient woke up without any additional neurological deficit.

The same anaesthetic protocol (propofol: 4-8 mg [kg.sup.-1 h.sup._1] and remifentanil: 0.10-0.30 meg [kg.sup.-1 min.sup.-1)] was administered in the next consecutive patient (a 58-year-old woman undergoing thoracic kyphosis correction). During closure, TcMEPs were temporally suppressed after the administration of 1.25 mg droperidol. Applying a double train of pulses allowed to obtain monitorable TcMEPs.

Discussion

These cases illustrate the importance of a fluid relationship between the different members in an operating room. The neurophysiological findings could be consequence of surgical damage, a systemic event or a pharmacologic interaction. Surgical damage was discarded by the surgeons as well as for TcMEPs loss on the upper extremities and hypotension, hypercapnia, hypoxemia or anaemia by the anaesthesiologist. The only remaining potential cause was the administration of droperidol.

To our knowledge, there is no report in the literature regarding the effect of droperidol on TcMEPs by electrical stimulation, even more since this drug it is not currently used since it was banished by the FDA. According to Kalkman, in humans, droperidol produces a sustained amplitude depression of the tibialis anterior and abductor hallucis TcMEPs by magnetic stimulation with no onset latency changes (6). The same findings were noted in primates (7).

As a D2 receptor antagonist, it is unknown how droperidol increases the TcMEP intensity threshold. We can assert that it has no peripheral effect as a muscle relaxant because changing the stimulation parameters to a double train of pulses allows obtaining motor responses.

Conclusion

Droperidol used as prophylaxis for preventing postoperative nausea and vomiting at standard doses (0.6-1.25 mg IV) administered prior to the end of the surgery temporally abolishes TcMEPs. Eliciting TcMEPs by applying a double train of stimuli can partially solve the suppression caused by droperidol. This effect must be taken into account, and droperidol should not be administered until after skin closure.

Informed Consent: Written informed consent was obtained from the parents of the patients who participated in this study.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept - A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Design - A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Supervision-A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Resources - A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Materials - A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Data Collection and/or Processing - A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Analysis and/or Interpretation - A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Literature Search - A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Writing Manuscript - A.S.G., P.J.PL., S.C.G., J.F.N.M., J.A.T.D.; Critical Review-AS.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Other - A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

Hasta Onami: Yazili hasta onami bu calismaya katilan hastalarin ailelerinden ahnmistir.

Hakem Degerlendirmesi: Dis bagimsiz.

Yazar Katkilari: Fikir-A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Tasanm - A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Denetleme - A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Kaynaklar - A.S.G., P.J.PL., S.C.G., J.F.N.M., J.A.T.D.; Malzemeler - A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Veri Toplanmasi ve/veya Islemesi - A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Analiz ve/veya Yorum - A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Literatur Taramasi - A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Yaziyi Yazan - A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Elestirel Inceleme - A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.; Diger-A.S.G., P.J.P.L., S.C.G., J.F.N.M., J.A.T.D.

cikar catismasi: Yazarlar cikar catismasi bildirmemislerdir.

Finalisai Destek: Yazarlar bu calisma icin finansal destek almadiklarini beyan etmislerdir.

References

1. Nuwer MR, Emerson RG, Gallway G, Legatt AD, Lopez J, Minahan R, et al. Evidence-based guideline update: Intraoperative spinal monitoring with somatosensory and transcranial electrical motor evoked potentials. J Clin Neurophysiol 2012; 29: 101-8. [CrossRef]

2. Sloan TB. Anesthetic effects on electrophysiologic recordings. J Clin Neurophysiol 1998; 15: 217-26. [CrossRef]

3. Henzi I, Sonderegger J, Tramer MR. Efficacy, dose-response, and adverse effects of droperidol for prevention of postoperative nausea and vomiting. Can J Anaesth 2000; 47: 537-51. [CrossRef]

4. Schaub I, Lysakowski C, Elia N, Tramer MR. Low-dose droperidol ([less than or equal to]1 mg or [less than or equal to]15 [mu]g kg-1) for the prevention of postoperative nausea and vomiting in adults: quantitative systematic review of randomised controlled trials. Eur J Anaesthesiol 2012; 29: 286-94. [CrossRef]

5. Journee HL, Polak HE, de Kleuver M, Langeloo DD, Postma AA. Improved neuromonitoring during spinal surgery using double-train transcranial electrical stimulation. Med Biol Eng Comput 2004; 42: 110-3. [CrossRef]

6. Kalkman CJ, Drummond JC, Patel PM, Sano T, Chesnut RM. Effects of droperidol, pentobarbital, and ketamine on myogenic transcranial magnetic motor-evoked responses in humans. Neurosurgery 1994; 35: 1066-71. [CrossRef]

7. Ghaly RF, Stone JL, Levy WJ, Kartha R Brunner EA, Aldrete JA, et al. The effect of neuroleptanalgesia (droperiodol-fentanyl) on motor potentials evoked by transcranial magnetic stimulation in the monkey. J Neurosurg Anesthesiol 1991; 3: 117-23. [CrossRef]

Angel Saponaro Gonzalez (1), Pedro Javier Perez Lorensu (1), Santiago Chaves Gomez (2), Josue Francisco Nodarse Medina (2), Jose Angel Torres Dios (2)

(1) Intraoperative Neurophysiologie Monitoring Unit, University Hospital Of Canarias, Santa Cruz De Thenerife, Spain

(2) Anaesthesiology Department, University Hospital Of Canarias, Santa Cruz De Thenerife, Spain

Address for Correspondence/Yazisma Adresi: Angel Saponaro Gonzalez E-mail: ansagol987@gmail.com

Received/GelisTarihi : 12.09.2016

Accepted / Kabul Taxihi : 17.10.2016

Cevrimici Yayin Tarihi / Available Online Date : 18.01.2017
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Title Annotation:Case Report / Olgu Sunumu
Author:Gonzalez, Angel Saponaro; Lorensu, Pedro Javier Perez; Gomez, Santiago Chaves; Medina, Josue Francis
Publication:Turkish Journal of Anaesthesiology and Reanimation
Date:Feb 1, 2017
Words:2168
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