Original ContributionsIntravenous administration of prochlorperazine by 15-minute infusion versus 2-minute bolus does not affect the incidence of akathisia: A prospective, randomized, controlled trial*,**
Introduction
Akathisia is an often distressing condition of restlessness that can include nervousness, a feeling that one's skin is “crawling,” and the inability to remain in a sitting position. After experiencing akathisia, Kendler wrote, “The intensity of the dysphoria was striking. With the possible exception of going on stage on an opening night, I cannot remember any feeling of anxiety so intense.”1 Anecdotally, this restlessness has been observed to be so intense that patients with drug-induced akathisia have been known to pull out their own intravenous lines and leave the emergency department.
Prochlorperazine, a phenothiazine used as an antiemetic for decades,2 is now also one of the mainstay therapies of acute cephalalgia in the ED.3, 4, 5, 6 As a phenothiazine, prochlorperazine displays extrapyramidal side effects that broadly fall into 4 categories: acute akathisia, acute dystonia, parkinsonism, and chronic tardive dyskinesia.7 Chronic use of phenothiazines has long been known to be associated with the development of akathisia and other movement disorders.8, 9, 10 However, single doses of a phenothiazine, including prochlorperazine, have also been reported to induce akathisia.4, 11
A study by Drotts and Vinson7 found a 44% incidence of akathisia in ED patients after a single intravenous bolus dose of prochlorperazine. Because akathisia is so common after even single intravenous doses of prochlorperazine and because the symptoms can be so distressing, methods of prophylaxis have been proposed. One strategy is to administer medications, including diphenydramine,12 benztropine, or lorazepam, with the prochlorperazine. Slowing the infusion rate of prochlorperazine has also been proposed.7 We conducted a study to test the latter strategy. We hypothesized that a 15-minute intravenous infusion would have a 50% lower incidence of akathisia than the label-recommended 2-minute intravenous bolus. The secondary objective was to evaluate whether the efficacy of prochlorperazine in treating headache and nausea was affected by the rate of administration.
Section snippets
Materials and methods
We conducted a prospective, randomized, double-blind study in the ED of Methodist Hospital, a teaching hospital located in central Indianapolis, IN. The annual ED census was 94,000 at the time of the study. The Clarian/Methodist Institutional Review Board approved the study. All study participants gave written informed consent before enrollment.
Patients aged 18 to 65 years were eligible for participation in this study if they were to receive intravenous prochlorperazine for the treatment of
Results
We enrolled 100 nonconsecutive study participants between July 7, 1999, and March 30, 2000. One study participant was excluded after a protocol violation (lorazepam was administered during the first 30 minutes) (Figure 1). Patient characteristics and baseline measures are presented in the Table.Characteristic Total (n=99) 2-Min Bolus (n=50) 15-Min Infusion (n=49) Female sex (%) 65 (65.7) 31 (62.0) 34 (69.4) White (%) 50 (50.5) 28 (56.0) 22 (44.9) Mean±SD age (y)
Discussion
The term “akathisia” is derived from the Greek words meaning inability to sit down. It was first coined in 1902 to describe restless patients with hysteria and neurasthenia.9 In the 1950s, some patients taking neuroleptic drugs were observed to manifest jittery, restless, or rhythmic movements, often of the feet, resembling those movements described by Haskovec.14 There is some debate whether akathisia is truly a movement disorder or an intense and uncomfortable mental state that leads to
Acknowledgements
Author contributions: JBJ, CDC, EJB, BKG, and WHC conceived the study and designed the trial. JBJ, BKG, and EJB supervised the conduct of the trial and all aspects of the data collection. RWC, JDHW, and BKG undertook the responsibility for patient recruitment including data management and entry. All statistical plans and analyses were supervised and performed by EJB. RWC and JDHW drafted the manuscript and all authors contributed extensively to its revision and final presentation. The paper was
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2011, Journal of Emergency MedicineCitation Excerpt :Friedman et al. concluded that pretreatment with diphenhydramine reduced akathisia in patients receiving higher-than-normal doses of metoclopramide (90). Slow infusion of prochlorperazine does not seem to affect development of akathisia (91,92). Droperidol is one of many commonly used drugs that prolong the QT interval (93,94).
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