Although the DPT combination-sometimes called the lytic cocktail or pedi-cocktail-has been commonly prescribed in pediatric medicine for many years, there are good reasons why it's no longer recommended. The main concern is safety. To underscore the risks, the AHCPR's Acute Pain Management Guideline Panel includes this warning in its 1992 Clinical Practice Guideline: "Exercise caution when using the mixture... DPT-given intramuscularly-has commonly been used for painful procedures. The efficacy of this mixture is poor when compared with alternative approaches, and it has been associated with a high frequency of adverse effects... It is not recommended for general use and should only be used in exceptional circumstances."
The DPT combination causes excessive CNS depression that results in prolonged, heavy sedation. This can be especially hazardous when pediatric patients are discharged shortly after a procedure and family members are responsible for observing them. One study, for example, found that two-thirds of the children who received DPT remained asleep for seven hours or more afterward. Four of 95 patients had respiratory depression--and one developed respiratory arrest.
Also, as noted in the previous answer, meperidine lowers the seizure threshold, especially in patients with sickle cell anemia or renal dysfunction. Although this is generally only a concern-with prolonged use, it can occur even with limited use and is an unnecessary risk. Chlorpromazine may potentiate the actions and increase the toxicity of meperidine, leading to CNS depression, respiratory depression, and hypotension. And promethazine has an antianalgesic effect, while chlorpromazine has an initial antianalgesic effect followed by a slight analgesic effect. So prescribing these two parts of the DPT combination for pain relief can't be justified.
Despite the new guidelines, you may find some clinicians who are resistant or hard to convince. One reason is that prescribing DPT is an entrenched practice and many may not be familiar with alternatives. If so, you may refer them to another authority, The Harriet Lane Handbook, which no longer lists DPT among its suggested drug combinations.
Other effective premedications include opioids, such as morphine or fentanyl, and sedatives such as diazepam, midazolam, or pentobarbital. For shorter painful procedures, IV fentanyl, administered slowly over three to five minutes, is considered safe and efficacious. It has a rapid onset (90 to 120 seconds), short duration of action (up to 60 minutes), and minimal adverse effects if it's given as suggested. Another benefit of fentanyl is that it has a less pronounced effect on the cardiovascular system than morphine. This means that it's less likely to cause hypotension, for example.
Donna L. Wong
March 15, 2002
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