Routine perioperative ketorolac administration is not associated with hemorrhage in pediatric neurosurgery patients

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>NSAIDs are effective perioperative analgesics. Many surgeons are reluctant to use NSAIDs perioperatively because of a theoretical increase in the risk for bleeding events. The authors assessed the effect of routine perioperative ketorolac use on intracranial hemorrhage in children undergoing a wide range of neurosurgical procedures.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>A retrospective single-institution analysis of 1451 neurosurgical cases was performed. Data included demographics, type of surgery, and perioperative ketorolac use. Outcomes included bleeding events requiring return to the operating room, bleeding seen on postoperative imaging, and the development of renal failure or gastrointestinal tract injury.</jats:p> <jats:p>Variables associated with both the exposure and outcomes (p &lt; 0.20) were evaluated as potential confounders for bleeding on postoperative imaging, and multivariable logistic regression was performed. Bivariable analysis was performed for bleeding events. Odds ratios and 95% CIs were estimated.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>Of the 1451 patients, 955 received ketorolac. Multivariate regression analysis demonstrated no significant association between clinically significant bleeding events (OR 0.69; 95% CI 0.15–3.1) or radiographic hemorrhage (OR 0.81; 95% CI 0.43–1.51) and the perioperative administration of ketorolac. Treatment with a medication that creates a known bleeding risk (OR 3.11; 95% CI 1.01–9.57), surgical procedure (OR 2.35; 95% CI 1.11–4.94), and craniotomy/craniectomy (OR 2.43; 95% CI 1.19–4.94) were associated with a significantly elevated risk for radiographically identified hemorrhage.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>Short-term ketorolac therapy does not appear to be associated with a statistically significant increase in the risk of bleeding documented on postoperative imaging in pediatric neurosurgical patients and may be considered as part of a perioperative analgesic regimen. Although no association was found between ketorolac and clinically significant bleeding events, a larger study needs to be conducted to control for confounding factors, because of the rarity of these events.</jats:p></jats:sec>

Administering analgesia sublingually is a suitable option for children with acute abdominal pain in the emergency department

“…The maximum dose of 30 mg of ketorolac was chosen in accordance with the maximum intravenous dose. It is notable that a single dose of ketorolac is considered safe even if a patient may undergo surgery . In our series, ketorolac and tramadol were not superior to paracetamol in managing pain, but children, who took tramadol experienced significantly more adverse events.…”

Paracetamol Instead of Ketorolac in Post-Video-Assisted Thoracic Surgery Pain Management: A Randomized Trial

“…The greater bleeding volume in the ketorolac group may be the reason for the higher heart rate in these patients. Richardson et al assessed 1,451 pediatric patients undergoing cranial surgery, and concluded that short-term ketorolac therapy was not associated with significantly increased bleeding on postoperative imaging or clinical evaluation ( 22 ). Jahangiri compared the efficacy of paracetamol and remifentanil for postoperative pain management in patients undergoing coronary artery bypass graft surgery, and showed better analgesic effects with paracetamol ( 23 ).…”

Efficacy and Safety of Ketorolac for Pain Management After Congenital Heart Surgery: A Comparison to Paracetamol

“…The patients underwent a standard anesthesia with ketamine 1 mg/kg, midazolam 0.1 mg/kg, and fentanyl [1][2][3][4][5] µg/kg for induction and atracurium 0.6 mg/kg to facilitate endotracheal intubation. Anesthesia was maintained with isoflurane 1.2 -2.5 minimum alveolar concentration (MAC) and additional fentanyl 5 µg/kg to maintain blood pressure and heart rates at 20% from baseline.…”

“…However, their safety is questioned in children undergoing heart surgery. Ketorolac has been used safely to manage postoperative pain in different pediatric surgeries (3)(4)(5)(6)(7)(8) including congenital heart surgery (9-11) with no adverse effects.…”