Safety Considerations in the Use of Ketorolac for Postoperative Pain

Maslin, Benjamin; Lipana, Lawrence; Roth, Brandon; Kodumudi, Gopal; Vadivelu, Nalini

doi:10.2174/1574886311666160719154420

Cited by 30 publications

(23 citation statements)

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“…Bleeding risk has been of primary concern with perioperative NSAID exposure given the anti-platelet effects of cyclooxygenase-1 (COX-1) inhibition. Bleeding times and postoperative bleeding events do not appear significantly affected by NSAIDs at usual doses, and this risk may be further mitigated by using COX-2 selective agents [211][212][213][214][215][216]. Traditional dogma has suggested avoiding NSAIDs in spinal/orthopedic fusion surgeries because of the risk of nonunion.…”

Section: Preoperative Phasementioning

confidence: 99%

“…Since inflammation is a key driver of pain after surgery, early anti-inflammatories may be the most effective postoperative analgesic strategies, as evidenced by their superior performance over opioids in analyses of randomized controlled studies [164,[393][394][395][396]. Novel intravenous formulations of ibuprofen and diclofenac currently have limited roles in therapy due to a lack of demonstrated superiority to ketorolac and significantly higher cost [214,215]. Escalating doses of ketorolac greater than 10-15 mg per dose and ibuprofen greater than 400 mg per dose may offer additional analgesic benefit, and the duration of ketorolac therapy should generally be limited to no more than 5 days [212,[397][398][399][400].…”

Section: Postoperative Nonopioid Considerationsmentioning

confidence: 99%

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Perioperative Pain Management and Opioid Stewardship: A Practical Guide

et al. 2021

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Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a “roadmap” for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

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Section: Preoperative Phasementioning

confidence: 99%

Section: Postoperative Nonopioid Considerationsmentioning

confidence: 99%

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

et al. 2021

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“…34-35 There is ongoing concern regarding increased postoperative hemorrhage when ketorolac is used for analgesia, but there is conflicting evidence regarding the safety of ketorolac in pediatric tonsillectomy. 36-37…”

Section: Discussionmentioning

confidence: 99%

“…[34][35] There is ongoing concern regarding increased postoperative hemorrhage when ketorolac is used for analgesia, but there is conflicting evidence regarding the safety of ketorolac in pediatric tonsillectomy. [36][37] The anesthesiologists who do use opioids in the PACU for a normal-weight child with severe OSA are most likely to use fentanyl (51.8%) which has a rapid onset and short duration of action. 33 There is an increase in analgesic and respiratory sensitivity to opioids in children with severe OSA.…”

Section: Discussionmentioning

confidence: 99%

How Pediatric Anesthesiologists Manage Children with OSA Undergoing Tonsillectomy

Roberts

Sayegh

Ellison

et al. 2019

Ann Otol Rhinol Laryngol

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Objective: The purpose of this study was to describe typical anesthesia practices for children with obstructive sleep apnea (OSA). Study Design: Online survey. Method: A sample of pediatric anesthesiologists received the survey by email. Results: 110 respondents were included. 46.4% worked in a free-standing children’s hospital and 32.7% worked in a children’s facility within a general hospital. 73.6% taught residents. 44.4% saw at least one child with OSA per week, 25.5% saw them daily. On a 100-mm visual analog scale, respondents rated their comfort with managing these children as 84.94 (SD 17.59). For children with severe OSA, 53.6% gave oral midazolam preoperatively, but 24.5% typically withheld premedication and had the parent present for induction. 68.2% would typically use nitrous oxide for inhalational induction. 68.2% used fentanyl intraoperatively, while 20.0% used morphine. 61.5% reduced their intraop narcotic dose for children with OSA. 98.2% used intraoperative dexamethasone, 58.2% used 0.5 mg/kg for the dose. 98.2% used ondansetron, 62.7% used IV acetaminophen, and 8.2% used IV NSAIDs. 83.6% extubated awake. 27.3% of respondents stated that their institution had standardized guidelines for perioperative management of children with OSA undergoing adenotonsillectomy. People who worked in children’s hospitals, who had >10 years of experience, or who saw children with OSA frequently were significantly more comfortable dealing with children with OSA ( P < 0.05). Conclusion: Apart from using intraoperative dexamethasone and ondansetron, management varied. These children would likely benefit from best practices perioperative management guidelines.

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“…Ketorolac is preferred to morphine in managing acute pain because, contrary to morphine, it does not have adverse effects on the central nervous system and does not cause respiratory depression and hypotension. Moreover, morphine reduces the movement of the digestive tract and may cause itching or allergic reactions; furthermore, the chronic use of morphine can lead to drug dependence (25). In addition, research has shown that ketorolac has proper efficacy in 25 to 50% of cases when compared to opiate drugs.…”

Section: Discussionmentioning

confidence: 99%

Pain Relief in the Sickle-Cell Crisis: Intravenous Morphine Versus Ketorolac; A Double-Blind, Randomized Clinical Trial

Doluee¹,

Kakhki²,

Mir³

et al. 2019

Iran Red Crescent Med J

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Background: Sickle cell disease (SCD) is a congenital hemoglobinopathy. A low Hb level and high hemoglobin-to-hematocrit ratio may lead to the vaso-occlusive crisis in patients, for the management of which hyperbaric oxygen, hydration, and pain relief therapy are proposed. Objectives: In this study, we sought to compare the effects of morphine and ketorolac on relieving painful sickle cell crisis. Methods: In this double-blind, randomized clinical trial, we recruited 92 SCD patients who referred to the Emergency Department of a university-affiliated hospital, in Mashhad, Iran, from December 2016 to May 2017. The patients were randomly assigned to two groups of ketorolac and morphine injections for relieving pain crisis according to the clinical conditions of the patients. Pain severity was measured by the visual analogue scale before and after the intervention. Data were analyzed using SPSS software. Results: A total of 92 SCD patients were evaluated, while, 19 (21%) were female and 73 (79%) were male, with the mean age of 20.77 ± 8.6 years. At the pre-injection phase, the mean pain scores were 9.1 ± 0.4 and 9.1 ± 0.7 in the ketorolac and morphine groups, respectively. After the intervention, the mean pain scores were 3.7 ± 1.2 and 4.9 ± 2.1 in the ketorolac and morphine groups, respectively. A significant association was found between the pain score after drug injection and the administered drug (P = 0.006). Conclusions: The management of pain crisis with ketorolac injection yielded the same results as the morphine injection in SCD patients. However, ketorolac was found to be associated with fewer side effects than morphine; thus, it can be beneficial for managing SCD patients suffering pain crisis.

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Safety Considerations in the Use of Ketorolac for Postoperative Pain

Cited by 30 publications

References 0 publications

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

How Pediatric Anesthesiologists Manage Children with OSA Undergoing Tonsillectomy

Pain Relief in the Sickle-Cell Crisis: Intravenous Morphine Versus Ketorolac; A Double-Blind, Randomized Clinical Trial

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