Ketorolac reduces postoperative narcotic requirements

doi:10.1053/jpsu.2001.20011

Journal of Pediatric Surgery

Volume 36, Issue 1, January 2001, Pages 76-79

Presented at the 31st Annual Meeting of the American Pediatric Surgical Association, Orlando, Florida, May 25-29, 2000.

https://doi.org/10.1053/jpsu.2001.20011 Get rights and content

Abstract

Background/Purpose: Adverse effects from narcotics complicate pain management in children. Ketorolac, a potent nonsteroidal antiinflammatory agent can be used as an adjuvant analgesic, yet concerns of bleeding and nephrotoxicity have limited routine use. The authors hypothesized that postoperative use of ketorolac in healthy pediatric surgical patients would limit narcotic requirements without increasing morbidity. Methods: A case-control clinical trial was conducted of 29 pediatric surgical cases prospectively administered ketorolac (0.5 mg/kg intravenously every 6 hours) supplemented with morphine. Controls receiving morphine only were matched for age (± 6 months) and surgical procedure. Incidence of respiratory depression, urinary retention, emesis, nephrotoxicity, and bleeding were recorded. Results: Patients receiving ketorolac plus morphine had significantly less morphine requirements in the first 48 postoperative hours (Ketorolac plus Morphine: 0.36 ± 0.16 mg/kg/d, Morphine only: 1.08 ± 0.16 mg/kg/d [P <.05, analysis by paired t test]). This decrease was noted despite mode of analgesia (patient controlled or nurse administered). Adverse effects of morphine including respiratory depression, emesis, and urinary retention were not affected by ketorolac. Patients administered ketorolac had no significant increase in bleeding or nephrotoxicity. Conclusion: Ketorolac exhibits significant opiate-sparing effects in the immediate postoperative period without introducing additional morbidity to pediatric surgical procedures. J Pediatr Surg 36:76-79. Copyright © 2001 by W.B. Saunders Company.

Section snippets

Study design

A case-control clinical trial was conducted of 29 pediatric inpatient surgical cases who were treated prospectively with a standard regimen of ketorolac (0.5 mg/kg intravenously every 6 hours) and supplemented with intravenous morphine sulfate (Table 1).

. Surgical Procedures Performed on 29 Matched Pairs Receiving Ketorolac Plus Morphine or Morphine Alone

Procedure	No.
Appendectomy (acute, nonperforated)	6
Appendectomy (acute, perforated)	4
Laparoscopic appendectomy	1
Nissen fundoplication	8
Laparoscopic

Results

Patients receiving ketorolac plus morphine showed a significant reduction in morphine requirements over the first 48 postoperative hours (Fig 1).

. Postoperative daily morphine requirements (milligrams per kilogram per day) in 29 pediatric inpatients surgical cases prospectively treated with a standard regimen of intravenous ketorolac and supplemented with intravenous morphine sulfate. Contemporary controls received morphine only. Pairs were frequency matched for age (± 6 months) and surgical

Discussion

Postoperative analgesia in children should use preventive strategies with fixed-interval dosing of potent analgesics with low toxicity. In the postoperative management of infants and children, this approach often is tempered by concerns of adverse effects related to narcotics.5, 16 Ketorolac is a nonsteroidal antiinflammatory drug with analgesic and antipyretic properties. It has potent antinocioceptive effects on peripheral neurons providing local antiinflammatory activity¹⁴ and also may blunt

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Effect of Ketorolac Tromethamine Combined With Remifentanil on Reducing Complications During the General Anesthesia Emergence
2023, Journal of Perianesthesia Nursing
To observe the effect of ketorolac tromethamine combined with remifentanil in sedation and analgesia during general anesthesia emergence and reducing general anesthesia complications.
This is an experimental design.
A total of 90 patients who underwent partial or total thyroidectomy in our hospital were selected and randomly divided into three groups with 30 cases in each group. Routine general anesthesia combined with endotracheal intubation was given for general anesthesia, and different treatments were administered when the skin was sutured. Group K: intravenous injection of ketorolac tromethamine 0.9 mg/kg, intravenous injection of normal saline 10 mL/h by micropump until awakening and extubation; R group: intravenous injection of normal saline 2 mL, micropump intravenous injection of remifentanil 0.1 mcg/kg/min until awakening and extubation; KR group: intravenous injection of ketorolac tromethamine 0.5 mg/kg, micropump intravenous injection remifentanil 0.05 mcg/kg/min until awakening and extubation. After the operation, all patients entered the postanesthesia care unit (PACU) for recovery, extubation, scoring. The incidence and condition of various complications were counted.
There was no significant difference in the general information or operation duration of the patients (P > .05). The types of general anesthesia induction drugs in each group were the same, and there was no significant difference in drug measurement (P > .05). The visual analogue scales of KR group were: 2.2 ± 0.6(T0) and 2.4 ± 0.9(T1), the Self-Rating Anxiety Scale scores of the KR groups were: 4.1 ± 0.6(T0), 3.7 ± 0.4(T1). Compared with the KR group, the visual analogue scale and Self-Rating Anxiety Scale scores of the K and R groups at T0 and T1 were increased (P < .05); the visual analogue scale and Self-Rating Anxiety Scale scores of the K and R groups at T0 and T1 were not significantly different (P > .05); at T2, there was no significant difference in visual analogue scale and Self-Rating Anxiety Scale scores among the three groups (P > .05). There was no significant difference in extubation time or PACU transfer time among the three groups (P > .05). The incidence of adverse reactions in KR group were: 3.3% (nausea), 3.3% (vomit), 0 (coughing and drowsiness). Compared with the KR group, the incidence of adverse reactions was higher in the K and R groups.
Ketorolac tromethamine combined with remifentanil can effectively relieve pain and sedation during general anesthesia recovery and reduce the incidence of complications related to general anesthesia recovery. At the same time, the application of ketorolac tromethamine can reduce the dosage of remifentanil and inhibit the occurrence of adverse reactions when used alone.
Comparison of intravenous ibuprofen versus ketorolac for postoperative analgesia in children undergoing lower abdominal surgery: A randomized, controlled, non-inferiority study
2022, Revista Espanola de Anestesiologia y Reanimacion
A menudo se utilizan antiinflamatorios no esteroideos para analgesia multimodal, para controlar el dolor postoperatorio. El objetivo de este estudio aleatorizado, controlado, doble ciego y de no inferioridad fue comparar los efectos analgésicos postoperatorios de ibuprofeno y ketorolaco intravenosos en niños tratados mediante cirugía unilateral abierta de la zona inferior del abdomen. Los autores supusieron que la analgesia postoperatoria producida por ibuprofeno intravenoso no sería inferior a la de ketorolaco intravenoso.
Sesenta y seis niños de 2 a 8 años de edad fueron programados para cirugía unilateral de la zona inferior del abdomen. Los pacientes del grupo ibuprofeno recibieron 10 mg/kg/6 h de ibuprofeno intravenoso y los pacientes del grupo ketorolaco recibieron 0,5 mg/kg/6 h de ketorolaco por vía intravenosa. La medida del objetivo primario fue el consumo morfina postoperatoria durante 24 h. Las medidas del resultado secundario fueron la puntuación del dolor postoperatorio, la incidencia de fiebre postoperatoria temprana y la incidencia de efectos adversos relativos a ibuprofeno y ketorolaco incluyendo dolor durante la infusión del fármaco, vómitos, dolor epigástrico y reacción alérgica.
Cincuenta y nueve pacientes completaron el estudio (30 de ibuprofeno y 29 de ketorolaco). No se produjo diferencia significativa (p = 0,305) en cuanto a consumo medio (desviación estándar) de morfina postoperatoria durante 24 h (μ/kg) entre el grupo ibuprofeno, 160 (5,31), y el grupo ketorolaco, 14,65 (4,61). Las puntuaciones de dolor reportadas fueron similares en ambos grupos. La incidencia de fiebre postoperatoria fue significativamente menor (p = 0,039) en el grupo ibuprofeno (3%) que en el grupo ketorolaco (20%). La incidencia de efectos adversos fue similar en ambos grupos.
Ibuprofeno intravenoso puede utilizarse como alternativa a ketorolaco para analgesia postoperatoria en niños tratados mediante cirugía unilateral de la zona inferior del abdomen, ya que ambos fármacos aportan analgesia postoperatoria segura, efectiva y similar.
Non-steroidal anti-inflammatory drugs are often used as part of multimodal analgesia to control postoperative pain. This randomized, controlled, double-blinded, non-inferiority study aimed to compare the postoperative analgesic effects of intravenous ibuprofen versus ketorolac in children undergoing open unilateral lower abdominal surgery. The authors hypothesized that postoperative analgesia produced by intravenous ibuprofen would be non-inferior to that of intravenous ketorolac.
Sixty-six children aged 2 to 8 years who were scheduled to undergo unilateral lower abdominal surgery, were recruited. Patients in the ibuprofen group received 10 mg/kg/6 h intravenous ibuprofen. Patients in the ketorolac group were given 0.5 mg/kg/6 h intravenous ketorolac. The primary outcome measure was 24-h postoperative morphine consumption. The secondary outcome measures were postoperative pain score, the incidence of early postoperative fever and the incidence of ibuprofen and ketorolac adverse effects including pain during drug infusion, vomiting, epigastric pain and allergic reaction.
Fifty-nine patients completed the study (30 ibuprofen, 29 ketorolac). There was no significant difference (P= .305) in the mean (SD) 24-h postoperative morphine consumption (μ/kg) between intravenous ibuprofen, 16.00 (5.31), and ketorolac, 14.65 (4.61). The reported pain scores were similar in both groups. The incidence of postoperative fever was significantly lower (p = 0.039) in the ibuprofen group (3%) than the ketorolac group (20%). The incidence of adverse effects was similar in both ibuprofen and ketorolac groups.
Intravenous ibuprofen can be used as an alternative to ketorolac for postoperative analgesia in children undergoing unilateral lower abdominal surgery because both drugs similarly provide safe and effective postoperative analgesia.
Pharmacokinetics and Pharmacology of Drugs Used in Children
2019, A Practice of Anesthesia for Infants and Children
The pharmacokinetics (PK) and pharmacodynamics (PD) of most medications in children especially neonates, differ from those in adults. Children exhibit different PK and PD from adults because of their immature renal and hepatic function, different body composition, altered protein binding, distinct disease spectrum, diverse behavior, and dissimilar receptor patterns. PK differences necessitate modification of the dose and the interval between doses to achieve the desired concentration associated with a clinical response and to avoid toxicity. In addition, some medications may displace bilirubin from its protein binding sites and possibly predispose to kernicterus in premature neonates. Drug effect may be influenced by altered capacity of the end organ, such as the heart or bronchial smooth muscle, to respond to medications in children compared with adults. In this chapter we discuss basic pharmacologic principles as they relate to drugs commonly used by anesthesiologists.
Pharmacokinetics and Pharmacology of Drugs Used in Children
2018, A Practice of Anesthesia for Infants and Children
The pharmacokinetics (PK) and pharmacodynamics (PD) of most medications in children especially neonates, differ from those in adults. Children exhibit different PK and PD from adults because of their immature renal and hepatic function, different body composition, altered protein binding, distinct disease spectrum, diverse behavior, and dissimilar receptor patterns. PK differences necessitate modification of the dose and the interval between doses to achieve the desired concentration associated with a clinical response and to avoid toxicity. In addition, some medications may displace bilirubin from its protein binding sites and possibly predispose to kernicterus in premature neonates. Drug effect may be influenced by altered capacity of the end organ, such as the heart or bronchial smooth muscle, to respond to medications in children compared with adults. In this chapter we discuss basic pharmacologic principles as they relate to drugs commonly used by anesthesiologists.
Hospital Charges and Length of Stay Following Radical Cystectomy in the Enhanced Recovery After Surgery Era
2018, Urology
To report our center's experience with enhanced recovery after surgery (ERAS) pathway for radical cystectomy (RC), specifically evaluating complications, LOS, 30- and 90-day readmissions, and hospital charges. Pathways of this type have been shown to decrease the length of stay (LOS) and postoperative ileus. However, concerns persist that ERAS is costly and increases readmissions. To date, limited studies have evaluated these concerns.
Our ERAS protocol was implemented for RC in December 2015. Outcomes in ERAS patients were compared with those in RC patients from the time period before ERAS. Patients were excluded if they underwent concomitant nephroureterectomy.
Fifty-six consecutive ERAS patients were compared with 54 pre-ERAS patients. The median charge for index hospitalization was $31,090 in the ERAS group and $35,489 in the pre-ERAS group (P = .036). The median LOS was 5.0 days in the ERAS group and 8.5 days in the pre-ERAS group (P = < .001). The pre-ERAS group had a significantly increased use of nasogastric tube (13.8% vs 30.0%) and parenteral nutrition (6.9% vs 20.4%). The overall complication rate (including infectious, renal, deep vein thrombosis and pulmonary embolism, myocardial infarction and stroke, and respiratory and gastrointestinal-related complications) was similar between the 2 groups (51.7% in the ERAS group and 62.0% in the pre-ERAS group, P = .28). Thirty- and 90-day readmissions also remained similar (19.0% vs 14.8%, P = .55, and 31.0% vs 27.7%, P = .64). The most common readmission reason was infection, specifically urinary tract infection.
Implementation of the ERAS pathway at our center resulted in significantly reduced LOS and total hospital charge, with comparable rates of complication and readmission, highlighting the need for ERAS pathways in patients undergoing RC.
Ketorolac does not reduce effectiveness of pleurodesis in pediatric patients with spontaneous pneumothorax
2015, Journal of Pediatric Surgery
Antiinflammatory medications are thought to reduce the effectiveness of pleurodesis performed for the treatment of spontaneous pneumothorax. We reviewed our experience with children undergoing video-assisted thorascopic surgery (VATS) with pleurodesis for pneumothorax to determine if ketorolac administration influences patient outcomes.
A retrospective review of patients who underwent VATS pleurodesis for spontaneous pneumothorax from 2009 to 2013 at a pediatric hospital was performed. Length of stay, radiographic pneumothorax resolution prior to discharge, and ipsilateral recurrence rates were compared in patients who did and did not receive perioperative ketorolac.
Over a 50-month period, 51 patients underwent VATS with mechanical pleurodesis for spontaneous pneumothorax. The average age was 15.5 years, and 76% were male. Ketorolac was administered to 26/51 patients. There were no differences in average length of stay (11.3 vs 10.9 days, p = 0.36), incidence of residual pneumothorax at discharge (22/41 vs 19/41, p = 0.48), or ipsilateral recurrence (5/10 vs 5/10, p = 1).
Despite the intrinsic antiinflammatory properties of ketorolac, our data suggests that its use for patients undergoing pleurodesis for spontaneous pneumothorax does not detrimentally influence the outcomes of surgery. Therefore, we conclude that ketorolac can be used for pain control in this population. Large-scale studies are warranted to validate these findings.

View all citing articles on Scopus

^☆: Address reprint requests to Linda A. Nicolette, MD, Pediatric Surgical Associates, Physician Office Building, Suite 401, 725 Irving Ave, Syracuse, NY 13210.

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Ketorolac reduces postoperative narcotic requirements☆

Abstract

Section snippets

Study design

Results

Discussion

Pain

Br J Anaesth

Br J Anesth

Pain

Pain

J Clin Anesth

Pain

J Clin Anaesth

Pediatric Pain Handbook

Ketorolac for postoperative pain management in children

Drug Safety

Postoperative morphine requirements, nausea and vomiting following anaesthesia for tonsillectomy. Comparison of intravenous morphine and non-opioid analgesic techniques

Paediatr Anaesth

A single dose of morphine sulfate increases the incidence of vomiting after outpatient inguinal surgery in children

Anesthesiology

A survey of pain in hospitalized patients aged 4-14 years

Clin J Pain

Postoperative nausea and vomiting. Its etiology, treatment, and prevention

Anesthesiology

Comparison of morphine patient-controlled analgesia with and without ketorolac for postoperative analgesia in pediatric orthopedic surgery

Am J Ortho

Effects of ketorolac on postoperative analgesia and bleeding time in children

Anesthesiology

Intravenous ketorolac as a adjuvant to pediatric patient-controlled analgesia with morphine

Anesthesiology