Visual loss in cytomegalovirus retinitis caused by cystoid macular edema in patients without the acquired immune deficiency syndrome

PURPOSE

Although serous macular exudation has been described in patients with the acquired immune deficiency syndrome (AIDS) with active cytomegalovirus (CMV) retinitis, cystoid macular edema (CME) is not encountered in this clinical setting. In contrast to these findings, we describe vision loss due to CME occurring in immunosuppressed patients without AIDS treated for CMV retinitis.

METHODS

Three patients (four eyes) with systemic immunodeficiency presenting with vision loss underwent ophthalmologic examination, including fundus photography and fluorescein angiography. Systemic evaluation was performed to establish the etiology of immunodeficiency and to rule out human immunodeficiency virus infection. Patients were treated with topical corticosteroid and nonsteroidal anti-inflammatory medications for CME.

RESULTS

All patients had severe generalized immune deficiency, related either to drug-induced immunosuppression or primary immunodeficiency. Laboratory studies confirmed the presence of systemic CMV infection. Affected eyes had mild reduction of central vision (range, 20/40 to 20/60). Three of four affected eyes had resolving CMV retinitis outside the posterior pole with mild panuveitis. These eyes showed CME on clinical examination and fluorescein angiography. The CMV lesions regressed after reduction of immunosuppressive agents or after systemic antiviral treatment. Response of CME to topical anti-inflammatory medication was variable.

CONCLUSIONS

Cystoid macular edema can occur in the setting of resolving CMV retinitis in patients with immunodeficiency other than AIDS. This entity is distinct from serous macular exudation, which can occur in patients with AIDS with active CMV retinitis involving the posterior pole. The disparity between patients with and without AIDS in the development of CME may be important in understanding the pathogenesis of CME.

Ketorolac versus meperidine for pain relief after orthopaedic surgery

In this double-blind, randomized, multicenter study, 244 patients with at least moderate pain after major orthopaedic surgery received intramuscular Ketorolac (60 mg followed by 30 mg) or intramuscular meperidine (100 mg or placebo) every 2 to 6 hours as needed for as many as 5 days. Analgesic response was evaluated for 6 hours after initial study drug administration and thereafter each night at bedtime. Both active treatment groups had similar 3-hour summed pain intensity difference and 3-hour total pain relief scores after the first dose that were superior to placebo. The 6-hour summed pain intensity difference and total pain relief scores were significantly higher with Ketorolac than with meperidine or placebo. The mean daily categorical pain intensity scores were comparable with Ketorolac and meperidine, and both were significantly superior to placebo. Patient ratings of overall medication efficacy were significantly better with Ketorolac than with meperidine. In both patient and observer evaluations, Ketorolac was significantly better tolerated than meperidine, and the number of patients reporting adverse events was lower with Ketorolac than with meperidine. Following major orthopaedic surgery, Ketorolac provided effective analgesia that was superior to placebo and at least comparable with meperidine. Ketorolac was better tolerated than meperidine.

Reduction of postburn hyperalgesia after local injection of ketorolac in healthy volunteers

BACKGROUND

Nonsteroidal antiinflammatory drugs may be particularly effective against prostaglandin-mediated, post-injury hyperalgesia and related inflammatory pain. However, their usefulness may be limited by their systemic side effects. The current study determined if local effectiveness can be achieved by low-dose intradermal nonsteroidal antiinflamatory drug administration.

METHODS

Ten healthy volunteers were asked to make magnitude estimations of the pain induced by a contact thermal stimulator at 1 degree C increments between 43 and 51 degrees C at three 1 x 1 cm study sites on each forearm during three study phases:(1) baseline; (2) after pretreatment with 10 microl 0.9% saline (n=1 site on each forearm), 0.3 mg ketorolac (n=1 on each forearm), or nothing (n=1 on each forearm); and (3) after "injury" by a mild burn at the ketorolac- and saline-treated sites on one arm or by injection of 10 nmol bradykinin at all three sites on the other arm. The effects of pretreatment on the pain induced by thermal testing were assessed using repeated-measures analysis of variance.

RESULTS

Pretreatment with ketorolac had a selective effect on the postburn injury hyperalgesia, reducing the increase in pain intensity (P<0.05) but not the decline in pain threshold. It had no effect on the responses to thermal stimuli before injury or on the pain of burning, which were similar at ketorolac- and saline-treated sites. The effect of pretreatment with ketorolac on bradykinin-induced hyperalgesia was not achieved after bradykinin injection at sites pretreated with saline as well as ketorolac.

Intraocular penetration of periocular ketorolac and efficacy in experimental uveitis

PURPOSE

To determine in rabbits whether periocular injection of ketorolac tromethamine effectively delivers the drug to the eye and, if so, whether this is efficacious in the treatment of experimental uveitis.

METHODS

Ketorolac was administered by anterior subconjunctival injection, posterior periocular injection, intramuscular injection, or topical eye drops. The aqueous and vitreous were assayed for ketorolac. Anterior subconjunctival and topical ketorolac were compared to control as well as topical and anterior subconjunctival steroid treatments in uveitis induced by the intravitreal injection of tumor necrosis factor.

RESULTS

Anterior subconjunctival injection led to high, though short-lived, levels of drug in the aqueous and vitreous. Posterior periocular injection led to much lower levels. Topical dosing led to relatively low aqueous and undetectable vitreous levels. No ocular levels were detected after intramuscular dosing. All tested antiinflammatory treatments were similarly effective in controlling uveitis.

CONCLUSIONS

Anterior subconjunctival injection of ketorolac produced high intraocular concentrations of drug and was beneficial in controlling the inflammation in this animal model of uveitis.

Is preoperative ketorolac a useful adjunct to regional anesthesia for inguinal herniorrhaphy?

BACKGROUND

Nonsteroidal antiinflammatory drugs (NSAIDs) have become a popular component of analgesia regimens, particularly in combination with narcotics. We questioned whether there might also be a place for their use in conjunction with regional anesthesia and whether there was a preferable route for NSAID administration.

METHODS

Ilioinguinal and field blocks were performed preoperatively on seventy patients undergoing outpatient inguinal hernia repair. Patients were divided into a control group who received no ketorolac and four study groups who received a preoperative dose of 30 mg ketorolac by one of the following routes: i.v., i.m., p.o., or intrawound (i.w.). The ketorolac in the i.w group was mixed in the syringe with the local anesthetic used for the field block. i.v. and i.m. groups also received ketorolac at the time of the preoperative regional anesthesia and the PO group received the dose at least one hour preoperatively. All patients received a similar general anesthetic intraoperatively.

RESULTS

Postoperative pain scores and analgesic requirements were lowest for the i.m., i.v., and i.w. groups. Pain scores and analgesic requirements for the PO group were less than for the control group but more than for the other three groups. Analgesic efficacy therefore ranked: i.m. = i.v. = i.w. > p.o. > control. Though no differences were found between groups in the time to discharge from the recovery room, the ease of nursing care paralleled the findings for pain scores and analgesia requirements.

CONCLUSION

Beyond the analgesia provided by the regional anesthesia of the ilioinguinal and field blocks, the preoperative use of ketorolac further reduced postoperative pain scores and the need for additional postoperative analgesic medication. Comparable outcomes for the i.v., i.m. and i.w. groups indicate the lack of any benefit to concentrating the non-steroidal anti-inflammatory drug at the wound (i.w.) or to achieving high blood levels rapidly (i.v.). In conclusion, ketorolac is a useful supplement to ilioinguinal plus field block regional anesthesia for hernia surgery and is most effective administered parenterally.

Indomethacin and ketorolac given preoperatively are equally effective in reducing early postoperative pain after laparoscopic cholecystectomy

OBJECTIVE

To evaluate the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) on pain after laparoscopic cholecystectomy.

DESIGN

A prospective, randomized, placebo-controlled, double-blind study.

SETTING

A university hospital.

PATIENTS

Fifty-two patients with cholelithiasis but without known allergy to one of the study drugs, history of bleeding, peptic ulcer disease, known cardiac, lung or renal disease, abnormal liver function or use of opiates or NSAIDs within 2 weeks before operation. Patients were assigned to one of three groups and treatment was randomized by placing the drugs in sealed, numbered envelopes.

INTERVENTION

Administration of the NSAIDs ketorolac, intramuscularly, or indomethacin, rectally, before laparoscopic cholecystectomy.

MAIN OUTCOME MEASURES

Postoperative pain scored on a a visual analogue scale and by nurse assessment, total dose of fentanyl citrate given, and nausea or emesis.

RESULTS

Patients in the placebo group reported significantly more pain than either NSAID group (p<0.05) and were reported as having significantly more pain by the nurses (P<0.05). These patients were subsequently treated with a higher mean postoperative dose of fentanyl citrate than either NSAID group (p<0.05). Furthermore, the placebo group reported more nausea and emesis (p<0.05). There was no significant difference in any of the parameters measured between the ketorolac or indomethacin group.

CONCLUSIONS

The data demonstrate that the NSAIDs ketorolac and indomethacin, administered preoperatively, decrease early postoperative pain and nausea after laparoscopic cholecystectomy and are equally efficacious in producing these results.

Effect of ketorolac on bleeding time and postoperative pain in children: a double-blind, placebo-controlled comparison with meperidine

STUDY OBJECTIVE

To determine whether ketorolac 0.75 mg/kg would provide a comparable degree of analgesia to that of meperidine 1 mg/kg in terms of postoperative opioid requirements and pain scores in children undergoing surgeries associated with mild to moderate postsurgical discomfort.

DESIGN

Randomized, prospective, placebo-controlled, double-blinded study of the initial 6 postsurgical hours.

SETTING

University affiliated teaching hospital.

PATIENTS

90 healthy ASA status I and II children scheduled for elective general, orthopedic, or genitourinary procedures associated with mild to moderate postsurgical pain. Extensive surgical procedures associated with a significant risk of bleeding were excluded.

INTERVENTIONS

Ketorolac 0.75 mg/kg, meperidine 1 mg/kg, or placebo (normal saline) was administered intramuscularly (IM) at the beginning of surgery.

MEASUREMENTS AND MAIN RESULTS

Bleeding times were measured prior to and 180 minutes after study drug administration. Time to first rescue medication, total opioid requirement, pain scores, incidence of vomiting and length of stay were evaluated. Placebo-treated patients were rescued earlier (p < 0.0001) and required twice the rescue dosage (p = 0.013) when compared with either the ketorolac or meperidine groups. The ketorolac and meperidine groups did not differ with regard to time until first rescue, cumulative proportion requiring rescue, or the number of rescue doses required. A single dose of IM ketorolac prolonged bleeding time by 53 +/- 75 seconds (p = 0.006).

CONCLUSIONS

Ketorolac provided analgesia comparable to that of meperidine and significantly reduced opioid requirements. Since ketorolac was not associated with a reduction in postoperative vomiting or length of stay, and in view of the uncertain risk of bleeding, it offers no advantage over meperidine in the management of mild to moderate acute postsurgical pain.

Effect of pretreatment with ketorolac tromethamine on post-operative pain following periodontal surgery

A double-blind, randomized, single-dose clinical trial to evaluate the analgesic efficacy of preoperative ketorolac tromethamine administration on periodontal postoperative pain was designed. One group received 20 mg ketorolac immediately before periodontal flap surgery, and the other group received placebo. Naproxen sodium was allowed postoperatively as rescue medication. The visual analog scale was used to estimate pain. Postoperative pain was assessed hourly for the first 10 h on the day of surgery, and 4 x daily on the 1st and 2nd postsurgical days. Timing and dose of rescue analgesic remedication were also recorded. Results indicated that preoperative treatment with ketorolac significantly reduced initial pain intensity and delayed the onset of postoperative pain as compared to placebo. Incidence and amount of naproxen consumption was similarly small in both ketorolac- and placebo-treated groups. No adverse reactions related to preoperative medication were observed.

Evaluation of the financial impact of ketorolac tromethamine therapy in hospitalized patients

This retrospective cohort study aimed to determine the resource utilization and cost consequences of ketorolac tromethamine in postoperative pain management in a variety of clinical circumstances. All patients were treated at LDS Hospital, Salt Lake City, Utah, a 520-bed teaching hospital. A long-term archive of clinical and financial data from a computerized hospital information system was searched for patients with specified primary International Classification of Diseases, 9th Revision, Clinical Modification discharge diagnoses treated from June 1, 1990, to July 1, 1992, who received ketorolac (n = 229). These patients were matched with cohort patients (n = 821) treated from July 1, 1989, to May 31, 1990, who did not receive ketorolac. The archive contained information on ketorolac exposure as well as concurrent drug therapy and adverse drug events that had been prospectively evaluated during hospitalization throughout the study and cohort periods. Detailed costs were available for each patient. The study examined attributable differences in lengths of stay and total costs using linear regression modeling. We found a statistically significant attributable decreased length of stay for ketorolac patients of 1.15 days. Case patients also had reduced usage of narcotic drugs (4.39 fewer doses than cohorts and 15.6 hours shorter duration of narcotics than cohorts), reduced use of antiemetic and antipruritic medications, and reduced numbers of adverse events. Linear regression modeling showed that ketorolac use was significantly related to reduced cost using inflation-adjusted dollars. We believe that ketorolac has significant cost advantages over opiate analgesics because of its narcotic-sparing effects. Advantages of ketorolac use include reduced rates of adverse drug events, reduced lengths of stay, especially for orthopedic surgery, and reduced overall hospital costs for diagnosis-related groups associated with cholecystectomy.

Intravenous ketorolac tromethamine versus meperidine for adjunctive sedation in upper gastrointestinal endoscopy: a pilot study

BACKGROUND

Meperidine is commonly used with a benzodiazepine to achieve conscious sedation but may potentiate respiratory depression. Ketorolac tromethamine has few sedative effects and no respiratory depression. The purpose of this study was to compare ketorolac to meperidine as adjuncts in conscious sedation for upper gastrointestinal endoscopy (EDG).

METHODS

Patients undergoing diagnostic EGD (n = 47) were randomly assigned to receive normal saline solution or 50 mg meperidine or 30 mg ketorolac intravenously. Midazolam was subsequently administered (as needed, to achieve adequate conscious sedation) by endoscopists who were blinded to the test substance given before the procedure.

RESULTS

For all treatment groups, there was no significant difference in extent or adequacy of sedation, incidence of oxygen desaturation, patient amnesia, time of procedure, or vital signs (except for a relative procedural tachycardia in the ketorolac and placebo groups as compared to baseline). The ketorolac group experienced more pain and anxiety. The meperidine group experienced less gagging, a shorter sedation time, less midazolam usage, and more discomfort at the intravenous site. Meperidine seemed to offer a "protective" effect against procedural tachycardia.

CONCLUSION

There is no benefit to ketorolac as an adjunct in conscious sedation for EGD. Meperidine had several benefits; however, discomfort at the intravenous site was common.

Intravenous ketorolac for pain management in a ventilator-dependent patient with thermal injury

A patient with a long-standing history of chronic obstructive pulmonary disease suffered a thermal injury over 20% of his total body surface area. He required opiates for pain management and benzodiazepines for anxiety associated with dressing changes. The narcotics compromised his pulmonary function and level of consciousness, and interfered with several attempts to wean him from ventilator support. Intravenous ketorolac instead of narcotics before dressing changes alleviated the respiratory depression and returned his partial pressure of carbon dioxide-mediated respiratory drive to normal. With these changes, including changes in respiratory rate to tidal volume, he was successfully weaned from ventilatory support. In addition, the patient's level of consciousness improved. These changes increased his participation in his daily physical therapy sessions.

Ketorolac appears to decrease polyuria during intracranial surgery

Two cases are described of patients, undergoing surgery for intracranial pathology, who developed polyuria intraoperatively. The urine output decreased to within normal range shortly after the administration of ketorolac, a nonsteroidal antiinflammatory drug. The possible mechanisms producing the increased urinary output and the influence of prostaglandins on renal function are discussed.

The analgesic efficacy of ketorolac for acute pain

Ketorolac is a nonsteroidal anti-inflammatory drug, available in both oral and parenteral forms, that possesses significant analgesic potency. Its analgesic efficacy has been studied extensively for the treatment of moderate-to-severe pain in many clinical settings. Although ketorolac possesses significant analgesic potency, it has limited utility as an analgesic for the acute treatment of moderate-to-severe pain in the emergency department. Oral ketorolac has been shown to provide analgesia that is the same or better than aspirin, acetaminophen, and dextropropoxyphene with acetaminophen, and equal analgesia to most other commonly available oral analgesics, including ibuprofen and acetaminophen with codeine. Intramuscular ketorolac provides analgesia equivalent to commonly used doses of meperidine and morphine. However, its utility in acute pain, when rapid relief is necessary, is limited due to a prolonged onset to analgesic action (30-60 min) and a significant number of patients who exhibit little or no response, more than 25% in most studies. The use of intravenous ketorolac has been less well studied. It has analgesic potency but its utility in patients with moderate-to-severe pain is also limited because there is a significant percentage of patients who fail to obtain adequate relief. Ketorolac may be most useful in supplementing parenteral opiates.

Efficacy of ketorolac in the management of pain associated with root canal treatment

Patients requiring root canal treatment were randomly assigned to one of three groups. The first group received Ketorolac oral 10 mg at six hour intervals for 24 hours, the second group received Ketorolac (Toradol) injectable 10 mg at the height/depth of the buccal vestibule of the tooth to be treated, and the third group received no assigned medication. Significantly better pain relief was achieved when Ketorolac injectable or oral was used then when no drug was administered. Some of the patients in the Ketorolac injectable group felt that an additional dose of medication would have been helpful at the six- to eight-hour postoperative period. However, there was no significant difference in pain relief between the two groups treated with different drug regimens.

Randomized double-blind comparison of the analgesic efficacy of intramuscular ketorolac and oral indomethacin in the treatment of acute gouty arthritis

STUDY OBJECTIVE

To compare the analgesic effect of IM ketorolac tromethamine with that of oral indomethacin in the treatment of acute gouty arthritis.

DESIGN

Prospective, randomized, double-blind, controlled, parallel group clinical trial.

SETTING

Two urban emergency departments.

PARTICIPANTS

Twenty consecutive patients who presented to the ED with acute gout.

INTERVENTIONS

Each patient was randomly assigned to receive in the ED (1) 60 mg of IM ketorolac and oral placebo or (2) 50 mg of oral indomethacin and IM placebo. The patients rated the intensity of their pain on a Wong-Baker pain scale (which runs from 0 to 5) before treatment and 30, 60, 90, and 120 minutes after treatment. All the patients were discharged with instructions to take oral indomethacin and to complete pain score cards at home at 6, 12, and 24 hours.

RESULTS

The 10 patients in each group were similar with regard to age, sex, race, and initial mean pain score. After 2 hours, the mean pain scores (+/- SD) for the ketorolac group had decreased from 4.5 +/- .71 to 1.4 +/- 1.43 (P < .05), and the mean score for the indomethacin group had decreased from 4.4 +/- .70 to 1.5 +/- 1.18 (P < .05). The difference between the two groups was not significant. At 6 hours, there was some pain rebound in the ketorolac group.

CONCLUSION

IM ketorolac and oral indomethacin are similar in the relief of the pain of acute gouty arthritis in the ED.

Nonopioid analgesics shorten the duration of postoperative ileus

Morphine inhibits propagating and stimulates nonpropagating colon contractions in monkeys and humans. The use of morphine or other opioids that inhibit propulsive contractions prolongs postoperative ileus. In contrast, ketorolac tromethamine, a nonsteroidal analgesic, has no effect on colon contractions in monkeys. In 14 patients having elective abdominal operations, bipolar electrodes were implanted on the right (n = 13) and left (n = 10) colon. Group A (n = 8) received ketorolac, 30 mg IM q6h, for pain relief. Group B (n = 6) needed supplemental morphine, 2-10 mg IV or IM, plus ketorolac to control their pain. Myoelectric activity was recorded from each subject on postop Days 1-5 and analyzed by computer for electrical control activity (ECA), short and long electrical response activity (ERA), and propagation of long ERA. There was a difference between the two groups in return of propagated long ERA bursts that correlated with clinical recovery from postoperative ileus. Postoperative analgesia with ketorolac resulted in faster resolution of ileus compared to morphine plus ketorolac because opioid-induced motor abnormalities in the colon were avoided.

[Evaluation of the synergism between ketorolac and morphine in the treatment of postoperative pain]

BACKGROUND

The aim of the study is to determine what concentration of ketorolac and morphine administered together i.v. achieve best synergic effect between NSAID antiinflammatory and opioids analgesic properties.

DESIGN

Randomized comparative study was carried out on 180 patients, ASA II-IV, undergoing major general surgery, in an University Clinic.

METHODS

Postoperative pain therapy by i.v. PCA: group 1 morphine 0.75 mg.ml + ketorolac 0.75 mg.ml; group 2 morphine 0.50 mg.ml + ketorolac 1.50 mg.ml; group 3 morphine 0.25 mg.ml + ketorolac 1.50 mg.ml; in saline solution. Initial bolus: 2 ml. Continuous infusion 1.5 ml.h. Demand bolus: 0.2 ml. Lockout time: 30 minutes. Evaluations included: pain intensity (T0, T3, T18); total amount of infused drugs (T18); number of valid demands and attempts (T18); amount of autoadministered analgesic drugs in percent of highest available amount (T18); side effects (T18); patient's judgment.

DATA ANALYSIS

ANOVA and Student's "t"-test.

RESULTS

A statistically significant reduction of pain intensity was found after 3 and 18 hours in the three groups, no differences were found among the groups. Group 2 required an amount of autoadministered drugs significantly lower than other groups. Rare side effects. Patient's judgment was generally positive.

CONCLUSIONS

Results suggest a greater synergetic effect between morphine and ketorolac in concentrations used in group 2.

A comparison of diclofenac with ketorolac for pain relief after knee arthroscopy

We performed a double-blind controlled trial to compare the analgesic effect of two nonsteroidal anti-inflammatory drugs. We compared rectal diclofenac 100 mg given 1 h before induction of anaesthesia with intravenous ketorolac 10 mg given immediately before anaesthesia in 40 patients undergoing arthroscopy of the knee as day cases. A visual analogue scale was used to assess pain prior to discharge. Pain, analgesic consumption, sleep disturbance and restriction of activities were recorded by telephone enquiry 24 h after surgery. There was no difference in the pain parameters, sleep disturbance, or restriction of activity between groups. We suggest that ketorolac 10 mg intravenously and diclofenac 100 mg rectally provide comparable postoperative analgesia in the first 24 h after arthroscopy of the knee.

[Postoperative analgesia in herniated disk surgery. Comparative study of diclofenac , lysine acetylsalicylate, and ketorolac]

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating musculoskeletal pain and are theoretically ideal for treating postoperative pain of the lumbar column.

OBJECTIVES

To compare the analgesic efficacy and side effects of treatment with 3 NSAIDs (lysine acetylsalicylate, ketorolac and diclofenac) in the treatment of pain after surgery for lumbar disc hernia.

PATIENTS AND METHODS

We enrolled 75 ASA I-II patients undergoing discectomy because of lumbar disc hernia; balanced general anesthesia was used in all cases. The patients were randomly distributed in 3 groups based on type of analgesia given in the immediate postoperative period. Group A received lysine acetylsalicylate (1800 mg), group B received ketorolac (30 mg) and group C received diclofenac (75 mg). The analgesics were diluted in 100 mg of saline solution and administered through a peripheral vein over 10 min. We evaluated the analgesia attained on a visual analog scale (VAS) and the physiological response to pain was assessed by monitoring changes in arterial pressure, heart rate and breathing frequency. If analgesia was insufficient 30 min after administration of the drug, 200 mg of lysine cloximate was given as a top-up. The side effects of each drug were also recorded.

RESULTS

VAS evaluation showed significant reductions in pain 60 min after administration in groups A and B and after 120 min in group C. Nine patients in each group required lysine cloximate. There were no significant differences in physiological response among the 3 groups. No patient suffered major side effects. Mild side effects were reported most often in group B.

CONCLUSIONS

The NSAIDs studied were inadequately for treating pain after surgery for lumbar disc hernia. Ketorolac was no better than the other analgesics studied but was associated with a higher number of mild side effects.

The effects of gynaecological surgery on coagulation activation, fibrinolysis and fibrinolytic inhibitor in patients with and without ketorolac infusion

The effects of gynaecological surgery on the fibrinolytic and inhibitor mechanisms were followed up for 24 h post-operatively in patients receiving a single dose of ketorolac infusion (n = 18) as compared with those not receiving ketorolac infusion (n = 11). A pre-operative state of lower mean t-PA activity and higher PAI-1 levels with increased platelet activation than that reported in normal subjects were observed in both groups of patients. Increased t-PA activity upon anaesthetic induction together with a decreased level at 24 h post-operation was seen in both groups. However, fibrinolytic 'shut-down' was not evident as significant increase in D-dimer levels was observed post-operatively, suggesting an enhanced lytic state concurrent with an enhanced activation of coagulation and diminished platelet activation although beta-TG remained above the normal level; plasmin from this enhanced lytic state affects platelet adhesion and cleaves platelet glycoprotein Ib thus inhibit release reaction. Ketorolac infusion elicited a significant response in PAI-1 activity within 24 h post-operation and this was not seen in the non-ketorolac group in spite of the rising trend by 24 h post-operation which did not achieve statistical significance. There were no statistical significant differences in blood loss and duration of surgery between the two groups of patients. Overall, both groups of patients showed similar haemostatic changes post-operatively for 24 h, a longer duration of post-operative study would have revealed any subtle changes in the molecular markers of thrombosis which was not the objective of this study.

[Ketorolac for prevention of acute postoperative pain]

BACKGROUND

Since NSAIDs are competitive antagonists of cyclooxygenase, they prevent the biosynthesis of prostaglandins, responsible for enhanced nociceptive sensitization and primary hyperalgesia. If NSAIDs administration is performed after eicosanoids cascade activation by surgical trauma, already released prostaglandins can exert their hyperalgesic effects for a finite time. Therefore prophylactic administration of NSAIDs (pre-emptive analgesia) should improve their effectiveness on acute postoperative pain.

AIM OF STUDY

To assess the analgesic effect of preoperatively administered ketorolac, compared with its administration after surgical trauma.

MATERIALS AND METHODS

Thirty adult patients, ASA physical status I-II, undergoing elective septoplasty, were allocated randomly in two groups, depending on timing of i.v. administration of ketorolac 0.4 mg/kg: 10 min before induction (group I); or 5 min after décollement of nasal septum cartilaginoid plan (group II). No other analgesic drugs were given. Postoperative pain was assessed with objective (SAP, DAP, HR) and subjective (VAS, BS 11) methods at 60, 90, 120, 150, and 180 min after the end of surgery. Rate and severity of any side-effect were recorded.

RESULTS

Both VAS and BS 11 showed significant better pain relief after preoperative ketorolac at all time, without any adverse effect. Same result was shown by SAP at 60 and 90 min postoperatively.

CONCLUSIONS

Due to prevention of nociceptive sensitization of prostaglandins released by tissue trauma, prophylactic NSAIDs administration to surgical patients with mild to moderate postoperative pain can improve their antinociceptive effects.