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Stanek K, Nussbaum L, Labow BI, Chacko S, Ganske IM, Ganor O, Vinson A, Greene AK, Nuzzi L, Rogers-Vizena CR. Understanding Hematoma Risk: Study of Patient and Perioperative Factors in a Large Cohort of Young Women Undergoing Reduction Mammaplasty. J Am Coll Surg 2024; 238:900-910. [PMID: 38084845 DOI: 10.1097/xcs.0000000000000926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2024]
Abstract
BACKGROUND Despite high satisfaction rates, reduction mammaplasty can have complications such as hematoma. Factors such as age, tobacco use, and comorbidities are known contributors, whereas the influence of race, BMI, certain medications, and blood pressure (BP) remain contentious. This study investigates hematoma risk factors in young women undergoing reduction mammaplasty. STUDY DESIGN A retrospective review was conducted including all female patients who underwent bilateral reduction mammaplasty at a single institution between 2012 and 2022. Data on demographics, BMI, medical comorbidities, surgical techniques, medications, and perioperative BP were collected. Differences between patients who developed a hematoma and those who did not were assessed using chi-square, Fisher's exact, and t -tests. The relationship between perioperative BP and hematoma formation was assessed using logistic regression. RESULTS Of 1,754 consecutive patients, 3% developed postoperative hematoma of any kind, with 1.8% returning to the operating room. Age (odds ratio [OR] 1.14, p = 0.01) and ketorolac use (OR 3.93, p = 0.01) were associated with hematoma development. Controlling for baseline BP, each 10 mmHg incremental increase in peak intraoperative BP (systolic BP [SBP]: OR 1.24, p = 0.03; mean arterial pressure: OR 1.24, p = 0.01) and postoperative BP (SBP: OR 1.41, p = 0.01; mean arterial pressure: OR 1.49, p = 0.01) escalated the odds of hematoma. Postoperative SBP variability also incrementally increased hematoma odds (OR 1.48, p < 0.01). Other factors, including race and surgical technique, were not significantly influential. CONCLUSIONS Age, ketorolac use, and intra- and postoperative BP peaks and variability are risk factors for hematoma in reduction mammaplasty. This emphasizes the importance of perioperative BP management and optimizing pain management protocols.
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Affiliation(s)
- Krystof Stanek
- From the Departments of Plastic and Oral Surgery (Stanek, Nussbaum, Labow, Ganske, Ganor, Greene, Nuzzi, Rogers-Vizena), Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA (Stanek, Labow, Chacko, Ganske, Ganor, Vinson, Greene, Rogers-Vizena)
| | - Lisa Nussbaum
- From the Departments of Plastic and Oral Surgery (Stanek, Nussbaum, Labow, Ganske, Ganor, Greene, Nuzzi, Rogers-Vizena), Boston Children's Hospital, Boston, MA
| | - Brian I Labow
- From the Departments of Plastic and Oral Surgery (Stanek, Nussbaum, Labow, Ganske, Ganor, Greene, Nuzzi, Rogers-Vizena), Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA (Stanek, Labow, Chacko, Ganske, Ganor, Vinson, Greene, Rogers-Vizena)
| | - Sabeena Chacko
- Anesthesiology (Chacko, Vinson), Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA (Stanek, Labow, Chacko, Ganske, Ganor, Vinson, Greene, Rogers-Vizena)
| | - Ingrid M Ganske
- From the Departments of Plastic and Oral Surgery (Stanek, Nussbaum, Labow, Ganske, Ganor, Greene, Nuzzi, Rogers-Vizena), Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA (Stanek, Labow, Chacko, Ganske, Ganor, Vinson, Greene, Rogers-Vizena)
| | - Oren Ganor
- From the Departments of Plastic and Oral Surgery (Stanek, Nussbaum, Labow, Ganske, Ganor, Greene, Nuzzi, Rogers-Vizena), Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA (Stanek, Labow, Chacko, Ganske, Ganor, Vinson, Greene, Rogers-Vizena)
| | - Amy Vinson
- Anesthesiology (Chacko, Vinson), Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA (Stanek, Labow, Chacko, Ganske, Ganor, Vinson, Greene, Rogers-Vizena)
| | - Arin K Greene
- From the Departments of Plastic and Oral Surgery (Stanek, Nussbaum, Labow, Ganske, Ganor, Greene, Nuzzi, Rogers-Vizena), Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA (Stanek, Labow, Chacko, Ganske, Ganor, Vinson, Greene, Rogers-Vizena)
| | - Laura Nuzzi
- From the Departments of Plastic and Oral Surgery (Stanek, Nussbaum, Labow, Ganske, Ganor, Greene, Nuzzi, Rogers-Vizena), Boston Children's Hospital, Boston, MA
| | - Carolyn R Rogers-Vizena
- From the Departments of Plastic and Oral Surgery (Stanek, Nussbaum, Labow, Ganske, Ganor, Greene, Nuzzi, Rogers-Vizena), Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA (Stanek, Labow, Chacko, Ganske, Ganor, Vinson, Greene, Rogers-Vizena)
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Zhang X, Chang J, Ran R, Xiao Y, Cao H, Wang Y. Effect of Ketorolac Tromethamine Combined With Remifentanil on Reducing Complications During the General Anesthesia Emergence. J Perianesth Nurs 2023; 38:748-752. [PMID: 37245134 DOI: 10.1016/j.jopan.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 12/21/2022] [Accepted: 01/07/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE To observe the effect of ketorolac tromethamine combined with remifentanil in sedation and analgesia during general anesthesia emergence and reducing general anesthesia complications. DESIGN This is an experimental design. METHODS 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. FINDINGS 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. CONCLUSIONS 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.
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Affiliation(s)
- Xi Zhang
- Department of Anesthesiology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, PR China
| | - Jie Chang
- Department of Anesthesiology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, PR China
| | - Ran Ran
- Department of Anesthesiology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, PR China
| | - Yun Xiao
- Department of Anesthesiology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, PR China
| | - Hong Cao
- Department of Orthopedic Surgery, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, PR China
| | - Yuqi Wang
- Department of Anesthesiology, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, PR China; Department of Orthopedic Surgery, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, PR China; Jinzhou Medical University Union Training Base, Shiyan, Hubei, PR China.
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Abdelbaser I, Mageed NA, El-Emam ESM, ALseoudy MM. Comparison of intravenous ibuprofen versus ketorolac for postoperative analgesia in children undergoing lower abdominal surgery: A randomized, controlled, non-inferiority study. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:463-471. [PMID: 36088270 DOI: 10.1016/j.redare.2022.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/04/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND 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. METHODS 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 10mg/kg/6h intravenous ibuprofen. Patients in the ketorolac group were given 0.5mg/kg/6h 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. RESULTS Fifty-nine patients completed the study (30 ibuprofen, 29 ketorolac). There was no significant difference (P=0.305) 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. CONCLUSIONS 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.
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Affiliation(s)
- I Abdelbaser
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| | - N A Mageed
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - E-S M El-Emam
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - M M ALseoudy
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Aboul Fetouh IS, Sherif NA, Osama NA, Mohamad MK. Comparative study between the analgesic effect of ketorolac when administrated intravenous preoperatively versus when added to local anesthesia in squint surgery. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2079894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
| | - Norhan A. Sherif
- Anesthesia Department, Research Institute of Ophthalmology, Giza, Egypt
| | - Noha A. Osama
- Anesthesia Department, Research Institute of Ophthalmology, Giza, Egypt
| | - Mayada K. Mohamad
- Anesthesia Department, Research Institute of Ophthalmology, Giza, Egypt
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Ghai B, Jafra A, Bhatia N, Chanana N, Bansal D, Mehta V. Opioid sparing strategies for perioperative pain management other than regional anaesthesia: A narrative review. J Anaesthesiol Clin Pharmacol 2022; 38:3-10. [PMID: 35706649 PMCID: PMC9191794 DOI: 10.4103/joacp.joacp_362_19] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 03/14/2020] [Accepted: 10/14/2020] [Indexed: 11/04/2022] Open
Abstract
Opioids play a crucial role in pain management in spite of causing increased hospital morbidity and related costs. It may also cause significant risks such as postoperative nausea and vomiting (PONV), sedation, sleep disturbances, urinary retention and respiratory depression (commonly referred to as opioid related adverse effects) in postoperative patients. In order to evade these opioid related side effects and also improve pain management, multimodal analgesia i.e., combination of different analgesics, was introduced more than a decade ago. Both pharmacological and non-pharmacological techniques are available as opioid sparing analgesia. Research from around the world have proved pharmacological techniques ranging from acetaminophen, NSAIDs (non-steroidal anti-inflammatory drugs), N-methyl-D-aspartate receptor antagonists (NDMA), alpha-2 agonists, anticonvulsants such as gamma aminobutyric acid analogues, beta-blockers, capsaicin, lignocaine infusion to glucocorticoids to be effective. On the other hand, non-pharmacological methods include techniques such as cognitive behavioral therapy, transcutaneous electrical nerve stimulation (TENS), electroanalgesia, acupuncture and hypnosis. However, research regarding the effect of these non-pharmacological techniques on pain management is still needed.
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Affiliation(s)
- Babita Ghai
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, India
| | - Anudeep Jafra
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, India
| | - Nidhi Bhatia
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, India
| | - Neha Chanana
- Department of Community Medicine, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, India
| | - Dipika Bansal
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research, Mohali, Punjab, India
| | - Vivek Mehta
- Consultant in Pain Medicine and Clinical Network Director Pain, St. Bartholomews Hospital, Barts Health NHS Trust West field, London
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NSAID Use and Effects on Pediatric Bone Healing: A Review of Current Literature. CHILDREN-BASEL 2021; 8:children8090821. [PMID: 34572253 PMCID: PMC8464945 DOI: 10.3390/children8090821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/08/2021] [Accepted: 09/12/2021] [Indexed: 11/16/2022]
Abstract
This systematic review evaluates and synthesizes the available peer-reviewed evidence regarding the impact of non-steroidal anti-inflammatory drugs (NSAIDs) on fracture healing in skeletally immature patients. Evidence supports the use of NSAIDs in this patient population for adequate pain control without increasing the risk of nonunion, particularly in long bone fractures and pseudoarthrosis after spine fusion. However, further clinical studies are needed to fill remaining gaps in knowledge, specifically with respect to the spectrum of available NSAIDs, dosage, and duration of use, in order to make broad evidence-based recommendations regarding the optimal use of NSAIDs during bone healing in skeletally immature patients.
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Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used for pediatric pain management in the emergency setting and postoperatively. This narrative literature review evaluates pain relief, opioid requirements, and adverse effects associated with NSAID use. A PubMed search was conducted to identify randomized controlled trials evaluating the use of conventional systemic NSAIDs as pain management for children in the perioperative or emergency department (traumatic injury) setting. Trials of cyclooxygenase-2 inhibitors ("coxibs") were excluded. Search results included studies of ibuprofen (n = 12), ketoprofen (n = 5), ketorolac (n = 6), and diclofenac (n = 4). NSAIDs reduced the opioid requirement in 10 of 13 studies in which this outcome was measured. NSAID use did not compromise pain relief; NSAIDs provided improved or similar pain scores compared with opioids (or other control) in 24 of 27 studies. Adverse event frequencies were reported in 26 studies; adverse event frequencies with NSAIDs were lower than with opioids (or other control) in three of 26 studies, similar in 21 of 26 studies, and more frequent in two of 26 studies. Perioperative and emergency department use of NSAIDs may reduce opioid requirements while maintaining pain control, with similar or reduced frequencies of opioid-associated adverse events.
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Affiliation(s)
- Maureen F Cooney
- Pain Management, Westchester Medical Center, Valhalla, NY, 10595, USA.
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Stone SB. Ketorolac in Postoperative Neonates and Infants: A Systematic Review. J Pediatr Pharmacol Ther 2021; 26:240-247. [PMID: 33833624 DOI: 10.5863/1551-6776-26.3.240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/22/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the pharmacokinetics and pharmacodynamics, dosing, efficacy, and safety of ketorolac in postoperative patients younger than 6 months of age. METHODS PubMed (1988-July 2020), Medline (1946-July 2020), and EBSCO Discovery Service (1988-July 2020) were searched to identify relevant published articles using the following search terms: ketorolac, neonate, infant. English-language articles evaluating the use of ketorolac in infants younger than 6 months of age were included. RESULTS Eight reports that included 239 infants receiving ketorolac were included. Of the included patients, 237 were younger than 6 months of age. Ketorolac exhibits rapid elimination of the analgesia-producing S (-) isomer, elimination half-life of 0.83 hours. Most patients received 0.5 mg/kg/dose every 6 hours for 48 to 72 hours. Analgesia was demonstrated by reduced use of open-label morphine and significant lowering of Neonatal/Infant Pain Scale scores. Adverse effects were minimal when ketorolac was used in term neonates and infants without baseline renal dysfunction. CONCLUSIONS Randomized placebo-controlled trials of ketorolac use in this population are lacking; however, most published reports noted efficacy and safety with ketorolac in properly selected infants.
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Kelley-Quon LI, Kirkpatrick MG, Ricca RL, Baird R, Harbaugh CM, Brady A, Garrett P, Wills H, Argo J, Diefenbach KA, Henry MCW, Sola JE, Mahdi EM, Goldin AB, St Peter SD, Downard CD, Azarow KS, Shields T, Kim E. Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion. JAMA Surg 2021; 156:76-90. [PMID: 33175130 PMCID: PMC8995055 DOI: 10.1001/jamasurg.2020.5045] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
IMPORTANCE Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking. OBJECTIVE To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery. EVIDENCE REVIEW Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique. FINDINGS Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery. CONCLUSIONS AND RELEVANCE These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.
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Affiliation(s)
- Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
- Department of Preventive Medicine, University of Southern California, Los Angeles
- Keck School of Medicine, Department of Surgery, University of Southern California, Los Angeles
| | | | - Robert L Ricca
- Department of Pediatric Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Robert Baird
- Division of Pediatric Surgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Ashley Brady
- Department of Pediatric Surgery, University of Michigan, Ann Arbor
| | - Paula Garrett
- Department of Pediatric Surgery, University of Michigan, Ann Arbor
| | - Hale Wills
- Division of Pediatric Surgery, Hasbro Children's Hospital, Providence, Rhode Island
- Department of Surgery, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Jonathan Argo
- Department of Pediatric Anesthesiology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Karen A Diefenbach
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Marion C W Henry
- Department of Surgery, University of Arizona College of Medicine, Tucson
| | - Juan E Sola
- Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Elaa M Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine, Department of Surgery, University of Southern California, Los Angeles
| | - Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, Washington
- Department of Surgery, University of Washington School of Medicine, Seattle
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Kenneth S Azarow
- Division of Pediatric Surgery, Department of Surgery, Oregon Health & Science University, Portland
| | - Tracy Shields
- Division of Library Services, Naval Medical Center, Portsmouth, Virginia
| | - Eugene Kim
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
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Post-operative non-steroidal anti-inflammatory drug use for pain in infant and paediatric cardiac surgery patients. Cardiol Young 2019; 29:1440-1444. [PMID: 31767042 DOI: 10.1017/s1047951119002312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Pain control is an important element of care for patients after surgery, leading to better outcomes, quicker transitions to recovery, and improvement in quality of life. The purpose of this study was to evaluate the safety and efficacy of non-steroidal anti-inflammatory drugs in children after cardiac surgery. MATERIALS AND METHODS Patients between the ages of 1 month and 18 years of age, who received intravenous or oral non-steroidal anti-inflammataory drugs after cardiac surgery, from November 2015 until September 2017 were included in this study. The primary endpoints were non-steroidal anti-inflammataory drug-associated renal dysfunction and post-operative bleeding. Secondary endpoints examined the effect of non-steroidal anti-inflammataory drug use on total daily dose of narcotics, number of intravenous PRN narcotic doses received, and pain assessment score. Data were analysed using descriptive statistics for frequencies and ranges. Multivariate analysis was performed to measure the association of all predictors and outcomes. Wilcoxon singed-rank test was performed for secondary outcomes. RESULTS There was no association between the incidence of renal dysfunction and the use of or duration of non-steroidal anti-inflammataory drugs; in addition no association was found with increased chest tube output. There was a statistically significant reduction of patients' median Face, Legs, Activity, Cry, Consolability (FLACC) scores (2-0; p = 0.003), seen within first 24 hours after initiation of ketorolac, and a significant reduction of morphine requirements seen from day 1 to day 2 (0.3 mg/kg versus 0.1 mg/kg; p < 0.001) and number of as-needed doses. CONCLUSION Non-steroidal anti-inflammataory drugs in paediatric cardiac surgery patients are safe and effective for post-operative pain management.
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Cravero JP, Agarwal R, Berde C, Birmingham P, Coté CJ, Galinkin J, Isaac L, Kost‐Byerly S, Krodel D, Maxwell L, Voepel‐Lewis T, Sethna N, Wilder R. The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period. Paediatr Anaesth 2019; 29:547-571. [PMID: 30929307 PMCID: PMC6851566 DOI: 10.1111/pan.13639] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 12/13/2022]
Abstract
Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every 2 years.
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Affiliation(s)
- Joseph P. Cravero
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Rita Agarwal
- Pediatric Anesthesiology DepartmentLucille Packard Children's Hospital, Stanford University Medical SchoolStanfordCalifornia
| | - Charles Berde
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Patrick Birmingham
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Charles J. Coté
- Department of AnesthesiologyMass General Hospital for Children, Harvard UniversityBostonMassachusetts
| | - Jeffrey Galinkin
- Anesthesiology DepartmentChildren's Hospital of Colorado, University of ColoradoAuroraColorado
| | - Lisa Isaac
- Department of Anesthesia and Pain MedicineHospital for Sick Children, University of TorontoTorontoOntarioCanada
| | - Sabine Kost‐Byerly
- Pediatric Anesthesiology and Critical Care MedicineJohns Hopkins University HospitalBaltimoreMaryland
| | - David Krodel
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Lynne Maxwell
- Department of Aneshtesiology and Critical Care MedicineChildren's Hospital of Philadelphia, Perelman School of Medicine at the University of PennsylvaniaPhiladelphia
| | - Terri Voepel‐Lewis
- Department of AneshteiologyC. S. Mott Children's Hospital, University of Michigan Medical SchoolAnn ArborMichigan
| | - Navil Sethna
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Robert Wilder
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMinnesota
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Eladi IA, Mourad KH, Youssef AN, Abdelrazek AA, Ramadan MA. Efficacy and Safety of Intravenous Ketorolac versus Nalbuphine in Relieving Postoperative Pain after Tonsillectomy in Children. Open Access Maced J Med Sci 2019; 7:1082-1086. [PMID: 31049085 PMCID: PMC6490483 DOI: 10.3889/oamjms.2019.243] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/22/2019] [Accepted: 03/23/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Pain is a major postoperative complication worldwide, which in turn impairs normal body performance and increases postoperative morbidity, hospitalisation, and the susceptibility to infections which also lead to chronic pain development. AIM The purpose of this study was to evaluate the efficacy of intravenous ketorolac versus nalbuphine as analgesia after adenotonsillectomy surgery to determine the optimal procedure for pain control and postoperative reduction of analgesic use. METHODS A group of 100 pediatric patients undergoing tonsillectomy or adenotonsillectomy were assigned as follows to two equal groups: Group A: 50 patients received intravenous ketorolac 0.9 mg/Kg. Group B: 50 patients received intravenous nalbuphine 0.25 mg/Kg. RESULTS FLACC (Face, Legs, Activity, Cry, Consolability) pain score was measured after recovery from anaesthesia (postoperative). There was a statistically significant difference concerning pain score between group 'A' and group 'B' as pain score in 'A' (ranging from 3.18 ± 0.87 to 4.68 ± 0.74) is lower compared to 'B' (ranging from 3.90 ± 0.76 to 5.54 ± 0.73) and probability value < 0.05 except at 90 & 120 min which was observed statistically insignificant. There was no serious postoperative complication detected in either group. CONCLUSION It is concluded that intravenous ketorolac is more effective than intravenous nalbuphine in reducing pain intensity and postoperative analgesic requirements after adenotonsillectomy in children.
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Affiliation(s)
- Islam Adel Eladi
- Department of Anesthesia, Surgical Intensive Care Unit and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Karim Hussein Mourad
- Department of Anesthesia, Surgical Intensive Care Unit and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Nabih Youssef
- Department of Anesthesia, Surgical Intensive Care Unit and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Abdelrazek Ahmed Abdelrazek
- Department of Anesthesia, Surgical Intensive Care Unit and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohammad Ahmed Ramadan
- Department of Anesthesia, Surgical Intensive Care Unit and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
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13
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Semerjian A, Milbar N, Kates M, Gorin MA, Patel HD, Chalfin HJ, Frank SM, Wu CL, Yang WW, Hobson D, Robertson L, Wick E, Schoenberg MP, Pierorazio PM, Johnson MH, Stimson CJ, Bivalacqua TJ. Hospital Charges and Length of Stay Following Radical Cystectomy in the Enhanced Recovery After Surgery Era. Urology 2017; 111:86-91. [PMID: 29032237 DOI: 10.1016/j.urology.2017.09.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 08/10/2017] [Accepted: 09/08/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVE 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. MATERIALS AND METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Alice Semerjian
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Niv Milbar
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Max Kates
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael A Gorin
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hiten D Patel
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Heather J Chalfin
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher L Wu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William W Yang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Deb Hobson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lindsay Robertson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Mark P Schoenberg
- Montefiore Medical Center and Albert Einstein College of Medicine, Department of Urology, Bronx, NY
| | - Phillip M Pierorazio
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael H Johnson
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C J Stimson
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
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14
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Yang HL, Liu FC, Tsai SC, Tsay PK, Lin HT, Liu HE. Ketorolac Tromethamine Spray Prevents Postendotracheal-Intubation-Induced Sore Throat after General Anesthesia. BIOMED RESEARCH INTERNATIONAL 2016; 2016:4582439. [PMID: 28025646 PMCID: PMC5153490 DOI: 10.1155/2016/4582439] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 10/27/2016] [Indexed: 11/17/2022]
Abstract
Background. Postoperative sore throat is one of the major complaints of general anesthesia in the postanesthesia care unit. This prospective study investigated the preventive effect of ketorolac tromethamine spray in postendotracheal-intubation-induced sore throat after general anesthesia. Methods. Surgical patients undergoing general anesthesia with endotracheal intubation were recruited from a medical center. Patients were randomly assigned to group K (treated with 5% ketorolac tromethamine spray) or group D (treated with distilled water spray). Before intubation, each endotracheal tube was sprayed with the appropriate solution by physicians over the 20 cm length of the cuff. Each group comprised 95 patients fitting the inclusion and exclusion criteria for whom complete data sets were collected. The intensity of the sore throat was measured at 1, 3, 6, and 24 h after surgery, and data were compared. Results. The two groups had similar characteristics. Postoperative sore throat was significantly less frequent in group K than in group D (p < 0.001) and the pain intensity was significantly lower in group K than in group D at each time point (all p < 0.001). Conclusions. This study demonstrated that preanesthesia 5% ketorolac tromethamine spray could effectively decrease postendotracheal-intubation-induced sore throat in patients undergoing general anesthesia.
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Affiliation(s)
- H. L. Yang
- Department of Nursing, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - F. C. Liu
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - S. C. Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - P. K. Tsay
- Department of Public Health and Center of Biostatistics, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - H. T. Lin
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - H. E. Liu
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Rheumatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- Department of Nursing, College of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
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15
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Abstract
Acute pain management is improving steadily over the past few years, but training and professional education are still lacking in many professions. Untreated or undertreated acute pain could have detrimental effects on the patient in terms of comfort and recovery from trauma or surgery. Acute undertreated pain can decrease a patient's vascular perfusion, increase oxygen demand, suppress the immune system, and possibly risk increased incidence of venous thrombosis. Although acute postoperative pain needs to be managed aggressively, patients are most vulnerable during this period for developing adverse effects, and therefore, patient assessment and careful drug therapy evaluation are necessary processes in therapeutic planning. Acute pain management requires careful and thorough initial assessment and follow-up reassessment in addition to frequent dosage adjustments, and managing analgesic induced side effects. Analgesic selection and dosing must be based on the patient's past and recent analgesic exposure. There is no single acute pain management regimen that is suitable for all patients. Analgesics must be tailored to the individual patient.
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Affiliation(s)
- Peter J. S. Koo
- Departments of Clinical Pharmacy and Pharmaceutical Services, University of California, San Francisco, San Francisco, California
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16
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Abstract
A growing body of evidence demonstrates that untreated pain is associated with adverse consequences that can compromise clinical and developmental outcomes in children but that these adverse consequences can be prevented or attenuated by appropriate analgesic therapy. Thus, effective treatment of acute pain must be a clinical priority for children of all ages. Over the past 20 years, extensive pediatric research exploring pain assessment, developmental pharmacology of analgesics, and the clinical use of analgesics has dispelled many myths and misconceptions about pain management in pediatric patients; proven that analgesics can be used safely in neonates, infants, and children; and provided a framework for the development of pediatric pain management guidelines. This article reviews guidelines recommended for managing acute pain in pediatric patients and the treatment options for children experiencing acute pain. Contemporary issues regarding acetaminophen, nonsteroidal anti-inflammatory agents, and opioids are discussed.
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Affiliation(s)
- Paul C. Walker
- Departement of Pharmacy Services, University of Michigan Health System, College of Pharmacy at the University of Michigan,
| | - Deborah S. Wagner
- College of Pharmacy and Medical School, University of Michigan and Clinical Pharmacist, Department of Pharmacy Services, University of Michigan Health System
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17
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Lizardo RE, Langness S, Davenport KP, Kling K, Fairbanks T, Bickler SW, Grabowski J. Ketorolac does not reduce effectiveness of pleurodesis in pediatric patients with spontaneous pneumothorax. J Pediatr Surg 2015; 50:2035-7. [PMID: 26385568 DOI: 10.1016/j.jpedsurg.2015.08.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 08/24/2015] [Indexed: 11/17/2022]
Abstract
PURPOSE 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. METHODS 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. RESULTS Over a 50-month period, 51 patients underwent VATS with mechanical pleurodesis for spontaneous pneumothorax. The average age was 15.5years, and 76% were male. Ketorolac was administered to 26/51 patients. There were no differences in average length of stay (11.3 vs 10.9days, 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). CONCLUSIONS 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.
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Affiliation(s)
- Radhames E Lizardo
- Department of Surgery, Naval Medical Center San Diego, San Diego, CA, USA; Division of Pediatric Surgery, Rady Children's Hospital San Diego, San Diego, CA, USA.
| | - Simone Langness
- Department of Surgery, University of California San Diego, La Jolla, CA, USA; Division of Pediatric Surgery, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Katherine P Davenport
- Department of Surgery, University of California San Diego, La Jolla, CA, USA; Division of Pediatric Surgery, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Karen Kling
- Department of Surgery, University of California San Diego, La Jolla, CA, USA; Division of Pediatric Surgery, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Timothy Fairbanks
- Department of Surgery, University of California San Diego, La Jolla, CA, USA; Division of Pediatric Surgery, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Stephen W Bickler
- Department of Surgery, University of California San Diego, La Jolla, CA, USA; Division of Pediatric Surgery, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Julia Grabowski
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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18
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Rokhtabnak F, Ale Bouyeh MR, Seyed Siamdust A, Masoomshahi M, Aghajani M. Comparison of the effects of intra-articular sole ropivacaine and combined ketorolac and ropivacaine for pain control after knee arthroscopy surgery. Br J Pain 2015; 9:149-56. [PMID: 26516571 DOI: 10.1177/2049463714553312] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Effective pain relief is important after arthroscopic knee surgery to permit initiation of daily activities of life. This study is performed in order to investigate the effect of multi-model therapy for pain control after surgery. This clinical, randomized and double-blind trial is conducted on patients who get knee arthroscopy surgery. METHODS Of these patients, 40 were divided into two groups by Block Randomization method: 1 - sole ropivacaine group (150 mg); 2 - combined ketorolac (30 mg); and ropivacain (150 mg) group. These drugs were injected intra-articularly at the end of knee arthroscopic surgery. The first consequence including measurement of pain severity after entrance to recovery room and 2, 4, 8, 12, 18 and 24 hours after surgery were evaluated according to the visual analogue pain score. The second consequence, including nausea, vomiting and sedation, was assessed by expert nurses in the recovery room and surgery part according to nausea and vomiting scale and Ramsay sedation scale, respectively. RESULTS All groups had excellent analgesia at 0 and 4 hours, postoperatively. Group-combined ketorolac and ropivacaine had significantly lower visual analogue pain score as well as higher sedative scale at 8, 12, 18 and 24 hours after surgery at rest and during movement compared with the other group (p < 0.05). Moreover, there was no statistical difference between groups in regard of nausea and vomiting. CONCLUSION Addition of ketolorac to ropivacaine intra-articularly in arthroscopic knee surgery enhances analgesic efficacy of local anaesthetics and cause more sedation after surgery.
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Affiliation(s)
- Faranak Rokhtabnak
- Firouzgar Hospital, Anesthesiology Group, Medical Faculty, Iran University of Medical Sciences, Tehran, Iran
| | - Mahmood Reza Ale Bouyeh
- Rasul Akram Hospital, Anesthesiology Group, Medical Faculty, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Seyed Siamdust
- Fatemeh Hospital, Anesthesiology Group, Medical Faculty, Iran University of Medical Sciences, Tehran, Iran
| | - Mehdi Masoomshahi
- Rasul Akram Hospital, Anesthesiology Group, Medical Faculty, Iran University of Medical Sciences, Tehran, Iran
| | - Marjan Aghajani
- Department of Physiology, Medical Faculty, Tehran University of Medical Sciences, Tehran, Iran
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Vadivelu N, Gowda AM, Urman RD, Jolly S, Kodumudi V, Maria M, Taylor R, Pergolizzi JV. Ketorolac tromethamine - routes and clinical implications. Pain Pract 2014; 15:175-93. [PMID: 24738596 DOI: 10.1111/papr.12198] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 01/27/2014] [Indexed: 11/29/2022]
Abstract
Opioids have long been used for analgesic purposes for a wide range of procedures. However, the binding of these drugs to opiate receptors has created various challenges to the clinician due to unfavorable side effect profiles and the potential for tolerance and abuse. In 1989, ketorolac became an approved nonsteroidal inflammatory drug (NSAID) for injectable use as an analgesic. Over the last 20 years, numerous studies have been conducted involving ketorolac. These studies have provided additional information about various routes of administration and their effect on the efficacy and the side effect profile of ketorolac. Moreover, ketorolac has been compared with several widely used analgesics. This review evaluates both the potential benefits and potential drawbacks of ketorolac generally, and specifically discusses routes of administration, including their advantages and disadvantages when compared to several traditional analgesics in both inpatient and outpatient settings.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
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20
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Abstract
Ketorolac has been used safely as an analgesic agent for children following cardiac surgery in selected populations. Controversy exists among institutions about the risks involved with this medication in this patient group. This article reviews the current literature regarding the safety of ketorolac for postoperative pain management in children after cardiac surgery. Specifically, concerns about renal dysfunction and increased bleeding risk are addressed. Additionally, the article details pharmacokinetics and potential benefits of ketorolac, such as its opioidsparing effect. The literature reflects that the use of this medication is not well studied in certain pediatric cardiac patients such as neonates and those with single-ventricle physiology, and the safety of this medication in regards to these special populations is reviewed. In conclusion, ketorolac can be used in specific pediatric patients after cardiac surgery with minimal risk of bleeding or renal dysfunction with appropriate dosing and duration of use.
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Affiliation(s)
- Meredith K. Jalkut
- Meredith K. Jalkut is Pediatric Nurse Practitioner, Children’s Hospital of Philadelphia, 1519 S Clarion St, Philadelphia, PA 19147
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21
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Partial versus total splenectomy in children with hereditary spherocytosis. Surgery 2013; 154:849-53; discussion 853-5. [DOI: 10.1016/j.surg.2013.07.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 07/19/2013] [Indexed: 11/18/2022]
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22
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Moore RP, Wester T, Sunder R, Schrock C, Park TS. Peri-operative pain management in children with cerebral palsy: comparative efficacy of epidural vs systemic analgesia protocols. Paediatr Anaesth 2013; 23:720-5. [PMID: 23682965 DOI: 10.1111/pan.12187] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2013] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Selective Dorsal Rhizotomy (SDR) is the only surgical intervention with class I evidence supporting permanent reduction in spasticity for children with cerebral palsy (Paediatr Anaesth, 12, 2002, 296; Neurosurg Focus, 21, 2006, e2). Postoperatively, adequate analgesia can be difficult to achieve (J Neurosurg, 105, 2006, 8; Childs Nerv Syst, 17, 2001, 556; Pediatr Neurosurg, 43, 2007, 107; Anesth Analg, 79, 1994, 340; Reg Anesth Pain Med, 24, 1999, 438; Pediatr Anesth, 19, 2009, 1213). This study examines a novel regimen utilizing the combination of epidurally infused ropivacaine - hydromorphone and scheduled ketorolac. This regimen was compared to a protocol utilizing systemic fentanyl and diazepam. METHODS Following IRB approval, 31 patients receiving epidural analgesia were compared with 41 patients who received systemic analgesia. All surgeries were performed by one surgeon with standardized anesthetic and nursing care. Studied outcomes included: pain scores; episodes of severe pain; nausea, itching; oxygen desaturation; and ICU admission. Data were analyzed using Mann-Whitney U-test, CHI square, and Fisher exact test where indicated with P < 0.05 considered significant. RESULTS Studied groups had similar demographics, biometrics and disease burdens. Patients in the epidural group had statistically and clinically significant reductions in peak recorded pain scores for each 4-h period in the first 24 postoperative hours. Severe pain (score >5) was markedly reduced in the epidural group with 9% of epidural patients vs. 68% of systemic patients experiencing at least one episode. Fewer epidural patients experienced oxygen desaturation during the first two postoperative days (6.5% vs. 41%, 6.5% vs. 39%). CONCLUSION Epidural analgesia resulted in substantial improvements in pain control and safety. The data supports the superiority of a multimodal analgesia approach centered on epidural analgesia. A similar protocol should be considered following simple laminectomies or procedures associated with lower-extremity muscle spasm.
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Affiliation(s)
- Robert P Moore
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA.
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Smith HAB, Brink E, Fuchs DC, Ely EW, Pandharipande PP. Pediatric delirium: monitoring and management in the pediatric intensive care unit. Pediatr Clin North Am 2013; 60:741-60. [PMID: 23639666 DOI: 10.1016/j.pcl.2013.02.010] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This review article updates the pediatric medical community on the current literature regarding diagnosis and treatment of delirium in critically ill children. This information will be of value to pediatricians, intensivists, and anesthesiologists in developing delirium monitoring and management protocols in their pediatric critical care units.
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Affiliation(s)
- Heidi A B Smith
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Vanderbilt University, Nashville, TN 37232, USA.
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24
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Drover DR, Hammer GB, Anderson BJ. The Pharmacokinetics of Ketorolac After Single Postoperative Intranasal Administration in Adolescent Patients. Anesth Analg 2012; 114:1270-6. [DOI: 10.1213/ane.0b013e31824f92c2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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25
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Retrospective evaluation of inpatient celecoxib use after total hip and knee arthroplasty at a Veterans Affairs Medical Center. J Arthroplasty 2012; 27:1033-40. [PMID: 22386610 DOI: 10.1016/j.arth.2012.01.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 01/20/2012] [Indexed: 02/01/2023] Open
Abstract
A retrospective cohort study (1.5 years) was performed to investigate the efficacy of celecoxib vs non-celecoxib use in patient who underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA). Study time frame encompassed a pre and post period of a local policy decision opening access to short-term celecoxib use after TKA/THA. Primary end point was the amount of opioid use during their inpatient stay postprocedure. The TKA (n = 81) and THA (n = 60) groups were analyzed independently. Both celecoxib groups used significantly less opioids during their inpatient stay vs noncelecoxib groups, given in oral morphine milligram equivalents (TKA: 203 vs 337 mg, P = .002; THA: 214 vs 336 mg, P = .005). Other secondary outcome measures showed that the celecoxib groups also reported reduction in pain scores, total as needed (PRN) opioid doses, PRN opioid doses per day, average dose of PRN opioids, total PRN opioids, use of intravenous opioids, and rehabilitation facility admissions (in the TKA group only). Linear regression analysis showed a statistically significant inverse relationship between opioid consumption and age. Short-term celecoxib use after TKA/THA may lead to a reduction in overall opioid use and improved pain scores; however, further studies will be required to validate the results of this study.
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Bulut T, Yilmazlar A, Yavascaoglu B, Sarisozen B. The effect of local anaesthetic on post-operative pain with wound instillation via a catheter for paediatric orthopaedic extremity surgery. J Child Orthop 2011; 5:179-85. [PMID: 22654979 PMCID: PMC3100459 DOI: 10.1007/s11832-011-0337-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2010] [Accepted: 03/06/2011] [Indexed: 02/03/2023] Open
Abstract
PURPOSE We aimed to investigate the effects on post-operative pain of local anaesthetic administration via a catheter placed into the operation site in patients who were undergoing upper and lower extremity paediatric orthopaedic surgery. METHODS In this randomised, double-blind and placebo study, 40 ASA I-II patients aged between 1 and 12 years were randomly allocated into two groups: study group (Group S: 0.2 ml/kg, 0.5% bupivacaine, n = 20) and control group (Group C: 0.2 ml/kg, serum physiologic, n = 20). Before the fascia was closed by the surgical team, the solution previously prepared by the chief nurse was injected into the subfascial soft tissue with the syringe as the "injected dose" of serum physiologic or bupivacaine. After the closure, 0.2 ml/kg (1 mg/kg) bupivacaine or saline was instillated as the "first instillated dose" into the surgical area via the catheter. Pain scores were recorded at 0, 1, 2, 4, 8, 12, 24 and 48 h post-operatively. Patients were administered 0.75 mg/kg meperidine intramuscularly post-operatively to equalise the pain scores. RESULTS No statistically significant difference was found between Group S and Group C in terms of demographic and other data and pain scores in the post-anaesthesia care unit, while a statistically significant decrease was found at 2, 4, 8, 12, 24 and 48 h in Group S and at 1, 2 and 4 h in Group C based on pain scores in the post-anaesthesia care unit (P < 0.05). A statistically significant decreasing pain score was found at 4, 8, 12, 24 and 48 h in Group S (P < 0.05). CONCLUSION The local anaesthetic administered via a catheter implanted in the surgical field may provide long-term and efficient post-operative analgesia.
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Affiliation(s)
- T. Bulut
- Department of Anesthesiology, Uludag University, Medical School, Görükle, Bursa, Turkey
| | - A. Yilmazlar
- Department of Anesthesiology, Uludag University, Medical School, Görükle, Bursa, Turkey
| | - B. Yavascaoglu
- Department of Anesthesiology, Uludag University, Medical School, Görükle, Bursa, Turkey
| | - B. Sarisozen
- Department of Orthopaedia and Traumatology, Uludag University, Bursa, Turkey
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Turner CL, Eggleston GW, Lunos S, Johnson N, Wiedmann TS, Bowles WR. Sniffing out endodontic pain: use of an intranasal analgesic in a randomized clinical trial. J Endod 2011; 37:439-44. [PMID: 21419286 DOI: 10.1016/j.joen.2010.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Revised: 12/10/2010] [Accepted: 12/20/2010] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Orofacial pain is a common encounter in dentistry (affecting 12% of the population) and is a primary reason for patients seeking emergency care. Dentists often prescribe oral analgesics, which have disadvantages of decreased absorption rates and delayed onset. Intranasal (IN) delivery takes advantage of a large surface area of mucosal tissue for rapid absorption. The purpose of this study was to evaluate the efficacy of IN ketorolac for endodontic pain using a randomized, double-blind, placebo-controlled parallel design study. METHODS Twenty-two patients presenting with moderate to severe endodontic pain were selected to receive IN treatment with placebo (n = 11) or ketorolac (n = 11) 30 minutes before endodontic treatment was started and immediately after the completion of endodontic treatment. Baseline pain levels were recorded before IN treatment. Pain levels were also recorded at 15 and 30 minutes after the initial IN dosing (before endodontic treatment); 30 minutes after completion of endodontic treatment; and 4, 8, and 12 hours after the initial IN spray. Primary analysis was a repeated-measures analysis of variance. RESULTS IN ketorolac alone or with endodontic treatment showed significantly better pain relief compared with IN placebo spray alone or with endodontic treatment at 30 minutes after the first or second intranasal dose and at 4 hours after the first intranasal dose (P = .03). CONCLUSIONS These results suggest that IN ketorolac may provide a novel and efficacious method for pain relief in endodontic pain patients.
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Hong JY, Won Han S, Kim WO, Kil HK. Fentanyl sparing effects of combined ketorolac and acetaminophen for outpatient inguinal hernia repair in children. J Urol 2010; 183:1551-5. [PMID: 20172547 DOI: 10.1016/j.juro.2009.12.043] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Indexed: 12/13/2022]
Abstract
PURPOSE In this prospective, randomized, double-blinded study we sought to evaluate the efficacy and safety of combined use of intravenous ketorolac and acetaminophen in small children undergoing outpatient inguinal hernia repair. MATERIALS AND METHODS We studied 55 children 1 to 5 years old who were undergoing elective repair of unilateral inguinal hernia. After induction of general anesthesia children in the experimental group (28 patients) received 1 mg/kg ketorolac and 20 mg/kg acetaminophen intravenously. In the control group (27 patients) the same volume of saline was administered. All patients received 1 microg/kg fentanyl intravenously before incision. We also evaluated the number of patients requiring postoperative rescue fentanyl, total fentanyl consumption, pain scores and side effects. RESULTS Significantly fewer patients receiving ketorolac-acetaminophen received postoperative rescue fentanyl compared to controls (28.6% vs 81.5%). A significantly lower total dose of fentanyl was administered to patients receiving ketorolac-acetaminophen compared to controls (0.54 vs 1.37 microg/kg). Pain scores were significantly higher in the control group immediately postoperatively but eventually decreased. The incidences of sedation use (55.6% vs 25.0%) and vomiting (33.3% vs 10.7%) were significantly higher in controls. CONCLUSIONS Preoperative intravenous coadministration of ketorolac and acetaminophen is a simple, safe and effective method for relieving postoperative pain, and demonstrates highly significant fentanyl sparing effects in small children after outpatient inguinal hernia repair.
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Affiliation(s)
- Jeong-Yeon Hong
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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Pruthi RS, Nielsen M, Smith A, Nix J, Schultz H, Wallen EM. Fast track program in patients undergoing radical cystectomy: results in 362 consecutive patients. J Am Coll Surg 2009; 210:93-9. [PMID: 20123338 DOI: 10.1016/j.jamcollsurg.2009.09.026] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Revised: 09/18/2009] [Accepted: 09/18/2009] [Indexed: 12/14/2022]
Abstract
BACKGROUND This article outlines our current perioperative management of patients undergoing cystectomy and urinary diversion using advancements in perioperative care to allow for early institution of an oral diet and early hospital discharge. STUDY DESIGN Three hundred sixty-two consecutive patients underwent radical cystectomy and urinary diversion with curative intent (2001 through 2008). Each underwent a perioperative care plan ("fast track" program). Throughout our experience, evidence-based modifications to this program were instituted. We analyzed the impact of these modifications and report the outcomes with the most recent 100 patients in whom no additional modification has been used. RESULTS Mean age of patients is 66.3 years, with 44% of the patients older than age 70 years and 12% older than age 80 years. We found no detrimental effects to immediate removal of the orogastric tube at the end of the procedure, but found a beneficial effect of empiric metoclopramide use, with lower rates of nausea and vomiting. Perioperative antibiotic coverage has been reduced to 24 hours as per American Urological Association guidelines. Gum-chewing has also been shown to be of benefit with regard to a more rapid recovery of bowel function. Use of nonnarcotic analgesics (eg, ketrolac) has also been central in the pathway. Finally, early institution of an oral diet has been an original and central component to our fast track program. CONCLUSIONS Successful application of a fast track program has been applied to our patients undergoing radical cystectomy and urinary diversion, with the potential to use evidence-based modifications to reduce morbidity and improve recovery.
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Affiliation(s)
- Raj S Pruthi
- Division of Urologic Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7235, USA.
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Inoue M, Caldarone CA, Frndova H, Cox PN, Ito S, Taddio A, Guerguerian AM. Safety and efficacy of ketorolac in children after cardiac surgery. Intensive Care Med 2009; 35:1584-92. [PMID: 19562323 DOI: 10.1007/s00134-009-1541-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 05/11/2009] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the nephrotoxic and opioid-sparing effects of ketorolac in children after cardiac surgery. DESIGN A retrospective cohort study. SETTING A Cardiac Critical Care Unit in a university-affiliated children's hospital. SUBJECTS Children less than 18 years of age who underwent low-risk cardiac surgery from July 2002 to December 2005. RESULTS Among 248 children studied, 108 received ketorolac and 140 did not. The ketorolac group was older, included a larger proportion of atrial septum defect repairs and a smaller proportion of ventricular septum defect repairs compared to the control group. The median change in serum creatinine did not differ between the ketorolac group and the control group (% change [IQR]); 12% [1-25] increase versus 12% [-3 to 31] increase, P = 0.86. On postoperative day 0 or 1, the ketorolac group received less opioids than control group. There was no difference in duration of mechanical ventilation or in length of stay between groups. CONCLUSION Ketorolac started in the first 12 h after a low-risk cardiac surgery in children is not associated with a measurable difference in renal function. The data suggest that ketorolac may be effective in reducing the exposure to opioids. Further studies are required to define subsets of children after cardiac surgery who could safely benefit from ketorolac therapy to reduce pain.
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Affiliation(s)
- Miho Inoue
- Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Moodie JE, Brown CR, Bisley EJ, Weber HU, Bynum L. The Safety and Analgesic Efficacy of Intranasal Ketorolac in Patients with Postoperative Pain. Anesth Analg 2008; 107:2025-31. [DOI: 10.1213/ane.0b013e318188b736] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Patrocínio LG, Rangel MDO, Marques Miziara GS, Rodrigues AM, Patrocínio JA, Patrocinio TG. A comparative study between ketorolac and ketoprofen in postoperative pain after uvulopalatopharyngoplasty. Braz J Otorhinolaryngol 2007; 73:339-42. [PMID: 17684654 PMCID: PMC9445687 DOI: 10.1016/s1808-8694(15)30077-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2006] [Accepted: 08/02/2006] [Indexed: 12/05/2022] Open
Abstract
Postoperative pain is a serious problem, requiring an appropriate response from the medical doctor. In otolaryngology special attention is needed after uvulopala topharyngoplasty (UP3). Aim: To compare the efficacy of postoperative analgesia using ketorolac and ketoprofen after UP3. Patients and Methods: A prospective, randomized, double-blind study was made of 24 patients that were divided into 2 groups (14 received ketorolac and 10 received ketoprofen). Pain intensity was based on an analog visual scale and the need for opioids (tramadol). Results: Of the 13 patients that received ketorolac, 3 (21%) required opioids; 7 of 10 (70%) patients in ketoprofen group used opioids. 12 hours after surgery, 71% of the patients that received ketorolac had mild or absence of pain. 70% of the ketoprofen users reported moderate to significant pain. 24 hours after surgery, 60% of the patients using ketoprofen reported moderate to significant pain, while 86% of the ketorolac users reported mild or absence of pain. Conclusion: We concluded that ketorolac is more effective compared to ketoprofen in the treatment of immediate postoperative pain after UP3, as patients using ketorolac had less pain and used opioids to a lesser degree.
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Kolesnikov Y, Sõritsa D. Analgesic synergy between topical opioids and topical non-steroidal anti-inflammatory drugs in the mouse model of thermal pain. Eur J Pharmacol 2007; 579:126-33. [PMID: 18001710 DOI: 10.1016/j.ejphar.2007.10.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Revised: 09/12/2007] [Accepted: 10/11/2007] [Indexed: 12/17/2022]
Abstract
The main aim of the study was to examine analgesic effects of the topical opioids and non-steroidal anti-inflammatory drugs (NSAIDs) in a radiant heat tail-flick nociception model. Also, we have tested whether the addition of lauric acid to propylene glycol improves skin permeation for the opioids and NSAIDs. We found that the addition of lauric acid to propylene glycol dramatically improves the penetration of the drugs, measured by the drug's ED(50). We observed a significant dose response shift to the left for all tested drugs. So, morphine's ED(50) was decreased by 19-fold. The duration of the analgesic activity of morphine dissolved in a combination of propylene glycol and lauric acid was much longer compared with the same dose of the drug dissolved in propylene glycol only. Methadone and hydrocodone also produced analgesic activity in this experimental paradigm. We then assessed potential interactions between opioids, ibuprofen and diclofenac using a fixed, low dose of each. The inclusion of either S-ibuprofen or diclofenac to a fixed, low dose of morphine raised the analgesic response from around 20% to 50% and 80%, respectively. Topical methadone and diclofenac alone produced analgesia in 30% of mice. The combination produced analgesia in 100% of mice (100% versus 60%, P<0.001) and the analgesic effect was observed for 90 min. Alone, topical methadone and S-ibuprofen produced analgesia in 25% and 30% of mice, respectively. The combination elicited analgesia in 100% of mice (100% versus 55%, P<0.001) and this analgesic effect lasted for 120 min. Our current findings support the supra-additive interaction of topical mu opioids, S-ibuprofen and diclofenac in a model of moderate to severe pain, radiant heat tail-flick assay.
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MESH Headings
- Administration, Cutaneous
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/pharmacokinetics
- Analgesics, Opioid/pharmacology
- Animals
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/pharmacokinetics
- Anti-Inflammatory Agents, Non-Steroidal/pharmacology
- Disease Models, Animal
- Dose-Response Relationship, Drug
- Drug Synergism
- Excipients/chemistry
- Hot Temperature
- Lauric Acids/chemistry
- Male
- Mice
- Mice, Inbred ICR
- Pain/drug therapy
- Pain Measurement
- Permeability
- Propylene Glycol/chemistry
- Tail
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Affiliation(s)
- Yuri Kolesnikov
- Institute of Technology, University of Tartu, Tartu, 50411, Estonia.
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Abstract
BACKGROUND Ketorolac is an injectable nonsteroidal anti-inflammatory drug that is often used as a transitional short-term analgesic to treat moderate pain and to decrease opioid use. There is a paucity of literature documenting the safety of using ketorolac in neonates and infants after cardiac surgery. METHODS A retrospective chart review was performed which identified all patients <6 months of age who received ketorolac after cardiac surgery. Patients' demographic, surgical, and dosing data were collected. A Student's t-test was used to identify significant differences in renal and hematologic laboratory values at baseline and at 48 h of treatment. RESULTS A total of 53 children <6 months of age received at least one dose of ketorolac after cardiac surgery. Eleven of 53 children (21%) were <1 month of age. The blood urea nitrogen/serum creatinine (SCr) levels increased from baseline at 48 h of therapy in all infants, but stayed within normal limits. The largest increase in SCr level from baseline on any day of ketorolac therapy was 26 micromol x l(-1) (0.3 mg x dl(-1)) which occurred in two neonates. Four patients (three infants and one neonate) had minor episodes of bleeding while being treated with ketorolac. There were no clinically significant changes in hemoglobin, hematocrit or platelet count. None of these episodes caused hemodynamic instability nor required transfusion of blood products. CONCLUSIONS Ketorolac was used safely in neonates and infants who have had cardiac surgery at our institution. Ketorolac was not associated with any adverse hematologic or renal effects. Prospective investigation is warranted to further assess the safety and effectiveness of ketorolac in this patient population.
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Affiliation(s)
- Brady S Moffett
- Department of Pharmacy, Texas Children's Hospital, Houston, TX 77030, USA.
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Singh VP, Patil CS, Kulkarni SK. Analysis of interaction between etoricoxib and tramadol against mechanical hyperalgesia of spinal cord injury in rats. Life Sci 2006; 78:1168-74. [PMID: 16182319 DOI: 10.1016/j.lfs.2005.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2004] [Accepted: 06/22/2005] [Indexed: 12/24/2022]
Abstract
Drug combinations have the potential advantage of greater analgesia over monotherapy. The present study was aimed to assess any possible interaction (additive or potentiation) in the antinociceptive effects of etoricoxib; a novel cyclooxygenase-2 inhibitor, and tramadol; a typical opioid agonist when administered in combination against mechanical hyperalgesia induced by spinal cord injury in rats. The nature of interaction was analyzed using surface of synergistic interaction (SSI) analysis and an isobolographic analysis. Etoricoxib or tramadol when administered alone to rats, exhibited different antihyperalgesic potencies (ED50 etoricoxib: 0.58+/-0.19 mg/kg, po; ED50 tramadol: 9.85+/-0.57 mg/kg, po). However, both the drugs were found to be long acting against this model of hyperalgesia. Further, etoricoxib and tramadol were co-administered in fixed ratios of ED50 fractions. One combination (0.29/4.79 mg/kg, po: etoricoxib/tramadol) exhibited additivity and other three combinations (0.15/2.39, 0.08/1.19, and 0.04/0.59 mg/kg, po: etoricoxib/tramadol) resulted in potentiation when analyzed by SSI. The SSI was calculated from the total antihyperalgesic effect produced by the combination after the subtraction of the antihyperalgesic effect produced by each of the individual drug. In the isobolographic analysis, the experimental ED50 was found to be far below the line of additivity also indicating a significant (P < 0.05) synergistic antihyperalgesic effect when etoricoxib and tramadol was co-administered to rats. The synergistic antihyperalgesic effect of etoricoxib and tramadol combination suggests that these combinations may have clinical utility in mechanical hyperalgesia associated with spinal injury.
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Affiliation(s)
- Vijay Pal Singh
- Pharmacology Division, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh 160 014, India
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Paediatric cancer pain management using the WHO analgesic ladder--results of a prospective analysis from 2265 treatment days during a quality improvement study. Eur J Pain 2005; 10:587-95. [PMID: 16243549 DOI: 10.1016/j.ejpain.2005.09.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2005] [Revised: 07/19/2005] [Accepted: 09/05/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To collect data on pain management in paediatric oncology with respect to the WHO ladder approach. SETTING, DESIGN, PATIENTS AND METHODS: Eight German tertiary care paediatric oncology centres prospectively documented all their in-patient pain treatment courses from June 1999 to December 2000. Pain was scored using a 1-6 faces scale. RESULTS Two hundred and twenty four patients (median age, 9 years; range 0.2-32.1) were enrolled. Three hundred and thirty three pain episodes comprising a total of 2265 treatment days were documented. Pain was mostly therapy associated. The most frequently administered non-opioid analgesics were dipyrone and paracetamol. On WHO step 2, tramadol was almost the only opioid used. During tramadol monotherapy average daily pain scores were lower than with a combination of tramadol and non-opioid analgesics. On WHO step 3, morphine was at least part of the analgesic regimen on most treatment days. Strong opioids were combined with a non-opioid analgesic on 41% of the treatment days. The mean intravenous morphine equivalence dose was 0.034 mg/kg/h. During opioid and non-opioid combination therapy, adverse effects were more frequent, and average pain scored higher than on opioid monotherapy. CONCLUSIONS WHO-guidelines were closely followed in Germany and seem to provide effective analgesia for children with cancer pain. In our patient group there is no evidence that a combination of an opioid with a non-opioid is more effective than opioid therapy alone in in-patient paediatric oncology pain treatment.
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Liu SY, Shieh JP, Tzeng JI, Chia-Hui H, Cheng YL, Huang KL, Wang JJ. Novel Depots of Ketorolac Esters Have Long-Acting Antinociceptive and Antiinflammatory Effects. Anesth Analg 2005; 101:785-792. [PMID: 16115992 DOI: 10.1213/01.ane.0000166978.12457.7a] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
No long-acting nonsteroidal antiinflammatory drug is clinically available for the treatment of pain. In this study, we evaluated the antinociceptive and antiinflammatory effects and duration of action of several novel depots of ketorolac esters, such as ketorolac propyl ester, pentyl ester, heptyl ester, and decyl ester, and observed whether they had a long-acting effect. Four studies in Sprague-Dawley rats were performed. In Studies 1-3, the antinociceptive and antiinflammatory effects of IM ketorolac tromethamine and its base and propyl ester were evaluated. In Study 4, the antinociceptive and antiinflammatory effects of several other ketorolac esters were evaluated. We found that ketorolac tromethamine 24, 80, and 240 micromol/kg (in saline) produced significant antinociceptive and antiinflammatory effects with duration of action of approximately 6-8 h. The four ketorolac esters at a dose of 240 micromol/kg (in oil) produced significant long-acting antinociceptive and antiinflammatory effects, with duration of action of approximately 52-76 h. We concluded that IM injection of novel depots of ketorolac esters in rats produce long-acting antinociceptive and antiinflammatory effects that are 6.5- to 9.5-fold longer than the traditional dosage form of ketorolac tromethamine.
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Affiliation(s)
- Shyun-Yeu Liu
- *Department of Oral and Maxillofacial Surgery, National Defense Medical Center, Taipei; †Department of Oral and Maxillofacial Surgery, Taipei Medical University, Taipei; and ‡Departments of Anesthesiology and Medical Research, Chi-Mei Medical Center, Tainan (Yung-Kang and Liou-Ying), Taiwan
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Zelcer S, Kolesnikov Y, Kovalyshyn I, Pasternak DA, Pasternak GW. Selective potentiation of opioid analgesia by nonsteroidal anti-inflammatory drugs. Brain Res 2005; 1040:151-6. [PMID: 15804436 DOI: 10.1016/j.brainres.2005.01.070] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2004] [Revised: 01/21/2005] [Accepted: 01/24/2005] [Indexed: 12/27/2022]
Abstract
Opioids are often used in conjunction with nonsteroidal anti-inflammatory drugs (NSAIDs) in the treatment of moderate to severe pain. In this study we have examined interactions between these two classes of drugs. NSAIDs are inactive in the radiant heat tail-flick test, an assay of moderate to severe pain in which opioids are effective. In this assay, ibuprofen potentiated the analgesic actions of hydrocodone and oxycodone, shifting their ED(50) values by 2.5-fold and 4.6-fold despite its inactivity when given alone. These opioid/NSAID interactions were dependent upon both the opioid and the NSAID. Neither aspirin nor ketorolac influenced hydrocodone actions in this model and ibuprofen did not potentiate fentanyl or morphine analgesia. Together, these studies demonstrate potent interactions between selected combinations of opioids and NSAIDS and may help explain the clinical utility of combinations. However, the findings also illustrate differences between the drugs within each class.
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Affiliation(s)
- Shayna Zelcer
- Departments of Pediatrics, Anesthesiology and Neurology, Laboratory of Molecular Neuropharmacology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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Abstract
PURPOSE OF REVIEW Pain management after thoracic surgery in children presents the challenge of providing adequate analgesia without excessive sedation, and maintaining adequate respiratory function in the face of compromise resulting from existing pathology, surgical trauma, single-lung ventilation and postoperative ventilation-perfusion abnormalities. In the pediatric population, pain assessment and reporting present additional challenges. The number and complexity of surgical procedures, including video-assisted thoracoscopic procedures, is increasing in the pediatric population. There is a need to explore pain management for these types of patients. RECENT FINDINGS There are effective and safe strategies whereby analgesia can be provided to this pediatric population. This review will outline the progress that has been made in this field, including the use of regional techniques. The routine use of caudal catheters in neonates and infants for thoracic surgical procedures and the use of electrical guidance of epidural catheters, the 'Tsui' technique, are reviewed. SUMMARY These techniques, applied within a comprehensive pain management strategy, can be extremely beneficial in the care of the pediatric thoracic patient.
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Affiliation(s)
- Brenda Golianu
- Stanford University School of Medicine, Stanford, California 94305, USA.
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Gupta A, Daggett C, Ludwick J, Wells W, Lewis A. Ketorolac after congenital heart surgery: does it increase the risk of significant bleeding complications? Paediatr Anaesth 2005; 15:139-42. [PMID: 15675931 DOI: 10.1111/j.1460-9592.2005.01409.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The routine use of ketorolac after congenital heart surgery in infants and children is limited by concerns for postoperative bleeding complications. The object of this study was to determine if the use of ketorolac is associated with an increased risk of significant postoperative bleeding after congenital heart surgery in infants and children. METHODS A retrospective chart review was performed. The exposure of interest was postoperative use of ketorolac after congenital heart surgery in infants and children. The outcome measured was postoperative bleeding requiring surgical exploration. The patients who received ketorolac were compared with an age- and diagnosis-matched comparison group who did not receive ketorolac. RESULTS Records of 842 infants and children who underwent congenital heart surgery between July 2001 and October 2002 were reviewed. 94 (11.1%) patients were treated with ketorolac postoperatively. The comparison group consisted of 94 matched subjects selected from the patients that did not receive ketorolac. The mean age of patient in the ketorolac group was 8.5 (+/-6.1) years. No (0%) patients in the ketorolac group and four (4.2%) patients in the nonketorolac group developed postoperative bleeding requiring surgical exploration. The relative risk for postoperative bleeding that required surgical exploration in the ketorolac group compared with the nonketorolac group was 0.2 (95% CI 0.02-1.67). CONCLUSIONS The use of ketorolac after congenital heart surgery in infants and children does not significantly increase the risk of bleeding complications requiring surgical exploration.
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Affiliation(s)
- Anuja Gupta
- Childrens Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA.
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Roh JH, Choe DH, Lee YW, Yoon DM. The Analgesic Interaction between Ketorolac and Morphine in Radiant Thermal Stimulation Rat. Korean J Pain 2005. [DOI: 10.3344/kjp.2005.18.1.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jang Ho Roh
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hun Choe
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Youn-Woo Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Duck Mi Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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López-Muñoz FJ, Díaz-Reval MI, Terrón JA, Déciga-Campos M. Analysis of the analgesic interactions between ketorolac and tramadol during arthritic nociception in rat. Eur J Pharmacol 2004; 484:157-65. [PMID: 14744599 DOI: 10.1016/j.ejphar.2003.11.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The potential advantage of using combination therapy is that analgesia can be maximized while minimizing the incidence of adverse effects. In order to assess a possible synergistic antinociceptive interactions, the antinociceptive effects of ketorolac tromethamine, p.o., a nonsteroidal anti-inflammatory drug (NSAID), and tramadol hydrochloride, p.o., an atypical opioid analgesic, administered either separately or in combination, were determined using a rat model of arthritic pain. The data were interpreted using the surface of synergistic interaction (SSI) analysis and an isobolographic analysis to establish the nature of the interaction. The surface of synergistic interaction was calculated from the total antinociceptive effect produced by the combination after subtraction of the antinociceptive effect produced by each individual drug. Female rats received orally ketorolac alone (0.18, 0.32, 0.56, 1.0, 1.78, 3.16, and 5.62 mg/kg), tramadol alone (3.16, 5.62, 10.0, 17.78, 31.62, 56.23, and 100.0 mg/kg), or 24 different combinations of ketorolac plus tramadol. Ten combinations exhibited various degrees of potentiation of antinociceptive effects (17.78 mg/kg tramadol with either 0.18, 0.32, or 0.56 mg/kg ketorolac; 10.0 mg/kg tramadol with either 0.18, 0.32, 0.56, or 1.8 mg/kg ketorolac; 5.6 mg/kg tramadol with either 0.32 or 0.56 mg/kg ketorolac; and 3.16 mg/kg tramadol with 0.32 mg/kg ketorolac), whereas the other 14 combinations showed additive antinociceptive effects. Three combinations of ketorolac+tramadol (1.0+17.78, 1.78+10, and 1.78+17.78, mg/kg respectively) produced the maximum antinociceptive effects, and two combinations (0.32+10.0 and 0.56+10.0 mg/kg, respectively) presented effects of high potentiation (P<0.001). This combination caused gastric injuries less severe than those observed with indomethacin. The synergistic antinociceptive effects of ketorolac and tramadol were important and suggest that combinations with these drugs may have clinical utility in pain therapy.
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Affiliation(s)
- Francisco Javier López-Muñoz
- Laboratorio No. 7, Dolor y Analgesia del Departamento de Farmacobiología, CINVESTAV-IPN, Calzada de los Tenorios No. 235, Col. Granjas Coapa, Deleg. Tlálpan, Mexico, DF, CP 14330 Mexico.
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Pruthi RS, Chun J, Richman M. Reducing time to oral diet and hospital discharge in patients undergoing radical cystectomy using a perioperative care plan. Urology 2003; 62:661-5; discussion 665-6. [PMID: 14550438 DOI: 10.1016/s0090-4295(03)00651-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To outline our current perioperative treatment of patients undergoing radical cystectomy and urinary diversion, which uses advancements in perioperative care to allow for early institution of an oral diet and early hospital discharge, and thereby overall improvement in patient recovery and outcome after this procedure. METHODS Forty consecutive patients underwent radical cystectomy and urinary diversion with curative intent from 2001 to 2002. A care plan was followed for all patients and included improvements in preoperative, intraoperative, and postoperative care. The preoperative care included limited outpatient bowel preparation with sodium phosphate solution and patient education. Operative modifications included reduced incision length, initial preperitoneal dissection, and the use of internal surgical stapling devices. The postoperative care included the use of prokinetic agents, early nasogastric tube removal, the use of non-narcotic analgesics, and early institution of an oral diet. The outcomes with regard to time to institution of an oral diet, tolerance of a regular diet, and hospital discharge were assessed. RESULTS The mean surgical time was 3.9 hours, and the mean estimated blood loss was 573 mL. The mean time to the institution of a clear liquid diet was 2.0 days and to a regular diet was 4.2 days. The mean time to hospital discharge was 5.1 days. No statistically significant differences were found in the time to resumption of a regular diet or to discharge between patients undergoing ileal conduits versus orthotopic ileal neobladders. Only 1 patient had any gastrointestinal dysfunction (ileus), and this patient was discharged on postoperative 7. No patient had any delayed complications involving problems with diet intolerance or other gastrointestinal dysfunction. The results of the current series were compared with those of historical controls. CONCLUSIONS Advancements in preoperative, intraoperative, and postoperative management have together been successfully used in our patient population to reduce morbidity and improve recovery with regard to the early institution of an oral diet and early hospital discharge.
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Affiliation(s)
- Raj S Pruthi
- Division of Urologic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
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Vitale MG, Choe JC, Hwang MW, Bauer RM, Hyman JE, Lee FY, Roye DP. Use of ketorolac tromethamine in children undergoing scoliosis surgery. an analysis of complications. Spine J 2003; 3:55-62. [PMID: 14589246 DOI: 10.1016/s1529-9430(02)00446-1] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Ketorolac Tromethamine (ketorolac) is a nonsteroidal anti-inflammatory drug (NSAID) with proven efficacy in decreasing postoperative pain in various surgical settings, including the treatment of spine deformities. However, some studies have raised questions regarding the potential side effects of this agent, such as increased bleeding and inhibition of bony fusion. PURPOSE This study was conducted to determine whether there is any association between the use of ketorolac and postoperative complications in a group of children who underwent scoliosis surgery. STUDY DESIGN/SETTING This is a retrospective review of a group of children who underwent spinal fusion between 1989 to 1999 at our institution. PATIENT SAMPLE Data on a total of 208 children were analyzed in this study. Sixty received ketorolac and 148 did not. OUTCOME MEASURES Postoperative transfusion and reoperation rates were the two main outcome measures of interest. METHODS A retrospective review of 208 children who underwent scoliosis surgery was conducted, with a focus on ketorolac use. Univariate analysis and logistic regression were used to quantify the determinants of postoperative complications. RESULTS Our analyses detected no significant differences in a broad range of socioclinical variables between the two patient groups, including age at surgery, gender, type of scoliosis, surgical approach, use of erythropoietin, levels of curvature and degree of curvature. Analysis of complication rates focusing on postoperative transfusion and revision surgery showed that there were no significant differences between the two groups. CONCLUSIONS In this retrospective study of 208 children undergoing spine surgery, postoperative use of ketorolac did not significantly increase complications, including transfusion and reoperation.
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Affiliation(s)
- Michael G Vitale
- International Center for Health Outcomes and Innovative Research, College of Physicians and Surgeons, and the Josepth L. Mailman School of Public Health, Columbia University and New York Presbyterian Hospital, New York, NY 10032, USA.
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MILLER ORENF, BLOOM TAMMYL, SMITH LORENJ, Mc ALEER IRENEM, KAPLAN GEORGEW, KOLON THOMASF. Early Hospital Discharge for Intravesical Ureteroneocystostomy. J Urol 2002. [DOI: 10.1016/s0022-5347(05)65036-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- OREN F. MILLER
- From the Naval Medical Center and Children’s Hospital and Health Center, San Diego, California
| | - TAMMY L. BLOOM
- From the Naval Medical Center and Children’s Hospital and Health Center, San Diego, California
| | - LOREN J. SMITH
- From the Naval Medical Center and Children’s Hospital and Health Center, San Diego, California
| | - IRENE M. Mc ALEER
- From the Naval Medical Center and Children’s Hospital and Health Center, San Diego, California
| | - GEORGE W. KAPLAN
- From the Naval Medical Center and Children’s Hospital and Health Center, San Diego, California
| | - THOMAS F. KOLON
- From the Naval Medical Center and Children’s Hospital and Health Center, San Diego, California
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Abstract
Without proper management, postoperative pain can grow to intolerable levels and interfere with functioning and healing. Historically, morphine had no equal for postoperative pain management. Its side effects, however, are troubling. Recently, researchers have developed many analgesics that do not induce the same side effects as morphine. Ketorolac is one example. Nevertheless, a single drug with an efficacy comparable with morphine remains elusive. In this article, the physiology of pain is reviewed and ketorolac is compared with morphine. Perianesthesia nurses are given pertinent information to enhance their ability to provide the best pain relief available for the patients in their care.
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Affiliation(s)
- Daniel Anthony
- Georgetown University School of Nursing & Health Studies, Washington, DC, USA
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Marley RA, Swanson J. Patient care after discharge from the ambulatory surgical center. J Perianesth Nurs 2001; 16:399-417; quiz 417-9. [PMID: 11740781 DOI: 10.1053/jpan.2001.28891] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
UNLABELLED An important and often forgotten aspect of postoperative care occurs after the patient is discharged from the ambulatory surgical center. With more than 60% of all surgeries and procedures occurring on an ambulatory basis, what happens after the patient is no longer in continuous professional care is of concern to the ambulatory nurse. Numerous physical postoperative complaints are common and expected sequelae of anesthesia and surgery in the ambulatory patient. In this article, important postdischarge complications are reviewed and contemporary management options discussed. The information contained in this review article is valuable to the provider in educating patients regarding their anticipated course of postoperative recovery. OBJECTIVES -Based on the content of this article, the reader should be able to (1) identify important postdischarge complications to provide patients with comprehensive discharge instructions regarding their continued recovery at home; (2) discuss contemporary management options available to treat postdischarge complications; (3) realize the incidence of specific postdischarge complications and how that relates to patient satisfaction with the surgical experience; (4) recognize signs and symptoms of postdischarge complications; and (5) identify risk factors of patients for developing specific complications in the postoperative phase.
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Affiliation(s)
- R A Marley
- Chief Nurse Anesthetist for Northern Colorado Anesthesia Professional Consultants, and Jan Swanson, Poudre Valley Hospital, Fort Collins, CO 80524, USA
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