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Modi J, Magee T, Rucker B, Flores H, Wise A, Kee M, Garrett M, Roberts W, Vassar M. An analysis of harms reporting in systematic reviews regarding ketorolac for management of perioperative pain. Br J Anaesth 2022; 129:767-775. [PMID: 36175184 DOI: 10.1016/j.bja.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/01/2022] [Accepted: 08/10/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Owing to the frequent perioperative use of ketorolac tromethamine and its ability to minimise postoperative opioid requirements, it is important to continually reassess harms associated with its use. Our primary objective was to investigate the extent of harms reporting in systematic reviews (SRs) on ketorolac for perioperative pain. METHODS In May 2022, we conducted a search of major databases, MEDLINE (PubMed and Ovid), Embase, Epistemonikos, and the Cochrane Database of Systematic Reviews to identify eligible SRs on ketorolac for perioperative pain. Screening and data extraction were performed in masked, duplicate fashion. A MeaSurement Tool to Assess systematic Reviews-2 (AMSTAR-2) was used to appraise the methodological quality of included SRs. Corrected covered area (CCA) was calculated to determine overlap of primary studies between SR dyads. RESULTS A total of 28 SRs evaluating 630 primary studies met the inclusion criteria. Seven SRs (7/28, 25%) reported no harms and 17 SRs (17/28, 60.7%) reported ≤50% of harms items. A significant association was found between completeness of harms reporting and whether harms were specified as a primary outcome (P<0.001). No other associations were statistically significant. Regarding methodological quality, 22 SRs were appraised as 'critically low' (22/28, 78.6%), 5 as 'low' (5/28, 17.9%), and 1 as 'high' (1/28, 3.6%). One SR dyad had a CCA >50% but neither reported harms. CONCLUSIONS The extent of harms reporting in systematic reviews was inadequate. Given the importance that systematic reviews have on guiding perioperative decision-making, it is essential to improve the completeness of harms reporting.
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Affiliation(s)
- Jay Modi
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA.
| | - Trevor Magee
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Brayden Rucker
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Holly Flores
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Audrey Wise
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Micah Kee
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Morgan Garrett
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Will Roberts
- Department of Anesthesiology, Oklahoma State University Medical Center, Tulsa, OK, USA
| | - Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA; Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
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Donahue RP, Stamm AW, Daily AM, Kozlowski PM, Porter CR, Govier FE, Cowan NG, Lucioni A, Kuhr CS, Kobashi KC, Hanson NA, Corman JM, Lee UJ. Opioid-Limiting Pain Control After Transurethral Resection of the Prostate: A Randomized Controlled Trial. Urology 2022; 166:202-208. [PMID: 35314185 DOI: 10.1016/j.urology.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/14/2022] [Accepted: 03/07/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess whether a multimodal opioid-limiting protocol and patient education intervention can reduce postoperative opioid use following transurethral resection of the prostate. METHODS This prospective, non-blinded, single-institution, randomized controlled trial (NCT04102566) assigned 50 patients undergoing a transurethral resection of the prostate to either a standard of care control (SOC) or multimodal experimental group (MMG). The intervention included adding ibuprofen to the postoperative pain regimen, promoting appropriate opioid use while hospitalized, an educational intervention, and discharging without opioid prescription. Data regarding demographics, operative data, opioid use, pain scores, and patient satisfaction were compared. RESULTS A total of 47 patients were included, n = 23 (MMG) and n = 24 (SOC). Demographic and operative findings were similar. Statistical analysis for noninferiority demonstrated non-inferior inpatient pain control (mean pain score 2.5 MMG vs 2.4 SOC, P = 0.0003). The multimodal group used significantly fewer morphine milligram equivalents after discharge (0 vs 4.1, P = 0.04). Inpatient use was reduced but did not reach statistical significance (6.0 vs 9.8, P = 0.2). Mean satisfaction scores with pain control were similar (9.6 MMG vs 9.2 SOC, P = 0.32). No opioid prescriptions were requested after discharge. Adverse events and medication side effects were infrequent and largely similar between groups. CONCLUSION Implementation of an opioid-limiting postoperative pain protocol and patient education resulted in no outpatient opioid use while maintaining patient satisfaction with pain control. Eliminating opioids following a common urologic procedure will decrease risk of opioid-related adverse events and have a positive downstream impact.
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Affiliation(s)
- Ryan P Donahue
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Andrew W Stamm
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Adam M Daily
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Paul M Kozlowski
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Christopher R Porter
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Fred E Govier
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Nicholas G Cowan
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Alvaro Lucioni
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Christian S Kuhr
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Kathleen C Kobashi
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Neil A Hanson
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN
| | - John M Corman
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Una J Lee
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA.
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McNicol ED, Ferguson MC, Schumann R. Single-dose intravenous ketorolac for acute postoperative pain in adults. Cochrane Database Syst Rev 2021; 5:CD013263. [PMID: 33998669 PMCID: PMC8127532 DOI: 10.1002/14651858.cd013263.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Postoperative pain is common and may be severe. Postoperative administration of non-steroidal anti-inflammatory drugs (NSAIDs) reduces patient opioid requirements and, in turn, may reduce the incidence and severity of opioid-induced adverse events (AEs). OBJECTIVES To assess the analgesic efficacy and adverse effects of single-dose intravenous ketorolac, compared with placebo or an active comparator, for moderate to severe postoperative pain in adults. SEARCH METHODS We searched the following databases without language restrictions: CENTRAL, MEDLINE, Embase and LILACS on 20 April 2020. We checked clinical trials registers and reference lists of retrieved articles for additional studies. SELECTION CRITERIA Randomized double-blind trials that compared a single postoperative dose of intravenous ketorolac with placebo or another active treatment, for treating acute postoperative pain in adults following any surgery. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our primary outcome was the number of participants in each arm achieving at least 50% pain relief over a four- and six-hour period. Our secondary outcomes were time to and number of participants using rescue medication; withdrawals due to lack of efficacy, adverse events (AEs), and for any other cause; and number of participants experiencing any AE, serious AEs (SAEs), and NSAID-related or opioid-related AEs. For subgroup analysis, we planned to analyze different doses of parenteral ketorolac separately and to analyze results based on the type of surgery performed. We assessed the certainty of evidence using GRADE. MAIN RESULTS We included 12 studies, involving 1905 participants undergoing various surgeries (pelvic/abdominal, dental, and orthopedic), with 17 to 83 participants receiving intravenous ketorolac in each study. Mean study population ages ranged from 22.5 years to 67.4 years. Most studies administered a dose of ketorolac of 30 mg; one study assessed 15 mg, and another administered 60 mg. Most studies had an unclear risk of bias for some domains, particularly allocation concealment and blinding, and a high risk of bias due to small sample size. The overall certainty of evidence for each outcome ranged from very low to moderate. Reasons for downgrading certainty included serious study limitations, inconsistency and imprecision. Ketorolac versus placebo Very low-certainty evidence from eight studies (658 participants) suggests that ketorolac results in a large increase in the number of participants achieving at least 50% pain relief over four hours compared to placebo, but the evidence is very uncertain (risk ratio (RR) 2.81, 95% confidence interval (CI) 1.80 to 4.37). The number needed to treat for one additional participant to benefit (NNTB) was 2.4 (95% CI 1.8 to 3.7). Low-certainty evidence from 10 studies (914 participants) demonstrates that ketorolac may result in a large increase in the number of participants achieving at least 50% pain relief over six hours compared to placebo (RR 3.26, 95% CI 1.93 to 5.51). The NNTB was 2.5 (95% CI 1.9 to 3.7). Among secondary outcomes, for time to rescue medication, moderate-certainty evidence comparing intravenous ketorolac versus placebo demonstrated a mean median of 271 minutes for ketorolac versus 104 minutes for placebo (6 studies, 633 participants). For the number of participants using rescue medication, very low-certainty evidence from five studies (417 participants) compared ketorolac with placebo. The RR was 0.60 (95% CI 0.36 to 1.00), that is, it did not demonstrate a difference between groups. Ketorolac probably results in a slight increase in total adverse event rates compared with placebo (74% versus 65%; 8 studies, 810 participants; RR 1.09, 95% CI 1.00 to 1.19; number needed to treat for an additional harmful event (NNTH) 16.7, 95% CI 8.3 to infinite, moderate-certainty evidence). Serious AEs were rare. Low-certainty evidence from eight studies (703 participants) did not demonstrate a difference in rates between ketorolac and placebo (RR 0.62, 95% CI 0.13 to 3.03). Ketorolac versus NSAIDs Ketorolac was compared to parecoxib in four studies and diclofenac in two studies. For our primary outcome, over both four and six hours there was no evidence of a difference between intravenous ketorolac and another NSAID (low-certainty and moderate-certainty evidence, respectively). Over four hours, four studies (337 participants) produced an RR of 1.04 (95% CI 0.89 to 1.21) and over six hours, six studies (603 participants) produced an RR of 1.06 (95% CI 0.95 to 1.19). For time to rescue medication, low-certainty evidence from four studies (427 participants) suggested that participants receiving ketorolac waited an extra 35 minutes (mean median 331 minutes versus 296 minutes). For the number of participants using rescue medication, very low-certainty evidence from three studies (260 participants) compared ketorolac with another NSAID. The RR was 0.90 (95% CI 0.58 to 1.40), that is, there may be little or no difference between groups. Ketorolac probably results in a slight increase in total adverse event rates compared with another NSAID (76% versus 68%, 5 studies, 516 participants; RR 1.11, 95% CI 1.00 to 1.23; NNTH 12.5, 95% CI 6.7 to infinite, moderate-certainty evidence). Serious AEs were rare. Low-certainty evidence from five studies (530 participants) did not demonstrate a difference in rates between ketorolac and another NSAID (RR 3.18, 95% CI 0.13 to 76.99). Only one of the five studies reported a single serious AE. AUTHORS' CONCLUSIONS The amount and certainty of evidence for the use of intravenous ketorolac as a treatment for postoperative pain varies across efficacy and safety outcomes and amongst comparators, from very low to moderate. The available evidence indicates that postoperative intravenous ketorolac administration may offer substantial pain relief for most patients, but further research may impact this estimate. Adverse events appear to occur at a slightly higher rate in comparison to placebo and to other NSAIDs. Insufficient information is available to assess whether intravenous ketorolac has a different rate of gastrointestinal or surgical-site bleeding, renal dysfunction, or cardiovascular events versus other NSAIDs. There was a lack of studies in cardiovascular surgeries and in elderly populations who may be at increased risk for adverse events.
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Affiliation(s)
- Ewan D McNicol
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - McKenzie C Ferguson
- Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, IL, USA
| | - Roman Schumann
- Department of Anesthesia, Critical Care and Pain Medicine, VA Boston Healthcare System, West Roxbury, Massachusetts, 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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Javaherforooshzadeh F, Abdalbeygi H, Janatmakan F, Gholizadeh B. Comparing the effects of ketorolac and Paracetamol on postoperative pain relief after coronary artery bypass graft surgery. A randomized clinical trial. J Cardiothorac Surg 2020; 15:80. [PMID: 32393370 PMCID: PMC7216617 DOI: 10.1186/s13019-020-01125-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/28/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Pain management after coronary artery bypass graft (CABG) surgery remains challenging. Objective This study aimed to compare the effects of Ketorolac and Paracetamol on postoperative CABG pain relief. Method This double-blind randomized clinical trial study was conducted in Ahvaz, Iran, from September 2018–December 2019. Two consecutive groups of 60 patients undergoing elective on-pump coronary artery bypass graft surgery. Intervention The patients were divided into 0.5 mg/kg of ketorolac mg/dl and 10 mg/kg of Paracetamol after surgery for pain management. Primary outcomes were: visual analog pain scale (VAS) at the time point immediately after extubation (baseline) and at 6, 12, 24 and 48 h and the total dose of morphine consumption. Secondary outcomes included the hemodynamic variables, weaning time, chest tube derange, in-hospital mortality and myocardial infarction. Statistical analysis: The data were analyzed using SPSS version 22(SPSS, Chicago, IL). The Mann-Whitney U-test was used to compare demographic data, VAS scores, vital signs, and side effects. Repeated measurements were tested within groups using Friedman’s ANOVA and the Wilcoxon rank-sum test. Values were expressed as means ± standard deviations. Statistical significance was defined as a p-value < 0.05. Results Compared with baseline scores, there were significant declines in VAS scores in both groups throughout the time sequence (P< 0.05). The statistical VAS score was slightly higher in the Paracetamol group at most time points, except for the time of 6 h. However, at 24 and 48 h, the VAS score in group Paracetamol was significantly higher than in group Ketorolac. There were no significant differences between groups about hemodynamic variables. Conclusion The efficacy of ketorolac is comparable to that of Paracetamol in postoperative CABG pain relief. Trial registry IRCT20150216021098N5. Registered at 2019-09-12.
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Affiliation(s)
- Fatemeh Javaherforooshzadeh
- Department of Cardiac Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Hasan Abdalbeygi
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Farahzad Janatmakan
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Behnam Gholizadeh
- Atherosclerosis Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Poljak D, Chappelle J. The effect of a scheduled regimen of acetaminophen and ibuprofen on opioid use following cesarean delivery. J Perinat Med 2020; 48:153-156. [PMID: 31951589 DOI: 10.1515/jpm-2019-0322] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/13/2019] [Indexed: 11/15/2022]
Abstract
Objective The primary objective was to evaluate if the administration of ibuprofen and acetaminophen at regularly scheduled intervals impacts pain scores and total opioid consumption, when compared to administration based on patient demand. Methods A retrospective chart review was performed comparing scheduled vs. as-needed acetaminophen and ibuprofen regimens, with 100 women included in each arm. Demographics and delivery characteristics were collected in addition to pain scores and total ibuprofen, acetaminophen and oxycodone use at 24, 48 and 72 h postoperatively. Results The scheduled dosing group was found to have a statistically significant decrease in pain scores at all time intervals. Acetaminophen and ibuprofen usage were also noted to be higher in this group while narcotic use was reduced by 64%. Conclusion Scheduled dosing of non-narcotic pain medications can substantially decrease opioid usage after cesarean delivery and improve post-operative pain.
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Affiliation(s)
- Dijana Poljak
- Washington University, Mail Stop 8064-37-1005, 4901 Forest Park Ave, St Louis, MO 63108, USA
| | - Joseph Chappelle
- Stony Brook University Hospital, 101 Nicolls Rd, HSC 9-090, Stony Brook, NY 11794, USA
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Onyeakusi NE, Gbadamosi SO, Mukhtar F, Orji C, Ugwuowo U, Igbeta O, Adejumo A, Akanbi O, Olufajo OA. Association between long-term NSAID use and opioid abuse among patients with breast cancer. Cancer Treat Res Commun 2019; 21:100156. [PMID: 31306996 DOI: 10.1016/j.ctarc.2019.100156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/01/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Improving survival rates among patients with breast cancer has been associated with an increase in the prevalence of co-morbidities like cancer-related pain. Opioids are an important component in the management of pain among these patients. However, the progression from judicious use to abuse defeats the aim of pain control. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as the first step in cancer-related pain management. Due to their anti-inflammatory, anti-neoplastic and neuroprotective properties, NSAIDs have been shown to reduce the risk of progression of certain cancers including breast cancers. In this study, we assessed whether an association exists between long-term NSAID use and opioid abuse among breast cancer survivors. We also explored the relationship between long-term NSAID use and inpatient mortality and length of stay (LOS). METHODS Using ICD-9-CM codes, we identified and selected women aged 18 years and older with breast cancer from the National Inpatient Sample. Our primary predictor was a history of long-term NSAID use. Multivariable regression models were employed in assessing the association between long-term NSAID use and opioid abuse, inpatient mortality and LOS. RESULTS Among 170,644 women with breast cancer, 7,838 (4.6%) reported a history of long-term NSAID use. Patients with a history of long-term NSAID use had lower odds of opioid abuse (adjusted odds ratio (aOR) 0.53; 95% CI [0.32-0.88]), lower in-hospital mortality (aOR 0.52; 95% CI [0.45-0.60]) and shorter LOS (7.12 vs. 8.11 days). DISCUSSION Further studies are needed to understand the underlying mechanism of the association between long-term NSAID use and opioid abuse.
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Affiliation(s)
- Nnaemeka E Onyeakusi
- Department of Anesthesiology, Case Western Reserve University
- MetroHealth Medical Center, Cleveland, OH, United States; Department of Pediatrics, BronxCare Hospital Center, Bronx, NY, United States.
| | - Semiu O Gbadamosi
- Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL, United States
| | - Fahad Mukhtar
- Department of Psychiatry, St. Elizabeth's Hospital, Washington, DC, United States
| | - Chinelo Orji
- Health Outcomes & Pharmacy Practice, University of Texas, Austin, TX, United States
| | - Ugochukwu Ugwuowo
- Applied Translational Research, Yale University School of Medicine, New Haven, CT, United States
| | - Onyenikewe Igbeta
- Department of Pediatrics, BronxCare Hospital Center, Bronx, NY, United States
| | - Adeyinka Adejumo
- Department of Medicine, North Shore Medical Center, Salem, MA, United States
| | - Olalekan Akanbi
- Department of Medicine, University of Kentucky, Lexington, KY, United States
| | - Olubode A Olufajo
- Department of Surgery, Howard University College of Medicine, Washington, DC, United States
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Use of Ketorolac After Outpatient Urogynecologic Surgery: A Randomized Control Trial. Female Pelvic Med Reconstr Surg 2019; 24:281-286. [PMID: 28914700 DOI: 10.1097/spv.0000000000000459] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Patient surveys highlight a prevalence of moderate to severe pain in the postanesthesia care unit. Multimodal analgesia has been promoted to improve this with fewer opioid-induced adverse effects. The aim of this study was to evaluate the opioid sparing and analgesic effect of postoperative intravenous (IV) ketorolac after outpatient transvaginal surgery. METHODS Forty patients were enrolled in this institutional review board-approved, randomized, double-blind, placebo-controlled study, to receive either 30 mg of IV ketorolac or IV saline placebo postoperatively. Pain was assessed by visual analog scale at timed intervals. Narcotic pain medication was provided upon request. Narcotic use was reassessed by telephone 5 to 7 days postoperatively. Categorical characteristics were compared by χ. Continuous variables were evaluated by Mann-Whitney U test. RESULTS Twenty patients were randomized to each group. Groups were similar in age, health, and operative factors. There was no significant difference in mean pain scores at any interval. The ketorolac group had a total morphine equivalent consumption median of 7.5 mg versus 4.0 mg for placebo, which was not significant (P = 0.17). Total use of narcotic pills postoperatively was equivalent (median, 5). There was no difference in postoperative nausea. One Dindo grade II complication was reported in the ketorolac group of a postoperative pelvic hematoma requiring transfusion. DISCUSSION Intravenous ketorolac administered after outpatient transvaginal surgery did not result in a reduction of pain scores or total morphine consumption. There was one Dindo grade II complication in the ketorolac group. Larger randomized control trials are needed to validate these findings.
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Bell S, Rennie T, Marwick CA, Davey P. Effects of peri-operative nonsteroidal anti-inflammatory drugs on post-operative kidney function for adults with normal kidney function. Cochrane Database Syst Rev 2018; 11:CD011274. [PMID: 30488949 PMCID: PMC6517026 DOI: 10.1002/14651858.cd011274.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) provide effective analgesia during the post-operative period but can cause acute kidney injury (AKI) when used peri-operatively (at or around the time of surgery). This is an update of a Cochrane review published in 2007. OBJECTIVES This review looked at the effect of NSAIDs used in the peri-operative period on post-operative kidney function in patients with normal kidney function. SEARCH METHODS We searched Cochrane Kidney and Transplant's Specialised Register to 4 January 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs (RCTs in which allocation to treatment was obtained by alternation, use of alternate medical records, date of birth or other predictable methods) looking at the use of NSAIDs versus placebo for the treatment of post-operative pain in patients with normal kidney function were included. DATA COLLECTION AND ANALYSIS Data extraction was carried out independently by two authors as was assessment of risk of bias. Disagreements were resolved by a third author. Dichotomous outcomes are reported as relative risk (RR) and continuous outcomes as mean difference (MD) together with their 95% confidence intervals (CI). Meta-analyses were used to assess the outcomes of AKI, change in serum creatinine (SCr), urine output, renal replacement therapy (RRT), death (all causes) and length of hospital stay. MAIN RESULTS We identified 26 studies (8835 participants). Risk of bias was high in 17, unclear in 6and low in three studies. There was high risk of attrition bias in six studies.Only two studies measured AKI. The use of NSAIDs had uncertain effects on the incidence of AKI compared to placebo (7066 participants: RR 1.79, 95% CI 0.40 to 7.96; I2 = 59%; very low certainty evidence). One study was stopped early by the data monitoring committee due to increased rates of AKI in the NSAID group. Moreover, both of these studies were examining NSAIDs for indications other than analgesia and therefore utilised relatively low doses.Compared to placebo, NSAIDs may slightly increase serum SCr (15 studies, 794 participants: MD 3.23 μmol/L, 95% CI -0.80 to 7.26; I2 = 63%; low certainty evidence). Studies displayed moderate to high heterogeneity and had multiple exclusion criteria including age and so were not representative of patients undergoing surgery. Three of these studies excluded patients if their creatinine rose post-operatively.NSAIDs may make little or no difference to post-operative urine output compared to placebo (6 studies, 149 participants: SMD -0.02, 95% CI -0.31 to 0.27). No reliable conclusions could be drawn from these studies due to the differing units of measurements and measurement time points.It is uncertain whether NSAIDs leads to the need for RRT because the certainty of this evidence is very low (2 studies, 7056 participants: RR 1.57, 95% CI 0.49 to 5.07; I2 = 26%); there were few events and the results were inconsistent.It is uncertain whether NSAIDs lead to more deaths (2 studies, 312 participants: RR 1.44, 95% CI 0.19 to 11.12; I2 = 38%) or increased the length of hospital stay (3 studies, 410 participants: MD 0.12 days, 95% CI -0.48 to 0.72; I2 = 24%). AUTHORS' CONCLUSIONS Overall NSAIDs had uncertain effects on the risk of post-operative AKI, may slightly increase post-operative SCr, and it is uncertain whether NSAIDs lead to the need for RRT, death or increases the length of hospital stay. The available data therefore does not confirm the safety of NSAIDs in patients undergoing surgery. Further larger studies using the Kidney Disease Improving Global Outcomes definition for AKI including patients with co-morbidities are required to confirm these findings. .
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Affiliation(s)
- Samira Bell
- NHS Tayside, Ninewells HospitalRenal UnitDundeeUKDD1 9SY
- University of DundeeDivision of Population Health and GenomicsDundeeUK
| | | | - Charis A Marwick
- University of DundeeDivision of Population Health and GenomicsDundeeUK
| | - Peter Davey
- University of DundeeDivision of Population Health and GenomicsDundeeUK
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Imani F, Rahimzadeh P, Faiz HR, Nowruzina S, Shakeri A, Ghahremani M. Comparison of the Post-Caesarean Analgesic Effect of Adding Dexmedetomidine to Paracetamol and Ketorolac: A Randomized Clinical Trial. Anesth Pain Med 2018; 8:e85311. [PMID: 30538943 PMCID: PMC6252045 DOI: 10.5812/aapm.85311] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 10/30/2018] [Accepted: 10/31/2018] [Indexed: 12/15/2022] Open
Abstract
Background Paracetamol and non-steroidal anti-inflammatory drugs (e.g. ketorolac) can be considered for mild to moderate post-caesarean pain. As a selective α-2 agonist adrenergic receptor, dexmedetomidine has analgesic and sedative effects without causing respiratory depression. Objectives This study aimed to evaluate the effects of adding dexmedetomidine to paracetamol or ketorolac on post-caesarean pain and the associated complications thereof. Methods Sixty pregnant women, who were candidates for caesarean section with spinal anesthesia, were randomly assigned to either of two groups of 30 patients. For post-operative pain management, an intravenous patient-controlled analgesia (PCA) device was used for 24 hours. Dexmedetomidine (3 µg kg-1) was added to paracetamol (35 mg kg-1) in the group DP and to ketorolac (1 mg kg-1) in the group DK. Visual analog scale (VAS), Ramsay sedation scale, hemodynamic changes, rescue analgesic (meperidine) consumption, patient satisfaction, and possible complications were recorded at 6, 12, and 24, hours after surgery, and compared afterward. Results The pain score was significantly lower in the DK group than in the DP group (P < 0.05). The hemodynamics and sedation scale were similar in both groups. The total meperidine consumption was higher in the DP group, but it was not significantly different. Maternal satisfaction was greater in the DK group (P < 0.05). Concerning complications, the two groups did not show statistically significant differences (P = 0.4). Conclusions The addition of dexmedetomidine to ketorolac, compared with its addition to paracetamol, causes further reduction in the post-operative pain score and provides more satisfaction.
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Affiliation(s)
- Farnad Imani
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Professor, MD, FIPP, Pain Research Center, Iran University of Medical Sciences, Tehran, Iran. Eamil:
| | - Poupak Rahimzadeh
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid-Reza Faiz
- Rasoul Akram Hospital, Clinical Research Development Center, Iran University of Medical Sciences, Tehran, Iran
| | - Shiva Nowruzina
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Pain Fellowship, Pain Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Asadolla Shakeri
- Department of Anesthesiology and Pain Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
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11
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Mariano F, Cogno C, Giaretta F, Deambrosis I, Pozza S, Berardino M, Massazza G, Biancone L. Urinary protein profiles in ketorolac-associated acute kidney injury in patients undergoing orthopedic day surgery. Int J Nephrol Renovasc Dis 2017; 10:269-274. [PMID: 29075132 PMCID: PMC5609791 DOI: 10.2147/ijnrd.s137102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Parenteral administration of ketorolac is very effective in controlling postoperative pain for orthopedic surgery. Ketorolac can induce clinically relevant renal alterations in elderly patients, whereas its short course is considered safe for young adults with normal preoperative renal function. In this study, of a cohort of young adults undergoing elective orthopedic day surgery, we sought cases complicated by readmission due to acute kidney injury (AKI). Patients and methods Among 1397 young adults, aged 18–32 years who were admitted to undergo orthopedic day surgery from 2013 to 2015, four patients (0.29%, three males/one female) treated in postprocedure with ketorolac (from 60 to 90 mg/day for 1–2 days) were readmitted for suspected severe AKI. We evaluated functional outcome, urinary protein profiles and kidney biopsy (1 patient). Results After day surgery discharge, they experienced gastrointestinal disturbances, flank pain and fever. Readmitted on post-surgery days 3–4, they presented with oliguric AKI (creatinine range 158.4–466.4 µmol/L) and frank proteinuria (albumin range 2.1–6.0 g/L). Urine protein profiles demonstrated a nonselective glomerular proteinuria, with a significant 9.4-fold increase in glomerular/tubular index on day 6. Kidney biopsy on day 19 showed normal glomeruli and minimal tubular alterations and negative immunofluorescence. All patients recovered their renal function, and after 20 days proteinuria disappeared. Conclusion AKI can ensue even in young adults who have undergone a short course of ketorolac, when they suffered from relative dehydration, abdominal disturbances, flank pain and oliguria after discharge. Urine findings were characterized by a marked nonselective glomerular proteinuria disappearing in 2–3 weeks.
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Affiliation(s)
- Filippo Mariano
- Department of General and Specialist Medicine, Nephrology, Dialysis and Transplantation Unit, City of Health and Science, CTO Hospital, Turin
| | - Chiara Cogno
- Department of General and Specialist Medicine, Nephrology, Dialysis and Transplantation Unit, City of Health and Science, CTO Hospital, Turin
| | - Fulvia Giaretta
- Department of General and Specialist Medicine, Laboratory of Nephrology and Immunopathology, City of Health and Science, Molinette Hospital, Turin.,Department of Medical Sciences, University of Turin, Turin
| | - Ilaria Deambrosis
- Department of General and Specialist Medicine, Laboratory of Nephrology and Immunopathology, City of Health and Science, Molinette Hospital, Turin.,Department of Medical Sciences, University of Turin, Turin
| | - Simona Pozza
- Department of Radiology and Radiotherapy, CTO Radiology, City of Health and Science, CTO Hospital, Turin
| | - Maurizio Berardino
- Department of Anesthesiology and Intensive Care, Anesthesiology and Intensive Care 5, City of Health and Science, CTO Hospital, Turin
| | - Giuseppe Massazza
- Department of Orthopedics and Traumatology, Week Hospital Unit, City of Health and Science, CTO Hospital, and University of Turin, Turin, Italy
| | - Luigi Biancone
- Department of General and Specialist Medicine, Nephrology, Dialysis and Transplantation Unit, City of Health and Science, CTO Hospital, Turin.,Department of Medical Sciences, University of Turin, Turin
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12
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Bianco AW, Moore GE, Cooper BR, Taylor SD. In vitro anti-LPS dose determination of ketorolac tromethamine and in vivo safety of repeated dosing in healthy horses. J Vet Pharmacol Ther 2017; 41:98-104. [PMID: 28600856 DOI: 10.1111/jvp.12425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 05/06/2017] [Indexed: 12/27/2022]
Affiliation(s)
- A. W. Bianco
- Department of Veterinary Clinical Sciences; College of Veterinary Medicine; Purdue University; West Lafayette IN USA
| | - G. E. Moore
- Department of Veterinary Administration; College of Veterinary Medicine; Purdue University; West Lafayette IN USA
| | - B. R. Cooper
- Bindley Bioscience Center; Purdue University; West Lafayette IN USA
| | - S. D. Taylor
- Department of Veterinary Clinical Sciences; College of Veterinary Medicine; Purdue University; West Lafayette IN USA
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13
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Duttchen KM, Lo A, Walker A, McLuckie D, De Guzman C, Roman-Smith H, Davis M. Intraoperative ketorolac dose of 15mg versus the standard 30mg on early postoperative pain after spine surgery: A randomized, blinded, non-inferiority trial. J Clin Anesth 2017; 41:11-15. [PMID: 28802594 DOI: 10.1016/j.jclinane.2017.05.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 05/11/2017] [Accepted: 05/20/2017] [Indexed: 01/30/2023]
Abstract
STUDY OBJECTIVE The primary aim of this study is to show the non-inferiority of 15mg intraoperative dose of ketorolac as compared to the standard 30mg ketorolac by looking at the visual analog scale pain (VAS) scores 4h after an adult spine surgery. DESIGN The study design is a prospective randomized non-inferiority clinical trial looking at non-inferiority of intraoperative 15mg ketorolac from the standard 30mg dose. SETTING Quaternary care center. PATIENTS 50 adult (18-65years of age) undergoing lumbar decompression spine surgery. INTERVENTIONS Group A received a single intraoperative dose of 15mg ketorolac at the end of surgery and group B received single intraoperative dose of 30mg ketorolac. MEASUREMENTS The primary outcome was the visual analog scale (VAS) pain scores 4h after an adult spine surgery. Secondary measures were morphine usage in the first 8 and 24h postoperatively, numeric rating scores (NRS) up to 24h, sedation, nausea, vomiting, respiratory depression, pruritus and bleeding complications. MAIN RESULTS Intention to treat analysis showed a mean increase in 4h VAS pain score of 7.9mm (95% CI: -4.5mm to 20.4mm) in patients administered 15mg ketorolac. This difference was neither statistically (P=0.207) nor clinically significant (<18mm on VAS scale). A similar increase in the 15mg group was noted through a per protocol analysis, 6.9mm (95% CI: -6.6mm to 20.5mm, P=0.307) greater in the 15mg group. Non-inferiority of 15mg was not confirmed. No significant difference was found in secondary endpoints. CONCLUSIONS Ketorolac 30mg intravenous was not superior to 15mg intravenous for post-operative pain management after spine surgery. However, 15mg failed to meet the pre-specified criteria for non-inferiority to the 30mg dose.
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Affiliation(s)
- Kaylene M Duttchen
- Department of Anesthesia, University of Calgary, 1403-29 St, NW, Calgary, AB T2N 2T9, Canada; O'Brien Institute for Public Health, Canada.
| | - Andy Lo
- Department of Anesthesia, University of Calgary, 1403-29 St, NW, Calgary, AB T2N 2T9, Canada
| | - Andrew Walker
- Department of Anesthesia, University of Calgary, 1403-29 St, NW, Calgary, AB T2N 2T9, Canada
| | - Duncan McLuckie
- Department of Anesthesia, University of Calgary, 1403-29 St, NW, Calgary, AB T2N 2T9, Canada
| | - Cecilia De Guzman
- Department of Anesthesia, University of Calgary, 1403-29 St, NW, Calgary, AB T2N 2T9, Canada
| | - Helen Roman-Smith
- Department of Anesthesia, University of Calgary, 1403-29 St, NW, Calgary, AB T2N 2T9, Canada
| | - Melinda Davis
- Department of Anesthesia, University of Calgary, 1403-29 St, NW, Calgary, AB T2N 2T9, Canada; Hotchkiss Brain Institute, Canada
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Välitalo PA, Kemppainen H, Kulo A, Smits A, van Calsteren K, Olkkola KT, de Hoon J, Knibbe CAJ, Allegaert K. Body weight, gender and pregnancy affect enantiomer-specific ketorolac pharmacokinetics. Br J Clin Pharmacol 2017; 83:1966-1975. [PMID: 28429492 DOI: 10.1111/bcp.13311] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 02/23/2017] [Accepted: 04/15/2017] [Indexed: 12/20/2022] Open
Abstract
AIMS Although ketorolac analgesia is linked only to the S-enantiomer, there is limited information on the stereo-selective pharmacokinetics of this agent. We studied the stereo-selective pharmacokinetics of ketorolac in a pooled dataset of two studies, with women at delivery and 4-5 months postpartum, and males and nonpregnant females. METHODS Nonlinear mixed-effect modelling was used to evaluate the stereo-selective pharmacokinetics of ketorolac tromethamine after a single intravenous injection immediately after delivery (n = 41), 4-5 months postpartum (n = 8, paired), and in male (n = 12) and nonpregnant female (n = 14) subjects. All of the males and six of the nonpregnant females were recruited from another study, in which they were undergoing blood sampling for 24 h. All remaining cases underwent blood sampling for 8 h. RESULTS For both the R- and S-enantiomers, body weight affected ketorolac clearance. In addition, clearance for both enantiomers was 36% [95% confidence interval (CI) 15%, 58%] higher in male than in female subjects of the same body weight, and 55% (95% CI 33%, 78%) higher in women at delivery than in nonpregnant women of the same body weight. Women at delivery also had a 27% (95% CI 8%, 46%) higher distribution volume than nonpregnant women. The proportional effects of the covariates were not significantly different for the two ketorolac enantiomers. CONCLUSIONS Besides the anticipated impact of body weight on clearance, R- and S-ketorolac clearance is increased in male subjects and in women at delivery. To reach an exposure equivalent to that in nonpregnant women, males should receive a 36% increased ketorolac dose and pregnant women a 55% increased dose, in addition to a dose adjustment by body weight.
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Affiliation(s)
- Pyry A Välitalo
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands
| | - Heidi Kemppainen
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Aida Kulo
- Institute of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Anne Smits
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Kristel van Calsteren
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, University Hospitals Leuven, Leuven, Belgium
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jan de Hoon
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Belgium.,Center for Clinical Pharmacology, University Hospitals Leuven, Leuven, Belgium
| | - Catherijne A J Knibbe
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands.,Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Karel Allegaert
- Department of Development and Regeneration, University Hospitals Leuven, Leuven, Belgium.,Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
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15
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Son JS, Doo A, Kwon YJ, Han YJ, Ko S. A comparison between ketorolac and nefopam as adjuvant analgesics for postoperative patient-controlled analgesia: a randomized, double-blind, prospective study. Korean J Anesthesiol 2017; 70:612-618. [PMID: 29225744 PMCID: PMC5716819 DOI: 10.4097/kjae.2017.70.6.612] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 03/24/2017] [Accepted: 03/29/2017] [Indexed: 11/12/2022] Open
Abstract
Background We compared the analgesic efficacy and side effects of ketorolac and nefopam that were co-administered with fentanyl via intravenous patient-controlled analgesia. Methods One hundred and sixty patients scheduled for laparoscopic cholecystectomy were randomly assigned to ketorolac (Group K) or nefopam (Group N) groups. The anesthetic regimen was standardized for all patients. The analgesic solution contained fentanyl 600 µg and ketorolac 180 mg in Group K, and fentanyl 600 µg and nefopam 120 mg in Group N. The total volume of analgesic solution was 120 ml. Postoperative analgesic consumption, recovery of pulmonary function, and pain intensities at rest and during the forced expiration were evaluated at postoperative 2, 6, 24, and 48 h. The postoperative side effects of analgesics were recorded. Results Cumulative postoperative analgesic consumptions at postoperative 48 h were comparable (Group K: 93.4 ± 24.0 ml vs. Group N: 92.9 ± 26.1 ml, P = 0.906) between the groups. Pain scores at rest and during deep breathing were similar at the time of each examination. The recovery of pulmonary function showed no significant differences between the groups. Overall, postoperative nausea and vomiting incidence was higher in Group N compared with Group K (59% vs. 34%, P = 0.015). The other side effects were comparable between both groups. Conclusions Analgesic efficacies of ketorolac and nefopam that were co-administered with fentanyl for postoperative pain management as adjuvant analgesics were similar. However, postoperative nausea and vomiting incidence was higher in the nefopam-fentanyl combination compared with the ketorolac-fentanyl combination.
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Affiliation(s)
- Ji-Seon Son
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Aram Doo
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Young-Jun Kwon
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Young-Jin Han
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Seonghoon Ko
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School and Hospital, Jeonju, Korea
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16
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Nistal-Nuño B. No preemptive analgesic effect of preoperative ketorolac administration following total abdominal hysterectomy: A randomized study. Saudi J Anaesth 2017; 11:169-176. [PMID: 28442955 PMCID: PMC5389235 DOI: 10.4103/1658-354x.203011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Experimental models using short-duration noxious stimuli have led to the concept of preemptive analgesia. Ketorolac, a nonsteroidal anti-inflammatory drug, has been shown to have a postoperative narcotic-sparing effect when given preoperatively and alternatively to not have this effect. This study was undertaken to determine whether a single intravenous (IV) dose of ketorolac would result in decreased postoperative pain and narcotic requirements. METHODS In a double-blind, randomized controlled trial, 48 women undergoing abdominal hysterectomy were studied. Patients in the ketorolac group received 30 mg of IV ketorolac 30 min before surgical incision, while the control group received normal saline. The postoperative analgesia was performed with a continuous infusion of tramadol at 12 mg/h with the possibility of a 10 mg bolus for every 10 min. Pain was assessed using the visual analog scale (VAS), tramadol consumption, and hemodynamic parameters at 0, 1, 2, 4, 8, 12, 16, and 24 h postoperatively. We quantified times to rescue analgesic (morphine), adverse effects, and patient satisfaction. RESULTS There were neither significant differences in VAS scores between groups (P > 0.05) nor in the cumulative or incremental consumption of tramadol at any time point (P > 0.05). The time to first requested rescue analgesia was 66.25 ± 38.61 min in the ketorolac group and 65 ± 28.86 min in the control group (P = 0.765). There were no significant differences in systolic blood pressure (BP) between both groups, except at 2 h (P = 0.02) and 4 h (P = 0.045). There were no significant differences in diastolic BP between both groups, except at 4 h (P = 0.013). The respiratory rate showed no differences between groups, except at 8 h (P = 0.017), 16 h (P = 0.011), and 24 h (P = 0.049). These differences were not clinically significant. There were no statistically significant differences between groups in heart rate (P > 0.05). CONCLUSIONS Preoperative ketorolac neither showed a preemptive analgesic effect nor was it effective as an adjuvant for decreasing opioid requirements or postoperative pain in patients receiving IV analgesia with tramadol after abdominal hysterectomy.
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Affiliation(s)
- Beatriz Nistal-Nuño
- Department of Cardiac and Thoracic Anesthesiology, The John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, United Kingdom
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17
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Schwinghammer AJ, Isaacs AN, Benner RW, Freeman H, O’Sullivan JA, Nisly SA. Continuous Infusion Ketorolac for Postoperative Analgesia Following Unilateral Total Knee Arthroplasty. Ann Pharmacother 2017; 51:451-456. [DOI: 10.1177/1060028017694655] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Background: Previous clinical trials have demonstrated benefit with the addition of continuous infusion (CI) ketorolac to a multimodal pain regimen in surgical patients. Data following major orthopedic surgery are minimal and conflicting. Objectives: To evaluate CI ketorolac use following unilateral total knee arthroplasty (TKA) through assessment of patient-reported pain scores, opioid consumption, and safety outcomes. Methods: This was a retrospective, open-label cohort study that included patients undergoing unilateral TKA at a single-center teaching hospital. Participants were categorized into 2 study groups based on postoperative management: CI ketorolac or opioid protocol (OP). The first group received a ketorolac 30-mg bolus followed by CI 3.6 mg/h plus as-needed (PRN) opioids. The OP group received PRN narcotics in a tiered protocol. The primary end point was comparison of median pain scores. Secondary end points included opioid consumption (morphine equivalent units [MEUs]) in the first 48 hours postoperatively, length of stay, and adverse effects. Results: Of 447 patients screened, 191 were analyzed (CI ketorolac, n = 116; OP, n = 75). Median pain scores were significantly lower in the CI ketorolac group at 48 hours postoperatively (3 [2-4] vs 3.5 [2.5-5], P = 0.033). Cumulative MEUs at 48 hours were significantly lower in the CI ketorolac group (33.9 ± 38.5 mg vs 301.6 ± 36.6 mg, P < 0.001). Patients in the CI ketorolac group experienced less respiratory depression (5.2% vs 25.3%, P < 0.001) and less naloxone administration (0% vs 8%, P = 0.002) compared with the OP group. Other adverse effects were similar among groups. Conclusions: Postoperative CI ketorolac improved pain control while reducing opioid consumption and adverse effects.
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Affiliation(s)
| | - Alex N. Isaacs
- Purdue University College of Pharmacy, Indianapolis, IN, USA
- Eskenazi Health, Indianapolis, IN, USA
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18
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A Single Perioperative Injection of Dexamethasone Decreases Nausea, Vomiting, and Pain after Laparoscopic Donor Nephrectomy. J Transplant 2017; 2017:3518103. [PMID: 28210502 PMCID: PMC5292178 DOI: 10.1155/2017/3518103] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 11/27/2016] [Indexed: 12/12/2022] Open
Abstract
Background. A single dose of perioperative dexamethasone (8–10 mg) reportedly decreases postoperative nausea, vomiting, and pain but has not been widely used in laparoscopic donor nephrectomy (LDN). Methods. We performed a retrospective cohort study of living donors who underwent LDN between 2013 and 2015. Donors who received a lower dose (4–6 mg) (n = 70) or a higher dose (8–14 mg) of dexamethasone (n = 100) were compared with 111 donors who did not receive dexamethasone (control). Outcomes and incidence of postoperative nausea, vomiting, and pain within 24 h after LDN were compared before and after propensity-score matching. Results. The higher dose of dexamethasone reduced postoperative nausea and vomiting incidences by 28% (P = 0.010) compared to control, but the lower dose did not. Total opioid use was 29% lower in donors who received the higher dose than in control (P = 0.004). The higher dose was identified as an independent factor for preventing postoperative nausea and vomiting. Postoperative complication rates and hospital stays did not differ between the groups. After propensity-score matching, the results were the same as for the unmatched analysis. Conclusion. A single perioperative injection of 8–14 mg dexamethasone decreases antiemetic and narcotic requirements in the first 24 h, with no increase in surgical complications.
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19
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Howard ML, Isaacs AN, Nisly SA. Continuous Infusion Nonsteroidal Anti-Inflammatory Drugs for Perioperative Pain Management. J Pharm Pract 2016; 31:66-81. [DOI: 10.1177/0897190016665539] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To review the use of continuous infusion (CI) nonsteroidal anti-inflammatory drugs (NSAIDs) as an alternative modality for pain control in surgical patient populations. Methods: A PubMed and MEDLINE search was conducted from 1964 through February 2016 using the following search terms alone or in combinations: continuous, infusion, nonsteroidal anti-inflammatory drug, diclofenac, ibuprofen, indomethacin, ketoprofen, ketorolac, and surgery. All English-language, prospective and retrospective, adult and pediatric studies evaluating intravenous or intramuscular CI NSAIDs for surgical pain were evaluated for inclusion in this review. Results: Twenty four prospective and retrospective publications evaluating CI NSAIDs were identified: 12 in abdominal surgery, 7 in orthopedic surgery, and 5 in pediatric surgery. Specific CI NSAIDs utilized included diclofenac, indomethacin, ketoprofen, and ketorolac. Most studies compared the CI NSAID to placebo or an alternative analgesic and evaluated pain control, supplemental opioid use, and related adverse effects. In these surgical populations, CI NSAIDs decreased opioid consumption, alongside provision of adequate pain control. While long-term adverse effects were rarely collected, a decrease in nausea and sedation was often seen with the CI NSAID groups. Conclusions: In the abdominal, orthopedic, and pediatric surgical populations, CI NSAIDs represent a feasible alternative modality for perioperative pain control.
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Affiliation(s)
- Meredith L. Howard
- Department of Pharmacotherapy, University of North Texas System College of Pharmacy, Fort Worth, TX, USA
| | - Alex N. Isaacs
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN, USA
- Department of Pharmacy, Eskenazi Health, Indianapolis, IN, USA
| | - Sarah A. Nisly
- School of Pharmacy, Wingate University, Wingate, NC, USA
- Department of Pharmacy, Wake Forest Baptist Medical Center, Winston Salem, NC, USA
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20
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Daniels SE, Gan TJT, Hamilton DA, Singla N, Lacouture PG, Johnson O, Min LH, Reyes CRD, Carr DB. A Pooled Analysis Evaluating Renal Safety in Placebo- and Active Comparator-Controlled Phase III Trials of Multiple-Dose Injectable HPβCD-Diclofenac in Subjects with Acute Postoperative Pain. PAIN MEDICINE 2016; 17:2378-2388. [PMID: 28025372 DOI: 10.1093/pm/pnw146] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE : While injectable nonsteroidal anti-inflammatory drugs (NSAIDs) are a key component of postoperative multimodal analgesia, renal safety concerns may limit use in some patients. This study examined the renal safety of injectable HPβCD-diclofenac when given for ≤ 5 days following orthopedic or abdominal/pelvic surgery. METHODS : Pooled analysis of data from two randomized, placebo- and active comparator-controlled phase III trials in 608 total patients was conducted. Renal safety was assessed by examining treatment-emergent adverse events (AEs) and postoperative blood urea nitrogen (BUN) and serum creatinine shifts. RESULTS : There were three renal AEs each in the HPβCD-diclofenac (n = 318 patients) and placebo (n = 148 patients) groups, and two renal AEs in the ketorolac group (n = 142 patients). No significant difference in renal AE risk was detected for patients receiving HPβCD-diclofenac (RR: 1.40 [0.15,13.3]; P = 0.75) or ketorolac (RR: 2.08 [0.19,22.7]; P = 0.56) versus placebo. All renal AEs were mild or moderate in severity, and a single renal AE (acute renal failure in a patient receiving HPβCD-diclofenac) was treatment-related. One incidence of postoperative shift to high (> upper limit of normal) serum creatinine occurred in the HPβCD-diclofenac group (n = 2 in the ketorolac group). Mean changes in serum creatinine or BUN did not differ significantly between patients receiving HPβCD-diclofenac and placebo. CONCLUSIONS : While this analysis examined relatively brief exposure typical for parenterally administered analgesics in the postoperative setting in patients with largely normal renal function, the results suggest that HPβCD-diclofenac use for acute postoperative pain may not be associated with added renal safety risks over placebo in this patient population.
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Affiliation(s)
| | - Tong J Tj Gan
- Department of Anesthesiology, Stony Brook University, Stony Brook, New York
| | - Douglas A Hamilton
- Javelin Pharmaceuticals, Inc. (now Hospira), a Pfizer Company, Lake Forest, Illinois.,New Biology Ventures LLC, San Mateo, California
| | - Neil Singla
- Lotus Clinical Research, LLC, Pasadena, California
| | - Peter G Lacouture
- Magidom Discovery, LLC, St. Augustine, Florida.,Brown University School of Medicine, Providence, Rhode Island
| | | | - Lauren H Min
- **Hospira, a Pfizer Company, Lake Forest, Illinois
| | | | - Daniel B Carr
- Javelin Pharmaceuticals, Inc. (now Hospira), a Pfizer Company, Lake Forest, Illinois .,Department of Anesthesiology, Tufts Medical Center, Boston, Massachusetts, USA
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Howard ML, Warhurst RD, Sheehan C. Safety of Continuous Infusion Ketorolac in Postoperative Coronary Artery Bypass Graft Surgery Patients. PHARMACY 2016; 4:pharmacy4030022. [PMID: 28970395 PMCID: PMC5419367 DOI: 10.3390/pharmacy4030022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/30/2016] [Accepted: 06/21/2016] [Indexed: 12/02/2022] Open
Abstract
Background:Continuous infusion ketorolac is sometimes utilized for analgesia in postoperative coronary artery bypass graft (CABG) patients despite contraindications for use. Limited literature surrounds this topic; therefore, this study was conducted to evaluate the safety of this practice. Methods: This retrospective cohort study evaluated the primary outcome of mortality and secondary outcomes of incidence of bleeding and myocardial infarction (MI). All patients who underwent isolated CABG surgeries and received continuous infusion ketorolac during the study period were included. An equal number of randomly selected isolated CABG patients served as control patients. Electronic medical records and the Society of Thoracic Surgeons (STS) database were utilized to determine baseline characteristics and outcomes; Results: One hundred and seventy-eight patients met inclusion; 89 in each group. More patients in the control group underwent on-pump surgeries (78.6% vs. 29.2%, p = 0.01) and had higher STS risk scores (1.1% vs. 0.6%, p = 0.003). There was no difference in mortality between the ketorolac group and control group (2.2% vs. 3.3%, p = 0.605). Additionally, no patients experienced a MI and there was no difference in bleeding incidence (5.5% vs. 6.7%, p = 0.58); Conclusions: No association was found between continuous infusion ketorolac and increased risk of mortality, MI, or bleeding events in postoperative CABG patients. Considerations to differences in baseline characteristics must be made when interpreting results.
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Affiliation(s)
- Meredith L Howard
- University of North Texas System College of Pharmacy, 3500 Camp Bowie Blvd, Fort Worth, TX 76107, USA.
| | - Robert D Warhurst
- Department of Pharmacy, Indiana University Health, Saxony Hospital, 13000 E. 136th St., Fishers, IN 46037, USA.
| | - Courtney Sheehan
- Department of Pharmacy, Indiana University Health, Methodist Hospital, 1701 N. Senate Ave., AG401, Indianapolis, IN 46202, USA.
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Secondary Alveolar Bone Grafting and Iliac Cancellous Bone Harvesting for Patients With Alveolar Cleft. J Craniofac Surg 2016; 27:883-91. [DOI: 10.1097/scs.0000000000002603] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Bianco AW, Constable PD, Cooper BR, Taylor SD. Pharmacokinetics of ketorolac tromethamine in horses after intravenous, intramuscular, and oral single-dose administration. J Vet Pharmacol Ther 2015; 39:167-75. [PMID: 26416348 DOI: 10.1111/jvp.12260] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 07/20/2015] [Indexed: 12/01/2022]
Affiliation(s)
- A. W. Bianco
- Department of Veterinary Clinical Sciences; College of Veterinary Medicine; Purdue University; West Lafayette IN USA
| | - P. D. Constable
- Department of Veterinary Clinical Medicine; College of Veterinary Medicine; University of Illinois; Urbana-Champaign IL USA
| | - B. R. Cooper
- Bindley Bioscience Center; Purdue University; West Lafayette IN USA
| | - S. D. Taylor
- Department of Veterinary Clinical Sciences; College of Veterinary Medicine; Purdue University; West Lafayette IN USA
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Heo BH, Park JH, Choi JI, Kim WM, Lee HG, Cho SY, Yoon MH. A Comparative Efficacy of Propacetamol and Ketorolac in Postoperative Patient Controlled Analgesia. Korean J Pain 2015; 28:203-9. [PMID: 26175881 PMCID: PMC4500785 DOI: 10.3344/kjp.2015.28.3.203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 05/04/2015] [Accepted: 05/07/2015] [Indexed: 12/17/2022] Open
Affiliation(s)
- Bong Ha Heo
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Ji Hun Park
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jung Il Choi
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Woong Mo Kim
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Hyoung Gon Lee
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Soo Young Cho
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Myoung Ha Yoon
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
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Grimsby GM, Andrews PE, Castle EP, Nunez R, Mihalik LA, Chang YHH, Humphreys MR. Long-term Renal Function After Donor Nephrectomy: Secondary Follow-up Analysis of the Randomized Trial of Ketorolac vs Placebo. Urology 2014; 84:78-81. [DOI: 10.1016/j.urology.2014.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 04/03/2014] [Accepted: 04/05/2014] [Indexed: 11/29/2022]
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Papic JC, Finnell SME, Howenstein AM, Breckler F, Leys CM. Postoperative opioid analgesic use after Nuss versus Ravitch pectus excavatum repair. J Pediatr Surg 2014; 49:919-23; discussion 923. [PMID: 24888835 DOI: 10.1016/j.jpedsurg.2014.01.025] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 01/27/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND/PURPOSE Anticipated postoperative pain may affect procedure choice in patients with pectus excavatum. This study aims to compare postoperative pain in patients undergoing Nuss and Ravitch procedures. METHODS A 5year retrospective review was performed. Data on age, gender, Haller index, procedure, pain scores, pain medications, and length of hospital stay were collected. Total inpatient opioid administration was converted to morphine equivalent daily dose per kilogram (MEDD/kg) and compared between procedures. RESULTS One hundred eighty-one patients underwent 125 (69%) Nuss and 56 (31%) Ravitch procedures. Ravitch patients were older (15.7 yo vs 14.6 yo, p=0.004) and had a higher Haller index (5.21 vs 4.10, p=<0.001). Nuss patients had higher average daily pain scores, received 25% more opioids (MEDD/kg 0.66 vs. 0.49, p=<0.001), and received twice as much IV diazepam/kg. In the multivariate analysis, higher MEDD/kg correlated with both the Nuss procedure and older age in the Nuss group. Opioid administration did not correlate with Haller index or Nuss bar fixation technique. Increased NSAID administration did not correlate with lower use of opioids. CONCLUSION The Nuss procedure is associated with greater postoperative pain compared to the Ravitch procedure. Opioid use is higher in older patients undergoing the Nuss procedure, but is not associated with severity of deformity.
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Affiliation(s)
- Jonathan C Papic
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - S Maria E Finnell
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA; Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Abby M Howenstein
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - Francine Breckler
- Department of Pharmacy, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA.
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Beltrán-Montoya JJ, Herrerias-Canedo T, Arzola-Paniagua A, Vadillo-Ortega F, Dueñas-Garcia OF, Rico-Olvera H. A randomized, clinical trial of ketorolac tromethamine vs ketorolac trometamine plus complex B vitamins for cesarean delivery analgesia. Saudi J Anaesth 2012; 6:207-12. [PMID: 23162391 PMCID: PMC3498656 DOI: 10.4103/1658-354x.101209] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Ketorolac is widely used for postoperative analgesia in patients who undergo cesarean delivery. In countries where the use of opioids is considerably restricted, alternatives to narcotics are required. Aim: We hypothesize that the addition of complex B synergize the analgesic effect of ketorolac in postoperative cesarean patients, thus requiring a smaller dose of the anti-inflammatory agent, and therefore decreasing the potential side effects of ketorolac. Methods: A randomized clinical trial with 100 patients undergoing a primary elective cesarean delivery enrolled in the study. Pain was assessed in the recovery room and then they were randomized to receive ketorolac 30 mg intramuscular (i.m.) or 15 mg of ketorolac plus complex B vitamin (CBV). The pain score with an analog scale was assessed 1, 2, 6, 12, 18, and 24 h after the baseline. The student's t test was performed to compare the demographic differences between the 2 means. Results: 100 patients were included in the study, showing no statistical differences in the demographics. The patient's pain score at 1, 2, 6, 12, 18 and 24 hours showed no statistical differences between the control group (ketorolac 30mg) compared to the group of ketorolac 15mg and complex B vitamins. No changes in the coagulation studies were found in both groups. Conclusion: The present study demonstrates that ketorolac 30 mg and ketorolac 15 mg plus complex B vitamins can provide acceptable analgesia in many patients with severe pain.
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Affiliation(s)
- J J Beltrán-Montoya
- Department of Obstetrics and Gynecology, Instituto Nacional de Perinatologia Isidro Espinosa de los Reyes. Montes Urales 800 Lomas Virreyes, Distrito Federal, Mexico
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Grimsby GM, Conley SP, Trentman TL, Castle EP, Andrews PE, Mihalik LA, Hentz JG, Humphreys MR. A double-blind randomized controlled trial of continuous intravenous Ketorolac vs placebo for adjuvant pain control after renal surgery. Mayo Clin Proc 2012; 87:1089-97. [PMID: 23058854 PMCID: PMC3532697 DOI: 10.1016/j.mayocp.2012.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Revised: 07/18/2012] [Accepted: 07/19/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of a novel, continuous intravenous infusion of ketorolac, a powerful nonopioid analgesic, for postoperative pain control. PATIENTS AND METHODS A prospective, double-blind, randomized, placebo-controlled trial of a continuous infusion of ketorolac tromethamine in 1 L of normal saline vs placebo was performed in 135 patients aged 18 to 75 years after laparoscopic donor nephrectomy or percutaneous nephrolithotomy completed from October 7, 2008, through July 21, 2010. Primary study end points were the 24-hour differences in visual analog pain scores and total narcotic consumption, whereas secondary end points were differences in urine output, serum creatinine level, and hemoglobin level. RESULTS The study was stopped after randomization of 135 patients (68 in the ketorolac group and 67 in the placebo group) when interim analysis indicated that the difference in mean pain scores between the 2 groups (difference, 0.6) was smaller than the 1-point threshold set forth in the power calculations. No statistically significant change was noted in hemoglobin levels from preoperative to postoperative values (P=.13) or in postoperative serum creatinine levels (P=.13). CONCLUSION Although continuous infusion of ketorolac produced only a modest decrease in the use of narcotics, it appears to offer a safe therapeutic option for nonnarcotic pain control. TRIAL REGISTRATION clinicaltrials.gov Identifiers: NCT00765128 and NCT00765232.
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Affiliation(s)
| | | | | | - Erik P. Castle
- Department of Urology, Mayo Clinic Hospital, Phoenix, AZ
| | | | | | | | - Mitchell R. Humphreys
- Department of Urology, Mayo Clinic Hospital, Phoenix, AZ
- Correspondence: Address to Mitchell R. Humphreys, MD, Department of Urology, Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054
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Abstract
Pain is abundant in the intensive care unit (ICU). Successful analgesia demands a comprehensive appreciation for the etiologies of pain, vigilant clinical assessment, and personalized treatments. For the critically ill, frequent threats to mental and bodily integrity magnify the experience of pain, challenging clinicians to respond swiftly and thoughtfully. Because pain is difficult to predict and physiologic correlates are not specific, self-report remains the gold standard assessment. When communication is limited by intubation or cognitive deficits, behavioral pain scales prove useful. Patient-tailored analgesia aspires to mitigate suffering while optimizing alertness and cognitive capacity. Mindfulness of the neuropsychiatric features of pain helps the ICU clinician to clarify limits of traditional analgesia and identify alternative approaches to care. Armed with empirical data and clinical practice recommendations to better conceptualize, identify, and treat pain and its neuropsychiatric comorbidities, the authors (psychiatric consultants, by trade) reinforce holistic approaches to pain management in the ICU. After all, without attempts to understand and relieve suffering on all fronts, pain will remain undertreated.
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Affiliation(s)
- Pierre N Azzam
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Kim JJ, Ha MH, Jung SH, Song NW. The efficiency of IV PCA with remifentanil and ketorolac after laparoscopic-assisted vaginal hysterectomy. Korean J Anesthesiol 2011; 61:42-9. [PMID: 21860750 PMCID: PMC3155136 DOI: 10.4097/kjae.2011.61.1.42] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 01/04/2011] [Accepted: 01/05/2011] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND This randomized, double-blinded clinical study was designed to evaluate the efficiency and safety of remifentanil with ketorolac for IV PCA after laparoscopic-assisted vaginal hysterectomy. METHODS Eighty patients were randomly allocated into four groups. Group R received IV PCA using only remifentanil at a basal rate of 0.025 µg/kg/min and a bolus of 0.375 µg/kg. Group RK1 received IV PCA using remifentanil at a basal rate of 0.015 µg/kg/min and a bolus of 0.225 µg/kg. Group RK2 received IV PCA using remifentanil at a basal rate of 0.0075 µg/kg/min and a bolus of 0.1125 µg/kg. Group F received IV PCA using fentanyl at a basal rate of 0.3 µg/kg/h and a bolus of 0.075 µg/kg. In addition, ketorolac at a basal rate of 0.04 mg/kg/h and a bolus of 0.01 mg/kg was added to Group RK1, RK2, and F. All PCA conditions had a lock out period of 15 minutes. Pulse rate, systolic and diastolic BP, sedation score, visual analogue scale (VAS), and PONV score were recorded at 1, 3, 6, 12, and 24 hours after the operation. Total opioid use and the patients' number for rescue analgesic drug were also collected. RESULTS The groups did not differ in PONV score and hemodynamic changes. The VAS in Group RK2 was high compared with the other groups. In addition, the sedation score was high in Group R. CONCLUSIONS The additional ketorolac administration in remifentanil IV PCA had remifentanil sparing effects and reduced sedation among the side effects. Further studies will be needed to evaluate the precise and adequate dosage of ketorolac.
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Affiliation(s)
- Jung-Jong Kim
- Department of Anesthesiology and Pain Medicine, Maryknoll Hospital Busan, Busan, Korea
| | - Myung-Hwa Ha
- Department of Anesthesiology and Pain Medicine, Maryknoll Hospital Busan, Busan, Korea
| | - Sang-Ho Jung
- Department of Anesthesiology and Pain Medicine, Maryknoll Hospital Busan, Busan, Korea
| | - Nam-Won Song
- Department of Anesthesiology and Pain Medicine, Maryknoll Hospital Busan, Busan, Korea
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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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Sánchez-Carpena J, Domínguez-Hervella F, García I, Gene E, Bugarín R, Martín A, Tomás-Vecina S, García D, Serrano JA, Roman A, Mariné M, Mosteiro ML. Comparison of intravenous dexketoprofen and dipyrone in acute renal colic. Eur J Clin Pharmacol 2007; 63:751-60. [PMID: 17571256 DOI: 10.1007/s00228-007-0322-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 05/02/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study was to assess the efficacy and safety of a single intravenous (i.v.) bolus of dexketoprofen trometamol compared with an i.v. infusion of dipyrone in patients with moderate to severe pain due to renal colic. METHODS A total of 308 patients with renal colic and visual analog scale (VAS) score >/=40 mm participated in a multicenter, randomized, double blind, double-dummy, parallel, and active-controlled study and were randomized to dexketoprofen 25 mg (n = 101), dexketoprofen 50 mg (n = 104), and dipyrone 2 g (n = 103). RESULTS Mean [+/- standard deviation (SD)] total pain relief (TOTPAR) scores were similar in the dexketoprofen 50 mg (15.3 +/- 8.6) and dipyrone (15.5 +/- 8.6) and slighly higher than in dexketoprofen 25 mg (13.5 +/- 8.6), although significant differences were not achieved. In the same way, patients in the dexketoprofen 50 mg and dipyrone groups showed higher scores in the sum of pain intensity differences (SPID) and the sum of analogue pain intensity differences (SAPID) than patients in the dexketoprofen 25 mg group, reaching statistical significance in comparison with dexketoprofen 25 mg and dipyrone for SPID and SAPID (p < 0.05). The time-effect course for pain intensity differences and pain relief showed significantly higher values for both doses of dexketoprofen during the first 30 min after drug administration (p < 0.05). Dexketoprofen 50 mg and dipyrone groups had 66% and 70%, respectively, of patients with at least 50% of maximum obtainable TOTPAR in comparison with 56% in the dexketoprofen 25 mg group. The study medications were well tolerated. CONCLUSIONS Dexketoprofen 50 mg administered as a single i.v. bolus was effective for the relief of moderate to severe pain in patients with renal colic, with a good safety profile and efficacy similar to i.v. dipyrone 2 g. Dexketoprofen produced analgesia that was faster in onset.
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Lee A, Cooper MG, Craig JC, Knight JF, Keneally JP. Effects of nonsteroidal anti-inflammatory drugs on postoperative renal function in adults with normal renal function. Cochrane Database Syst Rev 2007; 2007:CD002765. [PMID: 17443518 PMCID: PMC6516878 DOI: 10.1002/14651858.cd002765.pub3] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) can play a major role in the management of acute pain in the peri-operative period. However, there are conflicting views on whether NSAIDs are associated with adverse renal effects. OBJECTIVES The primary objective of this review was to determine the effects of NSAIDs on postoperative renal function in adults with normal preoperative renal function. SEARCH STRATEGY Electronic searches for relevant randomised and quasi-randomised controlled trials in Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE were performed. Attempts were also made to identify trials from citation lists of relevant trials, review articles and clinical practice guidelines. Handsearching of conference abstracts published in major anaesthetic journals was also performed. Date of most recent search: May 2006 SELECTION CRITERIA The inclusion criteria were randomised or quasi-randomised comparisons of individual NSAIDs with either each other or placebo for treatment of postoperative pain, with relevant postoperative renal outcome measures, in adult surgical patients with normal renal function. DATA COLLECTION AND ANALYSIS The data were extracted independently by two authors. The primary outcome measure was creatinine clearance within the first two days after surgery. Secondary outcome measures included serum creatinine, urine volume, urinary sodium level, urinary potassium level, fractional excretion of sodium, fractional excretion of potassium and need for dialysis. Weighted mean differences for continuous outcomes and relative risk (RR) and risk difference (RD) for dichotomous outcomes were estimated with 95% confidence intervals (CI). MAIN RESULTS Twenty-three trials (1459 patients) fulfilled the selection criteria for this review. NSAIDs reduced creatinine clearance by 16 mL/min (95%CI 5 to 28) and potassium output by 38 mmol/day (95%CI 19 to 56) on the first day after surgery compared to placebo. There was no significant difference in serum creatinine on the first day (0 umol/L, 95%CI -3 to 4) compared to placebo. No significant reduction in urine volume during the early postoperative period was found. There was no significant difference in serum creatinine in the early postoperative period between patients receiving diclofenac, ketorolac, indomethacin, ketoprofen or etodolac. No cases of postoperative renal failure requiring dialysis were described. The trials were not heterogeneous for the primary outcome. AUTHORS' CONCLUSIONS NSAIDs caused a clinically unimportant transient reduction in renal function in the early postoperative period in patients with normal preoperative renal function. NSAIDs should not be withheld from adults with normal preoperative renal function because of concerns about postoperative renal impairment.
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Affiliation(s)
- A Lee
- Chinese University of Hong Kong, Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Shatin, Hong Kong, China.
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Govindarajan R, Ghosh B, Sathyamoorthy MK, Kodali NS, Raza A, Aronsohn J, Rajpal S, Ramaswamy C, Abadir A. Efficacy of ketorolac in lieu of narcotics in the operative management of laparoscopic surgery for morbid obesity. Surg Obes Relat Dis 2006; 1:530-5; discussion 535-6. [PMID: 16925285 DOI: 10.1016/j.soard.2005.08.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2005] [Revised: 08/27/2005] [Accepted: 08/30/2005] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prompt recovery of protective airway reflexes, freedom from pain, ability to cooperate with respiratory physical therapy, early ambulation and discharge from the postanesthesia care unit (PACU), coupled with a stable intraoperative environment have been desired goals of anesthesia management of morbidly obese patients. We used ketorolac in lieu of narcotics toward this goal and present our subjective and objective data in this study. METHODS A total of 50 morbidly obese patients undergoing laparoscopic gastric bypass surgery were randomly assigned to 2 groups of 25 each. Group I received intravenous ketorolac perioperatively, which was continued 24 hours postoperatively. Group II received remifentanyl intraoperatively as a part of balanced anesthesia. Intraoperative hemodynamic stability was assessed based on blood pressure, pulse rate, and bispectral index score values. Postoperative pain intensity using a visual analogue scale, as well as the presence of nausea, vomiting, hypotension, or respiratory depression, were also recorded. RESULTS Postoperative side effects, including pain, nausea, and vomiting; requirements for analgesics and antiemetic medications in the PACU; and the time spent in the PACU varied significantly between the 2 groups. Continued administration of ketorolac during the first 24 hours postoperatively led to improved patient satisfaction and more enthusiastic participation in respiratory physical therapy. CONCLUSIONS Perioperative use of intravenous ketorolac up to 24 hours after laparoscopic gastric bypass surgery for morbid obesity helps provide a more stable intraoperative environment, earlier discharge from the PACU, and better outcome in this subset of patients.
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Affiliation(s)
- Ramasamy Govindarajan
- Department of Anesthesiology, Brookdale University Hospital and Medical Center, Brooklyn, New York, USA.
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Oberhofer D, Skok J, Nesek-Adam V. Intravenous Ketoprofen in Postoperative Pain Treatment after Major Abdominal Surgery. World J Surg 2005; 29:446-9. [PMID: 15776297 DOI: 10.1007/s00268-004-7612-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In recent years considerable attention has been paid to the treatment of postoperative pain, with regard to the favorable effect of adequate analgesia on patient outcome. Multimodal analgesia (e.g., opioids and nonsteroidal anti-inflammatory drugs [NSAIDs] or local anesthetics) is recommended for effective postoperative pain relief. There are few data on the use of NSAIDs in postoperative pain treatment after abdominal surgery. We conducted a randomized, double-blind, placebo-controlled study to assess the analgesic efficacy and safety of ketoprofen after major abdominal surgery. One and nine hours postoperatively patients received 100 mg of ketoprofen i.v. (n = 21) or placebo (n = 22) in addition to a pain-treatment protocol consisting of continuous infusion of tramadol 200 mg and metamizol 5 g over 24 hours with additional 25 mg i.v. tramadol in case of inadequate analgesia. Pain was assessed by numeric rating scale at rest and at deep breath 3, 6, 12, and 24 hours postoperatively and the total dose of tramadol used in the first 24 hours was recorded. Patients in the ketoprofen group had significantly lower pain scores both at rest and at deep breath, at 3 (p < 0.01), 6, and 12 hours (p < 0.05) postoperatively. The 24-hour use of tramadol was significantly lower in the ketoprofen group (p < 0.01), with less nausea and vomiting. There were no bleeding complications or other adverse events related to ketoprofen therapy. The study showed the value of short-term use of ketoprofen to improve the quality of analgesia after major abdominal surgery without significant adverse effects.
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Affiliation(s)
- Dagmar Oberhofer
- Department of Anaesthesiology and Intensive Care, Sveti Duh General Hospital, Sveti Duh 64, 10000 Zagreb, Croatia.
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Baevsky RH, Nyquist SN, Roy MN, Smithline HA. Antipyretic effectiveness of intravenous ketorolac tromethamine. J Emerg Med 2004; 26:407-10. [PMID: 15093845 DOI: 10.1016/j.jemermed.2003.12.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2002] [Revised: 10/01/2003] [Accepted: 12/09/2003] [Indexed: 11/29/2022]
Abstract
We assessed the antipyretic effectiveness of intravenously administered ketorolac tromethamine in the febrile adult. A double-blind placebo controlled trial enrolling a convenience sample of febrile (T > 38.0 degrees C, oral) patients (18-65 years old) randomized to receive either 0.5 mg/kg (max 30 mg) intravenous ketorolac or placebo. Oral temperatures were recorded every 15 min during the 1-h study period. There were 20 patients in each group. At 60 min, the temperature decrease was 0.4 degrees C (95% CI: 0.0 degrees, 0.7 degrees ) for the control group and 0.8 degrees C (95% CI: 0.5 degrees, 1.1 degrees ) for the ketorolac group. Logistic regression modeling of afebrile at 60 min, controlling for baseline temperature, yielded an odds ratio for ketorolac of 7.1 (95% CI: 1.3, 39.5). In conclusion, our data support that intravenously administered ketorolac has antipyretic properties.
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Affiliation(s)
- Robert H Baevsky
- Department of Emergency Medicine, Tufts University School of Medicine, Baystate Medical Center, Springfield, Massachusetts 01199, USA
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Han SH, Lim YJ, Ro YJ, Lee SC, Park YS, Kim YC. Efficacy of Prophylactic Ondansetron in a Patient-Controlled Analgesia Environment. J Int Med Res 2004; 32:160-5. [PMID: 15080019 DOI: 10.1177/147323000403200208] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We conducted a prospective, randomized, double-blind, placebo-controlled trial to examine the efficacy of prophylactic ondansetron on post-operative nausea and vomiting (PONV) during opioid patient-controlled analgesia (PCA). In total, 374 patients using opioid PCA, but otherwise considered to be low risk for PONV, were randomly allocated to ondansetron (4 mg given intravenously and 16 mg added into the PCA pump) or saline (control group). PONV was evaluated in terms of nausea graded on a visual analogue scale, and the number of patients who experienced emetic episodes or needed rescue anti-emetics in the 48-h post-operative period. Patient satisfaction for PCA was scored at the end of the evaluation period. The only difference between the two groups was the higher number of headaches in the ondansetron group. In patients using opioid PCA, but with no other high risk factors for PONV, prophylactic ondansetron does not have any clinical benefit.
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Affiliation(s)
- S H Han
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 28 Yongon-Dong, Chongno-Gu, Seoul, 110-744, Korea
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Sinatra RS, Shen QJ, Halaszynski T, Luther MA, Shaheen Y. Preoperative rofecoxib oral suspension as an analgesic adjunct after lower abdominal surgery: the effects on effort-dependent pain and pulmonary function. Anesth Analg 2004; 98:135-140. [PMID: 14693607 DOI: 10.1213/01.ane.0000085637.00864.d7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Rofecoxib is a selective cyclooxygenase-2 inhibitor that reduces pain and inflammation without inhibiting platelet function. We examined its effects on effort-dependent pain, postoperative morphine requirements, and pulmonary function in 48 patients recovering from open abdominal surgery. Spirometric measurement of forced expiratory volume(1) and vital capacity (FVC) were assessed preoperatively. One hour before the induction of a standardized general anesthetic, patients were given either placebo oral suspension (Group A), or rofecoxib oral suspension (25 mg [Group B] or 50 mg [Group C]) in a double-blinded manner. Postoperative pain control was provided with IV morphine in the postanesthesia care unit and IV-patient-controlled analgesia morphine on the patient care unit. Morphine dose, pain intensity at rest, and pain after respiratory effort (postoperative spirometry) were assessed at 12 and 24 h after study drug administration. The patient-controlled analgesia morphine dose at 24 h was reduced 44% in Group B (30.3 +/- 17.5 mg) and 59% in Group C (22.1 +/- 16.5 mg) versus Group A (53.7 +/- 31.1 mg); P < 0.01 (A versus B). At 12 h, pain scores at rest and after spirometry were lower in Groups B and C than in A (P < 0.05). At 24 h, resting pain scores were lowest in Group C (P < 0.05). Twelve-hour FVC was best preserved in Group C (P < 0.03). There were no inter-group differences in adverse effects or perioperative blood loss. Rofecoxib oral suspension provided a morphine-sparing effect, as well as improvements in pain control and 12-h FVC in patients recovering from open abdominal surgery. IMPLICATIONS Rofecoxib belongs to class of analgesics known as cyclooxygenase-2 inhibitors that reduce pain and inflammation with less risk of bleeding than standard nonsteroidal antiinflammatory drugs. We found that patients treated with rofecoxib 25 or 50 mg before open abdominal surgery required less IV morphine during the first day of recovery. Despite reductions in morphine requirements, rofecoxib-treated patients reported lower pain intensity scores at rest and after a vigorous cough. In the 50-mg group, improvements in pain control correlated with greater preservation of baseline cough effectiveness (vital capacity) at 12 h. These findings may offer clinical advantages in patients with preexisting pulmonary disease.
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Affiliation(s)
- Raymond S Sinatra
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
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Lee A, Cooper MC, Craig JC, Knight JF, Keneally JP. Effects of nonsteroidal anti-inflammatory drugs on postoperative renal function in adults with normal renal function. Cochrane Database Syst Rev 2004:CD002765. [PMID: 15106177 DOI: 10.1002/14651858.cd002765.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) can play a major role in the management of acute pain in the peri-operative period. However, there are conflicting views on whether NSAIDs are associated with adverse renal effects. OBJECTIVES The primary objective of this review was to determine the effects of NSAIDs on postoperative renal function in adults with normal preoperative renal function. SEARCH STRATEGY Electronic searches for relevant randomised and quasi-randomised controlled trials in Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE were performed. Attempts were also made to identify trials from citation lists of relevant trials, review articles and clinical practice guidelines. Handsearching of conference abstracts published in major anaesthetic journals was also performed. (Search date: 7 February 2003) SELECTION CRITERIA The inclusion criteria were randomised or quasi-randomised comparisons of individual NSAIDs with either each other or placebo for treatment of postoperative pain, with relevant postoperative renal outcome measures, in adult surgical patients with normal renal function. DATA COLLECTION AND ANALYSIS The data was extracted independently by two reviewers. The primary outcome measure was creatinine clearance within the first two days after surgery. Secondary outcome measures included serum creatinine, urine volume, urinary sodium level, urinary potassium level, fractional excretion of sodium, fractional excretion of potassium, need for dialysis and need for diuretic or dopamine treatment for renal insufficiency. Weighted mean differences for continuous outcomes and relative risk for dichotomous outcomes were estimated. MAIN RESULTS Nineteen trials ( n = 1204) fulfilled the selection criteria for this review. NSAIDs reduced creatinine clearance by 16 ml/min (95%CI 5 to 28) and potassium output by 38 mmol/day (95%CI 19 to 56) on the first day after surgery compared to placebo. There was no significant difference in serum creatinine on the first day (0 umol/L, 95%CI -5 to 4) compared to placebo. No significant reduction in urine volume during the early postoperative period was found. There was no significant difference in serum creatinine in the early postoperative period between patients receiving diclofenace and ketorolac (or indomethacin). No cases of postoperative renal failure requiring dialysis were described. The trials were homogeneous for the primary outcome. REVIEWERS' CONCLUSIONS NSAIDs caused a clinically unimportant transient reduction in renal function in the early postoperative period in patients with normal preoperative renal function. NSAIDs should not be withheld from adults with normal preoperative renal function because of concerns about postoperative renal impairment.
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Affiliation(s)
- A Lee
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
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Bianconi M, Ferraro L, Ricci R, Zanoli G, Antonelli T, Giulia B, Guberti A, Massari L. The Pharmacokinetics and Efficacy of Ropivacaine Continuous Wound Instillation After Spine Fusion Surgery. Anesth Analg 2004; 98:166-172. [PMID: 14693613 DOI: 10.1213/01.ane.0000093310.47375.44] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Because local anesthetic continuous wound instillation has not been evaluated after spine fusion surgery, we designed this study to determine whether this technique could enhance analgesia and improve patient outcome after posterior lumbar arthrodesis. Thirty-eight patients undergoing spine stabilization were randomly divided into two groups. The M group received a postoperative baseline IV infusion of morphine plus ketorolac for 24 h, and the R group received IV saline. In both groups, a multihole 16-gauge catheter was placed subcutaneously; in the R group, the wound was infiltrated with a solution of ropivacaine 0.5% 200 mg/40 mL, and infusion of ropivacaine 0.2% 5 mL/h was maintained for 55 h. In the M group, saline infusion was given at the same rate. Pain scores were taken at rest and on passive mobilization by nurses blinded to patient analgesic treatment. The total plasma ropivacaine concentration was evaluated. Pain scores and rescue medication requirements (diclofenac and tramadol) were significantly less in the R group than in the M group. Postoperative blood loss was less and the length of hospital stay was shorter in the R group. The ropivacaine peak total plasma concentration occurred at 24 h during infusion and was within safe limits; no toxic local anesthetic side effects were observed. These results suggest that wound infiltration and continuous instillation of ropivacaine 0.2% is effective for pain management after spine stabilization surgery. IMPLICATIONS Postoperative pain after lumbar arthrodesis is related to soft tissue and muscle dissection and to manipulations and removal at the operation site. By blocking noxious stimuli from the surgical area, infiltration and wound perfusion with ropivacaine were more effective in controlling pain than systemic analgesia.
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Affiliation(s)
- Margherita Bianconi
- Departments of *Anesthesiology and Intensive Care and §Clinical Pharmacology, St. Anna Hospital, Ferrara, Italy; and Departments of †Clinical and Experimental Medicine, Section of Pharmacology, and ‡Biomedical Sciences and Advanced Therapies, Section of Orthopaedics and Traumatology, University of Ferrara, Ferrara, Italy
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41
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Bianconi M, Ferraro L, Traina GC, Zanoli G, Antonelli T, Guberti A, Ricci R, Massari L. Pharmacokinetics and efficacy of ropivacaine continuous wound instillation after joint replacement surgery † †Declaration of interest. This work was supported by AstraZeneca, Basiglio, Milano, Italy. Presented in part at the Third European Congress of Orthopaedic Anaesthesia, 31 May–2 June 2001, London, UK. Br J Anaesth 2003; 91:830-5. [PMID: 14633754 DOI: 10.1093/bja/aeg277] [Citation(s) in RCA: 156] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND As continuous wound instillation with local anaesthetic has not been evaluated after hip/knee arthroplasties, our study was designed to determine whether this technique could enhance analgesia and improve patient outcome after joint replacement surgery. METHODS Thirty-seven patients undergoing elective hip/knee arthroplasties under spinal block were randomly assigned to two analgesia groups. Group M received continuous i.v. infusion of morphine plus ketorolac for 24 h. Then, a multi-hole 16 G catheter was placed subcutaneously and infusion of saline was maintained for 55 h. Group R received i.v. saline. Thereafter the wound was infiltrated with a solution of ropivacaine 0.5% 40 ml, then a multi-hole 16 G catheter was placed subcutaneously and an infusion of ropivacaine 0.2% 5 ml h(-1) was maintained for 55 h. Visual analogue scale scores were assessed at rest and on passive mobilization by nurses blinded to analgesic treatment. Total plasma ropivacaine concentration was measured. RESULTS Group R showed a significant reduction in postoperative pain at rest and on mobilization, while rescue medication requirements were greater in Group M. Total ropivacaine plasma concentration remained below toxic concentrations and no adverse effects occurred. Length of hospital stay was shorter in Group R. CONCLUSION Infiltration and wound instillation with ropivacaine 0.2% is more effective in controlling postoperative pain than systemic analgesia after major joint replacement surgery.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Amides/administration & dosage
- Amides/blood
- Analgesics, Opioid/administration & dosage
- Anesthetics, Local/administration & dosage
- Anesthetics, Local/blood
- Arthroplasty, Replacement, Hip
- Arthroplasty, Replacement, Knee
- Drug Administration Schedule
- Drug Combinations
- Female
- Humans
- Infusions, Intralesional
- Ketorolac/administration & dosage
- Length of Stay
- Male
- Middle Aged
- Morphine/administration & dosage
- Pain Measurement
- Pain, Postoperative/blood
- Pain, Postoperative/drug therapy
- Patient Satisfaction
- Ropivacaine
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Affiliation(s)
- M Bianconi
- Department of Anesthesiology and Intensive Care, St Anna Hospital Ferrara, Ferrara, Italy
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Curatolo M, Sveticic G. Drug combinations in pain treatment: a review of the published evidence and a method for finding the optimal combination. Best Pract Res Clin Anaesthesiol 2002; 16:507-19. [PMID: 12516888 DOI: 10.1053/bean.2002.0254] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The evidence of the usefulness of drug combinations in pain management is reviewed and the problem of finding the optimal combination is presented. For post-operative pain, adding a non-steroidal anti-inflammatory drug (NSAID) or paracetamol to intravenous morphine is beneficial. Adding ketamine to intravenous morphine may be advantageous, but ketamine has a narrow therapeutic window. The combination paracetamol-NSAID is probably superior to either component alone. For post-operative epidural analgesia, combinations of low doses of a local anaesthetic, an opioid and adrenaline (epinephrine) are superior to single-drug regimens. There are virtually no data on the advantages of combinations over single drugs in neuropathic and chronic musculoskeletal pain. Adding NSAIDs or ketamine to opioids may be useful in cancer pain. Because of the enormous number of possible combinations, randomized controlled trials may fail to test the optimal combination. A stepwise optimization model that has been applied in clinical investigations is presented.
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Affiliation(s)
- Michele Curatolo
- Department of Anaesthesiology, Division of Pain Therapy, University Hospital of Bern, Inselspital, 3010 Bern, Switzerland
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43
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Abstract
Patient-controlled analgesia (PCA) has become standard procedure in the clinical treatment of pain. Its widespread use in patients with all kinds of diseases opens a variety of possible interactions between analgesics used for PCA and other drugs that might be administered concomitantly to the patient. Many of these drug interactions are of little clinical importance. However, some drug interactions have been reported to result in serious clinical problems. Drug interactions can either predominantly affect the pharmacokinetics or pharmacodynamics of the drug. Most important pharmacokinetic drug interactions occur at the level of drug metabolism or protein binding. Acceleration of methadone metabolism caused by cytochrome P450 (CYP) 3A4 induction by antiretroviral drugs or rifampicin (rifampin) has caused methadone withdrawal symptoms. Lack of morphine formation from codeine as a result of CYP2D6 inhibition by quinidine results in an almost complete loss of the analgesic effects of codeine. Alterations of methadone protein binding caused by an inhibition of alpha1-acid glycoprotein synthesis by alkylating substances are another possibility for predominantly pharmacokinetically based drug interactions during PCA. Furthermore, inhibition of P-glycoprotein by anticancer drugs could result in altered transmembrane transport of morphine, methadone or fentanyl, although this has not been shown to be of clinical relevance. Synergistic effects of systemically administered opioids with spinally or topically delivered opioids or anaesthetics have been reported frequently. The same is true for the opioid-sparing effects of coadministered non-opioid analgesics. Antidepressants, anticonvulsants or alpha2-adrenoreceptor agonists have also been shown to exert additive analgesic effects when administered together with an opioid. Inconsistent findings, however, are reported regarding the treatment of patients with opioid-induced nausea and sedation, since coadministration of antiemetics either increased or decreased the respective adverse effects or revealed additional unwanted drug effects.
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Affiliation(s)
- Jorn Lotsch
- Pharmazentrum Frankfurt, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt, Germany.
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44
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Sinatra RS, Torres J, Bustos AM. Pain management after major orthopaedic surgery: current strategies and new concepts. J Am Acad Orthop Surg 2002; 10:117-29. [PMID: 11929206 DOI: 10.5435/00124635-200203000-00007] [Citation(s) in RCA: 180] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Several recently developed analgesic techniques effectively control pain after major orthopaedic surgery. Neuraxial analgesia provided by epidural and spinal administration of local anesthetics and opioids provides the highest level of pain control; however, such therapy is highly invasive and labor intensive. Neuraxial analgesia is contraindicated in patients receiving low-molecular-weight heparin. Continuous plexus and peripheral neural blockades offer excellent analgesia without the side effects associated with neuraxial and parenteral opioids. Intravenous patient-controlled analgesia allows patients to titrate analgesics in amounts proportional to perceived pain stimulus and provide improved analgesic uniformity. Oral sustained-release opioids offer superior pain control and greater convenience than short-duration agents provide. Opioid dose requirements may be reduced by coadministration of COX-2-type nonsteroidal analgesics.
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Affiliation(s)
- Raymond S Sinatra
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06520-8051, USA
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45
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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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46
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Abstract
Pain is one of the main postoperative adverse outcomes. Single analgesics, either opioid or nonsteroidal antiinflammatory drugs (NSAIDs), are not able to provide effective pain relief without side effects such as nausea, vomiting, sedation, or bleeding. A majority of double or single-blind studies investigating the use of NSAIDs and opioid analgesics with or without local anesthetic infiltration showed that patients experience lower pain scores, need fewer analgesics, and have a prolonged time to requiring analgesics after surgery. This review focuses on multimodal analgesia, which is currently recommended for effective postoperative pain control.
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Affiliation(s)
- F Jin
- Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, Ontario, Canada
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47
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Summer GJ, Puntillo KA. Management of Surgical and Procedural Pain in a Critical Care Setting. Crit Care Nurs Clin North Am 2001. [DOI: 10.1016/s0899-5885(18)30052-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Zhou TJ, Tang J, White PF. Propacetamol Versus Ketorolac for Treatment of Acute Postoperative Pain After Total Hip or Knee Replacement. Anesth Analg 2001; 92:1569-75. [PMID: 11375848 DOI: 10.1097/00000539-200106000-00044] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We assessed the analgesic efficacy of IV propacetamol and ketorolac in a double-blinded, placebo-controlled study involving patients undergoing total hip or knee replacement procedures. On the first morning after major joint replacement surgery, 164 patients experiencing moderate-to-severe pain were randomly assigned to receive an IV infusion of propacetamol (2 g), ketorolac (15 or 30 mg), or placebo (saline). Patient-controlled analgesia with morphine was made available as a "rescue" analgesic on patient's request during the 6-h postdosing evaluation period. The median time to onset of analgesia with propacetamol (8 [95% confidence interval 6,10] min) was shorter than ketorolac 15 mg (14 [7,16] min), and placebo (16 [8; not estimable] min) although the differences did not reach statistical significance. However, compared with ketorolac 30 mg, propacetamol had a shorter duration of analgesia (3.5 [2;5.4] vs 6 [3.3; not estimable] h). Analysis of pain intensity and pain relief scores demonstrated that propacetamol produced a significantly greater improvement in pain relief than saline from 45 min until 5 h after the injection. Propacetamol was not significantly different from ketorolac 15 mg and 30 mg with respect to the main analgesic efficacy variables during the 6-h assessment period. The most frequently reported adverse event with propacetamol was injection site pain (28% vs 19% for ketorolac 15 mg, 29% for ketorolac 30 mg, and 10% for placebo, respectively). In conclusion, propacetamol (2 g IV) possesses a similar analgesic efficacy to ketorolac (15 or 30 mg IV) after total hip or knee replacement surgery.
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Affiliation(s)
- T J Zhou
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Texas 75390-9068, USA
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49
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Pavy TJ, Paech MJ, Evans SF. The effect of intravenous ketorolac on opioid requirement and pain after cesarean delivery. Anesth Analg 2001; 92:1010-4. [PMID: 11273941 DOI: 10.1097/00000539-200104000-00038] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Nonsteroidal antiinflammatory drugs, including ketorolac, are widely used for postoperative analgesia. This randomized, double-blinded trial compared IV ketorolac or saline combined with meperidine patient-controlled epidural analgesia (PCEA) after cesarean delivery. Fifty healthy parturients scheduled for elective cesarean delivery under combined spinal-epidural anesthesia received PCEA plus either IV ketorolac (Group K) or saline (Group C) for 24 h. The ketorolac dose was modified, after six patients had been studied, based on new product information recommending a maximum of 120 mg ketorolac over 24 h. Group K (n = 24) and Group C (n = 20) were demographically similar. During the first 24 h, Group K used significantly less meperidine (P < 0.05). Postoperative pain at rest and with movement, and patient satisfaction, did not differ significantly between groups, except that worst pain at 12 h was less in Group K (P < 0.005). The two groups were similar with respect to patient recovery and side effects. IV ketorolac, as an adjunct to PCEA after cesarean delivery, produced a meperidine dose-sparing effect of approximately 30%, but did not significantly improve pain relief, reduce opioid-related side effects, or change patient outcome.
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Affiliation(s)
- T J Pavy
- Department of Anaesthesia and Women and Infants Research Foundation, King Edward Memorial Hospital for Women, Subiaco 6008, Western Australia, Australia
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50
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Shin D, Kim S, Kim CS, Kim HS. Postoperative pain management using intravenous patient-controlled analgesia for pediatric patients. J Craniofac Surg 2001; 12:129-33. [PMID: 11314621 DOI: 10.1097/00001665-200103000-00007] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Pain control is an important consideration after any surgical procedures. Especially in children, more attention and care are needed during the period of postoperative pain control, which must be both sufficiently safe and effective. In this respect, intravenous patient-controlled analgesia provides improved titration of analgesic drugs, thereby maintaining optimal analgesic status with few side effects. Thirty pediatric patients were randomly divided into two groups: the intravenous patient-controlled analgesia group (with nalbuphine HCl and ketorolac tromethamine) and the conventional pethidine HCl intramuscular group. The degree of analgesia was assessed every 4 hours until the second postoperative day. The intravenous patient-controlled analgesia group had significantly lower pain scores and took less time until they were able to walk to the bathroom, but as many side effects as the control group. We concluded that intravenous patient-controlled analgesia is safe and effective for pediatric patients who have moderate to severe pain after operations such as rib cartilage graft, iliac bone graft, and large flap surgeries.
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MESH Headings
- Analgesia, Patient-Controlled
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/adverse effects
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Bone Transplantation
- Cartilage/transplantation
- Child
- Child, Preschool
- Female
- Follow-Up Studies
- Headache/chemically induced
- Humans
- Injections, Intramuscular
- Injections, Intravenous
- Ketorolac Tromethamine/administration & dosage
- Ketorolac Tromethamine/adverse effects
- Ketorolac Tromethamine/therapeutic use
- Male
- Meperidine/administration & dosage
- Meperidine/adverse effects
- Meperidine/therapeutic use
- Nalbuphine/administration & dosage
- Nalbuphine/adverse effects
- Nalbuphine/therapeutic use
- Pain Measurement
- Pain, Postoperative/prevention & control
- Postoperative Nausea and Vomiting/chemically induced
- Safety
- Statistics, Nonparametric
- Surgical Flaps
- Time Factors
- Walking/physiology
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Affiliation(s)
- D Shin
- Division of Pediatric Plastic Surgery, Seoul National University Children's Hospital, Clinical Research Institute, Seoul, Korea
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