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Sudduth JD, Moss WD, Clinker C, Marquez JL, Anderson E, Eddington D, Agarwal J, Kwok AC. Scheduled Postoperative Ketorolac Does Not Decrease Opiate Use following Free Flap Breast Reconstruction. J Reconstr Microsurg 2023; 39:751-757. [PMID: 37068512 DOI: 10.1055/s-0043-1768220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
BACKGROUND In the setting of the opioid crisis, managing postoperative pain without the exclusive use of opiates has become a topic of interest. Many hospitals have begun implementing enhanced recovery after surgery protocols to decrease postoperative complications, hospital costs, and opiate utilization. Ketorolac has been added to many of these protocols, but few studies have examined its effects independently. METHODS A retrospective chart review was performed on all patients that received autologous breast reconstruction from October 2020 to June 2022 at an academic institution. We identified patients who did and did not receive postoperative ketorolac. Use of ketorolac was based upon surgeon preference. The two groups were compared in basic demographics, reconstruction characteristics, length of stay, complications, reoperations, and morphine milligram equivalents (MMEs). RESULTS One-hundred ten patients were included for the analysis, with 55 receiving scheduled postoperative ketorolac and 55 who did not receive ketorolac. There were seven incidences of postoperative complications in each group (12.7%, p = 1.00). The total mean postoperative MMEs were 344.7 for the nonketorolac group and 336.5 for the ketorolac group (p = 0.81). No variable was found to be independently associated with postoperative opiate use. Ketorolac was not found to contribute significantly to any postoperative complication. CONCLUSION In this study, the use of ketorolac did not significantly reduce opiate use in a cohort of 110 patients. Surgeons should consider whether the use of ketorolac alone is the best option to reduce postoperative opiate use following free flap breast reconstruction.
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Affiliation(s)
- Jack D Sudduth
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Whitney D Moss
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Christopher Clinker
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Jessica L Marquez
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Eric Anderson
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Devin Eddington
- Division of Epidemiology, Department of Internal Medicine, The University of Utah Hospital, Salt Lake City, Utah
| | - Jayant Agarwal
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
| | - Alvin C Kwok
- Division of Plastic Surgery, Department of Surgery, The University of Utah Hospital, Salt Lake City, Utah
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Gurunathan U, Parker SL, Maguire R, Ramdath D, Bijoor M, Wallis SC, Roberts JA. Population Pharmacokinetics of Periarticular Ketorolac in Adult Patients Undergoing Total Hip or Total Knee Replacement Surgery. Anesth Analg 2019; 129:701-708. [PMID: 31425209 DOI: 10.1213/ane.0000000000003377] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Ketorolac tromethamine has been used for joint infiltration by the orthopedic surgeons as a part of postoperative multimodal analgesia. The objective of this study is to investigate the pharmacokinetic properties of S (-) and R (+) enantiomers of ketorolac in adult patients undergoing total hip (THA) and knee arthroplasty (TKA). METHODS Adult patients with normal preoperative renal function received a periarticular infiltration of 30 mg of ketorolac tromethamine along with 100 mL of 0.2% ropivacaine and 1 mg of epinephrine at the end of their THA or TKA surgery. Blood samples were taken from a venous cannula at various time points after infiltration. Pharmacokinetic modeling was performed using PMetrics 1.5.0. RESULTS From 18 participants, 104 samples were analyzed. The peak plasma concentration for S (-) ketorolac was found to be lower than that of R (+) ketorolac, for both THA (0.19-1.22 mg/L vs 0.39-1.63 mg/L, respectively) and TKA (0.28-0.60 mg/L vs 0.48-0.88 mg/L, respectively). The clearance of the S (-) ketorolac enantiomer was higher than R (+) ketorolac (4.50 ± 2.27 vs 1.40 ± 0.694 L/h, respectively). CONCLUSIONS Our study demonstrates that with periarticular infiltration, S (-) ketorolac was observed to have increased clearance rate and highly variable volume of distribution and lower peak plasma concentration compared to R (+) ketorolac.
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MESH Headings
- Aged
- Aged, 80 and over
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/pharmacokinetics
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/trends
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/trends
- Female
- Humans
- Joint Capsule/drug effects
- Joint Capsule/metabolism
- Ketorolac/administration & dosage
- Ketorolac/pharmacokinetics
- Male
- Middle Aged
- Pain, Postoperative/blood
- Pain, Postoperative/drug therapy
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Affiliation(s)
- Usha Gurunathan
- From the Prince Charles Hospital & The University of Queensland, Brisbane, Queensland, Australia
| | - Suzanne L Parker
- Faculty of Medicine, University of Queensland Centre for Clinical Research
| | - Richard Maguire
- From the Prince Charles Hospital & The University of Queensland, Brisbane, Queensland, Australia
| | - Dale Ramdath
- From the Prince Charles Hospital & The University of Queensland, Brisbane, Queensland, Australia
| | - Manu Bijoor
- From the Prince Charles Hospital & The University of Queensland, Brisbane, Queensland, Australia
| | - Steven C Wallis
- Faculty of Medicine, University of Queensland Centre for Clinical Research
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
- Department of Pharmacy and Intensive Care Unit, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
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Pang PKM, Lim B, Lee KP, Lok CL, Chung CS, Ngan HK. How Evidence-Based is our Practice in a Hong Kong Emergency Department? HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790301000402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To evaluate how evidence-based our daily practice was. Design Retrospective study. Setting Emergency department of a public district hospital. Patients and Methods Between 1st August 2000 to 7th August 2000, 91 patients' records were chosen at random. A chief diagnosis was assigned for each patient. Corresponding treatments were reviewed by searching relevant randomised controlled trials (RCTs), systematic reviews and meta-analyses. Each patient had only one chief diagnosis but could have multiple interventions for that diagnosis. Results Out of 91 records, 14 were discarded. All of them had not been given any intervention and 11 required admission. For the remaining 77 records, there were 38 subjects in medical, paediatric, or gynaecological specialties and 39 in surgical or orthopaedic specialties. Intervention(s) given for each subject were then searched electronically through our hospital Knowledge Gateway and the results were expressed as either EBM-positive or EBM-negative. “EBM-positive” interventions denoted a support by RCTs. “EBM-negative” interventions denoted an absence of any supportive RCTs. Each patient might have EBM-positive and/or EBM-negative interventions together if that patient received more than one treatment. There were 52 patients (52/77 = 68%) who had one of their interventions being RCT-supported. The majority were patients with (1) antipyretic use of paracetamol in upper respiratory tract infection, or (2) control of pain by nonsteroidal anti-inflammatory drug, dologesic and paracetamol. There were 25 patients (25/77 = 32%) who did not receive any RCT-supported interventions. Concurrently 53 patients out of 77 (69%) received EBM-negative interventions. The majority were patients with (1) the use of antibiotics, antitussives and antihistamines in upper respiratory tract infection, (2) antispasmodics in gastroenteritis or patients with nonspecific abdominal pain, and (3) the use of analgesic balm in minor orthopaedic complaints. Conclusion Sixty-eight percent of patients had EBM-positive interventions. Thirty-two percent of patients did not receive any EBM-positive intervention. It was quite encouraging as compared to studies in other specialties with similar design. Concurrently 69% of patients had also been given EBM-negative interventions. There were areas for improvement if we were to implement EBM practice in the emergency department.
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Affiliation(s)
- PKM Pang
- Yan Chai Hospital, Accident and Emergency Department, Tsuen Wan, N.T., Hong Kong
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4
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Oxidation of ketorolac by permanganate in aqueous alkali: a thermodynamics and mechanistic study. MONATSHEFTE FUR CHEMIE 2014. [DOI: 10.1007/s00706-014-1265-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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AFFAS F, EKSBORG S, WRETENBERG P, OLOFSSON C, STEPHANSON N, STILLER CO. Plasma concentration of ketorolac after local infiltration analgesia in hip arthroplasty. Acta Anaesthesiol Scand 2014; 58:1140-5. [PMID: 25078268 DOI: 10.1111/aas.12371] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Local infiltration analgesia (LIA) with local anaesthetic (ropivacaine), a nonsteroidal anti-inflammatory drug (ketorolac) and epinephrine after lower extremity arthroplasty has gained increasing popularity during the last decade. This method has certain advantages, which include minimal systemic side effects, faster post-operative mobilization, earlier post-operative discharge from hospital and less opioid consumption. However, information regarding plasma concentrations of ketorolac after LIA mixture is insufficient to predict the risk of renal impairment in patients subjected to arthroplasty. AIM To determine the maximal plasma concentration and the exposure of ketorolac during the first 30 h following LIA in hip arthroplasty. METHODS Thirteen patients scheduled for primary total hip arthroplasty with LIA (ropivacaine 200 mg, ketorolac 30 mg and epinephrine 0.5 mg in a volume of 106 ml) were included. Plasma concentration of ketorolac was quantified by liquid chromatography-mass spectrometry. In addition, we assessed the effect of increasing age and decreasing glomerular filtration rate on the maximal plasma concentration and the total exposure to ketorolac during 30 h. RESULTS The range of the maximal plasma concentration, 0.3-2.2 mg/l, was detected 30 min-4 h after completing the infiltration. Similar plasma levels have been reported after intramuscular injection of the same dose of ketorolac to healthy elderly volunteers. CONCLUSION Exposure to ketorolac after LIA may be comparable to an intramuscular injection of the same dose. Decision of dose reduction should be based on clinical assessment of risk factors.
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Affiliation(s)
- F. AFFAS
- Department of Physiology and Pharmacology; Section of Anesthesia and Intensive Care; Karolinska Institutet and Karolinska University Hospital; Stockholm Sweden
| | - S. EKSBORG
- Department of Women's and Children's Health; Childhood Cancer Research Unit; Karolinska Institutet and Karolinska University Hospital; Stockholm Sweden
| | - P. WRETENBERG
- Department of Molecular Medicine; Section of Orthopedics; Karolinska Institutet and Karolinska University Hospital; Stockholm Sweden
| | - C. OLOFSSON
- Department of Physiology and Pharmacology; Section of Anesthesia and Intensive Care; Karolinska Institutet and Karolinska University Hospital; Stockholm Sweden
| | - N. STEPHANSON
- Department of Medicine, Clinical Pharmacology Unit; Karolinska Institutet and Karolinska University Hospital; Stockholm Sweden
| | - C.-O. STILLER
- Department of Medicine, Clinical Pharmacology Unit; Karolinska Institutet and Karolinska University Hospital; Stockholm Sweden
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Ammar HO, Ghorab M, Mahmoud AA, Makram TS, Ghoneim AM. Rapid pain relief using transdermal film forming polymeric solution of ketorolac. Pharm Dev Technol 2011; 18:1005-16. [DOI: 10.3109/10837450.2011.627867] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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8
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Inoue M, Caldarone CA, Frndova H, Cox PN, Ito S, Taddio A, Guerguerian AM. Safety and efficacy of ketorolac in children after cardiac surgery. Intensive Care Med 2009; 35:1584-92. [PMID: 19562323 DOI: 10.1007/s00134-009-1541-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 05/11/2009] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the nephrotoxic and opioid-sparing effects of ketorolac in children after cardiac surgery. DESIGN A retrospective cohort study. SETTING A Cardiac Critical Care Unit in a university-affiliated children's hospital. SUBJECTS Children less than 18 years of age who underwent low-risk cardiac surgery from July 2002 to December 2005. RESULTS Among 248 children studied, 108 received ketorolac and 140 did not. The ketorolac group was older, included a larger proportion of atrial septum defect repairs and a smaller proportion of ventricular septum defect repairs compared to the control group. The median change in serum creatinine did not differ between the ketorolac group and the control group (% change [IQR]); 12% [1-25] increase versus 12% [-3 to 31] increase, P = 0.86. On postoperative day 0 or 1, the ketorolac group received less opioids than control group. There was no difference in duration of mechanical ventilation or in length of stay between groups. CONCLUSION Ketorolac started in the first 12 h after a low-risk cardiac surgery in children is not associated with a measurable difference in renal function. The data suggest that ketorolac may be effective in reducing the exposure to opioids. Further studies are required to define subsets of children after cardiac surgery who could safely benefit from ketorolac therapy to reduce pain.
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Affiliation(s)
- Miho Inoue
- Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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9
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Affiliation(s)
- Chandra Kallanagowdar
- Division of Pediatric Nephrology, Department of Pediatrics, Louisiana State University Health Sciences Center and Children's Hospital, New Orleans, LA 70118, USA
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10
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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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11
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Fekrat S, Marsh MJ, Elsing SH, Raja SC, de Juan E, Campochiaro PA, Haller JA. Intraoperative ketorolac and eye pain after viteoretinal surgery: a prospective, randomized, placebo-controlled study. Retina 2003; 23:8-13. [PMID: 12652225 DOI: 10.1097/00006982-200302000-00002] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To compare the efficacy of one intraoperative dose of intravenous ketorolac tromethamine to saline placebo in controlling postoperative eye pain, nausea, and sedation following vitreoretinal surgery. STUDY DESIGN Prospective, randomized, placebo-controlled clinical trial. METHODS One hundred fourteen vitreoretinal surgical patients were randomized over a 7-month period to a single intraoperative intravenous dose of ketorolac tromethamine or placebo. All patients underwent surgery with intravenous sedation and retrobulbar anesthetic injection and had access to a standard postoperative analgesic regimen. After 2 and 5 hours, eye pain, nausea, and sedation levels were recorded using a standard visual analog scale. Analgesic requirements were tabulated. RESULTS Patients given ketorolac were significantly less likely to have postoperative eye pain than were placebo-treated patients (P = 0.0043). Fewer ketorolac patients required postoperative analgesia than placebo patients did (P < 0.0001). Four ketorolac patients (7%) required a narcotic compared to 11 placebo patients (20%) (P < 0.0001). Fewer ketorolac patients experienced nausea and sedation than placebo patients did, but this difference was not statistically significant. CONCLUSION Ketorolac tromethamine is an effective nonnarcotic choice for postoperative pain control following vitreoretinal surgery. Pain control is particularly important in this group of patients, whose compliance with postoperative procedures and positioning may significantly affect surgical outcome.
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Affiliation(s)
- Sharon Fekrat
- Duke University Eye Center, Duke University Medical Center, Durham, North Carolina, USA
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12
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Tokish JM, Powell ET, Schlegel TF, Hawkins RJ. Ketorolac use in the national football league: prevalence, efficacy, and adverse events. PHYSICIAN SPORTSMED 2002; 30:19-24. [PMID: 20086542 DOI: 10.3810/psm.2002.09.428] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Researchers who surveyed usage patterns, effectiveness, and possible adverse effects of ketorolac tromethamine among National Football League players found some common themes among the 31 teams that responded. Though isolated adverse events were noted, most team healthcare providers felt that ketorolac is effective and safe when the team physician directs its use.
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Affiliation(s)
- John M Tokish
- United States Air Force Medical Corps, United States Air Force Academy, Colorado Springs, CO, 80901, USA
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13
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Forrest JB, Camu F, Greer IA, Kehlet H, Abdalla M, Bonnet F, Ebrahim S, Escolar G, Jage J, Pocock S, Velo G, Langman MJS, Bianchi PG, Samama MM, Heitlinger E. Ketorolac, diclofenac, and ketoprofen are equally safe for pain relief after major surgery. Br J Anaesth 2002; 88:227-33. [PMID: 11883386 DOI: 10.1093/bja/88.2.227] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ketorolac is approved for the relief of postoperative pain but concerns have been raised over a possible risk of serious adverse effects and death. Two regulatory reviews in Europe on the safety of ketorolac found the data were inconclusive and lacked comparison with other non-steroidal anti-inflammatory drugs. The aim of this study was to compare the risk of serious adverse effects with ketorolac vs diclofenac or ketoprofen in adult patients after elective major surgery. METHODS This prospective, randomized multicentre trial evaluated the risks of death, increased surgical site bleeding, gastrointestinal bleeding, acute renal failure, and allergic reactions, with ketorolac vs diclofenac or ketoprofen administered according to their approved parenteral and oral dose and duration of treatment. Patients were followed for 30 days after surgery. RESULTS A total of 11,245 patients completed the trial at 49 European hospitals. Of these, 5634 patients received ketorolac and 5611 patients received one of the comparators. 155 patients (1.38%) had a serious adverse outcome, with 19 deaths (0. 17%), 117 patients with surgical site bleeding (1.04%), 12 patients with allergic reactions (0.12%), 10 patients with acute renal failure (0.09%), and four patients with gastrointestinal bleeding (0.04%). There were no differences between ketorolac and ketoprofen or diclofenac. Postoperative anticoagulants increased the risk of surgical site bleeding equally with ketorolac (odds ratio=2.65, 95% CI=1.51-4.67) and the comparators (odds ratio=3.58, 95% CI=1.93-6.70). Other risk factors for serious adverse outcomes were age, ASA score, and some types of surgery (plastic/ear, nose and throat, gynaecology, and urology). CONCLUSION We conclude that ketorolac is as safe as ketoprofen and diclofenac for the treatment of pain after major surgery.
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Affiliation(s)
- J B Forrest
- Department of Anaesthesia, McMaster University, Hamilton, Canada
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Weldon BC, Monk TG. The patient at risk for acute renal failure. Recognition, prevention, and preoperative optimization. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2000; 18:705-17. [PMID: 11094686 DOI: 10.1016/s0889-8537(05)70190-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Despite major advances in critical care medicine and extracorporeal renal support, the treatment of established postoperative ARF remains unsatisfactory and costly. The essential elements of perioperative renal preservation are early recognition of high-risk patients, preoperative optimization of fluid status and cardiovascular performance, intraoperative maintenance of renal perfusion, and avoidance of nephrotoxins. Pharmacologic interventions directed at preventing postoperative ARF are under intense investigation but presently are limited to renal transplant surgery.
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Affiliation(s)
- B C Weldon
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, USA
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15
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Pérez-Urizar J, Granados-Soto V, Castañeda-Hernández G, Hong E, González C, Martínez JL, Flores-Murrieta FJ. Analgesic efficacy and bioavailability of ketorolac in postoperative pain: a probability analysis. Arch Med Res 2000; 31:191-6. [PMID: 10880726 DOI: 10.1016/s0188-4409(00)00050-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The analgesic efficacy and bioavailability of 30 mg intramuscular ketorolac was studied in 24 patients with severe or very severe postoperative pain. METHODS Pain and pain relief were determined by a five-point verbal rating scale and data were submitted to a probability analysis. Ketorolac plasma levels were determined by high-performance liquid chromatography. RESULTS Two patients chose not to finish the study; 22 patients completed the study achieving at least good pain relief. Of these 22 patients, 13 reached complete pain relief. Ketorolac was rapidly absorbed. Notwithstanding, pain relief increased gradually, showing considerable delay with regard to plasma concentrations. Analysis of the probability-time curves revealed that 25% of the patients obtained moderate pain relief at 7 min after ketorolac administration, 50% at 11 min, 75% at 29 min, and 95% at 60 min. Good pain relief was achieved in 25, 50, and 75% of the patients at 1.1, 1.8, and 2.7 h, respectively. Complete pain relief was achieved in 25% and 50% of the patients at 2.6 h and 3.7 h, respectively. The probability of exhibiting an acceptable pain relief in responsive patients for more than 5 h was 0.97. No serious side effects were detected. CONCLUSIONS Results show that 30 mg intramuscular ketorolac is an adequate treatment for postoperative pain in the Mexican population. Therefore, the use of higher doses is not justified. Due to gradual installation of analgesia, administration of additional analgesic medication before 1 h is not recommended.
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MESH Headings
- Adult
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/blood
- Analgesics, Non-Narcotic/pharmacokinetics
- Analgesics, Non-Narcotic/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/blood
- Anti-Inflammatory Agents, Non-Steroidal/pharmacokinetics
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Biological Availability
- Chromatography, High Pressure Liquid
- Elective Surgical Procedures
- Female
- Humans
- Injections, Intramuscular
- Ketorolac/administration & dosage
- Ketorolac/blood
- Ketorolac/pharmacokinetics
- Ketorolac/therapeutic use
- Male
- Middle Aged
- Pain, Postoperative/blood
- Pain, Postoperative/drug therapy
- Treatment Outcome
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Affiliation(s)
- J Pérez-Urizar
- Departamento de Farmacología y Toxicología, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional (CINVESTAV del IPN), México, D.F., Mexico.
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Abstract
Pain and its treatment are known to have adverse effects on the organism, including deterioration in myocardial, diaphragmatic, and small bowel function. The provision of adequate intravenous analgesia, and the choice of agent, can ameliorate or exacerbate these manifestations of the stress response. The choice of agent, opioid or non-opioid, has in some respects become more difficult as more information has become available regarding the merits and adverse effects of each. Increased awareness of the frequency of hypoxemia secondary to the opioids' ability to cause an obstructive sleep apnea picture, and the cost efficiency of ketorolac through a reduction in opioid toxicity, contrast with recent studies which suggest that the gastrotoxic and nephrotoxic effects of ketorolac may occur earlier than previously suspected. The suitability of using the dissociative anesthetic agent ketamine in critically ill patients remains to be proven. Ketamine provides intense analgesia at subanesthetic doses. Its centrally mediated sympathomimetic action encourages hemodynamic stability, and it is relatively devoid of respiratory depressant activity. Increasing experience with ketamine outside the operating room has resulted in its successful use in cases of severe bronchospasm and status epilepticus.
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Affiliation(s)
- P McArdle
- Department of Anesthesiology, University of Alabama at Birmingham, USA
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17
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Abstract
Ketorolac is the only nonsteroidal anti-inflammatory drug (NSAID) in widespread clinical use that is available in an injectable form. Though similar to aspirin and ibuprofen, it is much more potent. In fact, it is potent enough to be useful for postsurgical pain either alone or in combination with other pain relief strategies. For many types of pain, ketorolac is comparable in potency with opioids though the mechanism by which it relieves pain is significantly different. Ketorolac has a much longer duration than morphine or meperidine but has a slower onset. Though we sometimes perceive NSAIDs as almost harmless, ketorolac is a potent drug and, like other potent drugs, has the potential to produce potent adverse effects including organ disfunction and allergic reaction. Risk factors for these adverse effects are well understood, allowing the clinician to plan the ketorolac use safely. Well planned patient selection and ketorolac administration can improve patient care by reducing opioid side effects and improving analgesia while speeding patient recovery and PACU discharge times.
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Affiliation(s)
- M A Fiedler
- Nurse Anesthesia Program, School of Health Related Professions, University of Alabama at Birmingham 35294, USA
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Witting MD. Renal papillary necrosis following emergency department treatment of migraine. J Emerg Med 1996; 14:373-6. [PMID: 8782036 DOI: 10.1016/0736-4679(96)00036-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
New medications have lessened the need for narcotic medications in the acute treatment of migraine. Some of these new medications include parenteral dihydroergotamine (DHE), sumatriptan, and ketorolac. Treatment failures still occur, though, and some cases necessitate adding a second agent to one that has been ineffective. We report a case of a 46-year-old man who suffered renal papillary necrosis 12 days after receiving parenteral DHE, sumatriptan, and ketorolac for treatment of a severe migraine headache. There were no signs of an adverse drug reaction at the time of his emergency department visit. The case illustrates a potential hazard of this combination in the acute treatment of migraine.
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Affiliation(s)
- M D Witting
- Department of Surgery, University of Maryland Medical Center, Baltimore 21201, USA
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