Use of ketorolac for postoperative pain of tonsillectomy

Phillips-Reed LD, et al. Pediatric Tonsillectomy and Ketorolac. J Perianesth Nurs. 2016 Dec;31(6):485-494.

There was no consensus on the increased risk of bleeding when nonsteriodal anti-inflammatory drugs such as ketorolac are given to pediatric patients undergoing tonsillectomy. The conclusions varied from ketorolac should not be used to it is safe to use with these patients. The perianesthesia team must carefully weigh the risks and benefits before deciding to use ketorolac with this subset of patients.

Full-text for Emory users.

Maslin B, et al. Safety Considerations in the Use of Ketorolac for Postoperative Pain. Curr Drug Saf. 2016 Jul 19. [Epub ahead of print]

Perioperative administration of ketorolac has been demonstrated to be safe and effective in healthy patients and is particularly beneficial as an opioid-sparing agent in vulnerable patient groups. However, in certain surgical and medical contexts, proper patient selection based on the multidisciplinary collaboration between perioperative clinician specialists will optimize patient safety and pain management outcomes.

Children’s and Emory users, request article from Emily Lawson.

Lewis SR, et al. Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database Syst Rev. 2013 Jul 18;(7):CD003591.

Do nonsteroidal anti-inflammatory drugs (NSAIDs) increase the risk of bleeding in children having their tonsils out?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for pain relief following tonsillectomy in children. Bleeding is a recognized complication of this procedure and NSAIDs can interfere with blood clotting, so there has been concern that these drugs will increase the risk of bleeding. If bleeding is severe this may result in the child being re-admitted to hospital, having a blood transfusion or returning to theatre. It was therefore important to establish whether these drugs are safe to use in children having their tonsils out. The review focused on clinically significant bleeding that results in the child requiring additional treatment rather than the measured blood loss. We also wanted to establish whether NSAIDs affect the incidence of oher postoperative complications such as nausea and vomiting when compared to other forms of analgesia. Additionally we aimed to investigate whether different types of NSAIDs were
more likely to lead to bleeding.

The main limitation of our updated review was that bleeding following tonsillectomy is an uncommon event (occurring in 3% to 5% of children). We found all the data from randomized controlled trials that are currently available (15 trials studying approximately 1000 children). Our results were consistent with both an increased and decreased risk of bleeding. There were insufficient data to compare the risk of bleeding with each individual type of NSAID. However, we were able to compare ketorolac, which has been perceived as having a greater risk of bleeding, with the other NSAIDs and found no increased risk of bleeding. There was less nausea and vomiting when NSAIDs were used as part of the pain relief regime than when NSAIDs were not used.

There is insufficient evidence to exclude an increased risk of bleeding when NSAIDs are used in paediatric tonsillectomy. They do, however, confer the benefit of a reduction in vomiting.

Full-text for Children’s and Emory users.

More PubMed results on NSAIDs and post-tonsillectomy pain.

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