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Narrative review shows that the short-term use of ketorolac is safe and effective in the management of moderate-to-severe pain in children.
Marzuillo, P, Calligaris, L, Amoroso, S, Barbi, E
Acta paediatrica (Oslo, Norway : 1992). 2018;(4):560-567
Abstract
UNLABELLED In June 2013, the European Medicine Agency recommended limiting codeine use in paediatric patients, creating a void in managing moderate pain. We reviewed the literature published in English (1985-June 2017) on the pharmacokinetic, pharmacodynamic and safety profile of ketorolac, a possible substitute for codeine and opioids, for treating moderate-to-severe pain. We found that gastrointestinal side effects were mainly reported with prolonged use, significant bleeding was reported in adenotonsillectomy, and adverse renal effects appeared to be limited to patients with specific coexisting risk factors. CONCLUSION The short-term use of ketorolac appears to be safe for children in many situations.
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Analgesic Effects of Locally Administered Ketorolac-based Analgesics After Breast Surgery: A Meta-Analysis of Randomized Controlled Trials.
Chen, JY, Feng, IJ, Loh, EW, Wang, LK, Lin, CC, Tam, KW
The Clinical journal of pain. 2018;(6):577-584
Abstract
OBJECTIVE Reducing postoperative pain following breast surgery is crucial for rapid recovery and shortening hospital stay. Ketorolac, a nonsteroidal anti-inflammatory drug, has been used as a postoperative analgesic in many surgical procedures. We conducted a systemic review and meta-analysis on the efficacy of locally administered ketorolac-based analgesics in managing pain after breast surgery. METHODS We searched the PubMed, Embase, Cochrane Library, Scopus, and ClinicalTrials.gov registry for randomized control trials (RCTs) published up to September 2016. The primary outcome was pain level assessed using a visual analog scale (VAS) at 1 and 6 hours following breast surgery. RESULTS We reviewed 4 RCTs with 255 patients. For meta-analysis, VAS at 1 and 6 hours of 3 similar RCTs were compared. At 1 hour, VAS scores were significantly lower in patients administered a ketorolac solution [weighted mean difference (WMD)=-2.04; 95% confidence interval (CI): -3.08 to -1.00] or ketorolac-bupivacaine solution (WMD=-2.30; 95% CI, -4.07 to -0.54) than in controls. At 6 hours, the ketorolac-bupivacaine solution reduced VAS scores significantly (WMD=-1.40; 95% CI, -2.48 to -0.32) compared with controls. However, at 1 hour, the ketorolac solution was significantly more effective than the bupivacaine solution was (WMD=-1.70; 95% CI, -2.81 to -0.59). DISCUSSION The effects of ketorolac-based analgesics vary as per the surgery and disease type. Locally administered ketorolac-based analgesics decreased postoperative pain in breast surgery patients, and the effect of local ketorolac was better than local bupivacaine. Therefore, ketorolac-based analgesics demonstrate considerable local infiltration during pain management after breast surgery.
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3.
Pediatric Tonsillectomy and Ketorolac.
Phillips-Reed, LD, Austin, PN, Rodriguez, RE
Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses. 2016;(6):485-494
Abstract
BACKGROUND The use of ketorolac in children undergoing tonsillectomy remains limited because of the concern about postoperative bleeding. METHODS A search was performed addressing the question: For patients undergoing a surgical tonsillectomy, does a weight-appropriate single dose of intravenous ketorolac affect the incidence of postoperative hemorrhage? RESULTS Five systematic reviews met the inclusion criteria. A Cochrane Review included 15 studies with 1,101 pediatric subjects and focused on perioperative bleeding requiring intervention. Many of the systematic reviews appraised the same studies. Subgroup analysis often allowed assessment of the effects of ketorolac administration. FINDING 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. CONCLUSIONS The perianesthesia team must carefully weigh the risks and benefits before deciding to use ketorolac with this subset of patients.
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4.
Intranasal ketorolac as part of a multimodal approach to postoperative pain.
Pergolizzi, JV, Taylor, R, Raffa, RB
Pain practice : the official journal of World Institute of Pain. 2015;(4):378-88
Abstract
Despite recent advances in the knowledge of pain mechanisms and pain management, postoperative pain continues to be a problem. Inadequately managed postsurgical pain has both clinical and economic consequences such as longer recovery times, delayed ambulation, higher incidence of complications, increased length of hospital stay, and potential to develop into chronic pain. Generally, opioids are the mainstay option for pain management in patients with moderate-to-severe postsurgical pain; however, opioids have significant side effects and have abuse potential. To improve patient and economic outcomes after surgery, postoperative pain guidelines have suggested incorporating a multi-modal/multi-mechanistic approach to pain treatment. A multi-modal approach is the simultaneous use of a combination of two or more (usually opioid and non-opioid) analgesics that provide two different mechanisms of actions. Utilizing a multi-modal approach may result in a greater reduction in pain vs. single therapies in addition to minimizing opioid use, thus reducing opioid related side effects. However, not all approaches may be effective for all types of patients and not all analgesics may be a viable option for outpatient settings, ambulatory surgery, or the fast-track surgical procedures. In this report, we present a review of the literature with a focus on intranasal ketorolac in order to provide a timely update regarding past, present, and future multi-modal treatment options for postoperative pain.
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5.
Perspectives in anaesthesia for cancer surgery.
Forget, P, De Kock, M
Journal of cancer research and clinical oncology. 2014;(3):353-9
Abstract
BACKGROUND It is a fact that inflammatory scores are important prognostic factors in cancer surgery. Many data have been published last year showing that inflammation is a causative event in many cancers and a concomitant event in all malignant tumours. MONITORING OF THE INFLAMMATION What is new is that we can assess inflammatory status during the preoperative period of our cancer patients with simple and widely available parameters, such as the neutrophil/lymphocyte ratio. This kind of biomarkers will be helpful, for the clinicians, to stratify the patients and, for the researcher, to incorporate it in clinical trials. RATIONALE FOR TRIALS AFTER DATABASE ANALYSES Promising clinical trials, focusing on perioperative inflammation, are ongoing. Rationale for these trials came from database analyses. This kind of analyses must be extended to follow the long-term effects of our interventions. NON-STEROIDAL ANTI-INFLAMMATORY DRUGS We have shown a correlation between non-steroidal anti-inflammatory drugs, especially ketorolac, and improved outcome (metastasis-free survival and/or overall survival) in breast and lung cancer patients. CONCLUSION Focusing on a high-risk group with preoperative inflammation could lead to a clinical trial to test the effect of ketorolac on cancer outcome.
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Ketorolac in the treatment of acute migraine: a systematic review.
Taggart, E, Doran, S, Kokotillo, A, Campbell, S, Villa-Roel, C, Rowe, BH
Headache. 2013;(2):277-87
Abstract
This systematic review examined the effectiveness of parenteral ketorolac (KET) in acute migraine. Acute migraine headaches are common emergency department presentations, and despite evidence for various treatments, there is conflicting evidence regarding the use of KET. Searches of MEDLINE, EMBASE, Cochrane, CINAHL, and gray literature sources were conducted. Included studies were randomized controlled trials in which KET alone or in combination with abortive therapy was compared with placebo or other standard therapy in adult patients with acute migraine. Two reviewers assessed relevance, inclusion, and study quality independently, and agreement was measured using kappa (k). Weighted mean differences (WMD) and relative risks are reported with 95% confidence intervals (CIs). Overall, the computerized search identified 418 citations and 1414 gray literature citations. From a list of 34 potentially relevant studies (k = 0.915), 8 trials were included, involving over 321 (141 KET) patients. The median quality scores were 3 (interquartile range: 2-4), and two used concealed allocation. There were no baseline differences in 10-point pain scores (WMD = 0.07; 95% CI: -0.39, 0.54). KET and meperidine resulted in similar pain scores at 60 minutes (WMD = 0.31; -0.68, 1.29); however, KET was more effective than intranasal sumatriptan (WMD = -4.07; 95% CI: -6.02 to -2.12). While there was no difference in pain relief at 60 minutes between KET and phenothiazine agents (WMD = 0.82; 95% CI: -1.33 to 2.98), heterogeneity was high (I(2) = 70%). Side effect profiles were similar between KET and comparison groups. Overall, KET is an effective alternative agent for the relief of acute migraine headache in the emergency department. KET results in similar pain relief, and is less potentially addictive than meperidine and more effective than sumatriptan; however, it may not be as effective as metoclopramide/phenothiazine agents.
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Ketorolac nasal spray--a new formulation of this non-narcotic pain reliever.
Wynn, RL
General dentistry. 2012;(2):90-2
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8.
Rapid regression of duodenal inflammatory myofibroblastic tumor after intravenous ketorolac: case report and review of the literature.
Mattei, P, Barnaby, K
Journal of pediatric surgery. 2008;(6):1196-9
Abstract
Inflammatory myofibroblastic tumors are known to sometimes regress spontaneously or in response to treatment with antiinflammatory drugs. We present the case of a 13-year-old boy with an inflammatory myofibroblastic tumor of the proximal duodenum, which regressed rapidly within days of an open surgical biopsy, resulting in perforation of the duodenum. Ketorolac was administered intravenously after the biopsy and is implicated as a potential cause of the rapid regression of the tumor. We discuss the surgical management of this patient and present a review of the literature.
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Postoperative pain management: morphine versus ketorolac.
Anthony, D, Jasinski, DM
Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses. 2002;(1):30-42
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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10.
Analgesia and COX-2 inhibition.
Dionne, RA, Khan, AA, Gordon, SM
Clinical and experimental rheumatology. 2001;(6 Suppl 25):S63-70
Abstract
While non-steroidal anti-inflammatory drugs (NSAIDs) are the mainstay of therapy for the management of acute pain and rheumatoid arthritis, toxicity associated with chronic administration limits their benefit-to-risk relationship in many patients. A series of studies is reviewed that assesses the relationship between cytokines released at the site of tissue injury and NSAID analgesia, and the in vivo selectivity of a selective cyclooxygenase (COX)-2 inhibitor (celecoxib) in comparison to a dual COX-1/COX-2 inhibitor (ketorolac). Three replicate studies in the oral surgery model of acute pain used submucosal microdialysis sample collection for the measurement of prostaglandin E2 (PGE2; a product of both COX-1 and COX-2) and thromboxane B2 (as a biomarker for COX-1 activity) with parallel assessments of pain. The time course of PGE2 production was consistent with early release due to COX-1 activity followed by increased production 2-3 hours after surgery, consistent with COX-2 expression. Ketorolac 30 mg at pain onset suppressed both pain and peripheral PGE2 levels. Ketorolac 1 mg either at the site of injury or intramuscularly also produced analgesia but without any effect on peripheral PGE2 levels. Celecoxib selectively suppressed PGE2 but not TxB2 at time points consistent with COX-2 activity, while producing analgesia. These studies demonstrate the ability to assess the time course and selective effects of COX-2 inhibitors in vivo and suggest that suppression of COX-2 mediated PGE2 is temporally related to NSAID analgesia.