Amanda Vanderwerf, PharmD
PGY2 Emergency Medicine Pharmacy Resident
Nebraska Medicine - Nebraska Medical Center
Omaha, NE
Disclosure information not submitted.
Gregory Peitz, PharmD, BCCCP, FCCM
Clinical Associate Professor and Critical Care Coordinator
Nebraska Medicine
Omaha, Nebraska, United States
Disclosure information not submitted.
Title: Evaluation of Intravenous Ketorolac in Cardiothoracic Surgery Patients
Introduction: Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) used as a non-opioid option for post-operative pain. It is contraindicated in patients undergoing coronary artery bypass grafting (CABG) due to increases in myocardial infarction, stroke, and thromboembolism as seen with NSAID COX-2 specific inhibitors. However, ketorolac has more balanced COX inhibition and is occasionally used in cardiothoracic surgery patients despite the contraindication. The goal of this study was to evaluate if intravenous ketorolac reduced opioid requirements following CABG compared to conventional pain management (CPM).
Methods: This was a retrospective, matched cohort study comparing CABG patients from September 1, 2012 to August 31, 2020, who received IV ketorolac on post-operative day (POD) 0 versus those that did not. Patients were matched based on gender and age. The primary outcome was cumulative opioid use at POD2, measured in morphine milligram equivalents (MME). Secondary outcomes included daily opioid use, concurrent sedation and analgesia doses, pain scores, discharge opioid prescriptions, length of mechanical ventilation (MV), ICU length of stay (LOS), incidence of delirium, chest tube output, incidence of acute kidney injury (AKI), and MI, stroke, or thrombosis at 10 and 30 days.
Results: After matching, 47 patients were included in each cohort. There was no difference in median [IQR] opioid use at POD2 between patients receiving ketorolac or CPM (651 [462, 836] MME vs. 698 [499, 891] MME, p 0.484). There were no differences in concurrent sedation and analgesic use, post-operative pain scores within 48 hours, or length of MV between the groups, but there was a shorter ICU LOS in the ketorolac group (2 days vs 3 days, p 0.008). A similar frequency of discharge opioid prescriptions (51.7% vs 48.3%, p 0.435) was observed between the cohorts. Chest tube output at 48 hours (840 mL vs 764 mL, p 0.416) did not differ between groups, but the incidence of AKI was lower in the ketorolac group compared to CPM (6.4% vs 27.7%, p 0.012).
Conclusions: The use of IV ketorolac did not reduce post-operative opioid use in CABG patients compared to CPM at POD2. Further studies are warranted to fully understand if ketorolac plays a meaningful role in the post-operative pain management of patients undergoing CABG.