IS KETOROLAC SAFE IN CRANIAL VAULT REMODELING SURGERY?

Background:

Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID), which has been shown to effectively control postoperative pain rather than narcotics alone in different studies. Many surgeons are reluctant to use ketorolac following major surgeries because of a theoretical increased risk of bleeding associated with NSAIDs. Our goal in this study is to assess the risk of postoperative bleeding associated with ketorolac use after cranial vault remodeling (CVR) surgery and to investigate its safety profile and possible secondary benefits.

Method:

All patients undergoing CVR for single/multi suture synostosis at a single institution over 56 months were retrospectively reviewed. Patients undergoing limited craniectomies were excluded. A total of 74 consecutive patients included in the study were divided into two groups: 43 in ketorolac and 31 in the control group. The primary outcome was the risk of bleeding associated with ketorolac use in this population. Secondary outcomes were other side effects of ketorolac such as intracranial hemorrhage, gastrointestinal bleeding or renal insufficiency. Primary outcome was investigated by intraoperative and postoperative transfusion rate and change in hemoglobin (Hb) over the postoperative period.  Total analgesic use, emesis and oral intake were also analyzed separately for each patient. Discharge Hb was expressed as a percentage of the first postoperative hemoglobin (postop Hb). Patient demographics and perioperative details were also analyzed.

Results:   

Groups (ketorolac vs control, respectively) showed no statistically significant differences in terms of age (1.1 vs 0.9, p=0.21), operative time (320 min vs 319 min, p=0.9) or type of suture synostosis (simple vs complex, 13/30 vs 8/23, p=0.6). Only significant difference between the groups was the higher ratio of posterior CVR to anterior CVR in ketorolac group (24/19 vs 7/24, p<0.01). Postoperative and intraoperative transfusion rates were similar between the groups (1/43 vs 2/31 and 7/43 vs 9/31, respectively). Mean discharge hemoglobin values in both groups were lower than the first postop Hb (9.2 vs 8.2 mg/dL in ketorolac group, 9.7 vs 9.1 mg/dL in control group). Ketorolac group showed a similar decrease in Hb to the control group (%10 vs %8.1, p=0.39). There was no incidence of bloody emesis suggesting gastrointestinal hemorrhage, no focal neurological deficits which would otherwise require imaging studies for intracranial hemorrhage, or no renal insufficiency. Patients in ketorolac group required less opioid for pain management (p=0.02) and had a shorter length of stay in the hospital (2.1 vs 2.6 days, p=0.04).  Oral intake and number of emesis episodes were similar in between the groups.

Conclusion:

This study provides evidence for safe administration of ketorolac in pediatric patients following major cranial vault remodeling surgery with secondary benefits such as less opioid consumption and shorter hospitalization.