Thursday, October 11, 2007

Toradol

Okay, so here's the deal. Ten years or so ago, I used toradol in most patients. That included breast implant patients. It really cut down on how much postoperative analgesic use. Then one of the older plastic surgeons in town mentioned that if I had a postoperative hematoma in one of my breast augmentation patients that I would have a difficult time defending myself in a law suit. I quit using toradol in all implant patients, but still used it in reduction patients, etc. Recently, I have had repeated discussions with a CRNA regarding the use of toradol in breast augmentation patients. I don't like my reason for not using it in these patients. So I went back to the literature to either remove my reason or bolster it. The literature was not much help. There doesn't seem to be any really great studies out there for either side. Here is what I found. Anyone have any other information to help me out? (photo credit)


Toradol (ketorolac tromethamine) causes significant inhibition of platelet aggregation by inhibiting cyclo-oxygenase and decreasing thromboxane A1 production. Ketorolac also inhibits platelet aggregation in response to collagen and arachidonic acid. Platelet aggregation is decreased by 25% three hours after a dose of ketorolac. Unlike the prolonged effects from aspirin, the inhibition of platelet function by ketorolac disappears within 24 to 48 hours after the drug is discontinued. This inhibition of platelet aggregation results in a significant prolongation of bleeding time. Healthy volunteers demonstrated prolonged bleeding times (from 4.9 to 7.8 minutes) after five days of parenteral ketorolac. Ketorolac significantly prolonged skin bleeding time from a baseline of 222 to 299 seconds one hour after an intramuscular dose in 50 surgical patients. Ketorolac does not affect platelet count, prothrombin time (PT) or partial thromboplastin time (PTT). Postoperative hematomas, operative site bleeding and other signs of would bleeding have occurred rarely with perioperative use of ketorolac. In controlled clinical studies, the incidence of clinically significant post-operative bleeding was 5/1170 (0.4%) compared to 1/570 (0.2%) in the control groups receiving opiates. Therefore, caution should be exercised where strict hemostasis is critical.


Dosage and Administration

Ketorolac tromethamine must not be used in children under 16 years of age. In adults, the loading dose is 30 to 60 mg IM/IV followed by a maintenance Dose --15 to 30 mg IM/IV every 6 hours or 10 mg po every 8-12 hours. Maximum Dose --150 mg on first day, then 120 mg per day, not to exceed 5 days.

Dosing Adjustments --A 30 mg loading dose and maintenance dose of 15 mg IM/IV q6h should be used for patients weighing 50 kg (110 lbs), patients over 65 years of age, or patients with decreased renal function (CrCl between 30 to 50 ml/min), and use should be discouraged in patients with CrCl less than 30 ml/min.

Ketorolac injection is indicated for the short-term management of pain, up to 5 days only. It is recommended to convert to oral NSAID therapy when the patient can tolerate oral medications. Concomitant use of anticoagulants (e.g., heparin, enoxaparin, warfarin) increases the risk of bleeding complications. Concomitant use of other NSAID therapy, including aspirin, may produce additive adverse effects.

The lowest effective dose should be given. A total daily dose of 90 mg for the non-elderly and 60 mg for the elderly should not be exceeded. (inserted article from the 5th reference below)



References

  • The Rational Use of Parenteral Ketorolac; Nancy E. Sloan, Pharm.D.; P&T News: May 1994, Vol. 14, No. 11
  • Incidence of hematoma associated with ketorolac after TRAM flap breast reconstruction; SHARMA Sanjay, CHANG David W., KOUTZ Cindy, EVANS Gregory R. D., ROBB Geoffrey L., LANGSTEIN Howard N., KROLL Stephen S.; Plastic and Reconstructive Surgery Journal, Vol 107, No 2, pp 352-355, 2001 (abstract here)
  • Facial plastic meeting yields surgical pearls; Source: Dermatology Times, Originally published: June 1, 2002
  • POSTOPERATIVE HEMATOMAS ASSOCIATED WITH TORADOL; Plastic & Reconstructive Surgery. 88(5):919, November 1991; Garcha, Iqbal S.; Bostwick, John M.D.
  • PERSONAL EXPERIENCES WITH TORADOL; Plastic & Reconstructive Surgery. 89(6):1183, June 1992; Dowbak, Gregory M.D.
  • The Effect of Ketorolac on Microvascular Thrombosis in an Experimental Rabbit Model; Plastic & Reconstructive Surgery. 98(1):140-145, July 1996.; Shufflebarger, John V. M.D.; Doyle, James Ph.D.; Roth, Tim M.S.; Maguire, Kevin M.D.; Rothkopf, Douglas M. M.D.

3 comments:

Enrico said...

Since opiates are so controlled and have to meet strict indications here in Mexico (read: docs and pharmacies don't want the hassle of "random" (often motivated by non-random factors) audits by the sec. of health "DEA" equivalent, so there's not a lot of liberal use outside the immediate perioperative period), drugs like ketorolac are used ALL the time solo or as adjuncts to opiate drugs (when _really_ needed).

Granted, there is not nearly the same litigious climate here, but the attitude here is, as the article said, only contraindicated when "strict hemostasis" is required and/or with coagulopathy (obviously).

Do you liberally infiltrate with bupivacaine or the like before closure? Also, what makes it "OK" to use it for reductions but not augmentations (from a wound/pt mgmt POV)?

rlbates said...

Enrico, I don't use bupivacaine or anything like it. Most of my patients do quite well in the pain department and are back to work on Monday after surgery on Thursday (whether submuscular or subglandular).

What makes it "ok" for reductions--I think (and always try) that hemostasis is important in every operation. But if you do get a hematoma in an augmentation patient, it is not a simple place needle and aspirate management, as it can be in a reduction patient. Because of the implant and it's risk of injury but said needle, it requires a return to the operating room. I've done that in three patients over 17 yrs of pactice, none that had Toradol.

I don't like the reason I've been using--"because Dr.__ said ......." We all know that even when all things are done correctly, sometimes complications occur. I would love to have some "science" to back me up. I think using Toradol is safe.

Mitch Keamy said...

Hey. Saw your post, thought I ought to comment. Toradol, you know, carries a "black box warning" which, in my (fairly extensive) medico-legal experience is a kiss of death if there is a complication. It's almost like a "res ipsa loquitor." You know; the outcome (bleeding) is considered as being beyond the need for proof as to negligent cause if toradol was administered. Having said this, I have used it extensively, and still do on occasion if the situation specifically warrants; that is, if I can make an argument justifying its use despite the concerns; i.e. heavy chronic narcotic users with obstructive sleep apnea. That is not to say that it is particularly risky in my view; I don't think it is. Clinically, anecdotally, it seems to be about as platelet inhibiting as other nsaids, and not as much so as chronic aspirin. This is not the first important drug to get whacked this way; droperidol, the most effective post-op anti-emetic, got the same black box warning, based upon its effect on prolonging QT interval in high doses and driving folks into torsades. I still use it after carefully documenting a regular or short QTc. The other drug that was whacked was nisentil (long before you were born) It was killed because DENTISTS were using it and precipitating respiratory arrests; so none of us could have it, whether we knew what we were doing or not.
A little antiplatelet activity is arugably a good thing; continuing aspirin after cardiac surgery decreases incidence of intercurrent organ system damage (stroke, increased creatinine) (Managano-NEJOM a couple of years back; old enough to be free on line) SPD's work at least in part by some anti-clotting activity besides just squeezing, too; so my surgeons say-I haven't read the literature.

My advice; use it yourself when your back hurts, but don't give it to patients. Play with tramadol if you want a non-narcotic analgesic. 800 of ibuprofen is pretty good, too, especially with tramadol. (If you are not comfortable with 800 of ibuprofen, then you shouldn't be comfortable with toradol)

Best regards.

Mitch