PHOENIX (FRONTLINE MEDICAL NEWS)The NSAID ketorolac is safe to use in very young children after cardiac surgery, and dramatically decreases and length of intubation and ICU stay as well as the use of opioids, according to a retrospective cohort study from the Cohen Children’s Medical Center in New Hyde Park, N.Y.

Ketorolac is catching on in some places for postoperative pain control, but there are still significant concerns about nephrotoxicity and bleeding, especially in children, said Dr. Tracie Lin, a pediatrics resident at the medical center.

Those potential side effects didn’t turn out to be problems when her team compared outcomes in 26 children who received ketorolac – 0.5 mg/kg to a maximum of 30 mg/day – to 34 who did not receive it following congenital heart surgery.

“Think twice before holding back on ketorolac. There seems to be a lot of benefit, and less harm than someone might expect,” Dr. Lin said at the meeting sponsored by the Society for Critical Care Medicine.

Patients who received ketorolac, a mean of 35.5 months old, received less than 0.5 mg/kg per day of morphine IV equivalents in the first day after surgery, even less on day 2, and virtually none on day 3. They were, on average, intubated less than a day, in the ICU for 110 hours, and in the hospital for 5 days.

Patients in the no-ketorolac group, a mean of 2 months old, received almost 4 mg/kg per day of morphine IV equivalents in the first and second postop day, and about 2 mg/kg per day on day 3. They were intubated for an average of 3 days, in the ICU for 188 hours, and in the hospital for 17 days.

The age difference between the two groups probably reflects the hesitancy to use ketorolac in children under 6 months old. Only a couple children under 6 months old received ketorolac in the study; it didn’t cause them any kidney problems, Dr. Lin said.

Pain control was statistically equal in both groups, with pain-free assessments over 75% of the time during the first 3 postop days in both groups, and there were no statistically significant differences in the rates of breakthrough pain.

Meanwhile, “we found no additional nephrotoxicity” in the children taking ketorolac, Dr. Lin said.

At ICU arrival and after cardiac surgery, about 60% of those taking ketorolac had some degree of acute kidney injury, mostly stage 1 or 2; the finding was the same at 2 weeks post op. About 40% of children in the no-ketorolac group arrived at the ICU with some degree of acute kidney injury, again the majority stage 1 and 2; at 2 weeks assessment, that number had increased to almost 60%.

The investigators did not directly assess postoperative bleeding, but children taking ketorolac had their chest tubes pulled at about 3 days, while those in the no-ketorolac group retained their chest tubes for about 5 days. The finding suggests that ketorolac didn’t cause bleeding problems that prevented chest tube removal, Dr. Lin said.

There were other differences between the groups; ketorolac patients had RACH-1 [Risk Adjustment for Congenital Heart Surgery] scores of 3 or less, and almost all had sternotomies.

Children in the no-ketorolac group had RACH-1 scores ranging from 1 to 5, and although the majority had sternotomies, about a quarter had thoracotomies. The differences in incision types were most likely related to age-specific indications for surgery.

Dr. Lin and her team adjusted for all those differences on multivariate analysis, and found that the benefits of ketorolac remained; they “were not due to confounders,” she said.

The investigators have no relevant disclosures, and there was no external funding for the project.


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