Past
Ketorolac is a potent non-steroidal anti-inflammatory analgesic which has become an integral part of opioid-sparing enhanced recovery after surgery pathways for mastectomy.1 Ketorolac is associated with an increased risk of bleeding, but meta-analysis of trials involving other kinds of surgery does not support that association.2 A recent retrospective study of lumpectomy and mastectomy patients also found no association of ketorolac with perioperative bleeding.3
Present
Our surgical center was conceived around standardized surgical pathways that are updated based on patient outcomes.4 We became concerned about anecdotal reports of perioperative bleeding requiring a return trip to the operating room. We found that ketorolac administration was associated with more than double the odds of reoperation for bleeding after mastectomy (odds ratio 2.43; 95% confidence interval 1.60, 3.70; P<0.0001).5 We also found that the use of ketorolac led to only a small reduction in the need for opioid analgesics. The magnitude of the result led us to remove ketorolac from our mastectomy pathway.
Future
Despite the single-center and retrospective nature of our study, the large sample size and effect size is persuasive evidence that holding ketorolac will improve patient outcome. Other mastectomy centers should evaluate this data and strongly consider discontinuing intraoperative ketorolac. Reoperation for bleeding is an outcome that other mastectomy ERAS programs should track, as it is less subjective than postoperative hematoma and is associated with defined costs.
Footnotes
Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.
Financial disclosures: Dr McCormick’s spouse holds stock in Johnson & Johnson.
Contributor Information
Patrick J. McCormick, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA..
Brett A. Simon, Department of Anesthesiology and Critical Care Medicine and Department of Surgery, Memorial Sloan Kettering Cancer Center; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA..
References
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