title: Routine perioperative ketorolac administration is not associated with hemorrhage in pediatric neurosurgery patients.
abstract: OBJECT NSAIDs are effective perioperative analgesics. Many surgeons are reluctant to use NSAIDs perioperatively because of a theoretical increase in the risk for bleeding events. The authors assessed the effect of routine perioperative ketorolac use on intracranial hemorrhage in children undergoing a wide range of neurosurgical procedures. METHODS A retrospective single-institution analysis of 1451 neurosurgical cases was performed. Data included demographics, type of surgery, and perioperative ketorolac use. Outcomes included bleeding events requiring return to the operating room, bleeding seen on postoperative imaging, and the development of renal failure or gastrointestinal tract injury. Variables associated with both the exposure and outcomes (p < 0.20) were evaluated as potential confounders for bleeding on postoperative imaging, and multivariable logistic regression was performed. Bivariable analysis was performed for bleeding events. Odds ratios and 95% CIs were estimated. RESULTS Of the 1451 patients, 955 received ketorolac. Multivariate regression analysis demonstrated no significant association between clinically significant bleeding events (OR 0.69; 95% CI 0.15-3.1) or radiographic hemorrhage (OR 0.81; 95% CI 0.43-1.51) and the perioperative administration of ketorolac. Treatment with a medication that creates a known bleeding risk (OR 3.11; 95% CI 1.01-9.57), surgical procedure (OR 2.35; 95% CI 1.11-4.94), and craniotomy/craniectomy (OR 2.43; 95% CI 1.19-4.94) were associated with a significantly elevated risk for radiographically identified hemorrhage. CONCLUSIONS Short-term ketorolac therapy does not appear to be associated with a statistically significant increase in the risk of bleeding documented on postoperative imaging in pediatric neurosurgical patients and may be considered as part of a perioperative analgesic regimen. Although no association was found between ketorolac and clinically significant bleeding events, a larger study needs to be conducted to control for confounding factors, because of the rarity of these events.
authors.affiliation: Department of Neurosurgery and.
authors.forename: Marlin Dustin
authors.initials: MD
authors.lastname: Richardson
authors.affiliation: College of Physicians and Surgeons, Columbia University, New York, New York;
authors.forename: Nicholas O
authors.initials: NO
authors.lastname: Palmeri
authors.affiliation: Tulane University, New Orleans, Louisiana; and.
authors.forename: Sarah A
authors.initials: SA
authors.lastname: Williams
authors.affiliation: Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, Colorado;|Pediatric Neurosurgery, Children's Hospital Colorado, Aurora, Colorado.
authors.forename: Michelle R
authors.initials: MR
authors.lastname: Torok
authors.affiliation: Department of Neurosurgery and.|Pediatric Neurosurgery, Children's Hospital Colorado, Aurora, Colorado.
authors.forename: Brent R
authors.initials: BR
authors.lastname: O'Neill
authors.affiliation: Department of Neurosurgery and.|Pediatric Neurosurgery, Children's Hospital Colorado, Aurora, Colorado.
authors.forename: Michael H
authors.initials: MH
authors.lastname: Handler
authors.affiliation: Department of Neurosurgery and.|Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, Colorado;|Pediatric Neurosurgery, Children's Hospital Colorado, Aurora, Colorado.
authors.forename: Todd C
authors.initials: TC
authors.lastname: Hankinson
mesh_terms: D000293:Adolescent; D000328:Adult; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage / Q000009:adverse effects*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D020300:Intracranial Hemorrhages / Q000139:chemically induced*; D020910:Ketorolac / Q000008:administration & dosage / Q000009:adverse effects*; D008297:Male; D019635:Neurosurgical Procedures / Q000379:methods*; D017063:Outcome Assessment, Health Care / Q000379:methods*; D019990:Perioperative Care / Q000009:adverse effects*; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D020910:Ketorolac
keywords: COX = cyclooxygenase; EVD = external ventricular drain; NSAID; Toradol; ketorolac; neurosurgery; postoperative bleeding; postoperative hemorrhage