Intravenous Ketorolac and Postoperative Pain and/or Opioid Consumption
Administration of IV ketorolac preoperatively, intraoperatively, or within 24 hours postoperatively reduces pain and opioid consumption postoperatively (within the first 48 hours) following primary TJA.
Anesthesia and Analgesia in Total Joint Arthroplasty
Developed by: American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, The Hip Society, and The Knee Society

Rationale

We reviewed seven randomized clinical trials that represented the best available evidence including four high quality and three moderate quality studies to assess the ability of IV ketorolac to reduce postoperative pain and/or opioid consumption following TJA.[21-27] Qualitative analysis consistently demonstrated statistically favorable outcomes for IV ketorolac compared to placebo regarding the reduction in postoperative pain and opioid consumption with no significant increase of medical complications such as adverse events, nausea/vomiting, blood loss, pruritus, urinary retention, or respiratory depression. Despite the high and moderate quality randomized clinical trials, only direct meta-analysis of opioid consumption could be performed due to inconsistency in the reporting of pain outcomes and timepoints for reporting the outcomes. The direct meta-analysis of opioid consumption significantly favored IV ketorolac compared to placebo with limited heterogeneity.

             Among the included studies, the total dosage of IV ketorolac administered to patients ranged between 15 mg and 150 mg given within the first 24 hours after surgery.[21-27] However, only one high quality study compared low- and high-doses of IV ketorolac, which demonstrated no difference between a single postoperative dose of 15 mg or 30 mg of IV ketorolac.[27] Although no difference was observed between the low- and high-dose treatments, 15 mg and 30 mg IV ketorolac doses are still considered relatively low-doses compared to the other published doses of IV ketorolac. Therefore, the lack of an observed difference could simply be the result of not having a large enough difference between the dose amounts to observe a dose response. Despite the potential for reduced postoperative pain and opioid consumption with higher IV ketorolac doses, the workgroup suggests the use of minimally effective doses to diminish the risk of medical complications such as acute kidney failure.


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