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. 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.
- Alexander R, El-Moalem HE, Gan TJ. Comparison of the morphine-sparing effects of diclofenac sodium and ketorolac tromethamine after major orthopedic surgery. J Clin Anesth 14(3): 187-92, 2002 DOI: 10.1016/s0952-8180(01)00382-8.
- Etches RC, Warriner CB, Badner N, Buckley DN, Beattie WS, Chan VW, Parsons D, Girard M. Continuous intravenous administration of ketorolac reduces pain and morphine consumption after total hip or knee arthroplasty. Anesthesia and analgesia 81(6): 1175-80, 1995 DOI: 10.1097/00000539-199512000-00010.
- Fletcher D, Zetlaoui P, Monin S, Bombart M, Samii K. Influence of timing on the analgesic effect of intravenous ketorolac after orthopedic surgery. Pain 61(2): 291-7, 1995 DOI: 10.1016/0304-3959(94)00184-g.
- Fragen RJ, Stulberg SD, Wixson R, Glisson S, Librojo E. Effect of ketorolac tromethamine on bleeding and on requirements for analgesia after total knee arthroplasty. The Journal of bone and joint surgery American volume 77(7): 998-1002, 1995 DOI: 10.2106/00004623-199507000-00004.
- Kostamovaara PA, Hendolin H, Kokki H, Nuutinen LS. Ketorolac, diclofenac and ketoprofen are equally efficacious for pain relief after total hip replacement surgery. British journal of anaesthesia 81(3): 369-72, 1998 DOI: 10.1093/bja/81.3.369.
- Rasmussen GL, Steckner K, Hogue C, Torri S, Hubbard RC. Intravenous parecoxib sodium foracute pain after orthopedic knee surgery. American journal of orthopedics 31(6): 336-43, 2002.
- Zhou TJ, Tang J, White PF. Propacetamol versus ketorolac for treatment of acute postoperative pain after total hip or knee replacement. Anesthesia and analgesia 92(6): 1569-75, 2001 DOI: 10.1097/00000539-200106000-00044.