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Post-cesarean Section Opioid Use and Estimated Blood Loss in Patients Who Received Ketorolac and Epidural Morphine versus Epidural Morphine Alone
Abstract Number: T-07
Abstract Type: Original Research
Background: Prior studies have shown opioid-sparing effects of ketorolac and other non-steroidal anti-inflammatory drugs in post-surgical patients (1). Despite this, ketorolac is not widely used due to concern for hemorrhage, secondary to platelet dysfunction and uterine atony (2,3). Recent studies in surgical specialties have found no clinically significant difference in estimated blood loss with ketorolac use (4). No study examines the effect of both intraoperative and postoperative dosing of ketorolac on opioid use and estimated blood loss in patients who underwent cesarean section. We performed a retrospective cohort study that examined whether patients post-cesarean section receiving ketorolac and epidural morphine versus epidural morphine alone required any additional intravenous opioid for the treatment of pain in the first 24 hours. We further assessed if ketorolac use led to an increase in estimated blood loss.
Methods: We performed a retrospective review of all Quality Assurance data for patients undergoing cesarean section at University Hospitals Case Medical Center from August 2014 to January 2015 (n=630). After removal of patients with exclusion criteria, 204 patients remained in the cohort: 166 received both intraoperative and postoperative ketorolac and 38 patients received no ketorolac. A fitted logistic regression model was used to evaluate our primary outcome. Secondary outcomes were evaluated fitting logistic regression or linear regression model, as appropriate. Significant secondary outcomes included estimated blood loss, misoprostol doses, methylergonovine doses and promethazine doses.
Results: We determined there was a statistically significant reduction the use of any hydromorphone to treat post cesarean section pain in patients who received ketorolac (odds ratio=0.3133, 95% confidence interval=1506-.6515, p value=0.002). We also found that patients who received ketorolac had a lower estimated blood loss than those who did not; 813.3ml versus 1097.8ml, respectively (p value<0.001). Misoprostol doses and methylergonovine doses were lower in the ketorolac group (p=0.008 and p<0.001). Promethazine doses were also lower in the ketorolac group (p=0.006). There was no statistically significant difference in demographic data between either group.
Conclusions: The use of intraoperative and postoperative ketorolac significantly reduced the likelihood of receiving any hydromorphone in the first 24 hours to treat post cesarean section pain. Lower promethazine doses in the ketorolac group likely signify decreased side effects secondary to decreased opioid usage. Decreased estimated blood loss and use of uterotonics in the ketorolac group likely represents patient selection bias.
1. Blackburn A. J Clin Anesth. 1995 Mar:103-8.
2. Elhakim M. Acta Anaesthesiol Scand. 2000 May: 555-9.
3. Diemunsch P. Eur J Obstet Gynecol Reprod Biol. 1997 Apr: 205-6.
4. Gobble RM. Plast Reconstr Surg. 2015 Jan 29: 741-755.