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Intramuscular ketorolac is as effective as intravenous ketorolac as part of multimodal analgesia for post-operative pain control after cesarean section.
Abstract Number: T2B-2
Abstract Type: Original Research
Optimal analgesia post-cesarean delivery is essential to promote maternal recovery for the care of the newborn. Intravenous (IV) ketorolac is commonly administered as a part of multi-modal analgesia for cesarean delivery. A meta-analysis shows that ketorolac has more opioid sparing effects when administered intramuscularly (IM) then when administered IV . In pregnancy, IV ketorolac pharmacokinetics are altered . We hypothesized that ketorolac would provide better analgesia and decrease opioid requirements when given IM instead of IV for post-cesarean analgesia.
We performed a prospective, double blinded, randomized controlled trial to assess the effectiveness of IV verse IM ketorolac administration on post-cesarean analgesia. Patients undergoing an elective cesarean delivery were randomized to receive either 30 mg IV ketorolac (Group 30IV), 30 mg IM ketorolac (Group 30IM), or 60 mg IM ketorolac (Group 60IM). All patients received a standardized spinal anesthetic with 1.4–1.6 mL 0.75% bupivacaine with 8.25% dextrose, 15 mcg fentanyl, and 0.15 mg morphine. All patients received a 2 mL IV injection and a 2 mL IM injection, one of which was ketorolac and one of which was placebo based on the group assignment.
Primary outcomes include time to the first analgesic, total analgesic consumption, and pain scores. Secondary outcomes include patient satisfaction and opioid related side effects.
A total of 135 patients were analyzed: 46 from group 30IV, 46 patients from group 30IM, and 43 patients from group 60IM. Patient demographic information did not differ significantly between groups. Although not statistically significant, the time to first break through pain was increased in the IM groups compared to the IV group [Group 30IV 8.78 (4.77) hr, Group 30IM 9.5 (5.04) hr, Group 60IM 9.82 (4.78) hr]. Pain scores did not differ significantly at 4 or 24 hours. At 8 hours, group 30IM had more patients with pain (VAS ≥ 3) compared to groups 30IV or 60IM. Post-operative ketorolac, acetaminophen, ibuprofen, and opioid consumption did not differ significantly between groups except that group 30 IM had lower morphine equivalents 24-48 hours post-operatively than groups 30 IV or 60 IM [Group 30IV 54 (17) mg, Group 30IM 42 (21) mg, Group 60IM 49 (19) mg]. Patient satisfaction and opioid related side effects did not differ between groups.
Group 60 IM and 30 IM have a clinically significant, but not statistically significant increased time to first opioid consumption. While group 30 IM had decreased opioid use 24-48 hours post-operatively, that group had higher pain scores at 8 hours post-operatively. These results suggest that outcome measures do not differ significantly based on the route of ketorolac administration. Larger studies are needed to further evaluate for a difference in effect.
1. Anesth Analg. 2012 Feb;114(2):424-33.
2. Int J Obstet Anesth. 2012 Oct;21(4):334-8.