Post Surgical Pain Management - 1247619

Mon, 09/03/2012 - 13:11

I was wondering if Dr. Walco (if available, or other faculty if not) could address the safety and efficacy of pre-operative Ketorac. I received this drug post operatively after my first VATS on the second day because opioids were only minimally effective, and it worked very well.

I was just reading that it has shown to be effective when given pre-operatively as well, and since I am not a candidate for epidural, I am most interested in this approach, but concerned about its safe use in a cirrhotic patient. Since I am coming up on another procedure, pain management is high on my list of priorities.

I saw this on Wiki... "Ketorolac is not recommended for pre-operative analgesia or co-administration with anesthesia because it inhibits platelet aggregation and thus may be associated with an increased risk of bleeding."

Any insight would be appreciated.

Debra

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JimC

Hi Debra,

I've sent your question to Dr. Walko, although with the holiday you may not receive a response until tomorrow.

Good luck on your upcoming procedure; you are always in my thoughts for good results, and your positive outlook is always heartening.

JimC
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dr walko

Double Trouble,

Ketorolac is a drug similar to ibuprofen (Advil) or napoxen but has the benefit of being injectable. Liver impairment like cirrhosis should not be a problem in terms of dose changes, kidney problems are a much bigger concern with the drug. However, there are limitations on how long the drug should be used because of increased risk of kidney and bleeding problems. Generally, most hospitals will only allow 4-5 days of the drug because after this, the risk of kidney and bleeding problems greatly increases.

The one area where the cirrhosis would potentially be a problem is with increased bleeding. Since the liver makes clotting factors, if it is severely damaged then it may not make the clotting factors and you can get increased risk of bleeding. Ketorolac also prevents the platelets from sticking together and forming a blood clot. The two together would cause me to be concerned about increased risk of bleeding pre-surgery, but since I do not know your specific condition or how your liver is functioning, I think you could ask your physician about his/her thoughts.

Hope that helps, best wishes,
Dr. Walko

double trouble

It helps a great deal. My platelets are low but PT/INR remain in the normal range so I think it would be okay for a couple of days post-op. Evidently, Duke puts you under the care of a "pain management team" after surgery so I'm sure we can figure out how to minimize opiates while still controlling the pain.
Thanks for taking the time to answer my question.
Debra

dr walko

The pain management team sounds like a good plan, hopefully they will meet with you up front to discuss goals like minimizing opioids. With a normal PT/INR, this means that your liver is still producing those clotting factors so risk of bleeding should not be much higher.

Hope all goes well!
Dr. Walko