Pharmacist Children's Healthcare of Atlanta Brookhaven, Georgia, United States
Abstract:
Introduction: Pain management for infants less than six months of age undergoing cardiac surgery historically primarily utilizes opioid analgesics. There is a paucity of data regarding safety and efficacy of ketorolac in this patient population. In August 2018, our institution implemented a new analgosedation protocol utilizing ketorolac. The primary aim of this study was to determine if ketorolac was effective to use in infants after cardiothoracic surgery.
Methods: A single center retrospective chart review was conducted at a pediatric tertiary care facility including infants (30 days of life to six months of age) undergoing congenital heart surgery between 09/01/2017 and 08/31/2019. Patients admitted prior to the analgosedation protocol whom did not receive ketorolac (09/01/2017-08/31/2018) were compared to patients initiated on the protocol and administered ketorolac (09/01/2018-08/31/2019). The primary outcome was efficacy of ketorolac in terms of total opiate use in morphine milligram equivalents for 72 hours post-operatively. Secondary safety outcomes evaluated the incidence of AKI defined by KDIGO and post-operative bleeding complications defined as the amount of drainage from chest tubes and need for transfusion.
Results: Two-hundred and forty three patient charts were evaluated with 145 included for analysis. Baseline demographics were similar amongst the two groups, with the only difference being type of congenital heart surgery (Table 1). Patients administered ketorolac used less cumulative opiates, in morphine milligram equivalents, for the first three days after surgery than the patients not receiving ketorolac (9.47 vs 12.68; p = 0.002) (Figure 1). There was a significantly higher incidence in stage 3 AKI in the no ketorolac group (12.9% vs 0; p = 0.022); however, there was no difference in stage 1 and stage 2 AKI between groups. After performing an adjusted model, the no ketorolac group had a higher mean change in serum creatinine compared to the ketorolac group (0.11 mg/dL vs 0.04 mg/dL: p < 0.001). There were no differences in average chest tube output (0.24 mL/kg/day vs 0.32 mL/kg/day; p = 0.569) or need for transfusion (35.71% vs 23.86%; p = 0.125) between the two groups, respectively.
Conclusion: The administration of ketorolac after cardiac surgery resulted in a significant reduction in opioid exposure, with no difference in rates of AKI or bleeding. Ketorolac is likely effective and safe to use in post-surgical infants less than six months of age.
