9 - Opioid use after cesarean with and without scheduled ketorolac administration: a randomized control trial

To evaluate the efficacy of prolonging scheduled ketorolac to reduce opioid use after cesarean section.

Study Design:

This was a single-center, randomized, double-blind trial to assess pain management following cesarean among individuals receiving post-operative ketorolac. All patients undergoing cesarean with neuraxial anesthesia who did not have a hypertensive disorder were approached for enrollment. Following consent, all individuals received two doses of 30mg IV ketorolac postoperatively. Study participants were then randomized to either an additional four doses of 30 mg of IV ketorolac or placebo every 6 hours. Acetaminophen and opioids were ordered for all study participants as needed. The primary outcome was total morphine milligram equivalents (MME) used in the first 72 postoperative hours. Secondary outcomes included the number of patients that used no opioid postoperatively, postoperative pain scores, postoperative change in hematocrit and creatinine, and postoperative satisfaction with inpatient care and pain management. A sample size of 74 per group (n=148) was planned.

Results:

From May 2019 to January 2022, 245 patients were screened and 148 patients were randomized (74 per group). Patient characteristics were similar between groups. Prolonged ketorolac prescription significantly decreased MME use after cesarean section (median 30.0, interquartile range [IQR] 0.0 to 67.5) compared to the placebo group (60.0, IQR 30.0 to 112.5) (p=0.0001). In addition, patients who received prolonged ketorolac prescription were less likely to have pain scores greater than 3 out of 10 (p = 0.0005). Prolonged ketorolac prescription compared to placebo did not cause a significant drop in hematocrit on postoperative (POD) 1 (p = 0.85). The ketorolac group compared to the placebo group showed less of a change in serum creatinine between POD1 and 2 (1.6% v 5.1% increase, p=0.01). Patient satisfaction with inpatient pain control and postoperative care was similar between groups.

Conclusion:

Six scheduled doses of ketorolac compared to only two significantly decreased opioid use after cesarean section.