Antiplatelet Effect of Ketorolac in Children After Congenital Cardiac Surgery

Kim, John S.; Kaufman, Jon; Patel, Sonali S.; Manco‐Johnson, Marilyn J.; Paola, Jorge Di; Cruz, Eduardo M. da

doi:10.1177/2150135118799041

Cited by 6 publications

(7 citation statements)

References 44 publications

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“…87 High Strong While NSAIDs may not be associated with clinical bleeding in patients without other risk factors, they may impact platelet function and research is needed to better understand the impact of NSAIDmediated platelet inhibition in children. 73,75,88 Moderate Weak…”

Section: Moderate Weakmentioning

confidence: 99%

“…92 Additionally, studies examining the risk of bleeding and changes to platelet function while receiving NSAIDs have found platelet function is altered but there is no increase in clinically significant bleeding. [73][74][75][76]79,88 It is unclear what the implication of changed platelet function is, and this warrants further research, particularly considering the additional risk factors in this population including cardiopulmonary bypass, presence of chest tubes, and surgical wounds.…”

Section: N/a Weakmentioning

confidence: 99%

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Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline

et al. 2022

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Background: Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline. Methods: A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus Results: 60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations. Conclusions: Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.

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Section: Moderate Weakmentioning

confidence: 99%

Section: N/a Weakmentioning

confidence: 99%

Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline

et al. 2022

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“…There were seven retrospective cohort studies; two prospective PD studies; two retrospective case-control studies; two prospective, randomised studies; and one post hoc analysis of a prospective observational cohort study. [80][81][82][83][84][85][86][87][88][89][90][91][92][93] Medications included in these studies were opioids (morphine [43%], fentanyl [29%], hydromorphone [7%], remifentanil [7%]), and non-steroidal anti-inflammatory drugs (ketorolac [36%], acetaminophen [7%]).…”

Section: Analgesicsmentioning

confidence: 99%

“…Multiple studies found no increase in adverse renal or haematologic events except when ketorolac was administered in conjunction with aspirin, even in children <6 months old, although there was evidence of platelet dysfunction. [88][89][90][91][92] In addition to pain control, acetaminophen may be protective against acute kidney injury. 93…”

Section: Analgesicsmentioning

confidence: 99%

A systematic review of the evidence supporting post-operative medication use in congenital heart disease

et al. 2021

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Background: Targeted drug development efforts in patients with CHD are needed to standardise care, improve outcomes, and limit adverse events in the post-operative period. To identify major gaps in knowledge that can be addressed by drug development efforts and provide a rationale for current clinical practice, this review evaluates the evidence behind the most common medication classes used in the post-operative care of children with CHD undergoing cardiac surgery with cardiopulmonary bypass. Methods: We systematically searched PubMed and EMBASE from 2000 to 2019 using a controlled vocabulary and keywords related to diuretics, vasoactives, sedatives, analgesics, pulmonary vasodilators, coagulation system medications, antiarrhythmics, steroids, and other endocrine drugs. We included studies of drugs given post-operatively to children with CHD undergoing repair or palliation with cardiopulmonary bypass. Results: We identified a total of 127 studies with 51,573 total children across medication classes. Most studies were retrospective cohorts at single centres. There is significant age- and disease-related variability in drug disposition, efficacy, and safety. Conclusion: In this study, we discovered major gaps in knowledge for each medication class and identified areas for future research. Advances in data collection through electronic health records, novel trial methods, and collaboration can aid drug development efforts in standardising care, improving outcomes, and limiting adverse events in the post-operative period.

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“…The Society for Pediatric Anesthesia recommends that ketorolac be considered as an adjunct to opioids in pediatric pain control, and data support its potential opioid-sparing effects in noncardiac surgery postoperative pediatric patients (17). In neonates, there is concern for acute renal dysfunction, necrotizing enterocolitis, and an increased risk of bleeding (18)(19)(20)(21)(22)(23)(24)(25)(26). Additionally, there are limited data on the use of ketorolac in neonates postcardiac surgery employing validated standardized definitions of renal impairment and bleeding.…”

mentioning

confidence: 99%

Ketorolac Dosing and Outcomes in Neonates Following Congenital Heart Surgery: A Retrospective Analysis

Kiskaddon,

Goldenberg,

Abel

et al. 2024

Critical Care Explorations

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BACKGROUND: Pain management is essential for postoperative surgery. Given the association of opioids with adverse outcomes, interest in the use of nonopioid analgesics, such as ketorolac, has increased. Published data on use in neonates are limited. OBJECTIVES: To describe ketorolac dosing and safety and efficacy outcomes in the first 48 hours postcardiac surgery in neonates. DESIGN: We performed a single-center retrospective cohort study of neonates (ages < 28 d) who received ketorolac following cardiac surgery from November 2020 to July 2023 (inclusive). The primary safety outcome was a clinically significant decline in renal function, as defined by the composite of an increase in serum creatinine by greater than or equal to 0.3 mg/dL from baseline within 96 hours of ketorolac initiation and urine output less than or equal to 0.5 mL/kg/hr for 6 hours. The secondary safety outcome was clinically significant bleeding, defined as the composite of major bleeding by the International Society on Thrombosis and Hemostasis pediatric criteria and severe/fatal bleeding by the criteria of Nellis et al (2019). Efficacy was measured by opioid utilization based on a standardized pain score-driven analgesia protocol. INTERVENTIONS: Ketorolac was administered at 0.5 mg/kg every 6 hours as per an institutional clinical management algorithm. MEASUREMENTS AND MAIN RESULTS: Thirty-nine patients met the eligibility criteria. The median ketorolac dose was 0.5 mg/kg/dose, and median (interquartile range [IQR]) duration of therapy was 48 hours (6–48 hr). No patients experienced a significant decline in renal function, and there were no clinically significant bleeding events. The median (IQR) IV morphine milligram equivalents (MMEs)/kg/d of opioid administration was 0.2 MME/kg/d (0.1–0.25 MME/kg/d) at the time of ketorolac initiation and 0.1 MME/kg/d (0.1–0.2 MME/kg/d) at 48 hours post-ketorolac initiation. CONCLUSIONS: If validated prospectively, these findings suggest that a ketorolac regimen of 0.5 mg/kg/dose every 6 hours in neonates postcardiac surgery may be safe with regard to renal function and bleeding risk. Additional randomized studies would be needed to determine efficacy with regard to opioid-sparing capacity.

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Antiplatelet Effect of Ketorolac in Children After Congenital Cardiac Surgery

Cited by 6 publications

References 44 publications

Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline

Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline

A systematic review of the evidence supporting post-operative medication use in congenital heart disease

Ketorolac Dosing and Outcomes in Neonates Following Congenital Heart Surgery: A Retrospective Analysis

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