Incidence of bleeding in children undergoing circumcision with ketorolac administration

Abstract

Introduction: Circumcision is the most common surgical procedure performed by pediatric urologists. Ketorolac has been shown to have an efficacy similar to morphine in multimodal analgesic regimens without the commonly associated adverse effects. Concerns with perioperative bleeding limit the use of ketorolac as an adjunct for pain control in surgical patients. As such, we sought to evaluate our institutional outcomes with respect to ketorolac and postoperative bleeding. Methods: We retrospectively reviewed all pediatric patients undergoing circumcision from January 1, 2014 to December 31, 2015 at the Alberta Children's Hospital. Demographics, perioperative analgesic regimens, and return to emergency department or clinic for bleeding were gathered through chart review. Results: A total of 475 patients undergoing circumcisions were studied, including 150 (32%) who received perioperative ketorolac and 325 (68%) There was no significant difference in the number of patients requiring postoperative admission or further medical intervention. Conclusions: Although a promising analgesic, ketorolac requires additional investigation for safe usage in circumcisions due to possible increased risk of bleeding. CUAJ -Original Research Gao et al Use of ketorolac in circumcision IntroductionCircumcision is a common surgical intervention in pediatric urology indicated in instances of refractory balanitis, pathological phimosis, or paraphimosis. The control of post-operative pain is essential in order to decrease patient morbidity and to improve patient and parent satisfaction. Methods to reduce post-operative morbidity in circumcision include the use of general anesthesia combined with regional block. Common regional blocks include dorsal penile nerve blocks (DPNB) or caudal epidural blocks (CB). Neither has been shown to be more effective than the other in terms of the need for rescue or other analgesia.1,2 DPNB may be preferred over CB in

Bleeding and ketorolac use in pediatric circumcision

“…They further commented that there was also an increase in sanguineous oozing requiring evaluation by the surgeon. 8 As a pharmacological agent, ketorolac has a small volume of distribution, is metabolized via the kidney, and has an elimination halflife of about 5 h in pediatric patients. 9 Due to this pharmacokinetic profile, the effects of ketorolac should be insignificant by 24 h, as 94%-97% of the drug will have been eliminated after this period of time.…”

“…Gao et al reported an increased incidence of bleeding events requiring medical attention after circumcision in patients who received ketorolac 0.5 mg/kg. They further commented that there was also an increase in sanguineous oozing requiring evaluation by the surgeon 8 …”

“…The bleeding complication rate was between 2% and 6% for boys circumcised after the age of 10, and 4%–12% for boys circumcised between the ages of 1 and 9 7 . A 2018 study in pediatric patients undergoing circumcision reported a significantly greater incidence of return to the emergency department or clinic for bleeding among those who received ketorolac compared to those who did not (13% vs. 5%, p = 0.005) 8 . Since our institution is a high‐volume circumcision center, we sought to determine the bleeding risk difference after circumcision in pediatric patients who received intraoperative ketorolac 0.5 mg/kg intravenously compared with those who did not receive ketorolac.…”

“…7 A 2018 study in pediatric patients undergoing circumcision reported a significantly greater incidence of return to the emergency department or clinic for bleeding among those who received ketorolac compared to those who did not (13% vs. 5%, p = 0.005). 8 Since our institution is a high-volume circumcision center, we sought to determine the bleeding risk difference after circumcision in pediatric patients who received intraoperative ketorolac 0.5 mg/kg intravenously compared with those who did not receive ketorolac. We hypothesized that there would not be a statistically significant risk difference of bleeding requiring pharmacologic or surgical intervention in patients receiving ketorolac.…”

The Benefits of Opioid Free Anesthesia and the Precautions Necessary When Employing It

“…There is also the risk of bleeding, renal impairment and gastritis and peptic ulceration when administered over several days. Bleeding was not an issue after breast surgery [23] but after circumcision the ketorolac group had more bleeding [24]. Unlike ketorolac the selective cyclooxygenase 2 inhibitors are not associated with bleeding but have a higher rate of thrombotic events and should be avoided in patients at risk ly leads to a plasma concentration of about 2 mcg/ml [37].…”