Postoperative Use of Ketorolac Improves Pain Management and Decreases Narcotic Use Following Primary Cleft Palate Surgery

Dudley, Samuel; Spence, Matthew; Frederick, Robert; Stocks, Rosemary

doi:10.1177/10556656211042168

Cited by 5 publications

(5 citation statements)

References 11 publications

(12 reference statements)

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“…13 While studies report mixed results regarding the efficacy of ketorolac in reducing postoperative pain and narcotic usage in palatoplasty patients, Dudley et al found that ketorolac decreased narcotic usage and postoperative pain scores. 29,30 Multidisciplinary teams may want to consider the incorporation of ketorolac in their ERAS protocols as well.…”

Section: Patient Safetymentioning

confidence: 99%

Closing the Gap: A Systematic Review and Meta-Analysis of Enhanced Recovery After Surgery Protocols in Primary Cleft Palate Repair

Asadourian

Wang

Demetres

et al. 2022

The Cleft Palate Craniofacial Journal

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Objective Assess the evidence for Enhanced Recovery After Surgery (ERAS) protocols in the cleft palate population. Design A systematic review of MEDLINE, Embase, Cochrane, and CINAHL databases for articles detailing the use of ERAS protocols in patients undergoing primary palatoplasty. Setting New York-Presbyterian Hospital. Patients/Participants Patients with cleft palate undergoing primary palatoplasty. Interventions Meta-analysis of reported patient outcomes in ERAS and control cohorts. Main Outcome Measure(s) Methodological quality of included studies, opioid use, postoperative length of stay (LOS), rate of return to emergency department (ED)/readmission, and postoperative complications. Results Following screening, 6 original articles were included; all were of Modified Downs & Black (MD&B) good or fair quality. A total of 354 and 366 were in ERAS and control cohorts, respectively. Meta-analysis of comparable ERAS studies showed a difference in LOS of 0.78 days for ERAS cohorts when compared to controls ( P < .05). Additionally, ERAS patients utilized significantly less postoperative opioids than control patients ( P < .05). Meta-analysis of the rate of readmission/return to ED shows no difference between ERAS and control groups ( P = .59). However, the lack of standardized reporting across studies limited the power of meta-analyses. Conclusions ERAS protocols for cleft palate repair offer many advantages for patients, including a significant decrease in the LOS and postoperative opioid use without elevating readmission and return to ED rates. However, this analysis was limited by the paucity of literature on the topic. Better standardization of data reporting in ERAS protocols is needed to facilitate pooled meta-analysis to analyze their effectiveness.

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Section: Patient Safetymentioning

confidence: 99%

Closing the Gap: A Systematic Review and Meta-Analysis of Enhanced Recovery After Surgery Protocols in Primary Cleft Palate Repair

Asadourian

Wang

Demetres

et al. 2022

The Cleft Palate Craniofacial Journal

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“…Studies investigating the topic of pain and analgesia were the most common (n=31; Supplemental Table 5, Supplemental Digital Content 5, http://links.lww.com/SCS/E642)12,13. Many of the included studies investigated the use of various analgesia techniques that aimed at reducing postoperative opioid consumption 2,14–29. Seven of the included studies investigated the effectiveness of bupivacaine for use in nerve block in cleft lip and/or palate repair 1,4,28,30–33.…”

Section: Resultsmentioning

confidence: 99%

“…Many of the included studies investigated the use of various analgesia techniques that aimed at reducing postoperative opioid consumption. 2,[14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29] Seven of the included studies investigated the effectiveness of bupivacaine for use in nerve block in cleft lip and/ or palate repair. 1,4,28,[30][31][32][33] All but 1 1 focused on infraorbital nerve block placement in cleft lip surgery patients.…”

Section: Pain and Analgesiamentioning

confidence: 99%

“…Stein et al 23 found single-dose ketorolac (0.5 mg/kg) to be comparable to historical controls without ketorolac in terms of length of stay, pain scores, and mean dose of opioid rescue medication after cleft palate surgery. Alternatively, Dudley et al 26 found that patients who received a single intraoperative dose of ketorolac, followed by IV ketorolac until oral ibuprofen was tolerated had lower pain scores (P < 0.001), and average morphine equivalents (P < 0.001), but equivalent length of stay compared with children who did not receive ketorolac.…”

Section: Pain and Analgesiamentioning

confidence: 99%

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Patient Safety and Quality Improvement Initiatives in Cleft Lip and Palate Surgery: A Systematic Review

Grue

McGuire

Hong

et al. 2022

Journal of Craniofacial Surgery

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Background: Cleft lip and/or palate repair techniques require continued reevaluation of best practice through high-quality evidence. The objective of this systematic review was to highlight the existing evidence for patient safety and quality improvement (QI) initiatives in cleft lip and palate surgery. Methods: A systematic review of published literature evaluating patient safety and QI in patients with cleft lip and/or palate was conducted from database inception to June 9, 2022, using Preferred Reporting Items for Systematic Reviews guidelines. Quality appraisal of included studies was conducted using Methodological Index for Non-Randomized Studies, Cochrane, or a Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 instruments, according to study type. Results: Sixty-one studies met inclusion criteria, with most published between 2010 and 2020 (63.9%). Randomized controlled trials represented the most common study design (37.7%). Half of all included studies were related to the topic of pain and analgesia, with many supporting the use of infraorbital nerve block using 0.25% bupivacaine. The second most common intervention examined was use of perioperative antibiotics in reducing fistula and infection (11.5%). Other studies examined optimal age and closure material for cleft lip repair, early recovery after surgery protocols, interventions to reduce blood loss, and safety of outpatient surgery. Conclusions: Patient safety and QI studies in cleft surgery were of moderate quality overall and covered a wide range of interventions. To further enhance PS in cleft repair, more highquality research in the areas of perioperative pharmaceutical usage, appropriate wound closure materials, and optimal surgical timing are needed.

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“…Likewise, another recent retrospective study similarly showed that the use of ketorolac in patients undergoing total cranial vault remodeling did not lead to significant postoperative bleeding events requiring transfusion 12 . In contrast, Dudley et al 13 reported 1 bleeding event in their retrospective study of patients treated with ketorolac after primary cleft palate repair; this adverse event occurred in a patient with multiple congenital anomalies and was treated with a topical hemostatic agent. In our small cohort of patients receiving ketorolac, no postoperative bleeding complications leading to transfusion of blood products or unplanned return to the OR were recorded.…”

Section: Discussionmentioning

confidence: 99%

The Limit Is Zero: A Prospective Evaluation of Ketorolac in Patients Undergoing Primary Palatoplasty to Reduce Narcotic Utilization

Cepeda,

Johnson,

Kelagere

et al. 2023

Journal of Craniofacial Surgery

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Background: Patients undergoing primary palatoplasty rely on narcotics for pain control, but narcotics can lead to sedation and respiratory depression. Recent research into Enhanced Recovery After Surgery (ERAS) pathways utilizing multimodal pain therapy has yielded promising results for patients undergoing palatoplasty in terms of decreased hospital length of stay (LOS), increased oral intake, and decreased narcotic usage. Despite the potential benefit of ketorolac after palatoplasty, there is a paucity of data regarding its use. Methods: A single-center cohort study of patients undergoing primary palatoplasty was performed using 2 cohorts: a retrospective cohort treated with our institution's prior ERAS protocol from 2016 to 2018 and a prospective group of patients who also received ketorolac (ERAS+K) postoperatively from 2020 to 2022. Results: A total of 85 patients (57 ERAS and 28 ERAS+K) were included. Compared with the ERAS group, the ERAS+K cohort had significantly decreased LOS (31.8 versus 55 h, P = 0.02), decreased morphine milligram equivalents administered at 24 hours (1.5 versus 2.5, P = 0.003), 48 hours (0 versus 1.5, P < 0.001), and total inpatient morphine milligram equivalents (1.9 versus 3.8, P = 0.001). The ERAS+K group also had a significant decrease in the prescribed narcotic rate (32.1% versus 61.4%, P = 0.006). No bleeding issues, blood transfusions, or reoperations were noted in either cohort. Conclusions: This study illustrates many potential benefits of using ketorolac as a pain management adjunct in combination with a multimodal pain regimen. Our results demonstrated favorable outcomes, including decreased narcotic usage and LOS as well as increased hourly oral intake, without increasing bleeding complications.

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Postoperative Use of Ketorolac Improves Pain Management and Decreases Narcotic Use Following Primary Cleft Palate Surgery

Cited by 5 publications

References 11 publications

Closing the Gap: A Systematic Review and Meta-Analysis of Enhanced Recovery After Surgery Protocols in Primary Cleft Palate Repair

Closing the Gap: A Systematic Review and Meta-Analysis of Enhanced Recovery After Surgery Protocols in Primary Cleft Palate Repair

Patient Safety and Quality Improvement Initiatives in Cleft Lip and Palate Surgery: A Systematic Review

The Limit Is Zero: A Prospective Evaluation of Ketorolac in Patients Undergoing Primary Palatoplasty to Reduce Narcotic Utilization

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