Preoperative ketorolac increases bleeding after tonsillectomy in children

Area of Science:

• Pediatric Anesthesiology
• Pain Management
• Surgical Complications

Background:

• Post-tonsillectomy nausea and vomiting (PONV) are common concerns in pediatric patients.
• Opioid and non-steroidal anti-inflammatory drug (NSAID) analgesics are frequently used for pain management, each with potential side effects.

Purpose of the Study:

• To compare the incidence of vomiting after codeine versus ketorolac administration for pain relief in children undergoing tonsillectomy.
• To evaluate the safety profile, specifically perioperative bleeding, associated with these analgesic choices.

Main Methods:

• A randomized, single-blind study planned for 240 pediatric patients (aged 2-12 years) undergoing tonsillectomy.
• The study was terminated early due to safety concerns after enrolling 64 patients, with interim analysis indicating increased bleeding risk with ketorolac.
• Patients received ondansetron and midazolam pre-anesthesia, followed by either codeine (1.5 mg/kg IM) or ketorolac (1 mg/kg IV) before surgery. Intraoperative blood loss and postoperative vomiting were recorded.

Main Results:

• Thirty-five patients received ketorolac, and data were comparable between groups.
• The incidence of postoperative vomiting was 31% in the codeine group and 40% in the ketorolac group.
• Intraoperative blood loss was significantly higher in the ketorolac group (2.2 ± 1.9 ml/kg) compared to the codeine group (1.3 ± 0.8 ml/kg; P < 0.05). Five ketorolac patients experienced bleeding requiring unscheduled hospital admission (P < 0.05).

Conclusions:

• Preoperative ketorolac administration in children undergoing tonsillectomy is associated with increased perioperative bleeding.
• Ketorolac did not demonstrate a beneficial effect in reducing postoperative vomiting compared to codeine.
• The findings suggest that ketorolac may increase the risk of excessive bleeding in this pediatric surgical population.