A prospective randomized trial of intravenous ketorolac vs. acetaminophen administered with opioid patient-controlled analgesia in gynecologic surgery

Comparison of ketorolac intravenous versus acetaminophen intravenous in treating headache following head trauma: a semi-experimental study

BACKGROUND

Post-traumatic headache is a disabling secondary headache disorder often attributed to traumatic brain injury and affects millions of individuals worldwide. Few studies have been done on the treatment needs of these patients in emergency departments. The purpose was to compare the effectiveness of ketorolac intravenous versus acetaminophen intravenous in reducing headaches in patients following head trauma.

METHODS

This was a semi-experimental study in which the participants were assigned two groups. In the acetaminophen intravenous group, 1 g acetaminophen and in the ketorolac intravenous group, 60 mg of this drug was injected. Statistical analysis was done with IBM SPSS statistical software version 21, and a P-value less than 0.05 was considered statistically significant.

RESULTS

Among samples after 6 h from the injection, the pain score in the ketorolac intravenous group was less than the acetaminophen intravenous group (P = 0.006). Also, the pain reduction rate in the ketorolac intravenous group was more than the acetaminophen intravenous group from before the injection until 2 h after it (P = 0.01) and before injection until 6 h after it (P = 0.001). The frequency of drowsiness in 2 and 6 h after drug administration in the ketorolac intravenous group was lower than the acetaminophen intravenous group, which is significant in 2 h after drug administration (P = 0.038). The verbal analog scale score comparison for two groups 2 h before medicine administration with pain control score (P = 0.03) and 6 h with pethidine use control (P = 0.003) is significant.

CONCLUSIONS

According to this study, ketorolac's intravenous effect on pain control is better than that of acetaminophen intravenous. With more samples, we can express the survey results more decisively in the future.

Effect of abdominal hot pack application on gastrointestinal motility recovery after comprehensive gynecologic staging surgery

OBJECTIVE

To evaluate whether abdominal hot water pack application improves gastrointestinal motility following gynecological oncology surgery.

METHODS

The study was registered at ClinicalTrials.gov (NCT04833699). (https://clinicaltrials.gov/ct2/show/NCT04833699?cond=NCT04833699&draw=2&rank=1). In this randomized controlled trial, participants were randomly assigned (1:1) to the hot water pack group (standardized enhanced recovery protocols plus rubber water bag with a fluffy cover filled with boiled tap water [80°C] and placed on the abdomen at 3, 6, 9, and 12 h postoperatively for 30 min each time) or the control group (standardized enhanced recovery protocols). A subumbilical or supraumbilical vertical midline incision was made to perform staging surgery procedures, including hysterectomy, salpingo-oophorectomy with retroperitoneal lymphadenectomy. The primary outcome was the time to first passage of flatus from the end of the staging procedure.

RESULTS

In total, 121 women were randomized to the control (n = 62) or hot water pack (n = 59) group. The use of an abdominal hot water pack significantly reduced the mean time to passing first flatus (25.2 ± 3.6 vs. 30.6 ± 3.9 h; hazard ratio [HR] = 4.4; 95% confidence interval [CI]: 2.8-7.1; P < 0.0001), mean time to first bowel movements (28.4 ± 4.0 vs. 34.4 ± 4.5 h; HR = 4.9; 95% CI: 3.0-7.9; P < 0.0001), mean time to first defecation (33.4 ± 4.9 vs. 41.0 ± 7.6 h; HR = 4.3; 95% CI: 2.1-6.8; P < 0.0001), and mean time to tolerating solid diet (2.1 ± 0.6 vs. 2.8 ± 1.0 days; HR = 4.4; 95% CI: 2.2-8.7; P < 0.0001) compared to the control group. The postoperative ileus incidence was significantly lower in the hot water pack group (3.4%) than the control group (16.1%) (P = 0.01).

CONCLUSION

Abdominal hot water pack application improved gastrointestinal function recovery in women following surgical staging procedures for gynecological malignancy.

Opioid-Sparing Multimodal Analgesia Efficacy in Hispanic Patients Undergoing Total Knee Arthroplasty

Adequate pain control after total knee arthroplasty (TKA) has been associated with improved patient mobility and satisfaction, and is a task that has historically relied on opioids. Multimodal analgesic regimens can be considered a therapeutic alternative for postoperative pain control to avoid opioid consumption and its adverse side effects. This study aimed to evaluate the use of a multimodal analgesia protocol based on nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen as an alternative to reduce opioid consumption in Hispanic patients undergoing primary TKA.

METHODS

An institutional review board-approved, randomized controlled trial evaluated postoperative pain control after TKA in a Hispanic population. The experimental opioid-sparing group received 30-mg ketorolac intravenously every 6 hours and 1-g acetaminophen orally every 6 hours as the patient requested. The experimental group had the option to use morphine and oxycodone combined with acetaminophen as a rescue therapy. The control group received opioids in the form of 0.1-mg/kg morphine intravenously every 6 hours and/or oxycodone combined with acetaminophen (2.5 and 325 mg), 2 tablets orally every 6 hours, as the patient requested. Sociodemographic, operative, and immediate postoperative data and pain intensity measurements according to the numerical rating scale (NRS) were compared between groups. Analgesic efficacy was assessed according to the NRS scores at 12, 24, and 48 hours postoperatively.

RESULTS

Eighty-one Hispanic patients met inclusion criteria: 42 patients in the experimental group and 39 patients in the control group. None of the patients in the experimental group requested oxycodone combined with acetaminophen as a rescue therapy. Only 2 patients in the experimental group used a mean of 3.0 ± 1.4 mg of rescue morphine; in comparison, the control group consumed a mean of 28.0 ± 7.9 mg of morphine and 64.8 ± 26.0 mg of oxycodone per patient. A pain intensity decrease was observed in the experimental and control groups, with no postoperative evaluation differences at 12 hours (6.7 ± 2.9 compared with 5.9 ± 2.8; p = 0.209), 24 hours (6.2 ± 2.0 compared with 6.1 ± 2.2; p = 0.813), and 48 hours (4.7 ± 2.1 compared with 4.6 ± 1.7; p = 0.835).

CONCLUSIONS

The use of a multimodal analgesic regimen based on intravenous ketorolac and oral acetaminophen was adequate in reducing postoperative pain and opioid consumption in Hispanic patients undergoing TKA.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Predictors and trends of opioid-sparing radical prostatectomy from a large national cohort

OBJECTIVE

To examine the use of pain medications after radical prostatectomy using a large national database.

METHODS

The Premier Hospital Database was queried to identify all robotic and laparoscopic radical prostatectomies from January 2015 - March 2020 with length of stay ≥1 day. "Opioid-sparing" was defined as absence of intravenous opioid use after post-operative day 0 and absence of oral opioid use throughout admission. Comparisons were made between opioid-sparing and non-opioid-sparing prostatectomy. Logistic multivariable regression was used to identify predictors of opioid-sparing prostatectomy.

RESULTS

A total of 62,660 patients were included, of whom 14,806 (23.6%) underwent opioid-sparing prostatectomy. Opioid-sparing prostatectomy was associated with older age (65 vs. 63 years, p<0.01), white vs. black race (76.3% vs. 73.4%, p<0.01), high-volume surgeons (75.2% vs. 70.0%, p<0.01), and use of intravenous ketorolac (62.2% vs. 48.0%, p<0.01), intravenous acetaminophen (32.5% vs. 30.1%, p<0.01), and liposomal bupivacaine (5.4% vs. 4.9%, p<0.01). On multivariable regression, ketorolac was the strongest predictor of opioid-sparing prostatectomy (odds ratio: 1.86, 95% confidence interval: 1.79 - 1.93, p<0.01), and black race was predictive of non-opioid sparing prostatectomy (odds ratio: 0.75, 95% confidence interval: 0.71 - 0.80, P<0.01). Ketorolac was not associated with increased risk of postoperative bleeding (0.3% vs. 0.3%, p=1.0) or dialysis requirement (<0.1% vs. <0.1%, p=0.91).

CONCLUSION

Opioid-sparing radical prostatectomy was feasible and associated with administration of each of the non-opioid pain medications assessed. Ketorolac was the strongest predictor of opioid-sparing prostatectomy and was not associated with increased risk of bleeding or dialysis.

Prevention and Management of Postoperative Ileus: A Review of Current Practice

Postoperative ileus (POI) has long been a challenging clinical problem for both patients and healthcare physicians alike. Although a standardized definition does not exist, it generally includes symptoms of intolerance to diet, lack of passing stool, abdominal distension, or flatus. Not only does prolonged POI increase patient discomfort and morbidity, but it is possibly the single most important factor that results in prolongation of the length of hospital stay with a significant deleterious effect on healthcare costs in surgical patients. Determining the exact pathogenesis of POI is difficult to achieve; however, it can be conceptually divided into patient-related and operative factors, which can further be broadly classified as neurogenic, inflammatory, hormonal, and pharmacological mechanisms.

Different strategies have been introduced aimed at improving the quality of perioperative care by reducing perioperative morbidity and length of stay, which include Enhanced Recovery After Surgery (ERAS) protocols, minimally invasive surgical approaches, and the use of specific pharmaceutical therapies. Recent studies have shown that the ERAS pathway and laparoscopic approach are generally effective in reducing patient morbidity with early return of gut function. Out of many studies on pharmacological agents over the recent years, alvimopan has shown the most promising results. However, due to its potential complications and cost, its clinical use is limited. Therefore, this article aimed to review the pathophysiology of POI and explore recent advances in treatment modalities and prevention of postoperative ileus.

Study on the Application Effect of Fast Track Surgery Care Combined With Continuous Care After Discharge in Patients With Laparoscopic Cholecystectomy

Purpose

To explore the application effect of fast track surgery (FTS) care combined with continuous care after discharge in patients with laparoscopic cholecystectomy (LC).

Methods

Two hundred patients treated with LC in our hospital from May 2020 to September 2021 were selected and divided into the routine group receiving routine care (n = 100) and the combined group receiving FTS care combined with continuous care after discharge (n = 100) according to their care methods. We observed the care effect, surgical stress levels [epinephrine, cortisol, Hamilton anxiety scale (HAMA)], postoperative recovery (time to first exhaust, time to first meal, time to first getting out of bed, time to hospitalization), complications, SF-36 scores after discharge, and care satisfaction in both groups.

Results

The total efficiency of care in the combined group was better than that in the routine group (P < 0.05). At 1 d after surgery, the levels of epinephrine and cortisol in both groups were significantly higher than those at 1 h before surgery, and the HAMA scores were significantly lower than those at 1 h before surgery, and the combined group was lower than the routine group (P < 0.05). The time to first exhaustion, time to first meal, time to first getting out of bed, and time to hospitalization were shorter in the combined group than in the routine group (P < 0.05). The overall complication rate in the combined group was lower than that in the routine group (P < 0.05). The each item of SF-36 scores after discharge were higher in the combined group than in the routine group (P < 0.05). The total satisfaction with care was higher in the combined group than in the routine group (P < 0.05).

Conclusion

The implementation of FTS care combined with continuous care after discharge in LC patients is ideal, which can significantly reduce the level of surgical stress, accelerate the recovery process, and reduce the occurrence of complications, and improve the postoperative quality of life of patients significantly, and with high satisfaction, which is worthy of application.

Bioactive Peptides: Synthesis, Sources, Applications, and Proposed Mechanisms of Action

Bioactive peptides are a group of biological molecules that are normally buried in the structure of parent proteins and become active after the cleavage of the proteins. Another group of peptides is actively produced and found in many microorganisms and the body of organisms. Today, many groups of bioactive peptides have been marketed chemically or recombinantly. This article reviews the various production methods and sources of these important/ubiquitous and useful biomolecules. Their applications, such as antimicrobial, antihypertensive, antioxidant activities, blood-lipid-lowering effect, opioid role, antiobesity, ability to bind minerals, antidiabetic, and antiaging effects, will be explored. The types of pathways proposed for bioactive applications will be in the next part of the article, and at the end, the future perspectives of bioactive peptides will be reviewed. Reading this article is recommended for researchers interested in various fields of physiology, microbiology, biochemistry, and nanotechnology and food industry professionals.

Single-dose intravenous ketorolac for acute postoperative pain in adults

BACKGROUND

Postoperative pain is common and may be severe. Postoperative administration of non-steroidal anti-inflammatory drugs (NSAIDs) reduces patient opioid requirements and, in turn, may reduce the incidence and severity of opioid-induced adverse events (AEs).

OBJECTIVES

To assess the analgesic efficacy and adverse effects of single-dose intravenous ketorolac, compared with placebo or an active comparator, for moderate to severe postoperative pain in adults.

SEARCH METHODS

We searched the following databases without language restrictions: CENTRAL, MEDLINE, Embase and LILACS on 20 April 2020. We checked clinical trials registers and reference lists of retrieved articles for additional studies.

SELECTION CRITERIA

Randomized double-blind trials that compared a single postoperative dose of intravenous ketorolac with placebo or another active treatment, for treating acute postoperative pain in adults following any surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.  Our primary outcome was the number of participants in each arm achieving at least 50% pain relief over a four- and six-hour period. Our secondary outcomes were time to and number of participants using rescue medication; withdrawals due to lack of efficacy, adverse events (AEs), and for any other cause; and number of participants experiencing any AE, serious AEs (SAEs), and NSAID-related or opioid-related AEs. For subgroup analysis, we planned to analyze different doses of parenteral ketorolac separately and to analyze results based on the type of surgery performed. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included 12 studies, involving 1905 participants undergoing various surgeries (pelvic/abdominal, dental, and orthopedic), with 17 to 83 participants receiving intravenous ketorolac in each study. Mean study population ages ranged from 22.5 years to 67.4 years. Most studies administered a dose of ketorolac of 30 mg; one study assessed 15 mg, and another administered 60 mg. Most studies had an unclear risk of bias for some domains, particularly allocation concealment and blinding, and a high risk of bias due to small sample size. The overall certainty of evidence for each outcome ranged from very low to moderate. Reasons for downgrading certainty included serious study limitations, inconsistency and imprecision. Ketorolac versus placebo Very low-certainty evidence from eight studies (658 participants) suggests that ketorolac results in a large increase in the number of participants achieving at least 50% pain relief over four hours compared to placebo, but the evidence is very uncertain (risk ratio (RR) 2.81, 95% confidence interval (CI) 1.80 to 4.37). The number needed to treat for one additional participant to benefit (NNTB) was 2.4 (95% CI 1.8 to 3.7). Low-certainty evidence from 10 studies (914 participants) demonstrates that ketorolac may result in a large increase in the number of participants achieving at least 50% pain relief over six hours compared to placebo (RR 3.26, 95% CI 1.93 to 5.51). The NNTB was 2.5 (95% CI 1.9 to 3.7). Among secondary outcomes, for time to rescue medication, moderate-certainty evidence comparing intravenous ketorolac versus placebo demonstrated a mean median of 271 minutes for ketorolac versus 104 minutes for placebo (6 studies, 633 participants). For the number of participants using rescue medication, very low-certainty evidence from five studies (417 participants) compared ketorolac with placebo. The RR was 0.60 (95% CI 0.36 to 1.00), that is, it did not demonstrate a difference between groups. Ketorolac probably results in a slight increase in total adverse event rates compared with placebo (74% versus 65%; 8 studies, 810 participants; RR 1.09, 95% CI 1.00 to 1.19; number needed to treat for an additional harmful event (NNTH) 16.7, 95% CI 8.3 to infinite, moderate-certainty evidence). Serious AEs were rare. Low-certainty evidence from eight studies (703 participants) did not demonstrate a difference in rates between ketorolac and placebo (RR 0.62, 95% CI 0.13 to 3.03). Ketorolac versus NSAIDs  Ketorolac was compared to parecoxib in four studies and diclofenac in two studies. For our primary outcome, over both four and six hours there was no evidence of a difference between intravenous ketorolac and another NSAID (low-certainty and moderate-certainty evidence, respectively). Over four hours, four studies (337 participants) produced an RR of 1.04 (95% CI 0.89 to 1.21) and over six hours, six studies (603 participants) produced an RR of 1.06 (95% CI 0.95 to 1.19). For time to rescue medication, low-certainty evidence from four studies (427 participants) suggested that participants receiving ketorolac waited an extra 35 minutes (mean median 331 minutes versus 296 minutes). For the number of participants using rescue medication, very low-certainty evidence from three studies (260 participants) compared ketorolac with another NSAID. The RR was 0.90 (95% CI 0.58 to 1.40), that is, there may be little or no difference between groups.   Ketorolac probably results in a slight increase in total adverse event rates compared with another NSAID (76% versus 68%, 5 studies, 516 participants; RR 1.11, 95% CI 1.00 to 1.23; NNTH 12.5, 95% CI 6.7 to infinite, moderate-certainty evidence). Serious AEs were rare. Low-certainty evidence from five studies (530 participants) did not demonstrate a difference in rates between ketorolac and another NSAID (RR 3.18, 95% CI 0.13 to 76.99). Only one of the five studies reported a single serious AE.

AUTHORS' CONCLUSIONS

The amount and certainty of evidence for the use of intravenous ketorolac as a treatment for postoperative pain varies across efficacy and safety outcomes and amongst comparators, from very low to moderate. The available evidence indicates that postoperative intravenous ketorolac administration may offer substantial pain relief for most patients, but further research may impact this estimate. Adverse events appear to occur at a slightly higher rate in comparison to placebo and to other NSAIDs. Insufficient information is available to assess whether intravenous ketorolac has a different rate of gastrointestinal or surgical-site bleeding, renal dysfunction, or cardiovascular events versus other NSAIDs. There was a lack of studies in cardiovascular surgeries and in elderly populations who may be at increased risk for adverse events.