Ketorolac not significantly related to bleeding risk in kids operated for perforated appendicitis

Ketorolac is an opioid-sparing medication that is commonly used in children. Ketorolac, on the other hand, should be avoided in children with peritonitis due to an increased risk of bleeding.

Perioperative ketorolac alone is not associated with an increased risk of significant bleeding in children undergoing appendectomy for perforated appendicitis, according to a new study. However, both ketorolac and ibuprofen use during hospitalization was linked to an increased risk of bleeding, though the precise timing of administration of these medications was unknown. Long-term ketorolac use was also linked to an increased risk of bleeding necessitating a blood transfusion.

This study was conducted by Paige Kingston and team with the objective to assess the effects of Ketorolac in children with perforated appendicitis. The findings of this study were published in the Journal of Pediatric surgery.

This was a retrospective cohort study from The Pediatric Health Information System (2009–2019) of healthy children aged 2–18 years who underwent appendectomy for perforated appendicitis. Adjusting for patient and hospital level factors, multivariable logistic regression was used to examine the relationship between perioperative ketorolac use and postoperative blood transfusions within 30 days of surgery. The interaction of ketorolac and ibuprofen was studied in order to identify synergistic effects.

The findings are as follow:

1. In total, 55,603 children with perforated appendicitis had appendectomy, with 82.3% (N = 45,769) receiving ketorolac. Ibuprofen was also given to 32% (N = 14,864) of those.

2. Blood transfusions were given infrequently (N = 189, 0.%). Perioperative ketorolac administration was associated with a lower risk of blood transfusion in a multivariable logistic regression analysis.

3. Children who received ketorolac and ibuprofen, on the other hand, were more likely to require a blood transfusion.

4. Each additional day of ketorolac was associated with an increased risk of blood transfusion in a subset of children receiving ketorolac.

These findings support the use of ketorolac as a multimodal pain management strategy that does not rely on opioids. While the use of ketorolac alone was not associated with an increased risk of significant bleeding, the authors concluded that caution is required when using ketorolac with nonsteroidal anti-inflammatory drugs (NSAIDs) and for long-term use.

Reference: 

Kingston, P., Lascano, D., Ourshalimian, S., Russell, C. J., Kim, E., & Kelley-Quon, L. I. (2021). Ketorolac use and risk of bleeding after appendectomy in children with perforated appendicitis. In Journal of Pediatric Surgery. Elsevier BV. https://doi.org/10.1016/j.jpedsurg.2021.11.019