P. Kingston2, D. Lascano1, S. Ourshalimian1, E. Kim1, C. Russell1,2, L. Kelley-Quon1,2 1Children’s Hospital Los Angeles,Los Angeles, CA, USA 2University Of Southern California,Los Angeles, CA, USA
Introduction: Ketorolac (Toradol®) – a nonsteroidal anti-inflammatory drug – can be used as part of an opioid-sparing regimen for postoperative pain management. However, surgeons may avoid ketorolac due to a possible increased risk of bleeding. We hypothesized that perioperative ketorolac used in children undergoing appendectomy for perforated appendicitis was not associated with clinically significant postoperative bleeding requiring blood transfusion.
Methods: A retrospective cohort analysis of healthy children 2-18 years who underwent appendectomy for perforated appendicitis from 2009-2019 was performed using the Pediatric Health Information System® (PHIS). Receipt of blood transfusion within 30 days of surgery was evaluated. Multivariable logistic regression with mixed effects modeling was used to evaluate the association between perioperative ketorolac use and postoperative blood transfusions, adjusting for patient and hospital characteristics. An interaction was evaluated between ketorolac and perioperative ibuprofen administration due to the risk of NSAID-related adverse effects.
Results: Overall, 56,719 children with perforated appendicitis underwent appendectomy and 189 (0.3%) received a blood transfusion within 30 days of surgery. Of the 46,489 (82%) children who received perioperative ketorolac, 14,929 (32%) also received ibuprofen during hospitalization. On unadjusted analysis, children who received ketorolac were less likely to require blood transfusions than children who did not receive ketorolac (0.3% vs. 0.5%, p<0.001). This relationship persisted on multivariable regression analysis; perioperative ketorolac was associated with a decreased likelihood of receiving a blood transfusion within 30 days (aOR = 0.54, 95% CI: 0.36-0.82). A significant interaction between ketorolac and ibuprofen was noted as patients who received both analgesics were more likely to require a blood transfusion within 30 days compared to ketorolac exposed patients (OR = 2.12, 95% CI: 1.52-2.96). Use of ibuprofen alone was not associated with increased risk of postoperative blood transfusion.
Conclusion: Significant postoperative bleeding requiring transfusion is rare after appendectomy for perforated appendicitis. Perioperative ketorolac alone was not associated with clinically significant bleeding requiring blood transfusions in children undergoing appendectomy for perforated appendicitis. Use of both ketorolac and ibuprofen was associated with an increased likelihood of bleeding requiring a blood transfusion. Ketorolac alone may be safe to administer for post-appendectomy pain control, but surgeons and anesthesiologists should ensure that patients have not also received ibuprofen during hospitalization.
