DOUBLE-UP NON-OPIOID PAIN MANAGEMENT

Most of us tend to underdose our patients with paracetamol (acetaminophen) and NSAIDs, and then just top up the opioids afterwards. Both non-opioid drug classes have a huge safety window, especially for short term treatment. With no present contraindications, I prefer to give a high dose of both to my anaesthetic patients. An initial dose of 1500 to 2000 mg of paracetamol if orally, or 1000 mg i.v. For NSAIDs I often find the ‘usual’ dose can be doubled with good effect and no real harm. Here is a meta-analysis on ketorolac for post-operative pain saying the same thing.

Better pain control, less opioids
The meta-analysis finds a highly significant effect of 60 mg ketorolac, especially if given i.m, compared to i.v. The often standard dose of 30 mg had much less effect. It did show effect on pain, but not really on nausea. 60 mg had better effect on both. There were no major side-effects noted in these studies – no excessive bleeding or renal failure. For any standard, elective surgery patient, I wouldn’t worry. Double up.

As noted above, the same goes for paracetamol dosing. I had an impressive talk by a paediatric anaesthetist recommending much higher paracetamol doses than I have been used to. Rectal is no good – you can’t really predict what concentration you will get in the blood stream. Oral is better, but slightly unreliable in fasting, pre-op patients. I.v. is best. I.v. paracetamol has also gotten pretty cheap. The same notion is supported by this study.

So there’s really no reason not to give your surgical patient a dose of 1000 mg paracetamol i.v, or double that for the oral route. And ketorolac double-up (60 mg), i.m. Better pain control, less opioids.

Perioperative single dose ketorolac to prevent postoperative pain: a meta-analysis of randomized trials, Anesth Analg, 2012 Feb;114(2):424-33.

And to enhance the effect, throw in a good dose of dexamethasone (~0.1mg/kg) before the surgical trauma starts:
Perioperative single dose systemic dexamethasone for postoperative pain: a meta-analysis of randomized controlled trials, Anesthesiology, 2011

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3 Responses to DOUBLE-UP NON-OPIOID PAIN MANAGEMENT

  1. Anthony Lewis says:

    Ketorolac is a great drug for bleeding.
    Potent anticoagulant, nearly withdrawn from the market many years ago with Black Box Warnings for stroke, GI bleeds and awesome haematomas with IM use.
    Rebranded and dose reduced (30mg). Not as effective as the classic (but dangerous) 60mg.
    NSAIDs are great, use them all the time, but Ketorolac gives me the heebie-jeebies.

    • Thomas D says:

      Thanks for your input, Anthony! I appreciate it! Yes, ketorolac has a anticoagulant effect. And I wouldn’t use it in a patient where bleeding was a problem.
      Having said that, I haven’t found any good studies looking at bleeding complications from ketorolac 60 mg im. The ones I have found conclude that there is a slight increase in bleeding, but it doesn’t really change management or outcome. So, in those studies, ketorolac has not been linked to adverse events. But again, the studies are retrospective, hetrogenous and not big enough, so they are far from perfect. Do you have any good references to (high does) ketorolac and bleeding?

  2. Tor Pedersen says:

    Personally I like toradol/ketorolac, excellent for reducing opioid usage. Plus, for some unexplained reason I like the name “toradol”… But there are a number of studies showing that ketorolac has an analgesic ceiling effect, so doses beyond 10mg does not give any additional pain relief, only more side effects… A little strange that the vials still come in 30mg. Read more here: http://www.medscape.com/viewarticle/811301

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