Abstract
The use of ketorolac injections in Indonesia is restricted with the provision of 2-3 ampoules per day with a maximum of two days even though the literature states that ketorolac could be used for no more than five days. This study aimed to determine the decrease in pain scale as well as gastrointestinal and renal adverse effects of ketorolac injections in two days of use. This study was an observational study with one-group pre-test post-test design conducted prospectively. The group was a group of patients with postoperative pain who received ketorolac injections and were treated during January till April 2018 in an academic hospital in Yogyakarta. The results showed that ketorolac injections did not provide a statistically significant decrease in pain scale in two days of use compared to before surgery (median [range] = 2.0[0.0-9.33] vs 1.33[0.0-8.33]; p=0.32). Ketorolac injections decreased the kidney function of subjects in two days of use compared to before surgery based on creatinine values (0.76mg/dL vs 0.80mg/dL; p=0.024) and GFR (96.13mL/min/m 2 vs 87.52mL/min/m 2 ; p=0.023), and as many as 31 subjects (43.06%) experienced complaints that were suspected to be the gastrointestinal adverse effects of ketorolac injections with the three most complaints were bloating (18.06%), nausea (16.67%), and heartburn (15.28%). Those three results support the use of ketorolac injections following what has been regulated in the Indonesian National Formulary.
Highlights
Postoperative pain is an unexpected subjective complaint
This study was beneficial as a basis for evaluating the restrictions on the use of ketorolac injections according to the Indonesian National Formulary, which states that ketorolac injections are only given in a maximum of two days with a dose of 2-3 ampoules per day (Kementerian Kesehatan, 2016) even though Vadivelvu et al (2017) states that ketorolac use may be used for not more than five days (Grosser et al, 2018; Vadivelu et al, 2017)
The study subjects admitted the hospital with a pain scale of 2.13±0.28 and normal kidney function which was seen through normal Blood Urea Nitrogen (BUN), creatinine, and GFR values
Summary
Postoperative pain is an unexpected subjective complaint. Data on the prevalence of postoperative pain in Indonesia is still not well documented, but in other countries such as studies conducted in Barcelona, it had shown that the prevalence of orthopedic postoperative pain and trauma was around 28% with mild pain of 15% and moderate to severe pain by 13% (Robleda et al, 2014). Another study showed that moderate to severe pain in the first 24h and the first 48h after surgery were 13% and 11.7%, respectively (Mwaka et al, 2013). A study showed that 89.7% of patients with postoperative pain in one hospital in Indonesia were treated using ketorolac (Permata, 2014). The results of several other studies showed that ketorolac could provide better postoperative pain management than placebo, tramadol (Shah et al, 2013), diclofenac (Mony et al, 2016), and significantly reduced pain intensity 30 minutes after surgery (Eftekharian and Pak, 2017). The risk of gastrointestinal bleeding due to ketorolac was known to be quite high and relatively higher than other NSAIDs. The results of a study showed that nonselective NSAIDs increased the relative risk of bleeding, but ketorolac could increase the risk of bleeding much even higher (Gonzalez et al, 2010). Other studies that have been conducted showed that in addition to gastrointestinal bleeding, the
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