Mo1982 INTRAPROCEDURAL KETOROLAC IS SAFE AND ASSOCIATED WITH LOWER RISK OF POST-ERCP PANCREATITIS IN HIGH RISK PEDIATRIC PATIENTS

Abstract

Rectal Indomethacin is standard of care for post-ERCP pancreatitis (PEP) prevention in adult high risk patients. However, rectal indomethacin is difficult to dose correctly in smaller patients, and use of NSAIDS for PEP prevention in pediatrics is not well studied. Because of difficulty in correctly dosing indomethacin in pediatric patients, we have used IV ketorolac for PEP prevention and present data on its safety and efficacy. Retrospective chart review of all ERCPs performed at a pediatric tertiary care center from 7/2010 to 6/2018. Routine use of IV ketorolac during ERCP at standard weight-based dosing (0.5 mg/kg/dose max 30 mg) began in 2014. Procedural factors were recorded and rates of PEP were obtained using our institutional prospective endoscopic adverse event monitoring system and verified with individual chart review. PEP was defined as increasing abdominal pain after ERCP with concurrent increasing lipase (to greater than 3 times upper limit of normal for patients without pre-existing pancreatitis and increasing from baseline for patients with pre-existing pancreatitis). A total of 309 ERCPs were performed. 11 were excluded from analysis for PEP rates because of post-surgical anatomy with biliary drainage separate from the major papilla. 132 ERCPs did not receive intraprocedural ketorolac, and 166 received ketorolac. Patient and procedural characteristics are summarized in Table 1. The rates of bleeding after ERCP were not significantly higher in patients who received ketorolac (0.6% vs 0% p = 1). The ketorolac group had statistically higher rates of some variables which may increase risk of PEP such as female gender, presence of trainee during the procedure, indication for ERCP of chronic pancreatitis, and intentional cannulation or injection of the pancreatic duct, however the overall rates of PEP were not significantly different between the ketorolac and no ketorolac group (9% vs 13% p = 0.29). However, for high risk patients with injection of contrast into and/or cannulation of the pancreatic duct, the rates of PEP were significantly lower in the ketorolac group (11% vs 25% p = 0.035). We found that routine administration of ketorolac during pediatric ERCP was not associated with significantly lower PEP rates. However, in high risk patients with manipulation of the pancreatic duct, ketorolac was associated with a significantly lower rate of PEP. Ketorolac was safe without a higher rate of bleeding after ERCP. These results may be helpful for providers performing pediatric ERCP to improve the safety of the procedure with careful patient selection of which children may benefit from ketorolac during ERCP.