The Role of Ketorolac in the Management of Patients Who Need Ambulatory Oral and Maxillofacial Surgery Under General Anesthesia

Abstract

Statement of the Problem: Despite a variety of choices of drugs available for safe and effective maxillofacial procedures under general anesthesia in the outpatient clinic setting, the most commonly used combination of drugs is versed, fentanyl, and propofol. Opioid-respiratory depression is the most dangerous potential side effect. Intraoperative ketorolac has been shown to have a postoperative narcotic-sparing effect. One of the major advantages of ketorolac over fentanyl is that it exhibits no depressant effects of respiratory function. The purpose of this study is to determine whether intraoperative ketorolac is an effective substitute for fentanyl in patients undergoing ambulatory oral and maxillofacial surgery under general anesthesia. Materials and Methods: A prospective randomized double-blind study of forty patients with ASA Status I or II, 18 years and older, undergoing extraction of at least one impacted third molar under general anesthesia was conducted between July 2005 and December 2005. Patients were randomly assigned to: group 1 (21 patients) who received versed, fentanyl, and propofol or group 2 (19 patients) who received versed, ketorolac, and propofol. A syringe containing 1 cc of either fentanyl or ketorolac was prepared and coded by the nursing staff; for group 1 patients, 50 mcg fentanyl was administered as soon as iv access was established, and for group 2 patients, 30 mg iv ketorolac was given. All patients were given midazolam. For induction and maintenance of general anesthesia propofol was used throughout the procedure. The surgeon and anesthetist monitored respiratory status using a precordial stethoscope, direct visualization, vital signs, and oxygen saturation. Postoperatively, both attending surgeon and resident surgeon made an overall assessment regarding induction, maintenance, and recovery phases of general anesthesia. Assessment can be either successful or unsuccessful with comments. Using Visual Analog Scales, patients recorded their pain level eight hours postoperatively. Method of Data Analysis: Anesthesia records were used to assess intraoperative findings: surgical time, amount of propofol and versed, recovery time, and immediate postoperative nausea and vomiting. The efficacy of general anesthesia provided was determined by the evaluating surgeons’ assessments. The incidence of intraoperative and postoperative complications was also determined. Results: The single intraoperative complication consisted of one episode of termination of general anesthesia due to inadequate result within normal doses of versed, ketorolac, propofol, and local anesthesia. All patients reported their pain score for the first eight hours, episode of nausea and vomiting, and the time until taking the first pain medication. Patients in group 2 (ketorolac group) reported less postoperative pain (pain scale 5.33 versus 5.71). Group 1 (fentanyl group) required more surgical time (38 minutes versus 31 minutes), longer recovery time (22 minutes versus 18 minutes), and more versed (3.14 mg versus 2.97 mg). In group 1 (fentanyl group) two patients could not be discharged for 50 and 60 minutes and one had a severe episode of nausea and vomiting in the recovery room. In group 2 (ketorolac group) everyone was discharged within 25 minutes after surgery. The reported overall satisfaction by the attending surgeons regarding group 1 and group 2 was 76% and 78% respectively, whereas the resident surgeons’ was 76% and 72%. Conclusion: Ketorolac appears to be at least as effective as fentanyl during general anesthesia in ambulatory oral and maxillofacial surgery, proving not only to be as effective an analgesic as fentanyl but also leading to decreased recovery time and fewer complications such as nausea and vomiting and, most importantly, respiratory depression.