Intramuscular Ketorolac Research Articles

Comparative Analgesic Efficacy of Intramuscular Dexamethasone, Ketorolac, Tramadol, and Butorphanol with Regard to Postoperative Pain After Mandibular Third Molar Surgery

ABSTRACT Surgical removal of the third molar often resulted in postoperative pain which affected the quality of life of the patients. Pharmacological management of pain includes NSAIDS or steroids. The present study compared four drugs, viz. Group 1 (4 mg dexamethasone injection); Group 2 (30 mg ketorolac); Group 3 (50 mg tramadol injection); and Group 4 (1 mg butorphanol injection) in the management of postoperative pain after third molar surgery. We observed that in comparison with the first and third postoperative pain between groups, it revealed the lowest mean pain score in the butorphanol group, followed by dexamethasone and tramadol group and the highest mean score in the ketorol group (P value <0.0001). We conclude that butorphanol with low dosage can be effectively used for reducing postoperative discomfort after surgery.

This Month in Adult Urology

This Month in Adult Urology

Efficacy of Intramuscular Ketorolac for Preventing Renal Colic Post Stent Removal: Randomized Controlled Trial.

The treatment of stones ureteroscopically is associated with postoperative pain, thought to be due largely to the use of ureteral stents. In some, stent removal precipitates renal colic that can last from minutes to hours. We sought to determine if intramuscular ketorolac could reduce post-stent removal renal colic. We performed a prospective, randomized, double-blind, placebo-controlled trial assessing the effects of ketorolac administered at time of stent removal. Patients were randomized to receive an intramuscular ketorolac 30 mg or placebo immediately prior to stent removal. Patients were contacted 1 and 7 days after stent removal to assess pain, need for opioids, emergency department or clinic visits and the need for surgical/medical interventions. A total of 124 patients (62 patients each in the control and treatment groups) were included in the study. The groups were comparable in demographic/operative characteristics. No difference in mean pain scores or proportion of patients who experienced severe pain at 1 and 7 days post stent removal was detected between groups. However, use of ketorolac resulted in significantly fewer renal colic-related unplanned emergency department/clinic visits in the treatment group (2%) compared with the control group (13%, p=0.032). Although administration of ketorolac prior to stent removal does not significantly reduce overall subjective pain experienced post stent removal compared to placebo, it does reduce the likelihood of severe renal colic requiring emergency department or office visits. Eligible patients may benefit from routine use of ketorolac injection at the time of stent removal.

Injectable Ketorolac and Corticosteroid Use in Athletes: A Systematic Review.

The use of injectable medications to help athletes quickly return to the field of play after injury is common. Understanding the effects and risks of these medications will help providers make informed decisions regarding their use in this patient population. To evaluate the utilization, efficacy, and adverse effects of injectable ketorolac and corticosteroids in athletes. This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A systematic search of the literature was performed using multiple databases (PubMed, Embase, Cochrane, Web of Science, and ClinicalTrials.gov). Secondary references were appraised for relevant articles. No randomized controlled trials or other prospective studies were identified. Articles included retrospective database reviews and physician survey studies. A total of 6 studies met the inclusion and exclusion criteria and were reviewed by 2 independent reviewers with a third consulted in the case of disagreement, which was not needed. Systematic review. Level 5. Two reviewers recorded rate of use, effectiveness of treatment, and reported side effect data. Most studies centered around the football athlete, either professional or collegiate. Professional football game day use of intramuscular ketorolac declined from 93.3% (28/30) in 2002 to 48% in 2016. Collegiate football game day use of intramuscular ketorolac declined from 62% in 2008 to 26% in 2016. Game day corticosteroid injection was far lower than ketorolac usage. Both medications were reported to be effective with few adverse events. Use of injectable ketorolac is common but declining in professional and college football. Pain control efficacy is good, and risk of adverse events is low. The incidence of injectable corticosteroid use in athletes is unknown. Use of injectable corticosteroids in athletes allows for early return to sport activities with no reported complications.

The Impact of Intraoperative Local Ketorolac on Opioid Use in the Management of Postoperative Pain in Thoracolumbar Spinal Fusions: A Retrospective Cohort Study.

The United States is facing an opioid addiction epidemic with >63,600 deaths from drug overdoses in 2016 alone. Ketorolac is a nonsteroidal anti-inflammatory drug that has been shown to decrease postoperative pain in decompressive lumbar laminectomies. We sought to demonstrate that intraoperative intramuscular (IM) ketorolac is associated with decreased opioid use in the management of acute postoperative pain in thoracolumbar spinal fusions. A retrospective review of consecutive patients undergoing open and minimally invasive (MIS) thoracolumbar fusions between 2017 and 2018. Ketorolac (30 mg) was injected into the paraspinal muscles adjacent to the operative site before closure. Patients were placed on a standard pain control regimen. All demographic and surgical data were assessed with univariate analysis to assess for differences between groups. Univariate analysis was used to identify significant covariates for the linear regressions with postoperative morphine equivalents, length of stay (LOS), and visual analog scale (VAS) for pain as dependent variables. A P < .025 was considered significant to account for multiple covariates. Two hundred twenty-five consecutive patients were included with 58 patients receiving intraoperative IM ketorolac. The average age of the ketorolac groups was 63.4 years (23-87 years) with an even distribution between genders. There was no significant difference in demographic or surgical data between the 2 cohorts. Postoperative opioid use, when corrected for LOS, showed no significance between cohorts, ketorolac 16.4 mg (95% confidence interval [CI]: 12.3-20.5) and nonketorolac 6.7 mg (95% CI: 14.1-19.4, P = .8729). Other than postoperative day zero VAS (P = .05), ketorolac was not a predictor of opioid use, LOS, or VAS. The use of a single dose of intraoperative IM ketorolac did not decrease the overall opioid requirements or shorten the LOS following open or MIS lumbar fusions. However, we did demonstrate benefit in early pain control, which makes this promising for further investigation. 3. This article promotes attention to the opioid crisis and the need for multimodal nonopioid based pain management in spine surgery.

MP22-18 EFFECT OF PRE-EMPTIVE INTRAMUSCULAR KETOROLAC ON POST-STENT COLIC

INTRODUCTION AND OBJECTIVE: Ureteroscopy (URS) for stones is associated with post-operative morbidity largely attributed to ureteral stents. Stent removal may precipitate debilitating renal colic within minutes to hours. We performed a prospective, double-blind placebo-controlled, randomized trial evaluating the effect of intramuscular (IM) ketorolac administered at time of stent removal. METHODS: After obtaining institutional review board approval, consecutive eligible patients who underwent URS/stent for stones were enrolled in a prospective, RCT. Patients in whom ketorolac is contraindicated (diabetes, elevated creatinine, NSAID allergy) were excluded from study. Patients were randomized via computer-based random sequence generator to receive an IM injection of 30mg in 1mL of ketorolac or 1mL of 0.9% normal saline immediately prior to office stent removal. The patient, doctor and nurse administering the injection were blinded to the contents of the syringes. Demographic, operative and post-stent data were collected prospectively. Patients were contacted by a blinded research associate 24 hours and 7 days following stent removal to assess level of pain using a visual analog pain scale (VAS); the occurrence of renal colic symptoms; use of narcotics; Emergency Department (ED) or unplanned clinic visits; or need for surgical/medical interventions related to renal colic were recorded. Student’s t-test and Fischer Exact test were used for statistical analysis. RESULTS: A total of 124 patients (62 patients each in the control and treatment arms) were included. Demographics, operative characteristics and stent duration were comparable (p > 0.05). No difference between the groups was detected in mean VAS pain scores at 24 hours and 7 days, and no injection site reactions or complications occurred in either group. Administration of ketorolac resulted in significantly fewer renal colic-related ED/unplanned clinic visits in the treatment group (2%) compared to the control group (13%) (p = 0.032) (table). CONCLUSIONS: Although administration of ketorolac prior to stent removal did not result in reduction of post-stent pain on average, it did reduce the likelihood of severe renal colic requiring ED or office visits. Patients may benefit from routine pre-emptive ketorolac injection at the time of stent removal.Source of Funding: None

Principal Factors Associated With Ketorolac-Refractory Pain Behavior After Pediatric Myringotomy and Pressure Equalization Tube Placement: A Retrospective Cohort Study.

Prophylactic analgesic administration reduces pain behavior after pediatric bilateral myringotomy and pressure equalization tube placement (BMT). We hypothesized that postoperative pain in children treated with intraoperative ketorolac would, among several exposures of interest, be strongly associated with ear condition. We conducted a retrospective cohort study of healthy children (9 months to 7 years) who underwent BMT at the Children's Hospital of Philadelphia or its ambulatory surgery centers from 2013 to 2016. Anesthetic care included preoperative oral midazolam, sevoflurane/nitrous oxide (N2O)/air/oxygen (O2) by mask, and intramuscular ketorolac. Demographic and procedural information included left and right tympanic membrane (normal, retracted, or bulging) and middle ear (normal/no, serous, mucoid, or purulent effusion) conditions. Because tympanic membrane and middle ear conditions were highly concordant and mean maximum Face, Legs, Activity, Cry and Consolability (FLACC) scores (0-10) were not different across the array of abnormal findings, we categorized each ear as normal or abnormal based on middle ear effusion alone. We then defined the ear condition of each child (primary exposure) using bilateral findings: normal/normal, normal/abnormal, and abnormal/abnormal. Secondary exposures included age, BMT history, procedure duration, facility location, and attending surgeon/anesthesiologist pair. The primary outcome was maximum postanesthesia care unit FLACC score: 4-10 (moderate-to-severe pain) versus 0-3 (no-to-low pain). Rescue oxycodone, acetaminophen administration, and emergence agitation were secondary outcomes. Statistical analysis incorporated generalized linear mixed models with random intercepts accounting for the clustering effect of provider pairs. Adjusting for multiple comparisons, significance level was set at P = .004. Excluding recurrent cases, 1922 unique evaluable subjects remained. The probability of moderate-to-severe pain behavior (FLACC, 4-10) was 52.4% (95% confidence interval [CI], 50.2-54.6) overall. In a confounder-adjusted model, ear condition was significantly associated with moderate-to-severe pain: compared to bilateral abnormal (effusions), odds ratio (OR) (95% CI) for bilateral normal was 2.2 (1.6-2.9), P < .0001. Younger age (OR, 1.1 [1.1-1.2] per year; P = .001) and longer procedure duration (OR, 1.1 [1.0-1.2] per minute; P = .0008) were likewise related to higher pain. With surgeon added to the model, variance explained by provider pairs decreased from 9.60% to 1.05%. Two secondary outcome associations also emerged: comparing bilateral normal to abnormal ears, ORs were 1.7 (1.3-2.2), P = .0001, for rescue oxycodone and 2.0 (1.2-3.3), P = .008, for emergence agitation. Pain behavior after BMT varies by surgeon and is strongly associated with ear condition. Ketorolac as a single prophylactic analgesic appears less effective in younger children with normal middle ear findings.

Management of Acute Trauma Pain in the Emergency Department – A Comparison of Intramuscular Ketorolac, Diclofenac and Tramadol

Management of Acute Trauma Pain in the Emergency Department – A Comparison of Intramuscular Ketorolac, Diclofenac and Tramadol

Atomized intranasal vs intravenous fentanyl in severe renal colic pain management: A randomized single-blinded clinical trial

ObjectivesRenal colic is one of the most common painful disorders in patients referred to the emergency department. The main purpose of this study was to compare the efficiency of two methods of intravenous (IVF) and intranasal (INF) fentanyl administration in pain management in patients with severe renal colic. Materials & methodsThis was a single-blind randomized clinical trial performed on patients with severe renal colic. The severity of pain was ≥8 based on the Numerical Rating Scale (NRS). The efficacy of pain management was compared within and between the IVF (intramuscular Ketorolac + intravenous fentanyl) and INF (intramuscular Ketorolac + intranasal fentanyl) groups at different times points. Oral consent was obtained from all the patients. ResultsOf 220 individuals, 96 (43.60%) were women and 124 (56.40%) were men. There were no significant differences between the two groups regarding the baseline pain severity, age, sex, history of urolithiasis and body mass index (BMI). The pain severity showed a significant reducing trend in both groups (p < 0.0001). There was also a significant difference comparing the mean pain severity between groups at different times (p < 0.0001). In each group, the severity of pain showed significant reduction compared with its prior measurement (P < 0.0001). ConclusionFentanyl is highly effective in controlling pain in patients with severe renal colic referring to the emergency department. Intranasal administration of fentanyl combination with ketorolac can be an appropriate, non-invasive, easy-to-use and fast alternative to the intravenous method to manage pain in these patients.

OnabotulinumtoxinA Wear-off Phenomenon in the Treatment of Chronic Migraine.

To evaluate the frequency and features of onabotulinumtoxinA (onabotA) wear-off in chronic migraine (CM). Clinical experience suggests that patients with CM frequently perceive onabotA treatment duration <12weeks, but this phenomenon has not been well explored. This study was a retrospective chart review of patients (n = 143) with CM initiated on onabotA over a 2-year period. Wear-off was considered present with the phrase documented, a quantitative headache day increase, or increased use of abortive medications, bridging therapies or emergency department visits in the 6weeks preceding the subsequent administration. Wear-off was present in 90/143 patients (62.9%). Age, sex, medication overuse, psychiatric comorbidity, injector training level, and mean days between injections did not differ between the wear-off and no wear-off groups. Mean units injected per session in the wear-off group until first documented wear-off were significantly less vs no wear-off group (166.0±13.1 vs 173.4±10.3, P=.0005). Wear-off most commonly occurred 2-4weeks before the next injection (43.3%) and after the very first injection (40.0%). Intramuscular ketorolac injections (33.3%) and peripheral nerve blocks (25.6%) were the most common bridge therapies used in the wear-off period. Most patients with CM receiving onabotA experience wear-off. Clinicians may consider increasing the units used from the treatment onset to reduce the frequent need for bridging therapies.

Multimodal Pain Management for Cesarean Delivery: A Double-Blinded, Placebo-Controlled, Randomized Clinical Trial.

Our objective was to evaluate the efficacy of perioperative multimodal pain management in reducing opioid use after elective cesarean delivery (CD). A single-center, double-blinded, placebo-controlled randomized trial of women undergoing elective CD. Participants were allocated 1:1 to receive the multimodal protocol or matching placebos. The multimodal protocol consisted of a preoperative dose of intravenous acetaminophen, preincision injection of subcutaneous bupivacaine, and intraoperative injection of intramuscular ketorolac. Primary outcome was total opioid intake at 48 hours postoperatively. Secondary outcomes were pain scores, time to first opioid intake, neonatal outcomes, and total outpatient opioid intake on postoperative day (POD) 7. Data were analyzed using parametric and nonparametric tests and quantile regression as appropriate. A total of 242 women were screened with 120 randomized, 60 to the multimodal group and 60 to control group. There was no significant difference in the primary outcome of opioid use nor in the secondary outcomes. Smokers and patients with a history of drug use had higher median postoperative opiate use and earlier administration. On POD 7, only 40% of prescribed opioids had been used, and there was no difference between the groups. This perioperative multimodal pain regimen did not reduce opioid use in 48 hours after CD. Patients who smoke or with a history of drug use required more opioids in the postoperative period. Providers significantly overprescribed opioids after CD.

Pre-emptive analgesic effects of paracetamol infusion versus intramuscular ketorolac in patients undergoing elective laparoscopic cholecystectomy: A comparative study

Pre-emptive analgesic effects of paracetamol infusion versus intramuscular ketorolac in patients undergoing elective laparoscopic cholecystectomy: A comparative study

Comparison of intramuscular injection of ketorolac and conventional treatment in the field of cost-effectiveness, length of stay and pain relief in patients admitted to the emergency department with renal colic

Background: Pain resulting from the stone passage is one of the most severe and intractable pain experiences. The aim of our study is evaluating the effect of intra-muscular ketorolac on pain reduction; reduce the length of stay and cost of patients with renal colic.Methods: This was a randomized clinical trial study which held in an academic emergency department (ED). Based on defined criteria, 222 patients with renal colic were randomized in two groups: half of them received a single intramuscular injection of 30 mg ketorolac, and other 111 patients got conventional treatment (hydration, morphine sulfate). Demographic characteristics, pain score after 30 minutes, the length of stay in ED, complications as well as hospital costs were recorded for both groups.Result: The baseline characteristics and pain score were similar in the two groups (p&gt;0.05). Ketorolac was significantly (p&lt;0.001) more effective than conventional treatment in reducing pain score. Those treated with ketorolac left the ED significantly earlier than those treated with conventional treatment (65.54; 95%CI, 59.7-71.5 vs. 193.1; 95%CI, 172.8-215.2 minutes, p&lt;0.001). Drug adverse effects (nausea, dizziness, and drowsiness) and cost of ketorolac group were significantly lower than the control group (43310 Tomans (110$) (95% CI, 42590-44030) vs. 150410 Tomans (350$) (95% CI, 240100-70940). (p&lt;0.001).Conclusion: This study showed that intramuscular ketorolac as a single agent for renal colic is cost-effective and promotes earlier discharge of renal colic patients from the ED.

A Randomized Controlled Trial of Intravenous and Intramuscular Ketorolac for Post-Cesarean Analgesia

A Randomized Controlled Trial of Intravenous and Intramuscular Ketorolac for Post-Cesarean Analgesia

Postoperative analgesia following elective abdominal surgery: a prospective observational study

Background: Laparotomy forms an important subset of general surgical operations. This study aimed at collecting the baseline information on postoperative analgesia, to detect deficiencies in current management of postoperative pain and to aid as a reference for future endeavours aimed at improving pain management following abdominal surgeries.Methods: It was conducted as a prospective descriptive study in patients undergoing elective laparotomies in the Department of General Surgery of a tertiary care institute, for two years. The patterns of prescription and administration of analgesic drugs for postoperative pain after abdominal surgery, incidence and severity of postoperative pain, adverse effects of drugs and patient satisfaction were assessed.Results: A total of 289 elective laparotomies were performed. Combinations of Non-steroidal anti-inflammatory drugs (NSAID) with opioids, epidural analgesia (EA) with supplemental intramuscular ketorolac and PCEA (Patient controlled EA) provided effective pain relief with high satisfaction score (3/4) and were associated with low sedation (1/3) and the least side effects. Patients receiving NSAIDs had higher pain score with lesser satisfaction score and lower sedation score. IV-PCA with morphine provided effective pain relief with high satisfaction score (3/4), with least side effects, but patients had high sedation score (2/3). Around 55 (55/289; 19.03%) patients experienced postoperative nausea and vomiting, which responded to antiemetic treatment.Conclusions: A combination of NSAIDs with opioids provided effective pain relief, high satisfaction with less sedation and least side effects. Epidural analgesia with supplemental intramuscular ketorolac and PCEA also provided effective pain relief with high satisfaction and less sedation with least side effects.

The Interaction of Intramuscular Ketorolac (Toradol) and Concussion in a Rat Model.

The purpose of this study was to examine the interaction of a single dose of Toradol and head impact in an in vivo rat model for sport-related concussion using a validated rat concussion model. Thirty-five Sprague-Dawley rats were placed into one of four groups: (1) Control, (2) Impact Only, (3) Toradol Only, (4) Impact and Toradol. Animals in the impact groups were subjected to a single head impact. Animals in the Toradol group received a single intramuscular injection of Toradol prior to impact. We examined magnetic resonance imaging, serum S100-B and cognitive function using a Morris Water Maze. In the control group, latency decreased significantly from day 0 (74.9s) to 24h (57.4s) after anesthesia. There was no statistically significant difference between time zero and 24h after impact in the Impact only or Impact and Toradol group. Our findings indicate that there were no differences between cognitive ability, MRI findings or S100B in rats that were administered a single dose of Toradol and subjected to a single impact and rats that were subjected to a single impact only. In both impact groups there were transient changes in cognitive ability as measured by the Morris Water Maze.

Nitrous oxide for pain management during in-office hysteroscopic sterilization: a randomized controlled trial

ObjectivesTo evaluate whether inhaled nitrous oxide with oxygen (N2O/O2) is associated with less pain compared to oral sedation for pain management during in-office hysteroscopic sterilization. Study designThis double blinded randomized controlled trial enrolled women undergoing in-office hysteroscopic sterilization. All participants received pre-procedure intramuscular ketorolac and a standardized paracervical block. The intervention group also received N2O/O2 via a nasal mask titrated to a maximum 70%:30% mixture by a nurse during the procedure and placebo pills pre-procedure and the active control group received inhaled O2 during the procedure and 5/325 mg hydrocodone/acetaminophen and 1 mg lorazepam pre-procedure. The primary outcome was maximum procedure pain on a 100 mm Visual Analog Scale (VAS with anchors at 0=no pain and 100=worst imaginable pain) assessed 3–5 min post procedure. Thirty women per treatment arm were required to detect a clinically significant pain difference of 20 mm. ResultsSeventy-two women, 36 per study arm, were randomized. Mean age of participants was 34.1±5.7 years and mean BMI was 30.1±6.6kg/m2. Mean maximum procedure pain scores were 22.8±27.6 mm and 54.5±32.7 mm for intervention and control groups, respectively (p<.001). Most study participants (97%) stated N2O/O2 should be offered for gynecologic office procedures and 86% would pay for it if not a covered benefit. ConclusionsN2O/O2 decreased pain with in-office hysteroscopic sterilization compared to oral sedation and is an effective pain management option for this procedure. ImplicationsGiven its safety and favorable side effect profile, N2O/O2 can be used for pain management for in-office hysteroscopic sterilization and adds a safe, easily administered option to currently available strategies.

Bimodal analgesia vs fentanyl in pediatric patients undergoing bilateral myringotomy and tympanostomy tube placement: a propensity matched cohort study

Study objectiveBilateral myringotomy and tympanostomy tube placement (BMT) is one of the most frequently performed pediatric outpatient procedures with 667,000 children receiving tympanostomy tubes annually. Because of this high volume, discovering the ideal analgesic regimen may lead to decreased overall postanesthesia care unit (PACU) costs while increasing patient and parent satisfaction. The purpose of this study is to determine if there is any benefit in supplementing intranasal (IN) fentanyl with intramuscular (IM) ketorolac with regard to immediate recovery characteristics. DesignRetrospective, cohort study. SettingUniversity-affiliated teaching hospital. PatientsOne thousand one hundred forty American Society of Anesthesiologists physical status 1 and 2 pediatric patients scheduled for BMT. InterventionsNo interventions were performed. MeasurementsA propensity matched cohort of pediatric patients who underwent BMT at Vanderbilt Children's Hospital from 2011 to 2014 was analyzed. The authors compared PACU recovery time, rescue analgesic administration, maximal PACU pain scores, and maximal PACU agitation scores between subgroups of patients given either IN fentanyl and IM ketorolac or IN fentanyl alone intraoperatively. Main resultsAfter adjusting for patient demographics and fentanyl dose, the fentanyl/ketorolac group received rescue analgesics 4.7% (95% confidence interval [CI], 2.0%-7.5%) less often, displayed moderate to severe pain 4.7% (95% CI, 1.5%-8.0%) less often, and experienced emergence agitation 3.6% (95% CI, 1.5%-5.8%) less often than patients in the fentanyl-only group. This corresponded to a relative risk reduction of 127%, 76%, and 200%, respectively. ConclusionsBased on our retrospective analysis, adding IM ketorolac to IN fentanyl may be beneficial to pediatric patients undergoing BMT. However, these results should be confirmed with a prospective, double-blinded, randomized study.

Comparative Evaluation of Preemptive Analgesic Effect of Injected Intramuscular Diclofenac and Ketorolac after Third Molar Surgery- A Randomized Controlled Trial.

Analgesia pre-emptively administered effect-ively aid in management of pain. Pre-emptive analgesia is anti-nociceptive treatment which prevents altered central sensitization of afferent inputs. To compare and evaluate the pre-emptive analgesic efficacy of preoperatively administered ketorolac and diclofenac for controlling postoperative pain after third molar surgery. A total of 50 patients with symmetrically impacted third molars were divided into two groups, 30mg intramuscular injection of ketorolac and 75 mg diclofenac sodium were used in the respective groups. The visual analogue scale was used to assess post operative pain for three days and the patients were also evaluated for the number of rescue analgesia. The data was statistically evaluated with paired t- test. The maximum time taken for pain perception for Group A Ketoralac was 5.48 hrs and Group B Diclofenac sodium was 4.9 hrs and p=0.235 which was not significant. The mean number of tablets taken by the patients in the first three post operative days was 3.24 in Group A i.e., Ketorolac and 4.04 in Group B i.e., Diclofenac sodium. The values were compared using the paired t test. The p value = 0.004, which was significant. Ketoralac showed better pre-emptive analgesic effect for post-operative pain management after third molar extraction. The immediate post-operative pain free period provided by both ketorolac and diclofenac by intramuscular route was same.

Ketorolac for Pain Control With Intrauterine Device Placement: A Randomized Controlled Trial.

To evaluate intramuscular ketorolac compared with placebo saline injection for pain control with intrauterine device (IUD) placement. We conducted a randomized, double-blind, placebo-controlled trial between July 2012 and March 2014. Patients received 30 mg ketorolac or placebo saline intramuscular injection 30 minutes before IUD placement. The primary outcome was pain with IUD placement on a 10-cm visual analog scale. Sample size was calculated to provide 80% power to show a 2.0-cm difference (α=0.05) in the primary outcome. Secondary outcomes included pain with study drug injection, speculum insertion, tenaculum placement, uterine sounding, and at 5 and 15 minutes after IUD placement. A total of 67 women participated in the study, 33 in the ketorolac arm and 34 in the placebo arm. There were no differences in baseline demographics including age, body mass index, and race. There were no differences in median pain scores for IUD placement in the placebo compared with ketorolac groups (5.2 compared with 3.6 cm, P=.99). There was a decrease in median pain scores at 5 minutes (2.2 compared with 0.3 cm, P≤.001) and 15 minutes (1.6 compared with 0.1 cm, P≤.001) after IUD placement but no difference for all other time points. Nulliparous participants (n=16, eight per arm) had a decrease in pain scores with IUD placement (8.1 compared with 5.4 cm, P=.02). In this study, 22% of participants in the placebo group and 18% in the ketorolac group reported injection pain was as painful as IUD placement. Ketorolac does not reduce pain with IUD placement but does reduce pain at 5 and 15 minutes after placement. ClinicalTrials.gov; www.clinicaltrials.gov, NCT01664559. I.