Use of ketorolac is associated with decreased pneumonia following rib fractures

doi:10.1016/j.amjsurg.2013.05.011

The American Journal of Surgery

Volume 207, Issue 4, April 2014, Pages 566-572

Findings from this study were presented at the Surgical Forum, American College of Surgeons Annual Clinical Congress, October 3, 2012, Chicago, Illinois.

https://doi.org/10.1016/j.amjsurg.2013.05.011 Get rights and content

Abstract

Background

The effectiveness of the nonsteroidal anti-inflammatory drug ketorolac in reducing pulmonary morbidity after rib fractures remains largely unknown.

Methods

A retrospective cohort study was conducted spanning January 2003 to June 2011 assessing pneumonia within 30 days and potential adverse effects of ketorolac among all patients with rib fractures who received ketorolac <4 days after injury compared with a random sample of those who did not.

Results

Among 202 patients who received ketorolac and 417 who did not, ketorolac use was associated with decreased pneumonia (odds ratio, .14; 95% confidence interval, .04 to .46) and increased ventilator-free days (difference, 1.8 days; 95% confidence interval, 1.1 to 2.5) and intensive care unit–free days (difference, 2.1 days; 95% confidence interval, 1.3 to 3.0) within 30 days. The rates of acute kidney injury, gastrointestinal hemorrhage, and fracture nonunion were not different.

Conclusions

Early administration of ketorolac to patients with rib fractures is associated with a decreased likelihood of pneumonia, without apparent risks.

Section snippets

Study design

We conducted a single-center retrospective cohort study. We hypothesized that the administration of ketorolac early after injury would decrease the likelihood of developing pneumonia during the first 30 days of hospitalization. The University of California, Davis, institutional review board approved of our planned study before we commenced.

Study setting and population

We identified hospitalized trauma patients using our center's trauma registry. We included patients hospitalized from January 1, 2003, to June 30, 2011, who

Results

We abstracted records for 417 control hospitalizations, which we compared with the 202 constituting the ketorolac group. All patients had either radiographic evidence of rib fractures or pleuritic pain on physical exam. The average age of the combined cohort was 48 ± 18 years, and the average Injury Severity Score was 12 ± 9 (Table 1). Motor vehicle collisions accounted for >50% of the hospitalizations in both groups. Abbreviated Injury Scale head and abdominal scores were greater in the

Comments

Our study suggests that the administration of ketorolac early after injury significantly decreases the risk for pneumonia among patients with rib fractures. It also appeared to reduce time on the ventilator and in the intensive care unit without any prominent increase in such known or hypothesized risks of nonsteroidal anti-inflammatory drugs as acute kidney injury, myocardial infarction, stroke, gastrointestinal hemorrhage, or fracture nonunion. Because pneumonia was a relatively rare outcome,

Acknowledgment

We thank the staff at the University of California, Davis, Clinical and Translational Science Center for assistance with data management.

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Les traumatismes thoraciques sont à l’origine de fractures de côtes qui sont très douloureuses et participent à l’aggravation de lésions sous jacentes comme les contusions pulmonaires et peuvent favoriser une décompensation respiratoire. L’analgésie systémique est insuffisante pour contrôler efficacement la douleur. Les techniques d’analgésie loco-régionale sont plus efficaces. Elles incluent l’analgésie péridurale notamment lorsque les lésions sont bilatérales, et les blocs de la paroi thoracique écho-guidés. Parmi ceux ci le bloc paravertébral reste la référence mais de nouveaux blocs tels que le bloc des érecteurs du rachis ou le bloc du serratus apportent des améliorations techniques, ou peuvent se révéler plus adaptés notamment en cas d’effraction pleural pariétale. Un contrôle précoce et efficace de la douleur est un aspect important de la prise en charge des patients.
Thoracic parietal trauma induce rib fractures which are especially painful and may worsen pulmonary lesion such as lung contusion leading to acute respiratory failure. Systemic analgesia fails to produce an effective pain control. Regional analgesic techniques are more effective. They include epidural analgesia dedicated to bilateral lesions and thoracic blocks such as paravertebral block which is the gold standard in this settings. However, some new blocks including the rector spinae block and the serratus block may introduce some technical improvement especially when pleural damage limits the efficacy of paravertebral block. An early control of pain is especially mandatory in those patients not only to improve their comfort but also to prevent the occurrence of severe complications.
Less Is More: A Multimodal Pain Management Strategy Is Associated With Reduced Opioid Use in Hospitalized Trauma Patients
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Citation Excerpt :
While a group recently published their successful utilization of a multimodal pain management strategy in trauma patients,9 the use of nonopioid medications in this population has not been thoroughly studied. Nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, nonbenzodiazepine skeletal muscle relaxants, subdissociative ketamine, lidocaine patches, and gabapentinoids have been described, but the quality of evidence is low.10-16 A protocolized multimodal and holistic approach is essential for optimal pain management in this complex population.
Adequate pain control is critical to the management and recovery of acutely injured patients. Opioids are associated with various adverse effects, and drug overdose is the leading cause of injury-related death in the United States. We hypothesized that a multimodal pain management protocol would reduce opioid use while still optimizing pain control.
The study included the preanalysis (August 2017-September 2018) and postanalysis (October 2018-August 2019) of a multimodal pain management strategy implemented in hospitalized adult patients admitted to the trauma service at a single American College of Surgeons-verified level-1 trauma center. Patients less than 18 y of age, pregnant patients, or imprisoned patients were excluded. The primary endpoint was opioid prescription on discharge (morphine milligram equivalent [MME]). The secondary endpoints included inpatient MMEs, nonopioid adjunct use, and pain scores. Subgroup analysis evaluating opioid use based on Injury Severity Score groups (mild, moderate, or severe) and by the Abbreviated Injury Scale body region was performed.
There were 1755 patients in the PRE group and 1723 patients in the POST group. MMEs prescribed on discharge decreased from median 15 (interquartile range: 37.5) to 1.2 (interquartile range: 22.5) (P < 0.001). More patients in the POST group were discharged opioid-free (44% versus 37%, P < 0.001). There was a significant increase in the use of all nonopioid pain medications. Pain scores did not change. Subgroup analysis revealed a significant decrease in discharge MMEs in mild and moderate Injury Severity Score groups and in all injured body regions except the chest.
The implementation of a multimodal pain management protocol in trauma patients targeting scheduled nonopioid medications and patient education is feasible and is associated with reduced opioid amount prescribed on discharge, without compromising pain control.
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Objective: To describe pain assessment and analgesic management practices in patients in intensive care units (ICUs) in Australia and New Zealand.
Design, setting and participants: Prospective, observational, multicentre, single-day point prevalence study conducted in Australian and New Zealand ICUs. Observational data were recorded for all adult patients admitted to an ICU without a neurological, neurosurgical or postoperative cardiac diagnosis. Demographic characteristics and data on pain assessment and analgesic management for a 24-hour period were collected.
Main outcome measures: Types of pain assessment tools used and frequency of their use, use of opioid analgesia, use of adjuvant analgesia, and differences in pain assessment and analgesic management between postoperative and non-operative patients.
Results: From the 499 patients enrolled from 45 ICUs, pain assessment was performed at least every 4 hours in 56% of patients (277/499), most commonly with a numerical rating scale. Overall, 286 patients (57%) received an opioid on the study day. Of the 181 mechanically ventilated patients, 135 (75%) received an intravenous opioid, with the predominant opioid infusion being fentanyl. The median dose of opioid infusion for ventilated patients was 140 mg oral morphine equivalents. Of the 318 non-ventilated patients, 41 (13%) received patient-controlled analgesia and 76 (24%) received an oral opioid, with the predominant opioid being oxycodone. Paracetamol was administered to 63 ventilated patients (35%) and 164 non-ventilated patients (52%), while 2% of all patients (11/499) received a non-steroidal anti-inflammatory drug. Ketamine infusion and regional analgesia were used in 15 patients (3%) and 17 patients (3%), respectively. Antineuropathic agents (predominantly gabapentinoids) were used in 53 patients (11%).
Conclusions: Although a majority of ICU patients were frequently assessed for pain with a validated pain assessment tool, cumulative daily doses of opioids were high, and the use of multimodal adjuvant analgesia was low. Our data on current pain assessment and analgesic management practices may inform further research in this area.

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: This publication was made possible by grant UL1 RR024146 from the National Center for Research Resources, a component of the National Institutes of Health, and the National Institutes of Health Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the National Center for Research Resources or National Institutes of Health.

: The authors declare no conflicts of interest.

View full text

Clinical ScienceUse of ketorolac is associated with decreased pneumonia following rib fractures

Abstract

Background

Methods

Results

Conclusions

Section snippets

Study design

Study setting and population

Results

Comments

Acknowledgment

J Am Coll Surg

Chest

Surgery

Br J Anaesth

Br J Anaesth

Thorac Surg Clin

J Cardiothorac Vasc Anesth

Br J Anaesth

Br J Anaesth

J Thorac Cardiovasc Surg

J Biomed Inform

The fractured rib in chest wall trauma

Chest Surg Clin N Am

The morbidity and mortality of rib fractures

J Trauma

A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management

Eur J Cardiothorac Surg

A stepwise logistic regression analysis of factors affecting morbidity and mortality after thoracic trauma: effect of epidural analgesia

J Trauma

Isolated rib fractures in elderly patients: mortality and morbidity

Can J Surg

Clinical Science
Use of ketorolac is associated with decreased pneumonia following rib fractures