IV Tylenol Offirmev

[Ignatius J]

I have a few points to add...

1. IV Tylenol absolutely works better than oral in more patients then we would like to admit. That is because of polymorphism in our cytochrome system. I don't remember the numbers exactly, but I think up to 1/3 of patients with 1gm of oral Tylenol will NOT get to a therapeutic level because of 1rst-pass metabolism. (So if you say tylenol doesn't work of you - it's probably true. Just know that it works great in others.) 100% of IV doses get to a therapeutic level.

2. Agree that ketoralac does not increase bleeding - lots of patients and doses to show this (in the literature) - except in tonsils where it has been shown to clearly increase post op bleeding. Don't use it in tonsils. As an interesting side note on Ketoralac... the oral, IM, and IV route all have the same bioavailability, onset and duration. I used to jam me in the muscle when I took a dose at work, now I just drink it - tastes horrible.

3. IV Tylenol probably doesn't have a huge effect - and you probably get the most bang for your buck by avoiding intraoperative opioids all together. However, it's probably worth $15.

Toradol has only been shown to increase post op bleeding in non-pediatric tonsillectomies. To my knowledge, it has has never definitively been shown by a large-scale, veritable study to increase bleeding in kids. And it is GREAT to use in this procedure for pain control.

I know because in residency I got kicked out of the OR for getting into an argument with the attending about it and did a lot of research thereafter into it. Whoops.

Just spitballing- basically, 30 years ago or so some studies showed that Toradol could increase bleeding in kids when dosed at 1 mg/kg (0.5mg/kg is sufficient btw). It was a very small sample size, BTW. Since, then there has been an even bigger transition from cold, hard steel (old school guys some years ago still used it) for tonsillar dissection to monocautery and harmonic scalpels and all sorts of cool instruments I may not even be familiar with that improve coagulation.

One hospital did a retrospective analysis of kids receiving Toradol for T&A and found that it did not increase bleeding, decreased PACU stay and decreased hospital admissions.

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[urge]

I don't understand how on this day and age we are arguing whether ketorolac causes bleeding or not. Do we argue whether you can do neuroaxial anesthesia in a patient taking aspirin? You can expect the same level of platelet inhibition for ketorolac. It's negligible.

I give it to pretty much everybody who is getting extubated.

 

[Hockeyguy]

C

Last I heard we're still paying $10.

Any way you could check on that? Is that a hospital system price? That's cheaper than Kaiser which usually gets the lowest price.

 

[epidural man]

I don't understand how on this day and age we are arguing whether ketorolac causes bleeding or not. Do we argue whether you can do neuroaxial anesthesia in a patient taking aspirin? You can expect the same level of platelet inhibition for ketorolac. It's negligible.

I give it to pretty much everybody who is getting extubated.

We argue about it because it still isn't clear in many peoples minds and there are many that say ...i knew this one guy that told me there isn't bleeding...etc.

But the literature is pretty clear.

Bleeding is increased significantly in tonsils. This has been shown in prospective studies, double blinded studies, and meta-analysis and retrospective. Of all those, I think there is one single meta-analysis that shows that it wasn't increased in tonsils in kids.

But your point may be that some increased intra-op bleeding, increased postop bleeding, and a 400% increase in re-operation (in tonsils) isn't that big of a deal - to that I say..go forth and use.

It should also be noted that in the largest retrospective (Strom BL. Parenteral ketorolac and risk of gastrointestinal and operative site bleeding. A postmarketing surveillance study. JAMA. 1996 Feb 7;275(5):376-82.), it seemed that patients over 75 did have a slight increase in surgical site bleeding.

In almost all studies, it does show in increase in GI complications.

I love ketoralac by the way - not arguing to not use it.

We just need to be clear - that's all.

 

[pgg]

Any way you could check on that? Is that a hospital system price? That's cheaper than Kaiser which usually gets the lowest price.

Just called our inpatient pharmacy. Our price is $7.32 per bottle.

 

[psychbender]

Just called our inpatient pharmacy. Our price is $7.32 per bottle.

Hooray government bulk discount.

 

[urge]

We argue about it because it still isn't clear in many peoples minds and there are many that say ...i knew this one guy that told me there isn't bleeding...etc.

But the literature is pretty clear.

Bleeding is increased significantly in tonsils. This has been shown in prospective studies, double blinded studies, and meta-analysis and retrospective. Of all those, I think there is one single meta-analysis that shows that it wasn't increased in tonsils in kids.

But your point may be that some increased intra-op bleeding, increased postop bleeding, and a 400% increase in re-operation (in tonsils) isn't that big of a deal - to that I say..go forth and use.

The same can be said of dexamethasone and it doesn't stop people from using it. 7 fold increase in bleeding, btw.

 

[Ignatius J]

We argue about it because it still isn't clear in many peoples minds and there are many that say ...i knew this one guy that told me there isn't bleeding...etc.

But the literature is pretty clear.

Bleeding is increased significantly in tonsils. This has been shown in prospective studies, double blinded studies, and meta-analysis and retrospective. Of all those, I think there is one single meta-analysis that shows that it wasn't increased in tonsils in kids.

But your point may be that some increased intra-op bleeding, increased postop bleeding, and a 400% increase in re-operation (in tonsils) isn't that big of a deal - to that I say..go forth and use.

It should also be noted that in the largest retrospective (Strom BL. Parenteral ketorolac and risk of gastrointestinal and operative site bleeding. A postmarketing surveillance study. JAMA. 1996 Feb 7;275(5):376-82.), it seemed that patients over 75 did have a slight increase in surgical site bleeding.

In almost all studies, it does show in increase in GI complications.

I love ketoralac by the way - not arguing to not use it.

We just need to be clear - that's all.

Just FYI, sorry to keep editing, but I believe the most recent literature says it only increases bleeding in adult tonsillectomies, not children.

 

[epidural man]

Just FYI, sorry to keep editing, but I believe the most recent literature says it only increases bleeding in adult tonsillectomies, not children.

You are correct.
Chan, Dylan K., and Sanjay R. Parikh. "Perioperative ketorolac increases post‐tonsillectomy hemorrhage in adults but not children." Laryngoscope. 2014 Aug;124(8):1789-93.

However, they are the only one to find this conclusion. When you look at the actually studies (randomized, etc), there is an increase.

Also, a recent meta-analysis said it didn't increase bleeding in all cases.
Gobble, Ryan M., et al. "Ketorolac Does Not Increase Perioperative Bleeding: A Meta-Analysis of Randomized Controlled Trials." Plastic and reconstructive surgery 133.3 (2014): 741-755.

What is interesting in this article is they claim this "This is the first meta-analysis" which is laughable since there is only about 4000 meta-analysis looking at the same thing.

 

[Ignatius J]

You are correct.
Chan, Dylan K., and Sanjay R. Parikh. "Perioperative ketorolac increases post‐tonsillectomy hemorrhage in adults but not children." Laryngoscope. 2014 Aug;124(8):1789-93.

However, they are the only one to find this conclusion. When you look at the actually studies (randomized, etc), there is an increase.

Also, a recent meta-analysis said it didn't increase bleeding in all cases.
Gobble, Ryan M., et al. "Ketorolac Does Not Increase Perioperative Bleeding: A Meta-Analysis of Randomized Controlled Trials." Plastic and reconstructive surgery 133.3 (2014): 741-755.

What is interesting in this article is they claim this "This is the first meta-analysis" which is laughable since there is only about 4000 meta-analysis looking at the same thing.

Looks like we are getting closer to a consensus.

Just a few off the cuff points:

The meta-analysis would have to find some valid studies discussing Toradol not being a factor in post-op bleeding to properly reach it's statistically significant conclusions.

Many studies use Toradol at 1mg/kg which in my opinion is a supra therapeutic dose. 0.5 mg/kg is sufficient.

Remember, a lot of the studies were done 20-25 years ago when Toradol first came out, and there has been improvement in dissection tools for tonsillectomies.