Toradol

[deleted171991]

No one (lawyers) cares if there is no evidence that toradol doesn't increase postop bleeding. Toradol has a BLACK BOX WARNING about bleeding. Go to your hospital pharmacy and ask for the insert label. My stand is to never give toradol. My CRNA's, if they give toradol, must document that the surgeon requested or approved it. There are better ways to treat pain. The only time I use toradol is when the pt is a recovering addict and there is a possibility of covering postop pain with APAP and Toradol. If there is no chance of pain control with those two, then unfortunately the pt may need to go through rehab again.

Seriously? You know, for the recovering addict or the chronic pain patient already on a ton of opiates, there is that ancient stuff, I think it's called ketamine.

Btw, here's the toradol insert: http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/019645s019lbl.pdf . The warning is about high bleeding-risk situations, not periop in general. I personally like to ask the surgeons; some of them want to feel in control, and were taught that Toradol is the devil's medicine.

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[Shouldawouldacouldas]

Who said anything about chronic pain pts? Recovering pts do not want anything, unless absolutely necessary. Are you calling up and following recovering pts for weeks? How are the pts going to get ketamine post op at home for those with expected severe pain? How many recovering pts do you see in your practice? I see enough because our little town has a noted rehab center.

Is it not your call concerning opioids and recovering pts.

You think the people in general are smart and educated like you? You think the jury won't think an operation is not a high bleeding risk situation? The jury will see operations as a high risk situation. I like toradol. I give toradol, but always with a note in the chart that the surgeon wanted or agreed to the toradol. Giving toradol without a surgeon's consent is foolish.

 

[teeva]

Geez some of you make it seem like toradol is lethal injection or career ending mistake or the precipitant of DIC. Maybe 30ml of it.

 

[Mman]

No one (lawyers) cares if there is no evidence that toradol doesn't increase postop bleeding. Toradol has a BLACK BOX WARNING about bleeding. Go to your hospital pharmacy and ask for the insert label. My stand is to never give toradol. My CRNA's, if they give toradol, must document that the surgeon requested or approved it. There are better ways to treat pain. The only time I use toradol is when the pt is a recovering addict and there is a possibility of covering postop pain with APAP and Toradol. If there is no chance of pain control with those two, then unfortunately the pt may need to go through rehab again.

Do you know what a BLACK BOX WARNING means legally? Nothing. Or at least nothing in it means as much or little as every other warning in the package insert and/or PDR. I have this straight from several medical malpractice experts.

Do you ever use benzos or narcotics or propofol during MAC cases? Because they all warn that they can cause respiratory depression. Perhaps you should skip them in the future.

 

[gotname]

Do you know what a BLACK BOX WARNING means legally? Nothing. Or at least nothing in it means as much or little as every other warning in the package insert and/or PDR.

In regards to ^, I'm a bit curious - Do you use phenergan? If so, are you still comfortable with IV? Or do you administer it IM as suggested due to black box warning?

 

[Mman]

In regards to ^, I'm a bit curious - Do you use phenergan? If so, are you still comfortable with IV? Or do you administer it IM as suggested due to black box warning?

it goes in the IV. A "black box warning" is simply a warning and a box. The box doesn't make the warning any stronger than any other warning.

 

[pgg]

In regards to ^, I'm a bit curious - Do you use phenergan? If so, are you still comfortable with IV? Or do you administer it IM as suggested due to black box warning?

IV. But, when I order it, I order 6.25 mg, and direct that it be diluted in 10 mL saline and given slowly through a free-flowing IV.

 

[divinemsm]

I wish I could like this a billion times. There are SO many doctors, let alone surgeons, whose lack of thought and knowledge is frightening . I don't claim to know everything-but why argue with fools?

I do as I please, unless I've had a previous altercation with that particular surgeon over the issue. Them, I will either ask or just skip it.

But I start from the default position that it's OK for me to do the right thing without their input.

It's just not worth arguing with someone who thinks it'll cause a post-lap-chole liver bleed.

 

[gotname]

@Mman & @pgg
Thanks. I have no idea as to how I can insert both your quotes in one reply so...

I brought up phenergan because I get it a lot and I have heard "black box warning against IV so we have to do IM" - I am fine with that but it happens a lot hence my query.

In fact, in July, an ED doc ordered IV phenergan but charge nurse gave my nurse a lecture about FDA warning etc. and went ahead and changed it to IM. Last year, two docs got into a debate about it. Personally, as long as it is diluted and they push it very, very slowly, I'm fine. If the IV is in the back of my hand, then I take it IM as it burns way too much.

 

[vector2]

I'm aware of the administration instructions, but anecdotally I've pushed 6.25-12.5mg of undiluted phenergan through firehose 18g's (using the proximal tubing port while the pit is running wide open) in about 50 awake C/S pts without any issues. In smaller than/really poorly running 18, I'd do pgg's method with dilution in 10cc and incremental 1cc push.

 

[Shouldawouldacouldas]

Lol. Use of toradol is relatively a small issue. My advice is avoid toradol. To treat pain you can use a narcotic or you can use/add toradol. It really is a no brainer. Use narcotics for pain control. Every day of your anesthetic career you will be evaluating one plan versus another; one drug versus another; etc... Why use a subpar drug for pain control with it's NSAID associated risks and interactions? Sometimes you will need to use toradol. You arrived at that decision, but get approval from the surgeon so that if there is post op bleed (unlikely related to toradol), he was involved and can't blame you for 'just doing it.'

Surgeon 1: Hey, Surgeon 2, I had a post op bleed in patient X.
Surgeon 2: Did anesthesia give toradol intraop? If so, that might have contributed.
Surgeon 1: I wish they would have asked me.
Anes 1: Meta-analysis of RCT conclude ketorolac does not increase perioperative bleeding.
Surgeon 1: To pt X's family, I have to take X back to OR to stop post op bleeding. I think a drug that anes gave may have contributed to it. Don't worry.
I will get a different anes person.

Remember anes is a service job. You can't just do what you want in private practice. Maybe in academic, military, or prison you can "do what you want" some of the time. In private practice at a for-profit-hospital, you don't blind side administration, you don't just make choices without the surgeon's input. Our job is like being married to two wives, one is the surgeon and one is the hospital. You always, always, always do want is best for the patient, but many time you have to get there with some communication and convincing.

 

[gotname]

So I have learned that Toradol is definitely not guilty of directly causing bleeding. However, what do you all think of it affecting platelets? Can that relation be made toradol->thrombocytopenia->bleeding or increased risk in susceptible patients hence the reluctance to use it (especially pre-op)?

Do let me know if or when I overstay my welcome!

 

[lobelsteve]

So I have learned that Toradol is definitely not guilty of directly causing bleeding. However, what do you all think of it affecting platelets? Can that relation be made toradol->thrombocytopenia->bleeding or increased risk in susceptible patients hence the reluctance to use it (especially pre-op)?

Do let me know if or when I overstay my welcome!

2 NSAIDs that do not have platelet effects are parecoxib (iv in Europe) and choline magnesium trilisate.

 

[Mman]

Lol. Use of toradol is relatively a small issue. My advice is avoid toradol. To treat pain you can use a narcotic or you can use/add toradol. It really is a no brainer. Use narcotics for pain control. Every day of your anesthetic career you will be evaluating one plan versus another; one drug versus another; etc... Why use a subpar drug for pain control with it's NSAID associated risks and interactions? Sometimes you will need to use toradol. You arrived at that decision, but get approval from the surgeon so that if there is post op bleed (unlikely related to toradol), he was involved and can't blame you for 'just doing it.'

So when your patient suffers a postop respiratory arrest on the floor in part due to the narcotics they received, can the surgeon blame you for "just doing it"? Do you double check with them before every narcotic dose?

Grow a pair. You are a doctor. Do what is right for the patient. Sometimes that involves informing/discussing with the surgeon if that makes you feel better.

 

[dhb]

Why use a subpar drug for pain control with it's NSAID associated risks and interactions?

Ketorolac is a very good analgesic

 

[pgg]

Right, because opiates are free of side effects and risk.

My god, just "use narcotics for pain control" is a ridiculous blanket statement. Ketorolac is a wonderful drug.

 

[PainDrain]

Ketorolac is a very good analgesic

Wasn't there a study showing 30mg toradol was equivalent to 10mg morphine? That sounds like a damn good analgesic if you ask me.

 

[agammaglobulin]

http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1942245

ketorolac decreases opioid consumption by 30-50%, decreases PONV by 30%, and decreases sedation by 30%.

https://scholar.google.com/scholar?...ved=0CB0QgQMwAGoVChMI3LKy3YWpyAIVh5eICh2vSQEz

Opioid only approach?! Using a multimodal approach to pain management I think is standard of care...

 

[gotname]

To treat pain you can use a narcotic or you can use/add toradol. It really is a no brainer. Use narcotics for pain control.

You always, always, always do want is best for the patient, but many time you have to get there with some communication and convincing.

I agree and would expect physicians should always want (as you state) and do the best thing for the patient and communication is essential. However, wouldn't that mean some decision making goes into play (risks/benefits etc.) and that sometimes opiates may not be the best thing in every situation?

 

[loveumms]

Re GI anastomotic procedures:

http://www.ncbi.nlm.nih.gov/pubmed/25607250

New article from WA state's surgical care and outcomes assessment program (SCOAP). Retrospective Cohort, 13,000 patients, NSAIDs started within 24 hrs after surgery. Excerpt from article 'We found an association of NSAIDs and anastomotic complications ISOLATED TO PATIENTS UNDERGOING NONELECTIVE colorectal surgery. These procedures likely take place in the settings of infection, inflammation and hemodynamic instability or shock'

This is one of them that I've reviewed when our colorectal surgeons started spouting this. I agree with you that it was nonelective surgery but I can't remember how it was defined and am not at work to look at the whole article. Remember, elective surgery is defined by the ACC/AHA as a case which can be delayed for a YEAR. I would argue that most colorectal surgeries are not elective and thus the patient population used in this study may be the same as you take care of. Most of my colorectal patients undergoing any type of surgery requiring an anastomosis are in an inflammatory state.

Anyway, I agree that there needs to be some prospective randomized controlled studies to really assess the risk (which is probably almost impossible to do properly). I guess I've always looked at it as what is the true benefit when there MAY be a risk. A little analgesia which can now be attained through multiple other mechanisms. Multimodal analgesia with ketamine, IV tylenol and a TAP block can get many patients through the operative period with very little narcotic analgesics.

Here are two that conflict but one of them found a correlation:
http://link.springer.com/article/10.1007/s11605-014-2563-8
http://link.springer.com/article/10.1007/s11605-014-2486-4

 

[loveumms]

I treat it like any other medication I give. I don't tell him that I'm giving Zofran, fentanyl, morphine, paralytic, etc. either. If I truly thought it could have a detrimental effect, I would say so. But the data says that it doesn't cause bleeding anymore (only exception is debate of tonsillectomies) than vaccines cause autism.

But it is a medication that we give that may be given in the postoperative period and when repeated at unsafe intervals can cause problems. I always discuss antibiotics, toradol and IV tylenol with the surgical team. Not to get their 'permission' because I'm a physician consultant but because we are mutually caring for the patient and they need to know about these medications so they can know when/if to give further dosing. I don't expect anyone to look at my anesthesia record because they can be difficult to interpret/find (ours are all electronic and even I hate looking through them).

 

[Ignatius J]

But it is a medication that we give that may be given in the postoperative period and when repeated at unsafe intervals can cause problems. I always discuss antibiotics, toradol and IV tylenol with the surgical team. Not to get their 'permission' because I'm a physician consultant but because we are mutually caring for the patient and they need to know about these medications so they can know when/if to give further dosing. I don't expect anyone to look at my anesthesia record because they can be difficult to interpret/find (ours are all electronic and even I hate looking through them).

I don't think that's unreasonable. Your reasoning above though isn't what was being described. Whereas you discuss it as a communication issue, others did it as an approval one. Any patient who may have post-operative pain control issues requiring multi-modal approaches during and after surgery should have a discussion. No question. Total agreement.