Stop giving 30 mg of ketorolac

[epidural man]

Why ibuprofen

Well for one, there are something like 18 black box warnings for Toradol....perhaps the most of any drug on the market.

does IV Ibuprofen have any? Maybe 1 or 2...if at all.

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[epidural man]

This is only GI bleeding, not surgical bleeding. I just got scolded by spine surgeon for using it. Do you just throw this article in their face, or do you suck it up and play along?

I don't make a big deal of it.

It is their patient - they have to deal with post operative pain, and bleeding.

Walk a mile in their shoes...right? I suspect if I was a surgeon, and had a bleeding complication, I would have a hard time not relying on anecdotal circumstances..i think that is just human nature.

I mean look at Nadal? Have you seen his ridiculous routine before serving? I sit on my couch thinking he is such an idiot and think..."Really? If you hit the ball well you really think it is because you rubbed your butt and nose 7 times - but your hard work, incredible talent, rigorous practice and meticulous diet don't have anything to do with it?" Yet I suspect if I hit an awesome shot, I might start to think...what did I do different? Did I touch my shoe a certain way?

Who knows...

 

[pgg]

I mean look at Nadal? Have you seen his ridiculous routine before serving?

It's mental conditioning. Repetitive, precise tasks done under pressure benefit from a mental and physical routine. It's focus and muscle memory. Lots of books have been written about it and good coaches will encourage it.

That's different from superstition and magical thinking about bleeding and ketorolac.

That said, I agree it's not a worthwhile hill to die on. But anyway, I usually don't say anything to the surgeon when I give some fentanyl, or ondansetron, or ketorolac. To date, no surgeon has ever looked at my anesthetic record and come back to me to gripe about ketorolac. Oddly enough I feel like I'm allowed to do the right thing.

 

[Timeoutofmind]

This is only GI bleeding, not surgical bleeding. I just got scolded by spine surgeon for using it. Do you just throw this article in their face, or do you suck it up and play along?

Not good to use in spine surgery

For instance, recommended not to give nsaids periop for SCS according to ASRA guidelines, and that is a lower bleeding risk than many spine surgeries

 

[Mman]

Not good to use in spine surgery

For instance, recommended not to give nsaids periop for SCS according to ASRA guidelines, and that is a lower bleeding risk than many spine surgeries

I'm pretty sure the SCS guidelines are because it's like a big epidural catheter and any bleeding in the closed epidural space is bad. There is no chance a dose of 15 mg of ketorolac causes significant postop bleeding for a spine fusion.

 

[Sublimazing]

All of the ketorolac perioperative bleeding literature I’ve seen uses “post operative bleeding events” as an outcome...and it’s pretty clear that particular outcome is not increased...but does anyone have a study that looke at intraoperative bleeding? It’s an NSAID so it seems like it would increase bleeding...and I’m just interested to see the studies where they’ve looked at the amount of intraop bleeding after its adminstration.

 

[MirrorTodd]

All of the ketorolac perioperative bleeding literature I’ve seen uses “post operative bleeding events” as an outcome...and it’s pretty clear that particular outcome is not increased...but does anyone have a study that looke at intraoperative bleeding? It’s an NSAID so it seems like it would increase bleeding...and I’m just interested to see the studies where they’ve looked at the amount of intraop bleeding after its adminstration.

You'd have to find surgeons who are willing to give an honest answer about how much intraop bleeding they are seeing.

 

[Sublimazing]

You'd have to find surgeons who are willing to give an honest answer about how much intraop bleeding they are seeing.

Well that would probably prove fruitless but if they were able to accurately track intraop bleeding with careful assessment of the neptune/cannister and blood volume in the sponges maybe a more objective figure could be reached.

I’ve had a lot of fellow anesthesia providers give the nsaid upfront for the increased benefit of early anti-inflammatory administration and when asked about the bleeding they all have cited the “no increased post operative bleeding events”...but that doesn’t account for increased intraoperative bleeding...it may not lead to a bleeding event, but it seems like it certainly can make the surgery more difficult causing increased surgery time or worse surgical outcomes.

If anyone has any data on it id love to look at it.

 

[Psai]

Well that would probably prove fruitless but if they were able to accurately track intraop bleeding with careful assessment of the neptune/cannister and blood volume in the sponges maybe a more objective figure could be reached.

I’ve had a lot of fellow anesthesia providers give the nsaid upfront for the increased benefit of early anti-inflammatory administration and when asked about the bleeding they all have cited the “no increased post operative bleeding events”...but that doesn’t account for increased intraoperative bleeding...it may not lead to a bleeding event, but it seems like it certainly can make the surgery more difficult causing increased surgery time or worse surgical outcomes.

If anyone has any data on it id love to look at it.

I give it at the end only

 

[NOsaintsfan]

For all those worried about intraop bleeding with NSAIDs do any of you use TXA?

 

[AnesRunner]

I give it post-induction and have never asked since residency. I teach my residents not to as well. We are not nurses that administer medications based on a surgeon's order. We do what we believe is best for the patient given the literature in front of us.

I previously trained as a surgeon. Intraoperative or postoperative bleeding is due to poor hemostasis (or, much less likely, a severe coagulopathy). But it's easier to always blame anesthesia, eh?

 

[Sublimazing]

I give it post-induction and have never asked since residency. I teach my residents not to as well. We are not nurses that administer medications based on a surgeon's order. We do what we believe is best for the patient given the literature in front of us.

I previously trained as a surgeon. Intraoperative or postoperative bleeding is due to poor hemostasis (or, much less likely, a severe coagulopathy). But it's easier to always blame anesthesia, eh?

Kind of an aggressive response. No one was blaming anesthesia. The goal of anesthesia is about optimizing the patient for surgery. Everywhere I’ve worked it has been a team approach. NSAIDs increase bleeding...if you’re causing the surgeon to spend more time suctioning, limiting his view, and going after oozing with the bovie then you’re prolonging the surgery...and i find it bizarre that you’d just routinely push it upfront without any discussion with the surgical team.

 

[Ronin786]

Kind of an aggressive response. No one was blaming anesthesia. The goal of anesthesia is about optimizing the patient for surgery. Everywhere I’ve worked it has been a team approach. NSAIDs increase bleeding...if you’re causing the surgeon to spend more time suctioning, limiting his view, and going after oozing with the bovie then you’re prolonging the surgery...and i find it bizarre that you’d just routinely push it upfront without any discussion with the surgical team.

NSAIDs increase bleeding. Nothing says a single dose of ketorolac does. That's the entire issue.

Also that's definitely not the role of an anesthesiologist. Part of my job description is making your job easier as a surgeon, but that falls far behind my duty to the patient to help them survive your assault in a safe and comfortable fashion. That mentality is why surgeons always think we're lazy for not overdoing it with paralytics or snowing patients during MAC.

 

[AnesRunner]

Kind of an aggressive response. No one was blaming anesthesia. The goal of anesthesia is about optimizing the patient for surgery. Everywhere I’ve worked it has been a team approach. NSAIDs increase bleeding...if you’re causing the surgeon to spend more time suctioning, limiting his view, and going after oozing with the bovie then you’re prolonging the surgery...and i find it bizarre that you’d just routinely push it upfront without any discussion with the surgical team.

There's a difference between a team approach and doing whatever a surgeon tells you to do. If you ask, a lot of surgeons will tell you not to give Toradol due to their lack of knowledge about the bleeding it "causes." Surgical training is not literature-based. You learn how to behave/care for patients based on what the prior generation tells you. In the case of Toradol, it is still propagated in residency from old surgeons who still believe it leads to bleeding, which it does not.

 

[dhb]

if you’re causing the surgeon to spend more time suctioning, limiting his view, and going after oozing with the bovie then you’re prolonging the surgery

you just found a new reason why anesthesia prolongs surgery! Clearly the reason why some surgeons can do x amount of time and some can't crack 3x

 

[Mman]

NSAIDs increase bleeding...if you’re causing the surgeon to spend more time suctioning, limiting his view, and going after oozing with the bovie then you’re prolonging the surgery...and i find it bizarre that you’d just routinely push it upfront without any discussion with the surgical team.

As mentioned, repeated doses of NSAIDs for weeks cause bleeding, not a single dose pre or intraop.

 

[Sublimazing]

As mentioned, repeated doses of NSAIDs for weeks cause bleeding, not a single dose pre or intraop.

That makes sense. I was just looking for evidence that proved it.

 

[Sublimazing]

There's a difference between a team approach and doing whatever a surgeon tells you to do. If you ask, a lot of surgeons will tell you not to give Toradol due to their lack of knowledge about the bleeding it "causes." Surgical training is not literature-based. You learn how to behave/care for patients based on what the prior generation tells you. In the case of Toradol, it is still propagated in residency from old surgeons who still believe it leads to bleeding, which it does not.

A surgeon telling you “don’t use toradol” is not a team approach and that’s not what i was talking about. But when you’re giving a medication thats own insert says not to give it, I think it’s fair to bring up why you’re administering the medication against the manufacturer’s explicit indications.

 

[deleted875186]

I don’t think it increases bleeding, but I haven’t found any good proof.

FYI, the FDA warning says: TORADOL is CONTRAINDICATED as prophylactic analgesic before any major surgery.

I do find it strange to give Todadol at the beginning of surgery, even if just for the off chance the surgery gets bloody I don’t want anyone “blaming me” for causing a coagukopathy.

 

[deleted171991]

A surgeon telling you “don’t use toradol” is not a team approach and that’s not what i was talking about. But when you’re giving a medication thats own insert says not to give it, I think it’s fair to bring up why you’re administering the medication against the manufacturer’s explicit indications.

Yes. And we give a ton of medications despite their "black box" warnings, because the events are extremely rare, and irrelevant with one-time doses, proper monitoring and in the proper settings. For this reason, for example, most urologists will be fine with giving Toradol after ureteroscopic procedures, and most surgeons (and me) will be antsy if it was a long, open abdominal procedure. Many surgeons will be fine with Toradol 48-72 hours after the same major open procedures, even if not immediately. It's called judgment call, and it's based on evidence and experience. The same 1 mg epinephrine vial that can easily give stroke and MI in your hands will save lives in mine in a whole host of situations, not just shock or cardiac arrest.

If we did only what's written in inserts by lawyers, or what's FDA-approved, the average life expectancy would be at least 10 years less. Heck, most of this country provides spinal anesthesia (e.g. for joints) with a vial that has NOT FOR SPINAL ANESTHESIA printed ON THE VIAL. Some of our favorite medications have black box warnings. (What matters is the context, the risks vs benefits analysis.)

This is what anesthesiologists specialize in: working with dangerous, even lethal, drugs. We are not nurses or techs, we are highly-trained physicians; we tend to know our stuff and be conservative about putting patients at risk (way more conservative than surgeons); we only use a potentially dangerous drug when we know that its benefits far exceed its risks. Nobody else in the OR has this training, so the PC/brainwash idea of a "team approach" is moot. The "team approach" is valuable when there is no clear expert on a subject; or do you ask your entire OR "team" what suture THEY think YOU should use? Do you REALLY think that a surgeon knows more pharmacology than an anesthesiologist, especially when about IV analgesic medications?

 

[nimbus]

Try giving a dose of toradol during a bilateral breast revision/capsulectomy. I did this once between the first and second sides. The difference in raw surface oozing was impressive. I reserve toradol for the end of procedures now.

 

[deleted171991]

Try giving a dose of toradol during a bilateral breast revision/capsulectomy. I did this once between the first and second sides. The difference in raw surface oozing was impressive. I reserve toradol for the end of procedures now.

I've had a similar experience. Because of that, I wait till the end, too. On the other hand, I still have to see postop bleeding from toradol in the ICU, even with multiple doses.

Let's recall physiology for a bit. Toradol degrades platelet function. If we look at a thromboelastogram, we see that platelets contribute the most to the clot formation time and plug strength (as expected, since primary hemostasis is a contributor to both). Stabilizing the primary platelet plug and resisting to clot lysis have nothing to do with platelets.

So, unless the surgeon did not do proper bleeding control during the surgery, unless there is still some ongoing minor bleed somewhere, giving Toradol at the end of the surgery won't do harm by itself. Now if the patient has other factors that interfere with hemostasis, one should take them into account, the same way one does for neuraxial blocks. It's a risks vs benefits analysis, starting with the worst case scenario (hence smart people don't give Toradol for big surgeries, or airway surgeries, for example).

 

[deleted697535]

Try giving a dose of toradol during a bilateral breast revision/capsulectomy. I did this once between the first and second sides. The difference in raw surface oozing was impressive. I reserve toradol for the end of procedures now.

Rigorous methodology there! Annals of surgery level

 

[nimbus]

Rigorous methodology there! Annals of surgery level

I would only suggest you try it yourself.

 

[Mman]

I would only suggest you try it yourself.

how big of a dose?

 

[Psai]

how big of a dose?

Not 30 that's for sure

 

[Sublimazing]

Yes. And we give a ton of medications despite their "black box" warnings, because the events are extremely rare, and irrelevant with one-time doses, proper monitoring and in the proper settings. For this reason, for example, most urologists will be fine with giving Toradol after ureteroscopic procedures, and most surgeons (and me) will be antsy if it was a long, open abdominal procedure. Many surgeons will be fine with Toradol 48-72 hours after the same major open procedures, even if not immediately. It's called judgment call, and it's based on evidence and experience. The same 1 mg epinephrine vial that can easily give stroke and MI in your hands will save lives in mine in a whole host of situations, not just shock or cardiac arrest.

If we did only what's written in inserts by lawyers, or what's FDA-approved, the average life expectancy would be at least 10 years less. Heck, most of this country provides spinal anesthesia (e.g. for joints) with a vial that has NOT FOR SPINAL ANESTHESIA printed ON THE VIAL. Some of our favorite medications have black box warnings. (What matters is the context, the risks vs benefits analysis.)

This is what anesthesiologists specialize in: working with dangerous, even lethal, drugs. We are not nurses or techs, we are highly-trained physicians; we tend to know our stuff and be conservative about putting patients at risk (way more conservative than surgeons); we only use a potentially dangerous drug when we know that its benefits far exceed its risks. Nobody else in the OR has this training, so the PC/brainwash idea of a "team approach" is moot. The "team approach" is valuable when there is no clear expert on a subject; or do you ask your entire OR "team" what suture THEY think YOU should use? Do you REALLY think that a surgeon knows more pharmacology than an anesthesiologist, especially when about IV analgesic medications?

What situations are you giving toradol before incision?

 

[nimbus]

how big of a dose?

It was 30. And it was 21 years ago.

 

[deleted171991]

What situations are you giving toradol before incision?

None. See my post above.