Intraoperative Ketorolac Use Does Not Increase the Risk of Bleeding in Breast Surgery
The use of nonsteroidal anti-inflammatory drugs is an effective adjunct in managing perioperative pain. We sought to determine if the use of intraoperative ketorolac as part of a multimodal ERAS protocol increased the risk of bleeding complications in breast surgery.
A subset analysis of a prospective cohort study including patients undergoing lumpectomy and mastectomy compared two groups: those who received intraoperative ketorolac and those who did not. Bleeding complications were compared using Fisher’s exact test or t test, and analyzed with respect to surgical modality. Patients undergoing immediate reconstruction were excluded.
Seven hundred and fifty-eight breast surgeries were performed in a 13-month period: 157 lumpectomy patients and 57 mastectomy patients met inclusion criteria between July 2017 and August 2018. Two hundred and fourteen patients were included in the analysis: 115 received ketorolac and 99 did not. The two groups were similar with regards to sex, age, race, tobacco use, and comorbidities. When analyzed together, there was no difference in bleeding complications between the group that received intraoperative ketorolac and those who did not (2% vs. 2.6%, p = 1.00). No hematomas occurred in the lumpectomy patients, and three occurred in mastectomy patients: one of which received ketorolac, and two did not (5.9% vs. 5.0%, p = 0.575). The rates of seroma, infection, or dehiscence were not significantly different between the two groups, regardless of surgical modality.
The use of intraoperative ketorolac is a useful adjunct in perioperative pain management in breast surgery and does not increase the risk of bleeding.
The authors acknowledge the Maimonides Medical Center anesthesiologists and perioperative staff, residents in the Departments of Surgery and Anesthesiology, pharmacists, and the administrative staff of the Brooklyn Breast Center of Maimonides Medical Center. They especially thank Johanna Yu, BSN, RN, Mohamad Hashim MD, Carin Zelkowitz PA-C, Jeffey Jacobs PA-C, and Mary-Ann Myrthil PA-C, whose cooperation and flexibility in implementing and promoting the ERAS protocol was not only beneficial to our study but to our patients.
Dr. P. Borgen and Dr. K. Rojas have received speaker’s honoraria from Pacira Pharmaceuticals, Inc. All other authors report no relevant commercial, financial, consultant, or institutional conflict of interest.
- 6.Liang X, Liu R, Chen C, Ji F, Li T. Opioid system modulates the immune function: a review. Transl Perioper Pain Med. 2016;1(1):5–13.Google Scholar
- 8.Gupta K, Kshirsagar S, Chang L, Schwartz R, Law PY, Yee D, Hebbel RP. Morphine stimulates angiogenesis by activating proangiogenic and survival-promoting signaling and promotes breast tumor growth. Cancer Res. 2002;62(15):4491–8.Google Scholar
- 9.Nestler EJ, Hyman SE, Holtzman DM, Malenka RC. Molecular neuropharmacology: a foundation for clinical neuroscience, 2nd edn. New York: McGraw-Hill Medical, 2009.Google Scholar
- 23.Mikhaylov Y, Weinstein B, Schrannk TP, Swartz JD, Ulm JP, Armstrong MB, Delaney KO. Ketorolac and hematoma incidence in postmastectomy implant-based breast reconstruction. Ann Plast Surg. 2018; 80(5):472–4.Google Scholar