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oxycodone versus patient-controlled analgesia with morphine in anterior cruciate ligament reconstruction patients
A Comparison of Ketorolac Tromethamine/Oxycodone Versus Patient-Controlled Analgesia With Morphine in Anterior Cruciate Ligament Reconstruction Patients James E. Popp, M.D., William A. Sanko, M.D., Aasha K. Sinha, B.V.Sc., and Christopher C. Kaeding, M.D.
Summary: Effective postoperative analgesia with minimal side effects remains an important goal in enabling increasingly complex surgical procedures to be performed on an outpatient basis. In this study, we examined the efficacy of postoperative analgesia in 90 patients undergoing anterior cruciate ligament reconstruction using a patellar tendon autograft, with a 24-hour hospital stay. Patients were randomized to receive either intramuscular ketorolac supplemented by oral oxycodone, or intravenous morphine via patient-controlled analgesia (PCA) device, for postoperative analgesia. Patients were monitored for 2 hours in the recovery room, then every 4 hours until discharge, for the presence of complications of nausea, vomiting, urinary retention, pruritus, and dizziness. Pain was assessed using a visual analog scale (VAS) on the morning of postoperative day one. All patients were discharged by 24 hours after surgery. Ten (20%) of the patients receiving ketorolac/oxycodone versus 31 (79%) of those receiving PCA morphine experienced postoperative complications (P ⬍ .05). Postoperative nausea, vomiting, and urinary retention were each significantly more common in the PCA morphine group (P ⬍ .05). The incidence of pruritus and dizziness was low overall. There was no significant difference between groups in the severity of postoperative pain as assessed using a VAS. We conclude that ketorolac/oxycodone may provide comparable analgesia with fewer undesirable side effects than PCA morphine in patients undergoing anterior cruciate ligament reconstruction. Patients receiving ketorolac/oxymorphone may have a better quality recovery and more rapid discharge. Key Words: Postoperative—Nausea—Vomiting—Outpatient— Pain—NSAID.
I
n today’s medical climate, there is growing pressure to reduce the length of hospital stay and perform elective surgical procedures on an outpatient basis. One of the major challenges in achieving this goal is the need to provide effective postoperative analgesia with minimal side effects. The narcotic analgesics, such as morphine, act centrally to mimic the action of From the Division of Orthopaedic Surgery, Department of Surgery, The Ohio State University, Columbus, Ohio, U.S.A. Address correspondence and reprint requests to Christopher C. Kaeding, M.D., The Ohio State University Sports Medicine Center, 2050 Kenny Rd, Columbus, OH 43221, U.S.A. r 1998 by the Arthroscopy Association of North America 0749-8063/98/1408-1435$3.00/0
816
endogenous opioids, and remain the most common drugs used to treat postoperative pain. Opioid analgesics can be titrated to achieve effective pain relief; however, side effects such as sedation, nausea, vomiting, urinary retention, and pruritus also occur in a dose-dependent manner. As a result, alternative analgesic regimens that reduce or eliminate the need for narcotics, are increasingly used. Nonsteroidal antiinflammatory drugs (NSAIDs), such as ketorolac tromethamine (Syntex Roche Laboratories, Palo Alto, CA) may be administered postoperatively and have analgesic, anti-inflammatory, and antipyretic effects, with their main mechanism of action via inhibition of prostaglandin synthesis. Use of NSAIDs may decrease
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 14, No 8 (November-December), 1998: pp 816–819
KETOROLAC/OXYMORPHINE VERSUS PCA MORPHINE or eliminate the need for narcotic analgesics in the early postoperative period, thereby facilitating discharge of most patients on the day of surgery. Previous studies have reported fewer undesirable side effects with a comparable level of analgesia, in surgical patients receiving ketorolac versus those receiving parenteral opioids.1-8 It is increasingly apparent that ketorolac tromethamine may provide effective analgesia even after major surgery and may be associated with fewer side effects when administered on a shortterm basis. A few previous studies have compared patient-controlled analgesia (PCA) using opioid analgesics with the use of ketorolac tromethamine.9-11 We performed a retrospective study examining the efficacy of postoperative analgesia in 90 patients undergoing elective anterior cruciate ligament (ACL) reconstruction with a patellar tendon autograft. Patients had a 24-hour hospital stay and were randomized to receive either intravenous (IV) morphine via PCA device, or intramuscular (IM) ketorolac tromethamine supplemented by oral oxycodone as needed, for postoperative analgesia. MATERIALS AND METHODS Ninety consecutive patients undergoing singleportal endoscopic ACL reconstruction with an ipsilateral patellar tendon autograft by the same surgeon (C.C.K.) were prospectively randomized by a coin toss to one of two groups. The ketorolac/oxycodone group comprised 51 patients who received 60 mg ketorolac tromethamine IM in the operating room at the completion of surgery, followed by 30 mg IM every 6 hours until discharge at 24 hours. Supplemental analgesia with 1 to 2 tablets oral oxycodone (Percocet (oxycodone HCL 5mg/acetaminophen 325mg); Endo Pharmaceuticals Inc, Wilmington, DE) was available for these patients every 4 hours as needed. The PCA with morphine group comprised the remaining 39 patients, who received a PCA device in the recovery room allowing 1 mg morphine sulfate IV, with an 8-minute lockout interval, until discharge at 24 hours. At the completion of surgery, which included placement of a subcutaneously located positive suction drain, each patient was observed for 2 hours in the recovery room. Patients were then evaluated every 4 hours for the presence of complications, including nausea requiring an antiemetic, vomiting, urinary retention requiring catheterization, significant pruritus, and dizziness while resting in bed. At 6 AM on postoperative day 1, drain output was recorded and patients were asked to rate their pain using a visual analog scale (VAS). This
817
assessment of pain was conducted independently by an anesthesia research nurse who was not involved with patient care. Also on the morning of the first postoperative day, functional capacity was evaluated by a physical therapist. Criteria assessed were ability to ambulate 100 feet using crutches, range of motion of the operated knee without restrictive bandages (goal 10° to 80°), and the ability to climb up and down three steps. Patients were discharged home within 24 hours. Statistical testing using -square analysis and analysis of variance for comparison of the two groups was performed using a statistical software package (SAS Institute, Cary, NC). Statistical significance was set at P ⬍ .05. RESULTS There were no significant differences between the two groups when age, sex, presence of concurrent meniscal injury, chronicity of injury, surgery time, or type of anesthesia, were compared. Overall, patients receiving ketorolac/oxycodone postoperatively experienced significantly fewer complications in the first 24 hours than those receiving PCA morphine (P ⬍ .05). Ten patients (20%) in the ketorolac/oxycodone versus 31 patients (79%) in the PCA morphine group experienced one or more complications in the first 24 hours after surgery (Table 1). Pruritus and dizziness occurred infrequently overall so that a statistical comparison between groups for these symptoms was not made. Variable amounts of oral oxycodone were taken by 41 patients (80%) in the ketorolac/oxycodone group (5.7 ⫾ 2.9 tablets, mean ⫾ SD). Two patients who had taken oxycodone within 4 hours of the VAS assessment of postoperative pain were excluded from this part of the study. The degree of pain as assessed on the morning of postoperative day 1, using the VAS, was not significantly different for the two groups (ketorolac/ oxycodone VAS mean ⫾ SD 2.6 ⫾ 1.7; PCA morphine VAS 3.2 ⫾ 1.6). Five patients were removed from the study for reasons related to analgesic regimen. Three TABLE 1. Number of Patients Experiencing Complications During the First 24 Hours Postoperatively Complication
Ketorolac/Oxycodone
PCA Morphine
Nausea* Vomiting* Urinary retention* Pruritis Dizziness
6 5 2 0 2
26 21 11 6 2
*Significant difference between groups (P ⬍ .05).
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J. E. POPP ET AL.
patients in the ketorolac/oxycodone group had inadequate pain control and required breakthrough with IV morphine. Two patients receiving PCA morphine were excluded because one had a severe anaphylactic reaction and the other developed shortness of breath. Both events resulted in cessation of morphine administration. Three out of three physical therapy goals were achieved by 34 patients (67%) in the ketorolac/ oxycodone group, and 19 patients (49%) in the PCA morphine group. Drainage volume as recorded the morning after surgery was not significantly different between groups (mean ⫾ SD, ketorolac/oxycodone 98 ⫾ 53 mL; PCA morphine 103 ⫾ 66 mL). DISCUSSION In this study, we found a significantly higher incidence of postoperative nausea, vomiting, and urinary retention in patients receiving IV morphine via PCA pump versus those receiving IM ketorolac tromethamine supplemented with oral oxycodone. There was no difference in analgesia as assessed by VAS the morning after surgery. All patients were able to be discharged within 24 hours after surgery. If the goal is to perform this procedure in an ambulatory setting, our findings suggest that discharge may be delayed in patients receiving IV morphine for treatment of postoperative pain. Postoperative nausea and vomiting are major determinants of suitability for discharge, as well reasons for unanticipated admission following ambulatory surgery.12 In addition, these symptoms are bothersome for the patient if they persist beyond discharge and cause unanticipated delays in return to work and resumption of other routine activities. Inability to void urine may also delay discharge and cause additional discomfort for the patient. As such, our finding that the incidence of urinary retention requiring catheterization was also more common in the PCA morphine group warrants consideration. Our finding that a similar degree of analgesia was achieved for patients receiving IM and oral pain medications, specifically ketorolac and oxycodone, as for those receiving IV morphine, supports previous reports. Brown et al.2 found a similar degree of analgesia for patients receiving 30 mg of ketorolac tromethamine IM versus patients given 12 mg morphine IV, with a significantly higher incidence of undesirable side effects in the morphine group. Spindler et al.5 also report comparable and adequate analgesic control after major surgery for patients receiving either ketorolac or morphine. Our results as well as those of others indicate that
NSAIDs such as ketorolac may have analgesic, antiinflammatory, and opioid-sparing effects that are beneficial to the postoperative patient. However, adverse effects including altered coagulation, gastrointestinal irritation and ulceration, and nephrotoxicity, should be considered. Previously, it was reported that ketorolac administered IM four times daily to normal volunteers caused a modest prolongation of bleeding time and a small decrease in platelet count, when hemostasis was assessed after 5 days.13 However, more recently, Thwaites et al.14 found that IV ketorolac did not alter platelet function in patients undergoing knee arthroscopy under general anesthesia. In the present study, patients received a single dose of ketorolac at the completion of surgery and there was no significant increase in drainage volume, one possible indicator of increased bleeding, in the NSAID-treated group. It is possible that postoperative versus preoperative administration allows normal hemostatic mechanisms to be effective. Although it is reported that gastrointestinal irritation is relatively common with NSAID use,12 serious problems such as ulceration and renal toxicity occur less commonly and appear unlikely with shortterm use in relatively healthy, young patients. The benefits of NSAIDs in ambulatory surgery patients should be weighed against the potential risks on an individual basis, and will vary depending on the procedure involved. Inadequate pain control and persistent nausea and vomiting are the most common nonsurgical causes of unplanned admission after outpatient surgery.12 Clearly, improved analgesic regimens with minimal side effects are desired when patient comfort and rapid discharge home are goals. In this study we have shown that satisfactory postoperative pain relief with minimal side effects can be achieved with IM ketorolac and oral oxycodone in ACL reconstruction patients. In the drive to perform more surgical procedures on an outpatient basis, treatment decisions compatible with both costcontainment and optimal patient care should remain our goal.
REFERENCES 1. Brown CR, Moodie JE, Dickie G, et al. Analgesic efficacy and safety of single dose oral and intramuscular ketorolac tromethamine for postoperative pain. Pharmacotherapy 1990;10:59S70S. 2. Brown CR, Mazzulla JP, Mok MS, Nussdorf RT, Rubin PD, Schwesinger WH. Comparison of repeated doses of intramuscular ketorolac tromethamine and morphine sulfate for analgesia after major surgery. Pharmacotherapy 1990;10:45S-50S.
KETOROLAC/OXYMORPHINE VERSUS PCA MORPHINE 3. O’Hara DA, Fragen RJ, Kinzer M, Pemberton D. Ketorolac tromethamine as compared with morphine sulfate for treatment of postoperative pain. Clin Pharmacol Ther 1987;41:556-561. 4. Power I, Douglas WE, Spence AA. Comparison of IM ketorolac trometamol and morphine sulphate for pain relief after cholecystectomy. Br J Anaesth 1990;65:448-455. 5. Spindler JS, Mehlisch D, Brown CR. Intramuscular ketorolac and morphine in the treatment of moderate to severe pain after major surgery. Pharmacotherapy 1990;10:51S-58S. 6. Yee JP, Koshiver JE, Allbon C, Brown CR. Comparison of intramuscular ketorolac tromethamine and morphine sulfate for analgesia of pain after major surgery. Pharmacotherapy 1986;6:253-261. 7. Yee JP, Waterbury LD. Ketorolac tromethamine is a new analgesic with efficacy comparable to morphine that does not bind to opioid receptors and has a low addiction potential. Clin Res 1987;35:163A (abstr). 8. Lopez M, Waterbury LD, Michel A, Seavey W, Yee JP. Lack of addictive potential of ketorolac tromethamine. Pharmacologist 1987;29:136 (abstr).
819
9. Black AM, Goodman NW, Bullingham RE, Lloyd J. Intramuscular ketorolac and morphine during patient controlled analgesia (PCA) after hysterectomy: Does PCA lock-out time reveal an efficacy limitation of ketorolac? Eur J Anaesth 1990;7:9-17. 10. Cataldo PA, Senegore AJ, Kilbride MJ. Ketorolac and patient controlled analgesia in the treatment of post-operative pain. Surg Gynecol Obstet 1993;176:435-438. 11. McGuire DA, Sanders K, Hendricks SD. Comparison of ketorolac and opioid analgesics in post-operative ACL reconstruction outpatient pain control. Arthroscopy 1993;9:653-661. 12. Rapp SE. Recovery and discharge. Anesth Clin North Am 1996;14:817-834. 13. Conrad KA, Fagan TC, Mackie MJ, Mayshar PV. Effects of ketorolac tromethamine on hemostasis in volunteers. Clin Pharmacol Ther 1988;43:542-456. 14. Thwaites BK, Nigus DB, Bouska GW et al. Intravenous ketorolac tromethamine does not worsen platelet function during knee arthroscopy under general anesthesia. Anesth Analg 1995;81:119-124.
Summary: Effective postoperative analgesia with minimal side effects remains an important goal in enabling increasingly complex surgical procedures to be performed on an outpatient basis. In this study, we examined the efficacy of postoperative analgesia in 90 patients undergoing anterior cruciate ligament reconstruction using a patellar tendon autograft, with a 24-hour hospital stay. Patients were randomized to receive either intramuscular ketorolac supplemented by oral oxycodone, or intravenous morphine via patient-controlled analgesia (PCA) device, for postoperative analgesia. Patients were monitored for 2 hours in the recovery room, then every 4 hours until discharge, for the presence of complications of nausea, vomiting, urinary retention, pruritus, and dizziness. Pain was assessed using a visual analog scale (VAS) on the morning of postoperative day one. All patients were discharged by 24 hours after surgery. Ten (20%) of the patients receiving ketorolac/oxycodone versus 31 (79%) of those receiving PCA morphine experienced postoperative complications (P ⬍ .05). Postoperative nausea, vomiting, and urinary retention were each significantly more common in the PCA morphine group (P ⬍ .05). The incidence of pruritus and dizziness was low overall. There was no significant difference between groups in the severity of postoperative pain as assessed using a VAS. We conclude that ketorolac/oxycodone may provide comparable analgesia with fewer undesirable side effects than PCA morphine in patients undergoing anterior cruciate ligament reconstruction. Patients receiving ketorolac/oxymorphone may have a better quality recovery and more rapid discharge. Key Words: Postoperative—Nausea—Vomiting—Outpatient— Pain—NSAID.
I
n today’s medical climate, there is growing pressure to reduce the length of hospital stay and perform elective surgical procedures on an outpatient basis. One of the major challenges in achieving this goal is the need to provide effective postoperative analgesia with minimal side effects. The narcotic analgesics, such as morphine, act centrally to mimic the action of From the Division of Orthopaedic Surgery, Department of Surgery, The Ohio State University, Columbus, Ohio, U.S.A. Address correspondence and reprint requests to Christopher C. Kaeding, M.D., The Ohio State University Sports Medicine Center, 2050 Kenny Rd, Columbus, OH 43221, U.S.A. r 1998 by the Arthroscopy Association of North America 0749-8063/98/1408-1435$3.00/0
816
endogenous opioids, and remain the most common drugs used to treat postoperative pain. Opioid analgesics can be titrated to achieve effective pain relief; however, side effects such as sedation, nausea, vomiting, urinary retention, and pruritus also occur in a dose-dependent manner. As a result, alternative analgesic regimens that reduce or eliminate the need for narcotics, are increasingly used. Nonsteroidal antiinflammatory drugs (NSAIDs), such as ketorolac tromethamine (Syntex Roche Laboratories, Palo Alto, CA) may be administered postoperatively and have analgesic, anti-inflammatory, and antipyretic effects, with their main mechanism of action via inhibition of prostaglandin synthesis. Use of NSAIDs may decrease
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 14, No 8 (November-December), 1998: pp 816–819
KETOROLAC/OXYMORPHINE VERSUS PCA MORPHINE or eliminate the need for narcotic analgesics in the early postoperative period, thereby facilitating discharge of most patients on the day of surgery. Previous studies have reported fewer undesirable side effects with a comparable level of analgesia, in surgical patients receiving ketorolac versus those receiving parenteral opioids.1-8 It is increasingly apparent that ketorolac tromethamine may provide effective analgesia even after major surgery and may be associated with fewer side effects when administered on a shortterm basis. A few previous studies have compared patient-controlled analgesia (PCA) using opioid analgesics with the use of ketorolac tromethamine.9-11 We performed a retrospective study examining the efficacy of postoperative analgesia in 90 patients undergoing elective anterior cruciate ligament (ACL) reconstruction with a patellar tendon autograft. Patients had a 24-hour hospital stay and were randomized to receive either intravenous (IV) morphine via PCA device, or intramuscular (IM) ketorolac tromethamine supplemented by oral oxycodone as needed, for postoperative analgesia. MATERIALS AND METHODS Ninety consecutive patients undergoing singleportal endoscopic ACL reconstruction with an ipsilateral patellar tendon autograft by the same surgeon (C.C.K.) were prospectively randomized by a coin toss to one of two groups. The ketorolac/oxycodone group comprised 51 patients who received 60 mg ketorolac tromethamine IM in the operating room at the completion of surgery, followed by 30 mg IM every 6 hours until discharge at 24 hours. Supplemental analgesia with 1 to 2 tablets oral oxycodone (Percocet (oxycodone HCL 5mg/acetaminophen 325mg); Endo Pharmaceuticals Inc, Wilmington, DE) was available for these patients every 4 hours as needed. The PCA with morphine group comprised the remaining 39 patients, who received a PCA device in the recovery room allowing 1 mg morphine sulfate IV, with an 8-minute lockout interval, until discharge at 24 hours. At the completion of surgery, which included placement of a subcutaneously located positive suction drain, each patient was observed for 2 hours in the recovery room. Patients were then evaluated every 4 hours for the presence of complications, including nausea requiring an antiemetic, vomiting, urinary retention requiring catheterization, significant pruritus, and dizziness while resting in bed. At 6 AM on postoperative day 1, drain output was recorded and patients were asked to rate their pain using a visual analog scale (VAS). This
817
assessment of pain was conducted independently by an anesthesia research nurse who was not involved with patient care. Also on the morning of the first postoperative day, functional capacity was evaluated by a physical therapist. Criteria assessed were ability to ambulate 100 feet using crutches, range of motion of the operated knee without restrictive bandages (goal 10° to 80°), and the ability to climb up and down three steps. Patients were discharged home within 24 hours. Statistical testing using -square analysis and analysis of variance for comparison of the two groups was performed using a statistical software package (SAS Institute, Cary, NC). Statistical significance was set at P ⬍ .05. RESULTS There were no significant differences between the two groups when age, sex, presence of concurrent meniscal injury, chronicity of injury, surgery time, or type of anesthesia, were compared. Overall, patients receiving ketorolac/oxycodone postoperatively experienced significantly fewer complications in the first 24 hours than those receiving PCA morphine (P ⬍ .05). Ten patients (20%) in the ketorolac/oxycodone versus 31 patients (79%) in the PCA morphine group experienced one or more complications in the first 24 hours after surgery (Table 1). Pruritus and dizziness occurred infrequently overall so that a statistical comparison between groups for these symptoms was not made. Variable amounts of oral oxycodone were taken by 41 patients (80%) in the ketorolac/oxycodone group (5.7 ⫾ 2.9 tablets, mean ⫾ SD). Two patients who had taken oxycodone within 4 hours of the VAS assessment of postoperative pain were excluded from this part of the study. The degree of pain as assessed on the morning of postoperative day 1, using the VAS, was not significantly different for the two groups (ketorolac/ oxycodone VAS mean ⫾ SD 2.6 ⫾ 1.7; PCA morphine VAS 3.2 ⫾ 1.6). Five patients were removed from the study for reasons related to analgesic regimen. Three TABLE 1. Number of Patients Experiencing Complications During the First 24 Hours Postoperatively Complication
Ketorolac/Oxycodone
PCA Morphine
Nausea* Vomiting* Urinary retention* Pruritis Dizziness
6 5 2 0 2
26 21 11 6 2
*Significant difference between groups (P ⬍ .05).
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J. E. POPP ET AL.
patients in the ketorolac/oxycodone group had inadequate pain control and required breakthrough with IV morphine. Two patients receiving PCA morphine were excluded because one had a severe anaphylactic reaction and the other developed shortness of breath. Both events resulted in cessation of morphine administration. Three out of three physical therapy goals were achieved by 34 patients (67%) in the ketorolac/ oxycodone group, and 19 patients (49%) in the PCA morphine group. Drainage volume as recorded the morning after surgery was not significantly different between groups (mean ⫾ SD, ketorolac/oxycodone 98 ⫾ 53 mL; PCA morphine 103 ⫾ 66 mL). DISCUSSION In this study, we found a significantly higher incidence of postoperative nausea, vomiting, and urinary retention in patients receiving IV morphine via PCA pump versus those receiving IM ketorolac tromethamine supplemented with oral oxycodone. There was no difference in analgesia as assessed by VAS the morning after surgery. All patients were able to be discharged within 24 hours after surgery. If the goal is to perform this procedure in an ambulatory setting, our findings suggest that discharge may be delayed in patients receiving IV morphine for treatment of postoperative pain. Postoperative nausea and vomiting are major determinants of suitability for discharge, as well reasons for unanticipated admission following ambulatory surgery.12 In addition, these symptoms are bothersome for the patient if they persist beyond discharge and cause unanticipated delays in return to work and resumption of other routine activities. Inability to void urine may also delay discharge and cause additional discomfort for the patient. As such, our finding that the incidence of urinary retention requiring catheterization was also more common in the PCA morphine group warrants consideration. Our finding that a similar degree of analgesia was achieved for patients receiving IM and oral pain medications, specifically ketorolac and oxycodone, as for those receiving IV morphine, supports previous reports. Brown et al.2 found a similar degree of analgesia for patients receiving 30 mg of ketorolac tromethamine IM versus patients given 12 mg morphine IV, with a significantly higher incidence of undesirable side effects in the morphine group. Spindler et al.5 also report comparable and adequate analgesic control after major surgery for patients receiving either ketorolac or morphine. Our results as well as those of others indicate that
NSAIDs such as ketorolac may have analgesic, antiinflammatory, and opioid-sparing effects that are beneficial to the postoperative patient. However, adverse effects including altered coagulation, gastrointestinal irritation and ulceration, and nephrotoxicity, should be considered. Previously, it was reported that ketorolac administered IM four times daily to normal volunteers caused a modest prolongation of bleeding time and a small decrease in platelet count, when hemostasis was assessed after 5 days.13 However, more recently, Thwaites et al.14 found that IV ketorolac did not alter platelet function in patients undergoing knee arthroscopy under general anesthesia. In the present study, patients received a single dose of ketorolac at the completion of surgery and there was no significant increase in drainage volume, one possible indicator of increased bleeding, in the NSAID-treated group. It is possible that postoperative versus preoperative administration allows normal hemostatic mechanisms to be effective. Although it is reported that gastrointestinal irritation is relatively common with NSAID use,12 serious problems such as ulceration and renal toxicity occur less commonly and appear unlikely with shortterm use in relatively healthy, young patients. The benefits of NSAIDs in ambulatory surgery patients should be weighed against the potential risks on an individual basis, and will vary depending on the procedure involved. Inadequate pain control and persistent nausea and vomiting are the most common nonsurgical causes of unplanned admission after outpatient surgery.12 Clearly, improved analgesic regimens with minimal side effects are desired when patient comfort and rapid discharge home are goals. In this study we have shown that satisfactory postoperative pain relief with minimal side effects can be achieved with IM ketorolac and oral oxycodone in ACL reconstruction patients. In the drive to perform more surgical procedures on an outpatient basis, treatment decisions compatible with both costcontainment and optimal patient care should remain our goal.
REFERENCES 1. Brown CR, Moodie JE, Dickie G, et al. Analgesic efficacy and safety of single dose oral and intramuscular ketorolac tromethamine for postoperative pain. Pharmacotherapy 1990;10:59S70S. 2. Brown CR, Mazzulla JP, Mok MS, Nussdorf RT, Rubin PD, Schwesinger WH. Comparison of repeated doses of intramuscular ketorolac tromethamine and morphine sulfate for analgesia after major surgery. Pharmacotherapy 1990;10:45S-50S.
KETOROLAC/OXYMORPHINE VERSUS PCA MORPHINE 3. O’Hara DA, Fragen RJ, Kinzer M, Pemberton D. Ketorolac tromethamine as compared with morphine sulfate for treatment of postoperative pain. Clin Pharmacol Ther 1987;41:556-561. 4. Power I, Douglas WE, Spence AA. Comparison of IM ketorolac trometamol and morphine sulphate for pain relief after cholecystectomy. Br J Anaesth 1990;65:448-455. 5. Spindler JS, Mehlisch D, Brown CR. Intramuscular ketorolac and morphine in the treatment of moderate to severe pain after major surgery. Pharmacotherapy 1990;10:51S-58S. 6. Yee JP, Koshiver JE, Allbon C, Brown CR. Comparison of intramuscular ketorolac tromethamine and morphine sulfate for analgesia of pain after major surgery. Pharmacotherapy 1986;6:253-261. 7. Yee JP, Waterbury LD. Ketorolac tromethamine is a new analgesic with efficacy comparable to morphine that does not bind to opioid receptors and has a low addiction potential. Clin Res 1987;35:163A (abstr). 8. Lopez M, Waterbury LD, Michel A, Seavey W, Yee JP. Lack of addictive potential of ketorolac tromethamine. Pharmacologist 1987;29:136 (abstr).
819
9. Black AM, Goodman NW, Bullingham RE, Lloyd J. Intramuscular ketorolac and morphine during patient controlled analgesia (PCA) after hysterectomy: Does PCA lock-out time reveal an efficacy limitation of ketorolac? Eur J Anaesth 1990;7:9-17. 10. Cataldo PA, Senegore AJ, Kilbride MJ. Ketorolac and patient controlled analgesia in the treatment of post-operative pain. Surg Gynecol Obstet 1993;176:435-438. 11. McGuire DA, Sanders K, Hendricks SD. Comparison of ketorolac and opioid analgesics in post-operative ACL reconstruction outpatient pain control. Arthroscopy 1993;9:653-661. 12. Rapp SE. Recovery and discharge. Anesth Clin North Am 1996;14:817-834. 13. Conrad KA, Fagan TC, Mackie MJ, Mayshar PV. Effects of ketorolac tromethamine on hemostasis in volunteers. Clin Pharmacol Ther 1988;43:542-456. 14. Thwaites BK, Nigus DB, Bouska GW et al. Intravenous ketorolac tromethamine does not worsen platelet function during knee arthroscopy under general anesthesia. Anesth Analg 1995;81:119-124.