de Almeida, Kristen

Gopalani, Radhan

Marr-Peralto, Andrea

Neubauer, Laura

English

Scholarly Commons@Baptist Health South Florida

Baptist Health South Florida Scholarly Commons @ Baptist Health South Florida All Publications 12-9-2020 Impact of ketorolac on opioid consumption after open heart surgery Laura Neubauer Baptist Hospital of Miami, LauraNeu@baptisthealth.net Radhan Gopalani Baptist Hospital of Miami, radhang@baptisthealth.net Kristen de Almeida Baptist Hospital of Miami, KristenDe@baptisthealth.net Andrea Marr-Peralto Baptist Hospital of Miami; Miami Cardiac & Vascular Institute, AndreaMPe@baptisthealth.net Follow this and additional works at: https://scholarlycommons.baptisthealth.net/se-all-publications  Part of the Heterocyclic Compounds Commons, and the Pharmacy and Pharmaceutical Sciences Commons Citation Neubauer, Laura; Gopalani, Radhan; de Almeida, Kristen; and Marr-Peralto, Andrea, "Impact of ketorolac on opioid consumption after open heart surgery" (2020). All Publications. 3761. https://scholarlycommons.baptisthealth.net/se-all-publications/3761 This Conference Poster -- Open Access is brought to you for free and open access by Scholarly Commons @ Baptist Health South Florida. It has been accepted for inclusion in All Publications by an authorized administrator of Scholarly Commons @ Baptist Health South Florida. For more information, please contact Carrief@baptisthealth.net. RESULTSRESULTSImpact of ketorolac on opioid consumption after open heart surgeryLaura Neubauer, Pharm.D.; Radhan B. Gopalani, Pharm.D., BCPS, BCCP; Kristen E. De Almeida, Pharm.D., BCCP; Andrea Marr-Peralto, DNP, AGACNP, APRN • Opioids are the most common analgesics used in the postoperative period despite their potentially serious side effects1,2• The use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) after open heart surgery for adjunctive pain control is controversial given the potential risks of acute kidney injury (AKI) with these agents• Despite the FDA contraindication for use in patients immediately following coronary artery bypass graft (CABG) surgery, NSAIDs are commonly used in this setting with one study showing ketorolac being the agent prescribed in 90% of cases1• According to the current Baptist Health post open heart order set, ketorolac use is not recommended in patients with active bleeding, Scr >1.6 mg/dL, > 80yo, or recent history of GI bleedTo evaluate the use of ketorolac in the immediate 48 hoursafter cardiac surgery at Baptist Hospital of Miami and SouthMiami HospitalStudy Design: Multicenter, retrospective quality improvement projectInclusion Criteria:‒ Adults ≥ 18 years of age ‒ Underwent open heart surgery (CABG, valvular replacement, CABG/valvular surgery, aortic surgery) performed between 1/1/2020 and 3/31/2020Exclusion Criteria:‒ Pregnant at time of hospitalization Primary Outcome:‒ Opioid consumption in morphine milligram equivalents (MME) within 48 hours after open heart surgerySecondary Outcomes:‒ Incidence of AKI within 48 hours after open heart surgery (↑ in Scr > 0.3 mg/dL in 48 hours)‒ Opioid-induced adverse drug reactions (ADRs)  Controlling for Confounding Factors‒ To control for selection bias, patients with baseline CKD and those who received fentanyl (IV push or infusion) during the immediate 48 hours postoperatively were removed from the final analysis All authors of this presentation have nothing to disclose concerning possiblefinancial or personal relationships with commercial entities that may havedirect or indirect interest in the subject matter of this presentation.• Use of ketorolac in the immediate postoperative period did not impact opioid consumption• Risk of postoperative AKI did not increase with ketorolac o Observed statistically significant difference in AKI is not clinically meaningful and is likely due to the patient population under reviewCONCLUSIONSLIMITATIONSDISCLOSURESREFERENCESDISCUSSIONMETHODSPURPOSEBACKGROUND• Baseline demographics were not statistically different between cohorts except for age (p<0.05)• There was no statistical difference in opioid consumption between cohorts (p=0.11)• Morphine and oxycodone/acetaminophen were the most commonly received opioids. Acetaminophen IV was the most commonly received non-opioid analgesic• Patients who did not receive ketorolac had a significantly higher rate of postoperative AKI (p<0.05), possibly due to the significantly older population in this cohort; other risk factors for AKI were similar between cohorts• Use of ketorolac per the recommendations in the Baptist Health open heart order set may have additionally contributed to selection bias • A total of 3 opioid-induced ADRs resulting in treatment discontinuation were reported (hallucinations, slight over-sedation, and nausea/vomiting)• Retrospective• Small study duration and sample size • Selection bias• Pain scores could not be evaluated due to inconsistent documentation1. Kulik A, Bykov K, Choudhry NK, et al. Non-steroidal anti-inflammatory drug administration after coronary artery bypass surgery: utilization persists despite the boxed warning. Pharmacoepidemiol Drug Saf. 2015;24:647-653.2. Martinez L, Ekman E, Nakhla N. Periopeartive Opioid-sparing Strategies: Utility of Conventional NSAIDs in Adults. Clin. Ther. 2019;41(12):2612-2628.3. Bainbridge D, Cheng DC, Martin JE, et al. NSAID-analgesia, pain control and morbidity in cardiothoracic surgery. Can J Anesth. 2006:53(1):46-59.DemographicsKetorolac(n=22)No Ketorolac (n=45)P-value Avg. age, years (SD) 63.2 + 9.2 68.4 + 9.0 < 0.05Age > 75 years – n (%) 2 (9) 11 (24.4) 0.20Gender – male, n (%) 18 (81.8) 33 (73.3) 0.55Outpatient use of opioids – n (%) 1 (4.5) 1 (2.2) 0.55Outpatient use of adjuvant pain meds – n (%) 2 (9) 4 (8.9) 1.00Non-Elective Procedure – n (%) 16 (73) 28 (62) 0.40Avg. Scr on admission, mg/dL (SD) 0.99 + 0.23 1.04 + 0.32 0.50Avg. Scr day of surgery, mg/dL (SD) 0.90 + 0.16 0.98 + 0.28 0.21Avg. Scr 48h postop, mg/dL (SD) 0.92 + 0.19 1.18 + 0.53 < 0.05OTHER RISK FACTORS FOR AKIUse of CPB – n (%) 20 (90.9) 39 (86.7) 0.62Dehydration postop (BUN:Scr > 20:1) – n (%) 12 (54.5) 28 (62.2) 0.55Use of vasopressors postop – n (%) 19 (86.4) 32 (71.1) 0.170 20 40 60 80 100No KetorolacKetorolacp-value= 0.11OPIOID CONSUMPTION WITHIN 48 HOURS POSTOPAvg. Morphine Milligram Equivalents (MME)ANALGESICS RECEIVED WITHIN 48 HOURS POSTOP8870POSTOP INCIDENCE OF AKI Analgesic – n (%)Ketorolac(n=22)No Ketorolac (n=45)Morphine 22 (100) 41 (91.1)Acetaminophen IV 21 (95.5) 41 (91.1)Oxycodone/Acetaminophen 19 (86.4) 37 (82.2)Acetaminophen PO 5 (22.7) 15 (33.3)Hydromorphone 0 4 (8.9)Gabapentin 0 3 (6.7)Tramadol 1 (4.5) 1 (2.2)0 10 20 30 40 50No KetorolacKetorolacp-value < 0.05404.5% Patients

Impact of ketorolac on opioid consumption after open heart surgery

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Impact of ketorolac on opioid consumption after open heart surgery

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