Optimizing Pain Management in Autologous Breast Reconstruction: Intravenous Ketorolac in the Enhanced Recovery After Surgery Pathway

Abstract

Background: Enhanced recovery after surgery (ERAS) pathways can decrease hospital length of stay (LOS) and oral morphine equivalent (OME) use after autologous breast reconstruction. Ketorolac is a powerful nonsteroidal anti-inflammatory drug used in our ERAS pathway. The purpose of this study was to analyze the safety and efficacy of scheduled low- versus high-dose intravenous (IV) ketorolac. Methods: A retrospective study of patients who underwent abdominally based breast reconstruction with our ERAS protocol was conducted from July 2015 to June 2020. Controls (group A) received no IV ketorolac, whereas cases received at least 3 doses of either low-dose (15 mg, group B) or high-dose (30 mg, group C) IV ketorolac. Outcomes of interest included LOS, OME use, acute kidney injury, 30-day return to operating room, and blood transfusion. Results: A total of 159 patients were included (group A = 62, group B = 43, group C = 54). The 3 groups differed only in mean age (group A = 52.6 y, group B = 50.9 y, group C = 46 y; P = 0.0018). Compared with controls (group A = 297.6 mg, 5.16 d), the administration of scheduled low- and high-dose ketorolac was associated with a significant reduction in mean OME use (group B = 120.3 mg, P = 0.0003; group C = 176.9 mg, P = 0.0415) and LOS (group B = 4.21 d, P < 0.0004; group C = 4.22 d, P = 0.001). Ketorolac use was not associated with a significant increase in complications. Conclusions: Scheduled postoperative ketorolac administration significantly reduces opioid consumption and LOS, without adverse effects, in patients undergoing abdominally based breast reconstruction.