Adult Tonsillectomy Patients Using Ketorolac at Greater Risk of Hemorrhage

What are the risks of post-tonsillectomy hemorrhage associated with peri-operative ketorolac use for adult and pediatric patients?

Background: Ketorolac, a nonsteroidal anti-inflammatory drug for analgesia, is associated with increased risk of post-operative hemorrhage in some settings; however, recommendations for its use lack clarity. A recent 2010 Cochrane review of NSAID use in children undergoing tonsillectomy found no statistically significant increased post-tonsillectomy hemorrhage risk in patients who receive ketorolac, while the 2011 American Academy of Otolaryngology–Head and Neck Surgery pediatric tonsillectomy guidelines advise avoiding ketorolac.

Study design: Systematic review and meta-analysis of 10 retrospective and prospective primary articles from 1970 to 2013.

Setting: PubMed database.

Synopsis: When all 10 studies were considered together, a summary relative risk (RR) of 2.04 was calculated, implying a significantly increased risk of post-tonsillectomy hemorrhage associated with ketorolac use. (One study was an outlier, with an RR of 9.17 but no notable study design features to explain the aberration.) When pediatric and adult patients were assessed independently, however, there was a greatly increased risk in adults (RR: 5.64) compared with children. Adults receiving ketorolac had more than five times the increased risk of bleeding—significantly elevated compared with control patients—but the risk of bleeding in children was not significantly increased. Timing of ketorolac administration did not affect the RR. Tonsillectomy technique was not included in the analysis because of reporting variability, but it is not definitively related to differential hemorrhage risk. Limitations included varying definitions of post-operative bleeding and post-tonsillectomy hemorrhage, length of follow-up issues, and a significant bias risk across many domains for all reports, including inconsistent and usually sparse detail regarding the exact method of randomization and treatment allocation.

Bottom line: Ketorolac can be used safely in children who receive tonsillectomies but is associated with a five-fold increased bleeding risk in adults.

Citation: Chan DK, Parikh SR. Perioperative ketorolac increases post-tonsillectomy hemorrhage in adults but not children. Laryngoscope. 2014:124:1789-1793.