Consumer Referee Request: Ketorolac for pain after surgery in children
The Pain, Palliative and Supportive Care Review Group (PaPaS) is seeking a consumer referee for a new review titled, Ketorolac for pain after surgery in children
There is no good evidence to support or reject the suggestion that ketorolac is effective or that it is associated with serious side effects in treating children's pain after surgery.
Children are at risk of experiencing pain in the short term after surgery. Non-steroidal anti-inflammatory drugs (NSAIDs, aspirin-like drugs) can reduce moderate to severe pain without many of the side effects associated with opioids (drugs like morphine). However, NSAIDs may cause bleeding and injury to the kidneys and gut. Ketorolac is an NSAID that can be given by injection into a vein, which may be useful when patients are not able to take medicines by mouth.
In September 2016, we searched for clinical trials where ketorolac was used to treat pain after surgery in children. We found 12 studies, enrolling 854 children, that met our requirements for the review. The studies were quite different in their design: the dose of ketorolac; the timing of (during or after surgery) and number of doses given; the type of surgery; and what ketorolac was compared to (either a placebo or another drug).
There was not enough information for a statistical analysis of the assessments we were most interested in: the number of children with at least 50% pain relief; or average pain intensity. Four studies reported that ketorolac was better at reducing pain intensity than placebo, but the studies were small and had various design issues. There was more information for other assessments, such as the number of children needing rescue medication (an additional pain medication that is given if the study medication is not helping the person's pain sufficiently) and how much of this rescue medication was used. Fewer children needed rescue medication in the ketorolac group than those who received placebo, although the result was not statistically different. In the four hours after they received study medications, children receiving ketorolac needed slightly less rescue pain medication than those who had received placebo. There was not enough information about ketorolac in direct comparisons with other medications.
There was also not enough information in the studies for us to make a good assessment of side effects and serious side effects when ketorolac is used in this setting. Serious side effects in those receiving ketorolac included bleeding, but it didn't occur often enough for us to make any firm conclusions. Very few children dropped out of the studies because of side effects. This is not unusual in studies where patients are only in the study for a short period of time.
Quality of the evidence
We rated the quality of the evidence as very low, due to methodological issues with many of the studies, differences in study designs, and low overall numbers of children enrolled. Very low quality evidence means that we are very uncertain about the results.
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We send a copy of the final published review to the consumer referee along with the peer referee comments and, where possible, the response from the authors to these comments.