Ketorolac for Postoperative Analgesia Following Mastectomy

• Suppression of prostaglandin synthesis at sites of inflammation:
  • Is the primary mechanism behind the antinociceptive effects of nonsteroidal anti-inflammatory drugs (NSAIDs)
• NSAIDs inhibit the activity of the cyclooxygenase isoforms 1 and 2, and their use can decrease opioid consumption
• Opioids prescribed preoperatively can lead to long-term use
• Risk factors for chronic opioid use after surgery among opioid-naive patients include:
  • Male gender
  • Age greater than 50 years
  • Preoperative use of benzodiazepines
  • Preoperative use of antidepressants
  • Depression history
  • Alcohol abuse history
  • Drug abuse history
• A systematic review of the literature demonstrated that:
  • Co-administration of acetaminophen and NSAIDs:
    • Decreased 24-hour postoperative morphine consumption
• Multimodal regimens are thought to have synergistic and opioid-sparing effects
• Intravenous lidocaine is one such opioid-sparing agent:
  • It exerts its analgesic effect by blocking sodium channels responsible for neural transmission of pain impulses
• N-methyl-D-aspartate receptor antagonism:
  • Describes the mechanism of ketamine, an opioid-sparing agent
• Regional nerve blockade and neuraxial anesthesia is theorized to prevent persistent opioid use by preventative analgesia:
  • Directly blocking pain impulses preventing central sensitization
• Inhibition at glutamatergic synapses:
  • Describes the antinociceptive mechanism of action of magnesium
• References:
  • Brown, EN, Pavone KJ, Naranjo M. Multimodal general anesthesia: theory and practice. Anesth Analg. 2018;127(5):1246–1258.
  • Hah, JM, Bateman BT, Ratliff J, Curtin C, Sun E. Chronic opioid use after surgery: implications for perioperative management in the face of the opioid epidemic. Anesth Anal. 2017;125(5):1733–1740.
  • Dunn LK, Durieux ME. Perioperative use of intravenous lidocaine. Anesthesiology. 2017;126:729–737

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