Perioperative Ketorolac and Postoperative Hematoma Formation in Adolescent Reduction Mammaplasty
Lauren C. Monoxelos, PA-C, MMSc, Joseph M. Firriolo, MD, Carolyn R. Rogers-Vizena, MD, Oren Ganor, MD, Arin K. Greene, MD, MMSc, Brian I. Labow, MD.
Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
BACKGROUND: The opioid crisis is a growing public health concern in the United States. In the past decade, opioid overdose rates have quadrupled, and it is now one of the leading causes of death in adolescents. Correspondingly, pain control is increasingly focused on minimizing the use of opioid medications in the perioperative period. Ketorolac is an analgesic and nonsteroidal anti-inflammatory drug (NSAID) proven to help manage postoperative pain and decrease the amount of required opioids. Historically the use of ketorolac has been limited in this setting due to concerns of postoperative bleeding and hematoma formation. The aim of this study was to explore the relationship between hematoma formation and the administration of perioperative ketorolac in adolescent females undergoing reduction mammaplasty.
METHODS: We performed a retrospective chart review of all female patients previously enrolled in our adolescent breast database who underwent reduction mammaplasty at our institution from 2008 to 2017. We collected data regarding patient demographics, the administration of intravenous ketorolac (both intra- and postoperative doses), and documented postoperative hematoma formation. A hematoma was defined as a clinically identifiable soft tissue swelling secondary to a localized collection of blood that required intervention (e.g. aspiration, drainage, or operative evacuation).
RESULTS: 344 patients were included in our analyses. The average age at the time of operation was 17.9 ± 1.9 years (range, 12.5-22.9 years). 253 (73.5%) patients received intravenous ketorolac in the perioperative period. Three (0.9%) patients developed a postoperative hematoma: one was drained under local anesthesia on postoperative day 13, and two underwent surgical drainage in the operating room within 24 hours of reduction mammaplasty. In addition, 12 patients presented with postoperative unilateral breast swelling and/or ecchymoses that resolved without intervention. Neither of the two patients that underwent operative hematoma drainage received ketorolac in the perioperative period. Hematoma was not associated with intraoperative ketorolac use (p=0.25), postoperative ketorolac use (p=0.57), or any perioperative ketorolac use (p=0.17). The three patients that developed a hematoma did not statistically significantly differ from the other 341 subjects in terms of age (p=0.16), intraoperative ketorolac dose (p=0.41), or total perioperative ketorolac dose (p=0.20); they did however have a statistically significantly lower postoperative ketorolac dose than adolescents without hematoma (p<0.001).
CONCLUSIONS: With routine use of intravenous ketorolac as an analgesic for adolescent reduction mammaplasty, we observed only a 0.9% hematoma rate. The hematomas identified in our patient sample did not demonstrate an association with ketorolac administration or dosage. These results suggest that intravenous ketorolac may be safe to use in adolescent reduction mammaplasty without increasing the risk of hematoma formation.
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