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Nick Macartney nick at macartney.org
Sat Apr 1 18:23:30 BST 2006

While I accept this discussion is not about anaesthesia, I might point out
that in the UK the datasheet says Ketorolac is contraindicated for
perioperative care. A great shame, as I used it from its release.
Nick Macartney 

> -----Original Message-----
> From: trauma-list-bounces at trauma.org 
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Krin135 at aol.com
> Sent: 01 April 2006 13:15
> To: trauma-list at trauma.org
> Subject: Re: Toradol
> In a message dated 31-Mar-06 23:39:34 Central Standard Time, 
> Lorick at Lorick.org writes:
> As with Dr. Muhammad, we use parenteral diclofenac (as well 
> as US  imported parenteral Toradol) here in Egypt fairly extensively.
> (The  injectable Voltaren is the pain drug of choice of my 
> Egyptian colleagues - I  tend to use Toradol when I don't use 
> a narc, although I tend toward morphine  or oral codeine, 
> since we have them available on our American compound, an  
> option our Egyptian colleagues do not have outside a hospital 
> setting.)  
> I've never seen a problem with either parenteral Toradol or  
> diclofenac...my experience mirrors Pret's, although I am 
> concerned about the  statement that it decreases ureteral 
> peristalsis made earlier; I've never seen  that information 
> before.  I am also concerned by the case report of renal  
> failure (being on high dose ARB personally and firmly 
> believing in Toradol for  acute pain in me, when I can't 
> afford sedation), and echo the question, does  anyone know of 
> any non-anecdotal data about this phenomena?  Re: Dr.  Krin's 
> post, I was in practice during the 89-93 era (trained in the 
> 78-80 era)  and never saw that, other than in my heart 
> transplant patients on  cyclosporine, in whom any NSAID was 
> guaranteed renal failure by the same  mechanism (and it 
> didn't take many doses, either!). 
> Our community hospital (175 or so beds, 20 or so FM 
> residents,  drawing charity cases from a 70 mile or so radius 
> (12 counties) didn't have many transplant cases even as 
> follow up...we did have some chemo patients, but even  those 
> were generally handled in special clinics, so not much 
> experience with cyclosporine. When the ACEi's first came out, 
> we did run into a half dozen cases where we managed to find 
> folks who were on captopril and also taking the recently over 
> the counter ibuprofen and ran into problems. Saw it once 
> myself,  up close and professional with an ICU patient with a 
> fever not responding to maximum dose acetominophen as well...
> My understanding was that ketorolac was strong in analgesia,  
> but weak as an anti-inflammatory, and that, as with any PGE 
> inhibitor,  multiple doses were required for any 
> anti-inflammatory effect; but I will  await some of those 
> with better pharmacology training to comment on that,  since 
> others have already raised some of those issues and I am sure 
> they will  be addressed shortly. :) It would not be the first 
> time my long held  "understandings" were proven wrong on this Board.
> I have never given more than two injections of Toradol, nor  
> continued it po for > 48 hours orally, but have done both a 
> fair amount  since the drug became available and fortunately 
> have no negative anecdotes to  add.
> That is my understanding of the actions as well...almost pure 
>  peripheral pain relief with little or no anti inflammatory 
> effect in the short  term (hours to days), and enough risk of 
> stomach upset in the medium term (a  week or so) to limit the 
> use to no more than 5 days po or 48 hours IV. Despite  using 
> it fairly frequently for both atypical migraines and renal 
> stones, I've  not seeing any serious side effects either. And 
> many of the surgeons that I used  to refer to (in Louisiana, 
> I'm now practicing in St Louis, where there are more 
> physicians in this city than I think were in the whole state 
> of Louisiana!) were  willing to accept pain relief with 
> Toredol (because it would dull the pain without dulling the 
> patient) in a patient I was transferring to their  service.
> I have been concerned about the anti-platelet function for 
> head  injuries, although the previous post about the 
> possibility of worsened  hemorrhagic stroke is the first case 
> report I've heard.  Again, does  anyone know of any data to 
> suggest this is clinically significant, wither in  head 
> injuries or in patients taken to surgery after receiving 
> Toradol in the  ER?  It seems to me that this happens often 
> enough in some places that IF  there was a clinically 
> significant issue, it would have been identified long  
> since...(Of course, one would have thought the same about 
> Zomax, and having  personally treated a near fatal event of 
> that anaphylaxis in a teen (1981), it  wasn't taken off the 
> market fast enough.)
> Agreed. I've not gotten any adverse feedback on the drug  
> either, except in terms of the stomach upset, which is why I 
> generally don't  prescribe it as an outpatient med. One 
> combination we have here in the US  includes both an NSAID 
> and mistoprolol, which would help reduce the chance of  
> stomach problems *in males and post menopausal females*!!
> ck
> Charles S. Krin, DO  FAAFP
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