Evidence Based Medicine Versus Experience Based Medicine in Plastic Surgery: The Role of Ketorolac in Plastic Surgery-an International Survey and Systematic Review of the Literature
The concept that patients undergoing elective, soft tissue-only procedures (aesthetic breast and face) have an increased propensity to develop bleeding complications after receiving intra- or post-operative ketorolac is a myth perpetuated in medical institutions. Opioid analgesics are used routinely for pain control, but have their own side effect profiles. This is an area in plastic surgery where experience-based medicine is challenged by evidence.
Methods/Technique:
Systematic literature review was performed using Medline, Embase, Pubmed and Cochrane databases to identify all studies evaluating ketorolac use after patients underwent plastic surgery. Final search was conducted in July 2013. MeSH search terms included: “ketorolac,” “Toradol,” “analgesia,” “pain control,” “bleeding,” “hematoma” and “plastic surgery." Three reviewers independently evaluated the studies for inclusion (criteria—level 1 and 2 studies and large retrospective reviews) or exclusion (criteria—case reports).
IRB exempt survey was electronically distributed to all ASPS members. Responses/data were collected over a 5-month period through SurveyMonkey.
Results/Complications:
109 articles published before July 2013 were identified. 27 articles remained after eliminating duplicates and applying inclusion criteria. After employing exclusion criteria, 24 articles remained. There was 100% agreement between three reviewers.
5299 questionnaires were distributed. 685 (13%) plastic surgeons responded. Respondents (54.8%) felt ketorolac increased post-operative bleeding propensity. 43.3% do NOT allow post-operative patients (normal renal function) to receive ketorolac. Of respondents permitting ketorolac administration, 83.9% allow single dose administration at surgery end prior to departing the OR. 75.5% permit patients to receive ketorolac in the ensuing 48 hour post-operative period.
Conclusion:
Critical literature review validates post-operative ketorolac is beneficial in decreasing opioid narcotic use. In addition, bleeding complications were recorded and critically evaluated. Evidence based medicine proves receiving post-operative ketorolac is of great benefit with minimal drawbacks for many appropriately screened patients. International survey results elucidate surgeon comprehension and effects on clinical practice.