Toradol versus Opiates in Postoperative Pain Control
Ashley Lundberg, Magdalena Stewart, Alicia Williamson, Patricia Beemer, Samantha Pedigo Ferris State University NURS 350
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In post-op patients, what is the effect of Toradol on pain control in combination with opiates versus opiates alone? Introduction Post-operative pain management involves more than just a prescription for opiates. Studies suggest using a multimodal pain management regimen not only decreases pain levels, but also reduces side effects caused from larger doses of opiate use. The length of a hospital stay may increase by the inability to control pain effectively. Providing proper pain management will provide a positive overall outcome post-surgery. Post-operative patients may experience high levels of pain. The goal is to manage pain effectively by not only to provide comfort for the patient, but also to reduce stress and to decrease the length of hospital stay. Data was collected from multiple articles related to post-operative pain management. Included are different multimodal pain management suggestions and examples of benefits. There are many benefits found from using a combination of opiates and nonsteroidal anti- inflammatory drugs such as Toradol for postoperative pain management. Postoperative pain is managed more effectively by a multimodal approach. The use of Toradol in combination with opiates reduces pain levels, decreases side effects, and shortens length of hospital stay and decrease the number of patients returning to the hospital after discharge. Literature Review The article Comparison of Morphine, Ketorolac, and Their Combination for Postoperative Pain (Cepeda, Carr, Miranda, Diaz, Silva, & Morales, 2005), describes a study that was done to compare the effectiveness of morphine versus Toradol for pain relief in 3 POSTOPERATIVE PAIN CONTROL
postoperative patients. The article discusses the benefits of adding a nonsteroidal anti- inflammatory drug (NSAID), such as Toradol, to a patients pain regimen. It has been found that administering Toradol, in addition to morphine, causes the patient to require less opiates; this means that the patient is less likely to experience side effects related to opiate use (constipation, nausea, sedation) (Cepeda et al., 2005). The results of the study showed that patients who had received only morphine had better pain control than those that only received Toradol; however, patients that received both medications required less morphine to achieve adequate pain control (Cepeda et al., 2005). This information relates to the PICO question in regards to identifying the level of pain relief achieved when a postoperative patient is given Toradol alone and in addition to an opiate. The article Postoperative Pain Management after Ambulatory Surgery: Role of Multimodal Analgesia (Elvir-Lazo & White, 2010) discusses the results of poorly controlled pain after surgery and the popular approach of using different types of pain medication to prevent and treat pain. Postoperative pain can be difficult to treat, it can lead to poor patient outcomes and inhibit the recovery process; pain also contributes to a delayed discharge after surgery (Elvir-Lazo & White, 2010). This article states that patients are experiencing increasing amounts of pain after surgery and that there is a need for clinicians to implement multimodal analgesic protocols to provide adequate postoperative pain management (Elvir-Lazo & White, 2010). The traditional method for treating postoperative pain is by using opiate analgesics; however, this medication can lead to a number of complications (Elvir-Lazo & White, 2010). It has been shown that relying on a single NSAID alone will not adequately control a patients severe pain; however, recent studies prove that a combination of non-opiate and opiate medications allow the patient adequate pain relief (Elvir-Lazo & White, 2010). In these studies, 4 POSTOPERATIVE PAIN CONTROL
the use of narcotic pain mediation was greatly decreased in patients who also received non-opiate analgesia. Elvir-Lazo and White (2010) state that non-opiate medications will most likely be used as a preventative measure for pain control in minimally invasive procedures. This article supports the PICO question with information regarding the benefits of using multimodal analgesia and its effectiveness. Ketorolac: A New Parenteral Nonsteroidal Anti-inflammatory Drug for Postoperative Pain Management (Lassen, Epstein-Stiles, & Olsson, 1992), this is an older article that describes the NSAID drug: Ketorolac (Toradol). The articles main focus is on the uses, benefits, side effects, and contraindications of Toradol. The article states that when given alone or with opiates, it is effective in managing moderate pain levels and decreases the amount opiate use. The authors describe the onset of Toradol and the pharmacology behind the drug. Lassen et al. states that in nearly all clinical studies performed, 10-30 mg doses of ketorolac were equal to 6- 12 mg doses of morphine (1992); however on postoperative day one, some patients required additional opiate analgesics for pain control. The benefits of using Toradol include a lack of side effects, decreased opiate use without inhibiting pain control, and lack of central nervous system, respiratory, or cardiac depression that usually occurs with opiate usage (Lassen et al., 1992). The article includes information on the effects (if any) that Toradol has on renal, hepatic, hemostasis, gastrointestinal, central nervous system, respiratory, and cardiovascular systems. This article gives more insight to the PICO question because it included information about the effectiveness of Toradol in pain control, but it also gives the reader a better understanding of the drug itself. The article Postoperative Pain Management by Michael Nett (2010) focuses on the importance of adequate postoperative pain control. Nett (2010) states that poorly controlled pain can lead to unwanted outcomes. The main focus of the article is postoperative pain control after a 5 POSTOPERATIVE PAIN CONTROL
total joint arthroplasty. The article discusses the fact that the most used form of pain control after this type of surgery is opiates, which often result in poor pain control and unwanted side effects (Nett, 2010). Multimodal pain control is mentioned as a way to improve pain management and minimize the side effects; this type of therapy is found to improve patient outcomes and shorten hospital stay (Nett, 2010). The author describes the use of NSAIDs in orthopedic surgery, stating that they greatly reduce postoperative opiate requirements, reduce postoperative vomiting, and improve patient satisfaction and range of motion in affected joint (Nett, 2010). This article relates to the PICO question because it discusses the benefits of using NSAIDs postoperatively and how patient outcomes are improved. Six of the articles found were not used because they either did not provide adequate information to support the PICO or contained repetitive information. Opioid Analgesics versus Ketorolac in Spine and Joint Procedures: Impact on Healthcare Resources (Gora-Harper, Record, Darkow, & Tibbs, 2001) focuses more on the financial aspect of Toradol, which does not relate to the PICO. Multimodal Pain Management in Orthopedics: Implications for Joint Arthroplasty Surgery (Parvisi & Bloomfield, 2013) includes a large amount of information regarding non-opiate pain medication but does not include very much about Toradol specifically. Multimodal Analgesia for Postoperative Pain Control (Jin & Chung, 2001) contains reliable information regarding postoperative pain medications but the focus is not on Toradol and therefore does not fit the PICO question. With Concerns Over Narcotics, Some Surgeons Develop Alternative Pain Management Protocols (Blisard, 2012) this article does not relate to the PICO as its focus is on addiction. Early Rehab Incorporating Pain Control May Lead to Better Postoperative Outcomes (Ranawat, 2006) focuses on the physical therapy aspect along with pain control postoperatively. Parecoxib: A Shift in Pain Management? (Dalpiaz & 6 POSTOPERATIVE PAIN CONTROL
Peterson, 2004) compares the drug parecoxib with Toradol and contained similar information to articles that had already been chosen to support the PICO question. Critical appraisal The four selected articles show evidence supporting the use of Toradol in post-operative pain. The article Ketorolac: A new parental Nonsteroidal Anti-inflammatory Drug for Postoperative Pain Management provides the information about Toradol, pharmacokinetics, indication and possible side effects. The article reports studies that have confirmed its effectiveness in controlling pain for various surgeries including orthopedic, abdominal and gynecologic. The article reports several studies that compare the use of Toradol with opiate analgesic. The results showed that given alone Toradol did not provide adequate pain control and additional opiates had to be used; however, the use of Toradol in combination with opiate analgesics was show to significantly decrease the use of opiates, thus decreasing the risk of opiate related side effects. Toradol does not bind to opioid receptors therefore it does not potentiate the effects on central nervous system and complications are low. The research shows that short term use of Toradol (maximum five days) is recommended and provides safe alternative to opiates after the patient is being discharged. The most common side effects associated with Toradol are gastrointestinal and include dyspepsia, nausea and diarrhea. The risk of gastric erosion is still significantly lower than when using oral aspirin. The article presents a case study in which a patient was successfully treated with Toradol intramuscularly for his post- operative surgery; the patient was able to be discharged on oral medications. The authors conclude that Toradol is a valuable addition to post-op pain management and can successfully decrease the use of opiates, resulting in safer care and faster discharge. 7 POSTOPERATIVE PAIN CONTROL
A good overview of the use of Toradol is presented in the second article Comparison of morphine, ketorolac, and their combination for postoperative pain. The authors describe a double blind, randomized controlled study that involved over 1000 adult patients. The researchers were studying the pain control in two groups of patients. One group received morphine and the other group received Toradol followed by the morphine if pain was not controlled. The results showed that adding Toradol to the pain regimen lowered the amount of received morphine and decreased the possible side effects. Patients who received morphine as the first line of pain medication achieved better pain control than the group that received Toradol; however this group required less morphine and experienced fewer side effects. The author noticed that one out of seven patients treated with just morphine experienced adverse effects that would not have occurred if the patient had received Toradol (Cepeda et al. 2005). Postoperative pain management after ambulatory surgery: role of multimodal analgesia discusses the issue of pain management as regulated by The Joint Commission. The author reports that in order to comply with the pain control requirements, the hospitals have been using more opiate medications to control pain thus increasing the chances of adverse side effects. Therefore there is a strong need to develop a standard treatment plan across the institutions that would provide adequate control without compromising patients central nervous system. The need for studies with the use of non-opiate medications is significant. The multimodal approach that is discussed in this article involves local analgesics, NSAIDs and acetaminophen; this approach is still controversial since there are no unified guidelines in literature for reference. The author appreciates the use of NSAIDs like Toradol and suggests its growing use as the number of minimally invasive procedures increases. The use of NSAIDs could significantly reduce the length of hospital stay and are noted to provide the best clinical outcome when used during the 8 POSTOPERATIVE PAIN CONTROL
first 3-4 days after the surgery. The conclusion summarizes the evidence that suggest the use of multimodal approach to control pain since it is proven to provide good control of pain and faster recovery (Elvir-Lazo, White, 2010). Another article that focuses on multimodal approach to pain is the article: Postoperative pain management. The author describes poor pain management as it relates to immobility, pneumonia, deep vein thrombosis (DVT), depression, and other undesirable outcomes. The traditional approach with the use of patient control analgesia is associated with a number of unwanted side effects. The focus of this research is to find an alternative pain regimen that would decrease the chances of these side effects. There are few studies reported by the author that showed the effectiveness of Toradol on pain post orthopedic surgeries. The use of Toradol lowered the need for stronger medications and lowered the risk for complications. The author states that there is enough evidence that shows adverse effects with the use of opiates; the recommendation is to use a multimodal approach to pain management (Nett, 2010). All four articles included in this paper state the rising need for better pain management and lowering risks of the adverse effects. The research shows that even though Toradol is not as effective as opiates when used alone, it does provide good pain control when combined with other medications. It significantly reduces the use of opiates and therefore the risk of opiate- related side effects. Integration With knowledge based from research providing the use of Toradol in combination with other modalities for pain control, significance must be considered when incorporating into current practice. Nurses and physicians play a vital role in assessing and managing patients' pain control, providing interventions, monitoring the effects of treatments, and communication of a 9 POSTOPERATIVE PAIN CONTROL
pain control plan. With this known, evidenced based care can have a major impact on treatment provided. According to Lassen et al, Toradol was the first approved parental NSAID in the US, and has proven to be an opiate-sparing drug (1992). With its minimized side effects and decreased need for other opiate use, it has become the preferred drug for nurses and patients. Nurses favor the use of Toradol because of its pain control benefits which reflect increased patient satisfaction and positive outcomes. Toradol has also shown to have less adverse effects further leading to shortened hospital stays. It can provide sustained relief for a duration of approximately five to six hours without side effects (Lassen et al, 1992). Patients are also finding that with Toradol administration, their mobilization is initiated early and they are achieving adequate pain management and control (Nett, 2010). While Toradol seems as if it should be ordered and administered to every patient for proper pain management and control, prescribing barriers are present. Contraindications to usage may include a patient with pre-existing conditions such as angioedema, bronchospasms, other NSAID use, renal failure, and bleeding disorders (Lassen et al, 1992). Some surgeons, particularly Orthopedic surgeons, may also avoid its use due to concern over bone re-growth or joint loosening (Nett, 2010). Aside from contraindications and surgeon preference in which limit the patient from receiving Toradol, other physicians prescribing such drug should continue so, considering the use of Toradol has a major impact on mobility, opiate usage, adverse effects, patient outcomes, and satisfaction. Integrating patient education into daily nursing care can also have a significant impact on pain management. Utilizing the opportunity to provide the patient with a NSAID along with educating the patient on proper pain management and pain control can further increase patient satisfaction and outcomes (Elvir-Lazo, O. & White, P, 2010). 10 POSTOPERATIVE PAIN CONTROL
Nurses should consider administering Toradol when appropriate as evidenced by the research provided. According to Nett, a study was conducted on post-operative total joint patients in which Toradol was compared to a placebo. The outcome revealed that the patients who received Toradol "reported better analgesia, less sedation, required less antiemetic medications, and received less morphine" (2010). In sum, integrating evidenced-based research such as the benefits of use of Toradol can truly optimize analgesia requirements and therefore benefit the patients' outcomes, and further benefit healthcare providers. Recommendations Information identified in the research would suggest that postoperative pain is not adequately managed, creating poor patient outcomes. Poorly controlled pain, especially when narcotic pain relievers are the treatment choice, results in negative patient outcomes both during hospitalization and after their return home. Although not identified as an objective to this paper, it should be pointed out that hospitals and other health care providers are in a financial crunch. Public and private insurance companies are expecting a higher degree of treatment for fewer dollars. To meet these demands, hospitals are trying to discharge quicker, have fewer occurrences of hospital acquired infections, and increased patient satisfaction. Elvir-Lazo & White noted that poorly managed pain has the potential to slow or hinder the recovery process, delaying discharge (Elvir-Lazo & White 2010). Potential outcomes of poorly controlled postoperative pain include pneumonia, atelectasis, immobility, deep vein thrombosis, chronic pain, depression, and anxiety (Nett, 2010). Implementation of a multimodal treatment regimen decreases the amount of opiate (such as morphine) used. This decreases the chance of side effects including constipation, sedation, nausea, vomiting, and urinary retention (Cepeda et al. 2005; Elvir-Lazo & White, 2010). 11 POSTOPERATIVE PAIN CONTROL
Early reports on the benefits of Toradol in the postoperative setting include decreasing the amount of opiates needed to obtain effective pain management. Other reports suggest a possibility of inhibiting new bone growth/spinal fusion following surgery, but have not been substantiated by evidence. Fears of its use in surgery increasing postoperative bleeding are also not founded (Lassen, Epstein-Stiles, & Olsson, 1992). Certain pre-existing medical conditions are either contraindicative or proceed with caution situations in which Toradol should not be used or dosing should be adjusted accordingly. These conditions include renal insufficiency, bleeding disorders, concurrent use of anticoagulants or Lithium, or heart conditions (Lassen et al., 1992). It is unquestionable that a multimodal pain management regimen should be implemented to improve patient outcomes postoperatively. Toradol has been identified as an effective adjunct to opioid treatment, with minimum side effects, but does not adequately control postop pain used alone. The downside to evidence presented specifically regarding side effects of Toradol is that it is dated. Before recommending that Toradol be used as the exclusive NSAID adjunct to opiates, further research is needed to evaluate potential negative effects. Other treatment adjuncts should also be evaluated in effectiveness for postoperative pain management. Suggestions for future research include determining the usefulness of non- pharmacological adjuncts to multimodal treatment such as massage, guided imagery, relaxation, or acupuncture. Also, comparing length of hospital stay (postoperatively) with the number of new cases of hospital acquired infections. This attributes to health facilities financial stability and nurse retention, the idea here being that if the hospital saves money by having shorter patient stays and fewer hospital acquired infections, they will have safer staffing grids, which in turn contributes to overall patient satisfaction and quicker post op ambulation and pain management. 12 POSTOPERATIVE PAIN CONTROL
References
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