Liposomal bupivacaine mixture has similar pain relief and significantly fewer complications at less cost compared with indwelling interscalene catheter in total elbow arthroplasty.

BACKGROUND: Postoperative pain control, short-term and long-term narcotic consumption, complication rates, and costs of indwelling interscalene catheter (ISC) were compared with a liposomal bupivacaine (LBC) mixture in patients undergoing primary total elbow arthroplasty. METHODS: Forty-four consecutive patients were identified, the first 28 with an ISC and the later 16 with intraoperative LBC injection that also included ketorolac and 0.5% bupivacaine. Medical records were reviewed for visual analog scale scores for pain, oral morphine equivalent (OME) use, complications, and facility charges. RESULTS: Average visual analog scale scores at 24 hours, 2 weeks, 6 weeks, and 12 weeks were not significantly different. Mean OME use was significantly greater in the LBC group at 24 hours but less at 12 weeks, although this difference was not statistically significant. Twelve anesthetic-related complications occurred in the ISC group (1 major and 11 minor); 10 patients (36%) had at least 1 complication. The major complication was respiratory failure requiring emergent tracheostomy. Minor complications included leaking pump/catheters, catheters inadvertently pulled out early, global hand paresthesias, forearm paresthesias, and pain at the catheter site. There were no anesthetic-related complications in the LBC group. The average charge for the LBC mixture was $327.10; charges for ISC, including equipment and anesthesia fees, were $1472.42. CONCLUSIONS: An LBC mixture provides similar pain relief with fewer complications at a lower cost than indwelling ISC after total elbow arthroplasty. Although the OME use in the LBC group was almost double that of the ISC group at 24 hours, there was no difference at later time points.

Economic Impact of Ketorolac vs Corticosteroid Intra-Articular Knee Injections for Osteoarthritis: A Randomized, Double-Blind, Prospective Study.

BACKGROUND: Knee osteoarthritis is a disabling disease that costs billions of dollars to treat. Corticosteroid gives varying pain relief and costs $12 per injection, whereas ketorolac costs $2 per injection, per institutional costs. The aim of this study was to compare ketorolac with corticosteroid based on pain relief using patient outcome measures and cost data. METHODS: A total of 35 patients were randomized to ketorolac or corticosteroid intra-articular knee injection in a double-blind, prospective study. Follow-up was 24 weeks. Osteoarthritis was evaluated using Kellgren-Lawrence grading. Visual analog scale (VAS) was the primary outcome measure. A query of the institutional database was performed for International Classification of Diseases, Ninth Revision codes 715.16 and 719.46, and procedure code 20610 over a 3-year period. Two-way, repeated measures analysis of variance and Spearman rank correlation were used for statistical analysis. RESULTS: Mean VAS for ketorolac and corticosteroid decreased significantly from baseline at 2 weeks, 6.3-4.6 and 5.2-3.6, respectively and remained decreased for 24 weeks. There was no correlation between VAS and demographics within treatments. There were 220, 602, and 405 injections performed on patients with the International Classification of Diseases, Ninth Revision codes 715.16 and 719.46 during 2013, 2014, and 2015, respectively. The cost savings per year using ketorolac instead of corticosteroid would be $2259.40, $6182.54, and $4159.35 for 2013, 2014, and 2015, respectively, with a total savings of $12,601.29 over this period. CONCLUSION: Pain relief was similar between ketorolac and corticosteroid injections. Ketorolac knee injection is safe and effective with a cost savings percentage difference of 143% when compared with corticosteroid.

[Pharmaco-economic efficiency of the treatment of patients with acute vertebrogenic lumbar pain syndrome].

The aim of the study was to evaluate pharmaco-economic efficiency of two therapeutic schemes for the treatment of acute vertebrogenic lumbar pain syndrome. One hundred patients (including 77 women) with this syndrome caused by vertebral osteochondrosis (VO) were examined. Mean age of the patients was 41.00 +/- 8.33, mean duration of exacerbation 6.92 +/- 4.55 days. The majority of the patients had roentgenologic stage II VO. Patients of one group (n=50) were given intramuscular injections of ketorol (1 ml twice daily for 5 days) and diclofenac-retard (100 mg per os twice daily for 10 days). The second group (n=50) received ketorol and nise (100 mg twice daily for 10 days). This treatment was followed by 10 seances of phonophoresis using 1% hydrocortisone ointment. The clinical efficiency of therapy was evaluated based on the visual analog scale and in terms of Lasagne symptom, muscular syndrome index, Schober test, Thomayer's symptom, vertebrogenic syndrome coefficient. Pharmaco-economic analysis included calculation of direct medical care expenses and cost index/efficiency. The efficiency of therapy in group 2 (restoration of lumbar vertebral column mobility and alleviation of pain) was higher than in group 1 while the number of adverse effects was lower and the periods of remission longer. Combined therapy with ketorol and nise per unit efficiency was more expensive but the total cost of the management of one case including all yearly relapses suggested its advantages over the alternative treatment with ketorol and diclofenacin terms of clinical and pharmaco-economic efficiency.

Subjective and objective comparison of critical care pathways for open donor nephrectomy.

PURPOSE: In the era of minimally invasive techniques and cost containment, care pathways after donor nephrectomy are important. While open donor nephrectomy remains the established procedure, questions regarding the surgical approach, postoperative care and patient morbidity/dissatisfaction have surfaced. We compared results of standard and fast-track care pathways after donor nephrectomy. MATERIALS AND METHODS: Between January 1998 and August 1999, 60 patients underwent open donor nephrectomy. By surgeon preference, patients received either ketorolac only (31), ketorolac plus morphine spinal (17) or patient controlled anesthesia (12). Data related to surgery, hospital course and cost were reviewed. Patients were surveyed regarding return to daily activities and groups were statistically analyzed. RESULTS: The mean dose per patient was 183 (ketorolac only), 180 (ketorolac plus morphine spinal) and 69 (patient controlled analgesia) mg. Median hospital stay was 2 days for the fast-track pathways (ketorolac only, ketorolac plus morphine spinal) compared to 3 days for the patient controlled analgesia group (p <0.001). Delayed oral intake was seen in 6% of patients on ketorolac only and 3% for those on ketorolac plus morphine spinal compared to 83% of the patient controlled analgesia group (p <0.001). Return to exercise (median weeks, p <0.79) was 2 for the ketorolac only group, 3.5 for ketorolac plus morphine spinal and 3.5 for patient controlled analgesia. Mean global cost was $9,394 for the ketorolac only group, $9,238 for ketorolac plus morphine spinal and $11,601 for patient controlled analgesia (p <0.02). CONCLUSIONS: Fast-track pathways significantly shortened hospital stay and quickened oral intake. Cost was significantly contained using new pathways. Resumption of daily activities was comparable among the groups. Comparisons of critical care pathways are required to optimize patient care after kidney donation. Prospective trials are needed to verify our results.

Prospective randomized trial of pre-emptive analgesics following ambulatory inguinal hernia repair: intravenous ketorolac versus diclofenac suppository.

BACKGROUND: A pre-emptive non-steroidal anti-inflammatory drug is routinely given to patients undergoing ambulatory inguinal hernia repair. The present prospective randomized trial was undertaken to compare the efficacy of intravenous ketorolac and rectal diclofenac for ambulatory inguinal hernia repairs. METHODS: Between June 1999 and February 2001, a total of 108 patients who underwent ambulatory inguinal hernia repairs under general anaesthesia were recruited. Patients were randomized to receive either intravenous ketorolac 30 mg immediately prior to induction of general anaesthesia (n = 54) or rectal diclofenac 50 mg after signing consent at the Day Surgery Centre (n = 54). RESULTS: The demographic features, hernia types, anaesthetic time, dosage of anaesthetic medication and operative details of the two groups were comparable. There was no significant difference in total amount of analgesic consumption and linear analogue pain scores after operation. With regard to recovery variables, the respective times taken to regain ambulation and micturition were similar in both groups. CONCLUSION: Diclofenac suppository 50 mg and intravenous ketorolac 30 mg provided equivalent postoperative analgesia following ambulatory inguinal hernia repair under general anaesthesia. Diclofenac suppository is an economical alternative to intravenous ketorolac. In the interests of cost containment rectal diclofenac could be considered the non-steroidal anti-inflammatory drug of choice for pre-emptive analgesia.

Opioid analgesics versus ketorolac in spine and joint procedures: impact on healthcare resources.

BACKGROUND: Ketorolac's efficacy as a postoperative analgesic has been shown to be comparable to that of narcotic analgesics, but with significantly fewer narcotic-related adverse events. OBJECTIVE: To assess whether the choice of postoperative analgesic, narcotic or ketorolac, has an impact on healthcare resource utilization and cost durng inpatients' recovery period. DESIGN: Retrospective, multicenter, controlled, parallel, cost-minimization analysis. SETTING: Six US teaching hospitals. PATIENTS: This study included 559 patients that underwent either a spine or joint procedure and received adequate doses of narcotic (n = 284 of either morphine or meperidine) or ketorolac (n = 275). MEASUREMENTS: Time to reach recovery milestones, average utilization of healthcare resources, and average per-case postoperative treatment cost. RESULTS: Several recovery milestones, including time to first bowel movement, first oral intake, and first unassisted ambulation, were reached sooner in the ketorolac group, with a resultant shorter mean length of postoperative stay (narcotic 3.78 d, ketorolac 2.80 d; p = 0.01). Total per-patient cost of treatment was 32% greater in the narcotic group, resulting primarily from higher costs associated with hospitalization. CONCLUSIONS: Despite the higher acquisition cost of medication, healthcare resource utilization and total per-patient cost of treatment were lower for patients in the ketorolac group compared with patients in the narcotic analgesic study group. The majority of patients in the ketorolac group were also given concurrent narcotic analgesics; therefore, the beneficial effects observed may be secondary to the combination of ketorolac and narcotic analgesics.

Cost effectiveness analysis of intravenous ketorolac and morphine for treating pain after limb injury: double blind randomised controlled trial.

OBJECTIVES: To investigate the cost effectiveness of intravenous ketorolac compared with intravenous morphine in relieving pain after blunt limb injury in an accident and emergency department. DESIGN: Double blind, randomised, controlled study and cost consequences analysis. SETTING: Emergency department of a university hospital in the New Territories of Hong Kong. PARTICIPANTS: 148 adult patients with painful isolated limb injuries (limb injuries without other injuries). MAIN OUTCOME MEASURES: Primary outcome measure was a cost consequences analysis comparing the use of ketorolac with morphine; secondary outcome measures were pain relief at rest and with limb movement, adverse events, patients' satisfaction, and time spent in the emergency department. RESULTS: No difference was found in the median time taken to achieve pain relief at rest between the group receiving ketorolac and the group receiving morphine, but with movement the median reduction in pain score in the ketorolac group was 1.09 per hour (95% confidence interval 1.05 to 2.02) compared with 0.87 (0.84 to 1.06) in the morphine group (P=0.003). The odds of experiencing adverse events was 144.2 (41.5 to 501.6) times more likely with morphine than with ketorolac. The median time from the initial delivery of analgesia to the participant leaving the department was 20 (4.0 to 39.0) minutes shorter in the ketorolac group than in the morphine group (P=0.02). The mean cost per person was $HK44 ( pound4; $5.6) in the ketorolac group and $HK229 in the morphine group (P<0.0001). The median score for patients' satisfaction was 6.0 for ketorolac and 5.0 for morphine (P<0.0001). CONCLUSION: Intravenous ketorolac is a more cost effective analgesic than intravenous morphine in the management of isolated limb injury in an emergency department in Hong Kong, and its use may be considered as the dominant strategy.