Ketorolac administration after cesarean delivery may reduce postoperative opioid use

1. In this randomized controlled trial, a 60‑mg IV ketorolac loading dose after cesarean delivery modestly reduced postoperative opioid use and delayed the need for first opioid administration compared with a 30‑mg dose.

Evidence Rating Level: 1 (Excellent) 

Cesarean delivery accounts for nearly one‑third of births in the United States, making effective postoperative pain control essential to improve recovery, support early mobility, and reduce opioid exposure. Although multimodal analgesia, including NSAIDs like ketorolac, is standard, the optimal ketorolac dose after cesarean delivery remains uncertain. Pregnancy has associated changes in drug metabolism that may increase ketorolac clearance and distribution. These physiologic differences suggest that a higher loading dose could provide better analgesia, prompting this study to compare 60 mg versus the standard 30 mg dose on postoperative opioid use and pain control. In this randomized controlled trial, pregnant individuals undergoing cesarean section were included, and randomization occurred in the operating room once surgery was complete. These 92 participants were randomized to receive either a 60 mg (n=46) or 30 mg (n=46) intravenous ketorolac loading dose after cesarean delivery. Median opioid use in the first 24 hours was similar in both groups at 7.5 morphine miligram equivalents (MMEs), though the distribution differed significantly (P=.02). Across the full delivery admission, patients receiving 60 mg required fewer opioids overall (15 MMEs, IQR 0–37.5) compared with those receiving 30 mg (30 MMEs, IQR 7.5–54.5; P=.043). The 60‑mg group also experienced a markedly longer interval before first opioid administration (15 hours vs 2.75 hours; P=.002) and reported lower pain scores on arrival to the postpartum unit (3 vs 5; P<.001). No treatment‑related adverse events occurred in either group, and no difference in pain scores. Overall, a 60 mg loading dose of IV ketorolac after cesarean delivery modestly reduced postoperative opioid use and delayed the need for first opioid administration compared with the standard 30 mg dose; however, the effect was modest, suggesting further research is needed to clarify its clinical value.

Click here to read this study in O&G Open

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