REFERENCES

1. Flickinger, J. E., Trusler, L. and Brock, J. W., 3rd: Clinical carepathway for the management of ureteroneocystostomy in thepediatric urology population. J Urol, part 2, 158: 1221, 1997

2. Buck, M. L.: Clinical experience with ketorolac in children. AnnPharmacother, 28: 1009, 1994

3. Lieh-Lai, M. W., Kauffman, R. E., Uy, H. G. et al: A randomizedcomparison of ketorolac tromethamine and morphine for post-operative analgesia in critically ill children. Crit Care Med, 27:2786, 1999

4. Gonzalez, A. and Smith, D. P.: Minimizing hospital length ofstay in children undergoing ureteroneocystostomy. Urology,52: 501, 1998

5. Eberson, C. P., Pacicca, D. M. and Ehrlich, M. G.: The role ofketorolac in decreasing length of stay and narcotic complica-tions in the postoperative pediatric orthopaedic patient. J Pe-diatr Orthop, 19: 688, 1999

6. Burke, J. P., Pestotnik, S. L., Classen, D. C. et al: Evaluation ofthe financial impact of ketorolac tromethamine therapy inhospitalized patients. Clin Ther, 18: 197, 1996

7. Park, J. M., Houck, C. S., Sethna, N. F. et al: Ketorolac sup-presses postoperative bladder spasms after pediatric ureteralreimplantation. Anesth Analg, 91: 11, 2000

EDITORIAL COMMENTS

We have all felt the economic pressure to lower health care costs byreducing the length of hospitalization, or even reducing many sur-geries to ambulatory procedures or 23-hour stays. However, as childadvocates, we can only comply with this paradigm when our patientsand the families would be better served at home. The ability toproduce adequate postoperative analgesia is crucial to this stipula-tion. The literature is replete with reports of the superior analgesicefficacy of ketorolac compared to narcotic agents in children under-going surgery. The reports in the pediatric urology literature havebeen few. The authors cite 2 recent articles, including 1 in which thelength of hospitalization was reduced after extravesical ureteralreimplantation, partly attributed to the use of ketorolac (reference 4in article), and another bladder spasms were reduced by ketorolacafter intravesical ureteral reimplantation (reference 7 in article).

In this study the authors evaluated the safety profile of ketorolacin children undergoing ureteral reimplantation and, in particular, 2of the most worrisome adverse effects, namely, bleeding and renalinsufficiency. A total of 118 children underwent either intravesical orextravesical ureteral reimplantation, including 50 who received cau-dal anesthesia along with either narcotics and 68 ketorolac. Therewere no differences between the groups in regard to minor or majoradverse effects of postoperative analgesia, including postoperativehematocrit and creatinine. Interestingly, children undergoing ure-teral reimplantation without other associated bladder pathology whoreceived ketorolac were discharged home 1 day earlier than thosereceiving narcotics.

We should be encouraged to learn that ketorolac has an excellent

safety profile for children undergoing ureteral reimplantation. Thisimportant information should be viewed in the context of otherpostoperative studies indicating the superior analgesic efficacy andperhaps antispasmodic effect of ketorolac after ureteral reimplanta-tion. These findings should be shared with our anesthesiology col-leagues so that we can better and more safely treat our patientpostoperative analgesia needs. If the secondary gain is a shorterhospital stay and reduced cost then certainly everyone benefits.

Lane S. PalmerSchneider Children’s Hospital/Long Island Jewish Medical

CenterNew Hyde Park, New York

I read with interest the report by Chauhan et al about the safetyof ketorolac in children undergoing ureteroneocystostomy from 1997to 1998. This paper provides an evaluation of the concerns that manypractitioners have when applying pain management techniques tothe pediatric population when the pharmacological tools and tech-niques have been historically ignored. Bleeding and kidney dysfunc-tion have always been a concern with the use of nonsteroidal anti-inflammatory drug perioperatively. However, we have notexperienced this as a major clinical event in the 10 years of ketorolacuse at the Children’s Hospital of Denver during this particularoperation when these drugs have been used appropriately.

I am concerned about the conclusions drawn from this retrospec-tive review, as many pieces of important information are not avail-able. For instance, the dose, drugs and additives to the caudal candramatically affect postoperative pain results. Epidural morphinecan last as long as 8 to 24 hours, whereas epidural fentanyl may onlylast a few hours. I am also unclear if only 1 dose of caudal drugs wasused and whether an epidural catheter was left in place to “top off”the block. Other areas of concern include a lack of evaluation of theperioperative fluids as well as the preoperative fast of each child.What other drugs, including antibiotic or anesthetic, may have beenused in those children in whom creatinines increased?

The authors imply that the gastrointestinal tract and some of theother side effects are not part of the ketorolac profile. However, wehave noted that many of the side effects, such as nausea, dyspepsia,headache and dizziness, may be attributed to nonsteroidal anti-inflammatory drug and ketorolac in particular.

At our institution the checking of preoperative and postoperativehematocrit, creatinine, and liver function test is not routinely per-formed. Is it ketorolac alone or a combination of multiple factors thatreally contributed to the reduced length of hospitalization reportedin this article? In summary this paper does provide more evidencedemonstrating the importance of balanced analgesia and how theuse of ketorolac may enhance the care of the reimplantation popu-lation without impacting patient safety.

Glenn R. MerrittDepartment of AnesthesiaUniversity of Colorado Health Sciences CenterThe Children’s HospitalDenver, Colorado

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