Safety and Efficacy of Ketorolac Use After Coronary Artery Bypass Graft Surgery

Introduction: Guidelines surrounding perioperative care in cardiac surgery recommend multimodal pain control. Although ketorolac carries a boxed warning for use after coronary artery bypass graft (CABG) surgery, retrospective evaluations have demonstrated similar or improved outcomes in patients receiving ketorolac versus those who do not. This study seeks to expand on the available evidence in a complex population.


Methods: This was a single-center retrospective, propensity-matched cohort study comparing patients who underwent CABG, with or without additional procedures. Patients who did or did not receive at least one dose of ketorolac post-operatively were matched by propensity score, based on baseline patient and surgical characteristics, and intraoperative blood product use. The primary outcome was a composite of 30-day mortality, post-operative permanent stroke, and renal failure during hospitalization as defined by the Society of Thoracic Surgeons. Secondary outcomes included 30-day readmission, post-operative bleeding, deep-sternal wound infection (DSWI), and new-onset atrial fibrillation.


Results: A total of 13,629 CABG cases performed from 2014-2024 were screened. The final analysis cohort comprised 482 matched pairs. Approximately 30% of patients underwent isolated CABG. Initial ketorolac doses were received a median of 41.7 (interquartile range 21.1-98.4) hours after surgery completion. Ketorolac administration was associated with a numerically lower rate of composite primary outcome occurrence [3.5% vs 5.8%; OR 0.61, (95% confidence interval (CI) 0.19-1.33)]. A lower rate of 30-day mortality in ketorolac treated patients accounted for the largest proportion of the primary outcome difference [0.2% vs 1.7%; OR 0.13 (95%CI 0.02, 1.00)]. Numerically reduced rates were observed in all other primary outcome components and secondary outcomes, except DSWI, which was extremely rare (0.2% vs 0%; p=NS).


Conclusions: Ketorolac administration after cardiac surgery involving CABG was associated with reduced rates of adverse clinical outcomes, except for deep-sternal wound infection in a large and complex patient population. Prospective evaluations are warranted to further evaluate this association.