1. PERI-OPERATIVE NSAID USE IN CHILDREN: COMPLICATIONS AND CONTROVERSY Lacey N. LaGrone University of Washington

2. WHY IT MATTERS.

3. 1. Figure 1. Overall Pain after Surgery Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 2003;97:534–40

4. 2. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 2003;97:534–40 Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology 2000;93:1123–33.

5. 3. “Unless contraindicated, all patients should receive an around-the-clock regimen of NSAIDs, COXIBs, or acetaminophen.” -Practice guidelines for acute pain management in the perioperative setting. An updated report by the American Society of Anesthesiologists task force on acute pain management. 2004. -Ashburn MA, Caplan RA, Carr DB, et al. Practice guidelines for acute pain management in the perioperative setting. An updated report by the American Society of Anesthesiologists task force on acute pain management. Anesthesiology 2004;100:1573–81. Acta Anaesthesiol Scand. 1994 Jul;38(5):467-72. Ibuprofen in the treatment of postoperative pain in small children. A randomized double-blind-placebo controlled parallel group study. Kokki H, Hendolin H, Maunuksela EL, Vainio J, Nuutinen L.

6. THE CONTROVERSY.  GI  Renal  Bone  Hematologic

7. THE CONTROVERSY.  GI  Adults < 5 days OR 1.30 (1.11 - 1.52) > 5 days OR 2.20 (1.36 - 3.57) > 75 yo OR 1.66 (1.23 - 2.25)  Kids 17/100,000 (3.5 - 49/100,000) RR 1.39 (0.92 - 2.10) Strom BL et. al. Strom BL et. al. Parenteral ketorolac and risk of gastrointestinal and operative site bleeding. A postmarketing surveillance study.. JAMA. 1996 Feb 7;275(5):376-82.JAMA. Samuel M. Lesko and Allen A. Mitchell The Safety of Acetaminophen and Ibuprofen among Children Younger Than Two Years Old. Pediatrics 1999;104;e39

8. THE CONTROVERSY.  GI  Renal  One Meta-analysis. Lee A, Cooper MG, Craig JC, Knight JF, Keneally JP. The effects of nonsteroidal anti-inflammatory drugs (NSAIDs) on postoperative renal function: a meta-analysis.. Anaesth Intensive Care. 1999 Dec;27(6):574-80

11. THE CONTROVERSY.  Renal  One Meta-analysis. Lee A, Cooper MG, Craig JC, Knight JF, Keneally JP. The effects of nonsteroidal anti-inflammatory drugs (NSAIDs) on postoperative renal function: a meta-analysis.. Anaesth Intensive Care. 1999 Dec;27(6):574-80  Many case studies.  Van Biljon G. Reversible renal failure associated with ibuprofen in a child. A case report. S Afr Med J 1989; 76: 34–35.  Primack WA, Rahman SM, Pullman J. Acute renal failure associated with amoxicillin and ibuprofen in an 11-year-old boy. Pediatr Nephrol 1997; 11: 125–126.  Buck ML, Norwood VF. Ketorolac-induced acute renal failure in a previously healthy adolescent. Pediatrics 1996; 98: Pediatr Nephrol 1997; 11: 125–126.  Ray PE, Rigolizzo D, Wara DR et al. Naproxen nephrotoxicity in a 2-year-old child. Am J Dis Child 1988; 142: 524–525.  Sheiner PA, Mor E, Chodoff L et al. Acute renal failure associated with the use of ibuprofen in two liver transplant recipients on FK506. Transplantation 1994; 57: 1132–1133.  Kovesi TA, Swartz R, MacDonald N. Transient renal failure due to simultaneous ibuprofen and aminoglycoside therapy in children with cystic fibrosis. N Engl J Med 1998; Drug Saf 1997; 16: 309–329.

12. THE CONTROVERSY.  GI  Renal  Bone NSAID Exposure and Risk of Nonunion: A Meta-Analysis of Case–Control and Cohort Studies Emily R. Dodwell Julius Gene Latorre Emilio ParisiniElisabeth Zwettler Divay Chandra Kishore Mulpuri Brian Snyder. Calcif Tissue Int (2010) 87:193–202

13. THE CONTROVERSY.  GI  Renal  Bone  Hematologic Niemi, T.T. Platelet dysfunction after intravenous ketorolac or propacetamol Acta Anaesthesiol Scand 2000; 44: 69– 74

14. Romsing J, Walther-Larsen S. Peri-operative use of nonsteroidal anti-inflammatory drugs in children: analgesic efficacy and bleeding. Anesthesia. 1997. 52 pages 673 – 683.

18. THE CONTROVERSY.  GI  Renal