Can patients take Toradol (Ketorolac) before an epidural procedure?

Can Patients Take Toradol Before an Epidural Procedure?

No, patients should not take Toradol (ketorolac) before an epidural procedure due to the significant risk of epidural hematoma from its antiplatelet effects combined with neuraxial instrumentation.

Primary Contraindication

Ketorolac inhibits platelet function and is contraindicated in patients at high risk of bleeding, including those undergoing neuraxial procedures. 1 The FDA label explicitly states that ketorolac is contraindicated in patients with "suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, incomplete hemostasis and those at high risk of bleeding." 1

Timing Guidelines for Discontinuation

If a patient has been taking ketorolac, it must be stopped at least 1 day (24 hours) before the epidural procedure to allow adequate clearance and restoration of platelet function. 2

• Ketorolac has a relatively short elimination half-life of 1-12 hours, but its antiplatelet effects persist beyond plasma clearance 3
• The 24-hour window allows for approximately 4-5 elimination half-lives, which is the standard pharmacokinetic approach for drug clearance 3

Risk of Epidural Hematoma

The combination of NSAIDs like ketorolac with neuraxial procedures significantly increases the risk of spinal epidural hematoma (SEH), a catastrophic complication that can result in permanent paralysis. 4

• A documented case report describes a patient who developed SEH and tetraplegia following a cervical epidural injection after receiving 30 mg intramuscular ketorolac immediately post-procedure 4
• The risk is particularly elevated when ketorolac is combined with other medications affecting hemostasis (anticoagulants, other antiplatelet agents, SSRIs like fluoxetine, fish oil, vitamin E) 4
• Even though the baseline incidence of SEH is rare (1.38 in 10,000 to 1 in 190,000), the consequences are devastating 4

Guideline Recommendations for NSAIDs and Neuraxial Procedures

Current guidelines from the French Working Group on Perioperative Haemostasis explicitly state that NSAIDs should NOT be administered perioperatively in patients requiring epidural procedures. 3

• NSAIDs do not require additional precautions for routine peripheral nerve blocks, but neuraxial procedures are categorically different due to the inability to compress bleeding in the epidural space 3
• The Association of Anaesthetists recommends "no additional precautions" for NSAIDs in general regional anesthesia, but this does NOT apply to high-risk neuraxial procedures where bleeding cannot be controlled 3

Special Considerations for High-Bleed-Risk Procedures

Epidural procedures are classified as high-bleed-risk interventions where even minor bleeding can have catastrophic consequences. 3

• The American College of Chest Physicians guidelines specifically mention that patients having neuraxial (spinal or epidural) anesthesia require more conservative anticoagulation management 3
• Anti-factor Xa measurement may be considered for patients undergoing spinal procedures when anticoagulation status is uncertain 3

Post-Procedure Considerations

If ketorolac is to be used for post-epidural pain management, it should only be administered after adequate hemostasis is confirmed and the epidural catheter is removed (if applicable). 5

• Injectable ketorolac should not be used with curative doses of anticoagulants 5
• If an epidural catheter is in place, ketorolac administration creates ongoing bleeding risk and should be avoided 3
• The catheter should be removed at least 4 hours after the last ketorolac dose if it was given, though this scenario should be avoided entirely 3

Alternative Analgesic Strategies

Multimodal analgesia using acetaminophen and, if necessary, opioids should be considered instead of ketorolac in the peri-epidural period. 5

• Acetaminophen does not affect platelet function and poses no additional bleeding risk 5
• Short-acting opioids can be used safely without increasing epidural hematoma risk 3

Common Pitfalls to Avoid

• Do not assume that because NSAIDs are "safe" for general anesthesia, they are safe for neuraxial procedures - the bleeding risk profile is fundamentally different 3
• Do not rely solely on medical consultants to identify medication risks - spine and pain physicians must independently verify that antiplatelet medications are stopped appropriately 2
• Do not administer ketorolac immediately after an epidural procedure for spasmodic pain, as documented in the case report where this led to catastrophic SEH 4
• Do not overlook cumulative bleeding risk from multiple agents - ketorolac combined with SSRIs, supplements (fish oil, vitamin E), or other antiplatelet agents dramatically increases risk 4