Is it okay to take intramuscular (IM) Toradol (ketorolac) before surgery?

Preoperative IM Toradol (Ketorolac) Administration

No, IM Toradol (ketorolac) should not be administered before surgery. Ketorolac is explicitly contraindicated as prophylactic analgesic before any major surgery according to FDA labeling 1.

FDA Contraindication

The FDA drug label for ketorolac clearly states that it is "CONTRAINDICATED as prophylactic analgesic before any major surgery" due to multiple serious risks 1:

• Bleeding risk: Ketorolac inhibits platelet function and is contraindicated in patients at high risk of bleeding 1
• Cardiovascular thrombotic events: NSAIDs increase risk of myocardial infarction and stroke, which may occur early in treatment 1
• Renal impairment: Contraindicated in patients at risk for renal failure due to volume depletion 1
• Gastrointestinal complications: Can cause peptic ulcers, bleeding, and perforation without warning 1

Guideline Recommendations for Perioperative NSAID Use

NSAIDs should be administered intraoperatively or postoperatively, not preoperatively 2:

• The Society for Perioperative Assessment and Quality Improvement (SPAQI) recommends continuing chronic NSAIDs up to the day of surgery for patients already taking them, but does not recommend initiating NSAIDs preoperatively 2
• French expert panel guidelines recommend NSAIDs (including ketorolac) be given during or after surgery in association with morphine for postoperative pain, not before 2

Timing of NSAID Administration

The appropriate timing for ketorolac is intraoperatively (after surgical incision) or postoperatively 2, 3:

• One study comparing preoperative versus postoperative ketorolac (30 mg IV) found that preoperative administration provided no additional benefit for postoperative analgesia 3
• More than 50% of patients still required opioid rescue regardless of preoperative ketorolac timing 3
• Ketorolac administered at skin closure or postoperatively provides effective analgesia equivalent to morphine 4, 5

Specific Bleeding Concerns

The bleeding risk is particularly problematic in the preoperative setting 1, 6:

• Ketorolac's antiplatelet effects persist beyond its 2-4 hour half-life 6
• Combined NSAID use (e.g., if patient already taking ibuprofen) significantly increases risk of gastrointestinal bleeding, perforation, and acute kidney injury 6
• The risk of operative site bleeding increases when ketorolac is used, especially at high doses or for prolonged duration 4

Appropriate Perioperative NSAID Strategy

For optimal perioperative pain management without preoperative NSAID administration 2:

• Administer ketorolac intraoperatively after surgical incision or at time of wound closure 2
• Standard intraoperative dose: 60 mg IM (can repeat to maximum 120 mg/day) 2
• Continue postoperatively for up to 5 days maximum 1
• Combine with multimodal analgesia including acetaminophen, regional anesthesia, and opioids as needed 2

Common Pitfall to Avoid

Do not confuse continuation of chronic NSAIDs with prophylactic preoperative administration 2:

• Patients on long-term NSAIDs for chronic conditions may continue their home medication up to surgery 2
• However, initiating ketorolac specifically before surgery as prophylactic analgesia is contraindicated 1
• This distinction is critical for patient safety and medicolegal compliance 1