Timing of Ketorolac (Toradol) Injection Before Surgery
NSAIDs including ketorolac should be stopped 1 day (24 hours) before surgery to minimize bleeding risk. 1
Preoperative Discontinuation Guidelines
The timing for stopping ketorolac depends on the drug's elimination characteristics and the bleeding risk of the planned procedure:
- Standard recommendation: Discontinue ketorolac at least 1 day (24 hours) prior to elective surgery 1
- Rationale: NSAIDs should be withheld preoperatively for five elimination half-lives of the medication 2
- Ketorolac half-life: Approximately 4-6 hours in adults, meaning 20-30 hours allows for complete drug clearance 3
Risk Considerations by Patient Population
Standard Adult Patients (<65 years)
- Minimum preoperative interval: 24 hours before incision 1
- This allows adequate clearance given ketorolac's reversible antiplatelet effects 4
High-Risk Populations Requiring Extended Intervals
Elderly patients (≥65 years):
- Prolonged ketorolac elimination increases bleeding risk 2
- Consider extending the discontinuation period beyond 24 hours 2
Patients with renal impairment:
Patients on anticoagulants:
- Face 3-6 fold increased risk of bleeding when NSAIDs are combined 2, 5
- Require careful coordination of all anticoagulant and antiplatelet medication timing 1
Procedure-Specific Bleeding Risk
High bleeding risk surgeries (requiring 4-5 drug half-lives clearance):
- Major abdominal surgery 6
- Spinal procedures 1
- Prostatectomy 6
- Any surgery requiring neuraxial anesthesia 6
Lower bleeding risk procedures (may tolerate 2-3 drug half-lives):
Intraoperative Administration
Ketorolac can be safely administered intraoperatively once surgical hemostasis is achieved:
- Timing: Administer 30 minutes before expected end of surgery 7
- Dosing: 30-60 mg IV depending on patient age and weight 3
- Benefit: Intraoperative administration provides superior early postoperative pain control compared to postoperative dosing alone 7
- Safety: No increased bleeding complications when given after surgical hemostasis is secured 7, 8
Postoperative Use
Standard postoperative regimen:
- Initial dose: 30 mg IV for patients <65 years; 15 mg IV for patients ≥65 years 3
- Maintenance: Every 6 hours as needed 3
- Maximum duration: 5 days total therapy 3
- Maximum daily dose: 120 mg for patients <65 years; 60 mg for patients ≥65 years 3
Common Pitfalls to Avoid
- Do not combine ketorolac with other NSAIDs: Wait 6-8 hours after last NSAID dose before giving ketorolac 2, 5
- Do not exceed 5 days total therapy: Prolonged use significantly increases adverse event risk 3
- Do not use in patients with active bleeding or coagulopathy: Absolute contraindication 3
- Monitor renal function: Especially in elderly, volume-depleted, or renally impaired patients 2, 5
Alternative Analgesic Strategies
When ketorolac must be discontinued preoperatively, consider:
- Acetaminophen: No antiplatelet effects, safe perioperatively 6, 2
- Regional anesthesia techniques: TAP blocks, epidural analgesia 6
- Opioid analgesics: Morphine PCA, fentanyl 6
- Multimodal approach: Combining acetaminophen with regional techniques and opioids provides superior analgesia without NSAID-related bleeding risk 6