TORADOL (ketorolac) linked to Recurrence Prevention
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Stephy TRUST ME lol this is why you should trust me...............I know my chit... I was a leader in teaching trauma care in the 70's and 80's I helped write the first Prehospital Trauma Life Support (PHTLS) book in 1985. Over 300,000 now are certified in PHTLS worlwide. I trained hundreds of paramedics in the program I ran. Trained residents and nurse. I know this chit.
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Ladies - I didn't mean to cause any confusion jumping in very late to these discussions. My comments were based on my background as a Medical Technologist in Blood Bank for 8 years (previous life MANY years ago). My memory is rusty too!!!
Steph - feel better soon!!
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CP418. You are an absolute asset here. Thank you for joining and I hope you stay forever. LOLwe all have rusty memories, we all have been poisoned with numerous drugs. We all need each other to keep things right.
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Stephy I'm sending my phone number by PM. Please, call me
Stephy what time zone are you in. Your posts keep appearing behind me(mine). I'm in EST(USA)
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Stephy, Toradol didn't drop your platelet count. Something else did.
Toradol interferes with platelet aggregation. That means it prevents platelets from clumping together to clot. Toradol does not damage, or prevent new formation.
Something else caused your platelets to drop and possibly interfere with their new formation.
Stephy, I'm getting worn out. I'm getting the feeling you aren't reading my posts.
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Rainnyc, glad to see you're doing o.k. Thanks for checking in.
Re: higher percentages of TN in Nigeria - my understanding is that Black women in this country tend to be more likely to be TN than the population overall. Obviously, this could be genetic so it doesn't surprise me that Nigerian women experience TN in higher numbers as well. There are probably additional factors at work, of course.
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sazz thanks for the concern I'm doing ok feeling better no bleeding and getting transfusion my sisters a nurse and has been helping me through this process she agreed with oxygen
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Steph, glad to see no more bleeding and that you're feeling better! Hope you're back home soon.
Good to see Rainnyc is doing O.K., too.
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http://www.medscape.com/viewarticle/778807
See if this is it...
That study is an eye-opener. I still hadn't completely finished recon. I think that seals the deal for me. It's interesting...it seems that maybe jostling around the vessels stimulates the recurrence. Small study here too though.
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This may be premature, but Dr Retsky, put me in contact with Dr. Forget. We've exchanged emails. He may come. If both become available at times for questions it would be an absolute dream. "It's unknown when a pebble is thrown into a pond, how far the ripples will travel"
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Sent a Pm to geewhiz, absolutely curious as to her delete. I told her she could never say anything that wasn't wonderful.
Stephy. Wonderful you have a sister whose a nurse. That makes me seriously happy. Has she been reading here? Have her join BCO and she can keep up with all that you do. erhhhhhhhhhh if you like LOL. Glad she agrees with the oxygen. NOW do you have oxygen ON ? Please, review with her the concerns I have about it being something else that caused the platelet count drop. It will take some detective work. The importance in identifying the cause, is to do avoidance in the future. If it can't be definitively pinpointed, having a Hematologist do a chart review is a strong recommendation. It is unacceptable in this situation that someone saying "I think it was bc/of________" is an answer. If the causative agent/reason is not identified, and you are again exposed in the future, you could be harmed more than what has occurred now.
Please, appease me and tell me what your pre-op and all post op platelet counts have been in sequence. Pretty please, with cherries and whip cream
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Lost a post--------Now I can't remember what I was gong to write. I think that's a signal to go play.
Everyone have a wonderful afternoon.
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I'm home on my laptop (iPad in the hospital kept losing my posts). Surgery went well: sentinel node clear on one side and missing on the other (maybe chemo blasted it out of existence?) so they took a small cluster of maybe four axillary nodes. Waiting for path report.
As for matters relevant to this thread, to the best of my memory, which is shaky in a few places.... The morning of surgery, I spoke for the first time with the anesthesiologist, who could not have been less interested in what I had to say. No to paravertebral block; apparently a couple of breast surgeons at MSK (Sloan Kettering) use them, but my surgeon does not. Yes to Toradol, but I could not get him to commit to using it pre-incision. Suspect he did not. When I pressed him, he did rattle off a few drugs that would be used in the OR; I didn't write them down but if someone reminds me of what the drugs might be I might be able to say yes or no. I was assured that Toradol was used in the OR and there may have been an infusion used in the recovery room; one of a few points I'm not clear on. I think I remember someone saying something about bleeding that may have happened in the OR, but this may or may not be true. Will ask the surgeon when I go for follow-up. What I do know--because my head had cleared at that point--is that I received 15 mg. infusions of Toradol at 6:00 PM and around 11:30 PM, after which the IV was removed.
Here's the interesting part: before surgery, I spoke to a couple of the OR nurses and raised the issue of Toradol. They were all over it! Very familiar with what is going on and seemed to know about Forget/Retzky in particular. Told me that someone is putting together a clinical trial but didn't specify where--but in the US, I think. Seemed surprised to hear a patient bring this up but unsurprised when I said that it was being discussed online in the breast cancer community. So it is being discussed at MSK and I suspect plays into the fact that it was very easy for me to get Toradol upon request (my surgeon did tell me that it is more commonly used in Europe than in the US. It also was easy for me to have my voice heard about as few opiods as possible; they typically set up patients coming out of the OR with a pain pump, but when I mentioned nausea coming out of surgery in the past (a couple of decades ago), they agreed to forgo that. Floor RNs are all over getting off opiods as quickly as possible. They sent me home with a couple of oral medications: diclofenac 2x daily and Norco as needed. It seems clear that I am to transition off Norco to Tylenol.
So I suspect I have had significantly less pain than Steph because no reconstruction (though plan to go that route in future, once I'm healed from rads).
There is wonderful research in this thread; thanks to those who put it together. I only wish I'd discovered it sooner! I think my situation is different from many BC patients in that I had neoadjuvant chemo before surgery, whereas most people seem to have surgery first, so they are processing many things in the original diagnosis and may not have the time and inclination to research this. I certainly would not have done so in that difficult first month after I was diagnosed. I guess my question is: what do we know for sure amongst some of the confusing and contradictory details, and what would be most helpful for patients to know in conversation with their surgeons? And once we know those things, might that be a separate thread to help others?
All for now. The last Norco was at six hours back, and I am going to take another....
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Solfeo - one commonly used supplement, fish oil, is apparently also a blood thinner. After having a hematoma with my first biopsy I was told to avoid it before the 2nd biopsy and prior to any subsequent procedures. So, if you're currently taking fish oil, stop 3-7 days (I'd go with 7 for surgery) prior.
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Hi Rain,
So glad you made it through surgery well, and sentinel node was clear! I hope the auxillary nodes are, also. Good that you got ketorolac post-op, and hopefully during surgery. You sure got a lot of interesting info from your nurses! Very cool that they are onto the ketorolac already, and exciting that someone is putting together a U.S. study. Also great that they were willing to minimize the opioids.
I gotta say, even on my best day, my brain doesn't work as well as yours, the day after surgery! Rest well.
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Rainny, WOW, congratulations on all counts. Your report is very useful. I'm sure Retsky and Forget will find it very interesting. There are many that brought research links here. The importance of what we are doing is making folks aware that they're may be a way to interfere with recurrence by the drugs used during initial surgery and subsequent surgery. This is huge really, have faith we are changing the world.
Retsky's and Forget's studies are retrospective(looking back). They, also, want to do a prospective study(clinical trial--double blind study). The fact that Sloan Kettering folks, docs and nurses, are so aware is encouraging. That tells me the impact of Retsky's and Forget's studies are valued. The fact that the nurse's were able to say that someone's trying to put a trial together--encouraging. I love teaching hospitals. The energy and interest in learning is way different than in non-teaching hospitals. I've worked in both settings. Frankly, it's an embarrassment of the lack of interest in learning in non-teaching hospitals.
I agree as time goes on putting together a plan with all the details that the research supports is what our goal should be. The Dear Doctor letter that I put together is a beginning. It is something that can help get a doc not aware of the research on Toradol and bleeding to pay attention now. But we can go much farther with it. Be patient it will happen. Eventually, putting it in a new thread that simply defines our expectations is where we need to head. Effectively, it would read like an algorithm for CPR.
The Mods and the bosses are watching what's happening here. They are as excited as we are that Dr. Retsky came here. Wouldn't surprise me at all if they didn't contact him and have a main discussion board topic developed. I've been here since 2009, many main board topics developed out of our thread topics. We are their best resource for determining what is important to talk about. (Mods--Waving and smiling).
Your discharge instructions are above average in content. You describe that you clearly know when to move to a different level of drug. This is very important. I have seen many discharge instruction forms that varied in clarity. The best forms assume that the patient will remember nothing. May sound weird. But remember we are under the influence of drugs at discharge. We can say yes, I understand everything and 5 minutes later not remember anything.
Rainy your memory BTW of all that occurred, is way above average. Bless you. I am sure that many will find your post very useful
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To all , I have many mantra's that guide what I do. The mantra that guided me this week was "When you don't have an absolute answer, it is time to give the question to a more knowledgeable person". I've used this for decades to train Emt-A's , Paramedics, nurses, residents, docs etc. The morning that I woke and decided to call Dr. Retsky was based on this mantra. We all know him coming here has made a difference. We have more confidence. We have more strength in what we believe we have learned from our study.
While Dr. Retsky or Dr. Forget haven't committed to spending time here. What I suggest is that when you have a question for them, rather than addressing it to me to seek an answer from them, address it to them. This is important because if they do consider coming here they may not have time to read all the posts. It allows them to identify what is needed directly.
For those folks that are here now, pretty well, all are well versed in the studies. i.e done the homework. For those coming in the future, do your homework re: reading the studies, keep current, and then if your question isn't answered address it to our experts. Their time is limited. But they gain from being here too. Our questions, may lead them to areas of thought they hadn't considered. We both benefit.
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Dr Retsky /Dr Forget. Question from Solfeo
In my immediate situation I would like to know if the risk of bleeding with Toradol is higher with some procedures vs. others. For instance, Steph had problems with her BMX w/TE, but seems that rainnyc didn't have issues with her BMX alone (if I didn't mistake the kind of surgery rainnyc had). Could the TE placement have affected risk of bleeding? The longer surgery?I understand that if I have delayed reconstruction I will still need Toradol, but what I need to do now is choose between immediate and delayed reconstruction. Steph's bleeding problem obviously has me concerned about my own risk. A big consideration is that if the Toradol causes bleeding the first time I won't be able to have it again, and I might not want to have any more surgeries that are not absolutely necessary. There are many implications to that to think about. Is there anything that can be done before surgery to predict or reduce the risk of bleeding from the Toradol? (Besides the standard advice to avoid all blood thinning meds & supplements prior to surgery)
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Stephy, I'm sure you are getting some well needed rest. Hoping your pain is controlled. Hope all is well with your baby. Please, if you can post a pic of her. we all would love to see her...........Stephy, in the scope of all things, determining why you bled is important. It's not a fault finding thing. If it can be determined why, then it may help someone in the future. Think in terms of yourself, I remember you saying you wanted to do everything you could to assure you would survive b/c of your baby. You were willing to go through tortuous surgery without pain medication if that could improve your survival. You braved more than most. You are amazing.
Help us. Consider another Mom in your same scenario. A Mom that might avoid Toradol b/c of a worry about a bleed.
BTW--let me know what they instructed you about arm movement. They're is no current research that says limitation of arm movement is correct. 6am the morning after my BMX, I did full range of motion. As a result I had no shoulder problems. The only literature in 2009, that addressed the question stated it should be limited so as not to dislodge the tube in the arm upper arm portion of the axilla. My movement didn't dislodge them.
What I think has happened is that the limited arm motion is a carry over from a century ago, that hasn't had much of a relook by today's general/breast surgeons. They're is a movement to change this. How wide spread it is I don't know. A member Chickadee treated at the Cleveland Clinic, had a BMX with te's and no drainage tubes. She didn't realize her treatment was revolutionary until I told her. This was several years ago.
The Orthopedic docs have advanced shoulder range of motion after surgery to be specific to the need of the surgery. Some surgeries need immbolization others need to have mobilization within hours of surgery.
General surgery/breast surgery has not been as quick to determine need for change re shoulder movement/range of motion. The reason this is important to you is you have along life to look forward to:), you don't need to have shoulders that don't work.
Hugs, sassy
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Solfeo, the docs aren't here....." In my immediate situation I would like to know if the risk of bleeding with Toradol is higher with some procedures vs. others."
Possibly a known fact. But none of us have come across it. With Stephy, I believe they're were other circumstances. Can't say for certain, I don't have enough facts to support my positon.
The problem we are now presented with is, we have real experts that can answer our questions. We've mentally flipped from flying by the seat of our pants to soaring like eagles. What we also have to deal with is they might not be available at the time we need an answer. Solfeo, I know you are essentially on call for your surgery. Go back and Look at Forget's studies.........................I don't remember I'll go look..............too tired solfeo It's 3am, the words weren't gelling. Sorry.
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going home today feeling a little nauseous but pain is well controlled on norco every 6 hours seems to be working well had the paravertebral block pulled didn't want to go home with it here's pics of my kids can't wait to see them!
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Aw, Steph, your little ones are adorable!! Kisses from those guys ought to be a pretty good pain reliever, too!
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Awww...precious little ones. The reason we fight this battle with all of our might
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Stephy beautiful kids. YAY for going home.
SolfeoI sent your question off to the docs .(thurs 12n)
Rainy When you feel up to it, jot down notes as you recover as to what you would like to have included while it's fresh in your mind.
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Solfeo, Dr R sent me an email I think wed that he was out of the office for a few days.
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Sassy, what do you mean, "what I would like to have included?" You mean in terms of medications? Education?
Decided today to see if I could get by on Tylenol during the day and save the opiod for bedtime. So far, so good. I'm achy, but it's survivable. And I'm not trying to be a hero....happily taking the extra strength tylenol as needed.
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Dear all,
Very difficult to answer as a doctor to specific questions about specific stories. I would be in fault to give the impression that we can "consult" online. Nevertheless, this discussion is an opportunity to give some general answers.
1. Bleeding in surgery is a very legitim problem, but most often a surgical problem. Therefore, it is logically influenced by the surgery (including the type one). The best counselor is the surgeon himselg who can explain which exact type of surgery can be linked to an increased, or decreased, risk of bleeding. In general, raw surfaces are more prone to bleeding. Of course, coagulation as platelet aggregation can have an impact, possibly impacted by medications of course, as by medical conditions. In case of doubt, hematologists are mostly the right people to investigate objectively if there are concerns for future surgery. In the case of Toradol, we can say that bleeding has been inconsistently increased, and most often not increased in studies. Certainly not as massive as by great vessels injuries remaining open.
2. At this time, and this is unfortunate, we cannot recommand (yet?) Toradol for an anticancer effect, not (yet) proven, even if the signal (in retrospective studies) exists. Maybe in the next future? Trials are absolutely mandatory to confirm the signal.
Hope these are satisfactory answers.
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Good Morning,
PrPF, You didn't send a pm regarding your screen name. I don't want to assume who you are
The initials are right. The p instead of a d, if P is for professor That's is the most complete, succinct summary of the last 14 pages. Thank you
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PrPF, yes they are satisfactory answers. We really appreciate you taking the time to write to us.
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Stephy, please, tell me what you think of PrPf's response. He's is recommending the same thing I did. He's not specifically saying you, but I am. Your bleed was significant. You dropped from a 12.6 HGB to 7.2 HGB. This amount of blood loss after a BMX is unusual. It's important that a hematologist determines that there wasn't a coagulation problem other than related to a surgical origin. If there is no coagulation problem. Then the origin was either surgical as PrPF indicates or it was the Toradol. The reason this is important to absolutely know if you have a coagulation problem is because you are young. The potential for future surgery is possible.
Solfeo, please, did PrPf's response answer your question?
Rainy, Sorry, I didn't state it well. You've read everything. You've had the surgery. Your surgery was at SK a premier oncology facility. At this moment in time, I think you can bring a unique perspective of what to include in a "package" for future readers. The Dear Doctor letter from a few pages ago is a start. What else, needs to be added to that letter to make it more workable. BTW I did go back and modify the opening sentence so it was less 'challenging'.
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