Comparison of Two Dosing Regimens of Intravenous Ketorolac for Post-Cesarean Pain Control

Spinal anesthesia will be achieved by injecting 10 mg hyperbaric bupivacaine 0.5% plus 25 mcg fentanyl Prophylactic vasopressor will be administered in all patients, Following delivery, all patients will receive a single dose of dexamethasone (8 mg) along with the first dose of intravenous ketorolac. Subsequent ketorolac doses will be administered every 8 hours.

After closing the fascia, the subcutaneous layer will be infiltrated with 30 mL of 0.25% bupivacaine.

Postoperatively, if the Numeric rating scale is > 3, intravenous nalbuphine 0.1 mg/kg titrated to response, with maximum single dose of 20 mg and maximum daily dose of 160 mg.

• Ketorolac 30 mg (Drug): administered intravenously as 30 mg diluted in 10 mL of normal saline and injected over more than 15 seconds
• Ketorolac 15mg (Drug): administered intravenously as either 15 mg diluted in 10 mL of normal saline and injected over more than 15 seconds.

Primary outcomes

• numeric rating scale at rest [6 hours postoperatively]: the patient rates their pain on a scale of 0 to 10, with 0 being "no pain" and 10 being the "worst pain imaginable"

Secondary outcomes

• numeric rating scale at rest [at 30 minutes, 12-, 18-, and 24 hours postoperatively]: person rates their pain on a scale of 0 to 10, with 0 being "no pain" and 10 being the "worst pain imaginable"
• numeric rating scale during movement [at 30 minutes, 6-, 12-, 18-, and 24 hours postoperatively]: person rates their pain on a scale of 0 to 10, with 0 being "no pain" and 10 being the "worst pain imaginable" during change position from supine to sitting or ambulation
• total nalbuphine consumption [from 0.5 hour postoperatively to 24 hour postoperatively]: mg
• time to first analgesic requirement [time from immediately postoperatively to time of first analgesic requirement during the first 24 hours]: hours
• ObsQoR-11 score [24 hour postoperatively]: The ObsQoR-11 is an 11-item questionnaire to assess a patient's recovery after a C-section, with a total score ranging from 0 to 100, where 100 is the best possible recovery
• patient's satisfaction [24 hour postoperatively]: At the end of the study the patient will be asked to rate her satisfaction with pain control using the NRS 10= strongly unsatisfied, 0= strongly satisfied

Sex: Female, ages: 18 Years to 35 Years

Inclusion Criteria:

* full-term, singleton, pregnant women,
* aged 18-35 years,
* scheduled for elective cesarean delivery under spinal anesthesia

Exclusion Criteria:

* American Society of Anesthesiologists (ASA) physical class III or more
* multiple gestation. Patients with a history of allergy to any of the study drugs,
* renal impairment,
* gastrointestinal bleeding or ulceration
* inflammatory bowel disease,
* chronic pain or regular opioid use.
* Inability to comprehend the numeric pain scale (NRS) or the ObsQoR-11 score
* requirement for conversion to general anesthesia after spinal anesthesia

• ahmed hasanin, Principal investigator, Cairo University Kasr Alainy Faculty of Medicine