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Foreign. Okay, this is not a regular episode at all, but it was so good. The mini conversation I had via voice memo was so good with one of our podcast family members and good friend Carrie that I'm like, I gotta put this out. This is not a full episode. This should be like five minutes. Famous last words. But I gotta relate something that an MFM friend of mine, she is phenomenal, by the way, sent me as a voice memo regarding the recent episode that we did on two perioptoses of Keter Warlak around C section. All right, so this was the RCT that was in O N G open from the Ohio State University. Go back and listen to that episode. We're not going to rehash all that. But Carrie had two good points here that are absolutely spot on that may have affected some of the findings here and maybe not. So let me just quickly explain. Remember that in the control group, that was the group that had the 30 milligram IV dose of ketorolac in the OR before going to recovery compared to the intervention group that had the 60 milligram dose of ketorolac IV in recovery before. I mean, in the OR before going to recovery. Those patients each, each one of those controlling the intervention had in the first 24 hours a maximum of 120 milligrams of ketorolac to keep it standardized. However, Those in the 30 milligram camp to go up to the full 120 needed three 30 milligram subsequent injections every six hours. So get 90 plus 30. That's the 120. Whereas those who had 60 milligrams in the or before they went to recovery, in order to get to the 120 milligrams in the first 24 hours, only had two subsequent injections of 30 milligrams. Everybody with me? Everybody with me. If you're like, what is he talking about? It's because he didn't listen to the episode. You got to go back and listen. So Carrie's point is very good. Wait a minute. In those patients who received two injections, wouldn't they subconsciously go, wait, I haven't gotten as much medication here. I'm going to ask for more pain medicine. Whereas those who say, oh, I'm getting every six hours, I'm getting this additional medication that would get less medication. In other words, it would bias against the 60 milligram intervention group because they're receiving less injections. Maybe they would ask then for more pain medication. Totally makes sense. That's called the nocebo effect. Okay? There's placebo where you think you get better with nothing. And then the opposite of placebo is the nocebo effect, where you attribute a negative effect on a treatment to something that's. That's really not there at all. All right? So a placebo tends to make you better. Nocebo is. You kind of think you're worse. So you have an adverse perception of that. So getting two injections in the 60 milligram cohort could lead to a nocebo effect where those patients would artificially ask for more pain medication because those patients were not blinded. They didn't have a control. It would have been great in the 60 milligram cohort if the patient had an additional saline injection so that they all got three shots, but one was a saline injection versus Toradol in the 60 milligram cohort. All right, to equal three medications given at six hours apart. But that wasn't done. However, here's why. It probably didn't make a difference. They didn't know what they were supposed to get anyway. Does that make sense? So it's not like they're like, hey, the other group got three injections. I'm only getting two, so I'm gonna ask for more pain medicine. So that likely, while it could affect the results with a nocebo effect, it likely didn't do that because they weren't any wiser for the weary. Okay? So, yes, that's a great point. Carrie, please go back. Everybody else, if you haven't heard the episode, go back and listen to the best dose for keto or lactis is what we're talking about. And the second thing is, why did the author say, it's a very small sample effect? Okay? And right in their print, I've said, hey, while Toradol looks like it did good, it reduced their overall morphine milligram equivalence in the overall hospital stay. But it's still a small sample effect. Why is that? Well, even though. Here it is, guys, quickly. Even though in the intervention group, the 60mg IV Toradol in the OR at the end of the case, even though they had 15 morphine milligram equivalents MMEs throughout their whole duration to stay, and the control that had 30 milligrams of Toradol in the recovery room. I mean, in the OR before going to recovery room, while they had 30. So it's like, hey, those in the higher dose of toradol had less MME's morphine milligram equivalents throughout their hospital stay. That's a win. Yes, it is. But don't forget that MME is a math formula. The absolute number here. Here's the catch, guys. Here's the catch. The absolute number is probably like 2 less of 5 milligram oxycodone. Okay? So while the MME looks like it half, and it is 15 MMEs versus 30 MMEs, so those who had the 60 milligram dose required less morphine milligram equivalents. That is true throughout their whole hospitalization. What it comes out to in a true actual pill is like 2.5mg oxycodone. Now, that's not me saying that. The authors do mention that in the. In the narrative in their discussion. Like, ah, that's why it's. Maybe it's a small sample size, but hey, 2 less oxycodone is 2 less oxycodone. So I still think it's a win, but that's why they say small sample size. Also, remember very quickly, because I didn't put this in the original episode, because I just wanted it to be quick, that within the first 24 hours, which was their main endpoint, guys, right? The number of morphine milligram equivalents on opioids taken by mouth in the first 24 hours really wasn't vastly different. Between the 60 milligrams and the 30 milligrams, the median opioid consumption based on interquartile was basically the same. However. However, Those who had 60 milligrams, they did require opioid much later than those who had 30 milligrams. And there was still a shift towards lower opioid use in the 60mg keto orlac group within the first 24 hours. Even though this. They had identical median values. Remember, that's the median. But there was definitely a shift to less opioid use in the first 24 hours. So short of it is, hey, Toradol. It's not gonna take away all the pain. It's not gonna take away all the need for opioids, but it does do a role, although more information is needed. So I decided to call this episode Carrie's Knowledge kk Because I don't know. It's catchy. Cari, great question. Always good to hear from you. Keep up the great work that you're doing. You're such a great person and a great physician. Anyway, great insights that. That could possibly be a nocebo effect. If the 60 milligram received less injection, one less injection than the 30 milligram, but they didn't know that they were supposed to get, you know, two or three anyway, so it probably didn't bias it in the long run. All right, podcast family, just a quick shout out to my friend Carrie. Keep it up. And that is all for now. We'll see you on the next episode of the no Spin Podcast.
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We're just trying to fulfill our life calling and our mission. This is Dr. Chapas. We OBGYN no Spin podcast.