Corneal sensitivity and burning sensation. Comparing topical ketorolac and diclofenac

OBJECTIVES

To compare the effect of topical 0.5% ketorolac tromethamine and 0.1% diclofenac sodium on human corneal sensitivity and to assess the intensity of burning sensation at specific intervals after drop instillation.

DESIGN AND SETTING

Double-masked parallel clinical study.

PATIENTS

Eleven women and 4 men (8 white, 4 Hispanic, 3 Asian), 22 to 60 years of age (mean [ +/- SD], 34 +/- 10 years).

INTERVENTIONS

Repeated instillation of either ketorolac and placebo or diclofenac and placebo at 5-minute intervals.

MAIN OUTCOME MEASURES

Assessment of corneal sensitivity before instillation, immediately after instillation, and after termination of drop application; and subjective evaluation of burning sensation by asking participants to rate burning on a scale ranging from 0 (none) to 3 (severe) after each drop application.

RESULTS

Both diclofenac (P < .01) and ketorolac (P < .01) decreased corneal sensitivity significantly, while the placebo had no measurable effect. After administration of additional drops over time, the effect of diclofenac and ketorolac increased. After termination of the drug instillation, corneal sensitivity returned to baseline significantly slower (P < .01) in participants receiving diclofenac than in those receiving ketorolac. Ketorolac (P = .01) and diclofenac (P < .05) were significantly more effective in whites than in nonwhites. Mean burning sensation was mild, and there was no statistically significant difference between the 2 drugs on this measure (P = .12).

CONCLUSIONS

The decrease in corneal sensitivity in normal human corneas is more pronounced and longer lasting with diclofenac than with ketorolac. Both drugs are well tolerated topically and may be useful for pain reduction after refractive corneal surgery.

Safety of intravenous ketorolac therapy in children and cost savings with a unit dosing system

OBJECTIVE

To determine the incidence of side effects with the short-term use of intravenously administered ketorolac in children and the overall cost savings with a unit dosing system.

STUDY DESIGN

We prospectively examined the incidence of complications arising from the intravenous administration of ketorolac to 1747 children (14,810 doses) during a 3-year, 3-month period and assessed cost savings resulting from dividing 60 mg syringes into 7.5, 15, 30, and 60 mg unit doses. Complications were recorded prospectively into a computerized database. Estimated drug costs to the pharmacy were calculated on the basis of the total numbers of each drug fraction administered, with allowance for 1O% wastage as a result of drug expiration.

RESULTS

Side effects occurring with ketorolac administration were rare. Four patients (0.2%) had hypersensitivity reactions to the drug, two of them possibly on the basis of latex allergy. Two patients (O.1%) had renal complications but were subsequently found to have underlying causes that could account for their renal symptoms. One patient (0.05%) had massive gastrointestinal bleeding in the postoperative period. With fractionation of 60 mg syringes, total drug cost to the pharmacy was $34,786, rather than the $86,639 that would have been spent had a single syringe been used for each dose.

CONCLUSION

Ketorolac proved safe for short-term intravenous use in children more than 1 year of age when patients with known contraindications to the use of non-steroidal antiinflammatory drugs were excluded. A considerable reduction in drug costs can be achieved with fractionation of premixed syringes into unit doses.

Intrathecal ketorolac tromethamine produces analgesia after chronic constriction injury of sciatic nerve in rat

PURPOSE

The study compared analgesic efficacy of intrathecally administered ketorolac tromethamine (K) and morphine hydrochloride (M) (in equimolar doses) in the chronic neuropathic pain model, induced by chronic constriction injury (CCI) of the sciatic nerve in rat.

METHODS

Male Sprague-Dawley rats (n = 30) were anaesthetized with halothane and an intrathecal catheter was inserted to the mid-lumbar level of the spinal cord. On the 5th post-operative day, rats were anaesthetized with halothane and four ligatures were loosely applied around the right sciatic nerve. Seven days later, those animals were randomly divided into three groups and were injected with either saline, M (20 nmoles) or K (20 nmoles). Two pain responses (foot-withdrawal delay and hind paw elevation time) were measured on both sides using the radiant heat method. Further, thermal ("cold") allodynia was assessed by measuring of the total time of hind paw elevation in animals placed on the cold metal plate.

RESULTS

Twenty nmoles of M and K injected intrathecally produced decrease of differential pain score calculated for both measured responses (hind paw withdrawal and hind paw elevation), compared with saline injected animals (P < 0.05). The reduction in pain response produced by K was less (P < 0.05). than the reduction in pain response observed in the animals receiving intrathecal M. Measurement of cold allodynia revealed that the animals in M and K injected groups demonstrated decreases in the total hind paw elevation time, when compared with saline-injected animals (P < 0.05).

CONCLUSION

M and K produced hypoalgesia after intrathecal administration in rats with CCI, with M being more potent than K at an equimolar dose range. The analgesic effect of K was equal to equimolar doses of M for alleviation of cold allodynia.

Single-dose intramuscular ketorolac versus diclofenac for pain management in renal colic

A double-blind controlled study was designed to compare the effective- ness of a single intramuscular dose of 60 mg ketorolac with that of 75 mg diclofenac in the treatment of renal colic and to monitor side effects. Fifty-seven patients completed the study, 27 in the ketorolac group and 30 in the diclofenac group. Effectiveness of treatment was monitored by pain relief reported on a 4-point verbal scale at different time points. At 60 minutes 77.8% and 86.6% (P = 0.4) of patients, and at 120 minutes 81.5% and 96.6% (P = .1 5) of patients, reported significant pain relief following ketorolac and diclofenac doses, respectively. Both groups had an equal 92% significant pain relief at discharge from the emergency department. Both drugs were well tolerated by the patients. Ketorolac therefore, seems as effective as diclofenac in the treatment of renal colic.

Efficacy of ketorolac tromethamine and extrapleural intercostal nerve block on post-thoracotomy pain. A prospective, randomized study

BACKGROUND

Post-thoracotomy pain causes severe impairment of the respiratory function. Epidural analgesia is effective in the treatment of post-thoracotomy pain but may give rise to significant side-effects. Other low-risk and cost-effective analgesic treatments are therefore required.

METHODS

Thirty male patients who had undergone pulmonary lobectomy entered a prospective, randomized trial to evaluate the efficacy of ketorolac tromethamine (Group 2) and extrapleural intercostal nerve block (Group 3) with intermittent low-dose bupivacaine. Objective and subjective assessment was carried out at 8, 16, 24 and 48 hours postoperatively.

RESULTS

There were no significant differences between Groups 1 (control group) and 2. Vital capacity was significantly lower in Group 3 (p<0.05) than in Group 1 after 16 hours. Forced Vital Capacity was significantly higher in Group 2 than in Group 3 after 16 and 24 hours (p<0.05). Peak expiratory flow was also significantly better in Group 2 than in Group 3 after 16 hours (p<0.05). On-demand opioid consumption was significantly lower in Group 2 (p<0.001) and Group 3 (p<0.05). No side-effects were observed.

CONCLUSIONS

Ketorolac tromethamine was effective in the treatment of post-thoracotomy pain. Extrapleural intercostal nerve block allowed a significant reduction in the consumption of opioids. These analgesic techniques could be useful as low-risk, cost-effective and reproducible treatments when more effective techniques, such as epidural analgesia, are contraindicated.

Contact lens induced conjunctivitis: a model of human ocular inflammation

PURPOSE

To demonstrate the usefulness of contact lens induced conjunctivitis as a model of human ocular inflammation and to evaluate the effect of antiallergic eyedrops on this model.

METHODS

We recruited 40 subjects with contact lens induced conjunctivitis. Half were treated with ketorolac tromethamine (KT), and half with iodoxamide tromethamine (LT). Signs, symptoms, contact lens wearing time, and wearing time until discomfort developed were evaluated at baseline, day 7, and day 14.

RESULTS

The group receiving LT showed improvement of symptoms 7 days after beginning the study (P = 0.016), and both the LT and KT groups showed improvement from baseline on day 14 (P = 0.001 and P = 0.004, respectively). Signs improved for both the KT group (P = 0.011) and the LT group (P = 0.043) on day 7 and day 14 (P = 0.033 and P = 0.007, respectively). Mean contact lens wearing time improved on day 14 for the group treated with KT (P = 0.001).

CONCLUSIONS

Contact lens induced conjunctivitis appears to be a useful model of human ocular inflammation. Both antiallergics KT and LT improve contact lens tolerance in subjects with contact lens induced conjunctivitis. Two weeks of treatment may be required to demonstrate therapeutic benefits of antiallergic drops.

The effect of ketorolac on microvascular thrombosis in an experimental rabbit model

This study was undertaken to evaluate the effect of ketorolac (Toradol), a potent cyclooxygenase inhibitor used for postoperative pain, on microvascular thrombosis in an established thrombosis model. Bilateral 3-mm arterial inversion grafts (n = 66) were constructed in the femoral arteries of New Zealand White rabbits. ALZET (ALZA Corporation, Palo Alto, Calif.) osmotic pumps were implanted in the external jugular veins for drug delivery. The blinded protocol called for the experimental animals to receive intravenous doses of ketorolac of 1.72 mg/kg per day (group 1) or 3.44 mg/kg per day (group 2), while control animals received equivalent volumes of saline. Patency was assessed at 7 days. Whereas 52 percent (13 of 25) of control vessels remained patent, 70 percent (14 of 20) and 86 percent (18 of 21) of group 1 and group 2 vessels, respectively, were patent at 1 week. This decrease in microvascular thrombosis with delivery of ketorolac was statistically significant (p = 0.0094). Ketorolac, at experimental doses approximating 9 and 18 mg IV q6h in a 70-kg man, demonstrated a statistically significant reduction in microvascular thrombosis. This study supports its use in clinical microvascular surgery.

A comparison of the effect of intramuscular diclofenac, ketorolac or piroxicam on post-operative pain following laparoscopy

Sixty patients presenting for in-patient gynaecological laparoscopic surgery were randomly allocated to receive either diclofenac 75 mg (n = 20), ketorolac 30 mg (n = 20) or piroxicam 20 mg (n = 20) as an intramuscular (i.m.) injection immediately after induction of anaesthesia. Post-operative Visual Analogue Scores at rest, over the first 24 h after surgery, using a 10 cm scale, ranged from 3.2-0.5 in the diclofenac group, 2.7-0.85 in the ketorolac group and 2.8-0.5 in the piroxicam group. The scores did not differ significantly between the three groups (P > 0.05). Mean time (SD) to first analgesia was 27 (94) min in the piroxicam group, 16 (30) min in the diclofenac group and 62 (120) min in the piroxicam group. Six out of 20 patients in the diclofenac group required further analgesia compared with nine out of 20 in the other two drug groups, this was not significant. There were no reports of increased bleeding, bronchoconstriction, bleeding from the upper gastrointestinal tract, renal impairment or pain from the intramuscular (i.m.) injection site in any of the groups. The administration of a non-steroidal anti-inflammatory drug to patients presenting for laparoscopic surgery reduces post-operative pain and analgesic requirements, and piroxicam 20 mg provides a suitable alternative to 75 mg diclofenac and 20 mg ketorolac.

Pain following iliac crest bone grafting of alveolar clefts

The purpose of this study was to investigate pain following iliac crest bone grafting of alveolar clefts. The study involved 34 consecutive patients requiring secondary alveolar bone grafting. The study population consisted of 21 males and 13 females with a mean age of 11 years (SD = 3.4). Twenty-three patients had unilateral and 11 patients bilateral clefts. The patients were treated in a like manner with harvesting of an iliac crest cortico-cancellous block concurrently with the raising of flaps and cleft closure. All surgery was performed by combinations of the authors. Eighteen patients were placed on postoperative intravenous ketorolac and the remainder were not. All patients received patient controlled analgesia at a dose of 0.015 mg/kg of morphine with an 8 min exclusion period before re-dosing. Total narcotic usage averaged 0.18 mg/kg (SD = 0.19) with 31 patients using less than 0.4 mg/kg. Regular ketorolac did not influence narcotic usage, nor did sex, age or nature of the cleft. Thirty-one patients began ambulating on the first postoperative day and 27 were discharged within 2 days of surgery. No long-term donor site morbidity was observed. Our results suggest that pain following iliac crest bone grafting of alveolar clefts is not severe and is readily alleviated with small quantities of analgesic drugs. It would appear that short-term morbidity following these procedures is frequently overstated and is in itself not a valid reason to change to calvarial or mandibular donor sites.

Comparative efficacy of topically applied flurbiprofen, diclofenac, tolmetin, and suprofen for the treatment of experimentally induced blood-aqueous barrier disruption in dogs

OBJECTIVE

To compare the relative efficacies of 4 topical nonsteroidal anti-inflammatory drugs at preventing blood-aqueous barrier (BAB) disruption in dogs.

DESIGN

1 eye of each dog was treated with 1% suspensions of diclofenac, flurbiprofen, suprofen, or tolmetin, or with control solution. After 4 applications of eyedrops at 10-minute intervals, BAB disruption was induced in the treated eye by anterior chamber paracentesis. The severity of BAB disruption was measured by anterior chamber fluorophotometry.

ANIMALS

40 ocular-normal dogs.

PROCEDURE

After pretreatment with eyedrops, rapid 100-microliters nonleaking anterior chamber paracentesis was performed in 1 eye of each dog to induce BAB disruption. 1 day after paracentesis, 1 ml of 10% fluorescein sodium was injected i.v.. The amount of fluorescein entering the anterior chamber of each eye was measured 30 to 60 minutes later by use of a computerized scanning fluorophotometer. The degree of BAB disruption was determined by comparing the amount of fluorescein entering the aqueous humor of the paracentesed eye with that of the nonparacentesed eye.

RESULTS

At postparacentesis day 1, the order of statistically significant BAB-stabilizing efficacy among groups was: diclofenac > flurbiprofen > suprofen > tolmetin = control solution.

CONCLUSIONS

Topically applied 1% suspensions of diclofenac, flurbiprofen, and suprofen are effective at preventing BAB disruption after paracentesis in dogs, indicating their potential usefulness for treatment of prostaglandin-mediated ocular disease. 1% tolmetin is no more effective than control solution.

Preoperative ketorolac increases bleeding after tonsillectomy in children

PURPOSE

To compare the incidence of vomiting following codeine or ketorolac for tonsillectomy in children.

METHODS

We had planned to enrol 240 patients, aged 2-12 yr undergoing elective tonsillectomy into a randomized, single-blind study in University Children's Hospital. The study was terminated, after 64 patients because interim analysis of the data by a blinded non-study scientist concluded that the patients were at undue risk of excessive perioperative bleeding. After induction of anaesthesia by inhalation with N2O/halothane or with propofol 2.5-3.5 mg.kg-1 i.v., the children were administered 150 micrograms.kg-1 ondansetron and 50 micrograms.kg-1 midazolam. Maintenance of anaesthesia was with N2O and halothane in O2. Subjects were administered either 1.5 mg.kg-1 codeine im or 1 mg.kg-1 ketorolac i.v. before the commencement of surgery. Intraoperative blood loss was measured with a Baxter Medi-Vac Universal Critical Measurement Unit. Postoperative management of vomiting and pain was standardized. Vomiting was recorded for 24 hr after anaesthesia. Data were compared with ANOVA, Chi-Square analysis and Fisher Exact Test.

RESULTS

Thirty-five subjects received ketorolac. Demographic data were similar. The incidence of vomiting during the postoperative period was 31% in the codeine-group and 40% in the ketorolac-group. Intraoperative blood losses was 1.3 +/- 0.8 ml.kg-1 after codeine and 2.2 +/- 1.9 ml.kg-1 after ketorolac (mean +/- SD) P < 0.05. Five ketorolac-treated patients had bleeding which led to unscheduled admission to hospital, P < 0.05, Exact Test.

CONCLUSION

Preoperative ketorolac increases perioperative bleeding among children undergoing tonsillectomy without beneficial effects.

Interaction of low molecular weight heparin with ketorolac

Postoperative patients may receive ketorolac, a nonsteroidal antiinflammatory drug that inhibits platelet function, for analgesia and may receive low-molecular-weight heparin (LMWH) for thrombosis prevention. We investigated whether the combination of these two agents increases blood loss in a rabbit model of hemostasis. In a randomized, blinded study, animals received either intramuscular ketorolac (0.5 mg/kg or 1.0 mg/kg) and subcutaneous saline solution, subcutaneous LMWH (100 U/kg) and intramuscular saline solution, ketorolac (0.5 mg/kg or 1.0 mg/kg) and subcutaneous LMWH (100 U/kg), or intramuscular and subcutaneous saline solution given 30 minutes before ear incision and measurement of blood loss. Collagen-induced platelet aggregation was examined and anti-Xa levels were determined by using a chromogenic substrate method. As compared with results in saline-treated controls, blood loss was significantly increased in animals receiving ketorolac in a dose of 1.0 mg/kg but not in those treated with 0.5 mg/kg. The addition of LMWH did not further increase blood loss above that observed with either dose of ketorolac alone. Platelet aggregation was inhibited by both doses of ketorolac. The anti-Xa levels in the LMWH-treated animals were comparable to those measured in patients receiving these agents for prophylaxis (0.09 to 0.13 U/ml). We conclude that in the rabbit model, LMWH does not augment ketorolac-associated bleeding when both agents are used in doses comparable to those given to human patients.

A comparison of the effect of intramuscular diclofenac, ketorolac or piroxicam on postoperative pain following laparoscopy

Sixty patients presenting for in-patient gynaecological laparoscopic surgery were randomly allocated to receive either diclofenac 75 mg (n = 20), ketorolac 30 mg (n = 20) or piroxicam 20 mg (n = 20) as an intra-muscular injection immediately after induction of anaesthesia. Postoperative visual analogue scores over the first 24 hours, using a 10 cm scale, ranged from 3.2-0.5 in the diclofenac group, 2.7-0.85 in the ketorolac group and 2.8-0.5 in the piroxicam group. The scores did not differ significantly between the three groups (p > 0.05). Mean time (SD) to first analgesia was 27(94) minutes in the piroxicam group, 16 (30) minutes in the diclofenac group and 62 (120) minutes in the piroxicam group. Six out of twenty patients in the diclofenac group required further analgesia compared to nine out of twenty in the other two drug groups. This difference was not significant. There were no reports of increased bleeding, bronchoconstriction, bleeding from the upper gastrointestinal tract, renal impairment or pain from the intra-muscular injection site in any of the groups. The administration of a non-steroidal anti-inflammatory drug to patients presenting for laparoscopic surgery reduces postoperative pain. There were no obvious differences between the agents used.

Postarthroscopic meniscus repair analgesia with intraarticular ketorolac or morphine

Both ketorolac, a nonsteroidal antiinflammatory drug, and morphine, an opioid agonist, provide enhanced patient analgesia after arthroscopic knee surgery when administered via the intraarticular route. This study was designed to determine whether ketorolac or morphine results in better patient analgesia and whether their combination would provide superior analgesia to either drug alone. Patients undergoing arthroscopic knee meniscus repair under local anesthesia with sedation were evaluated. Each of the study groups evaluated received ketorolac (either via the parenteral or intraarticular route) and morphine (via either the parenteral or intraarticular route). This study revealed a significant benefit from the individual intraarticular administration of both morphine and ketorolac. The combination of these drugs did not result in decreased postoperative pain or need for postoperative analgesics, and it did not result in an increased analgesic duration. We conclude that the use of either intraarticular ketorolac or intraarticular morphine improves the comfort in patients undergoing arthroscopic meniscus repair and that their combination offers no advantage over either drug alone.

Intraoperative ketorolac has an opioid-sparing effect in women after diagnostic laparoscopy but not after laparoscopic tubal ligation

Ketorolac tromethamine (Toradol) is a parenteral, nonsteroidal antiinflammatory drug that is being extensively used to provide postoperative analgesia. This study evaluated whether intraoperative ketorolac would act synergistically with fentanyl to decrease postoperative analgesic requirements in outpatients undergoing gynecologic procedures. The patients studied were adult ASA physical status I or II females scheduled for diagnostic laparoscopy (DL) (n = 80) or laparoscopic tubal ligation (TL) (n = 46). Each patient received fentanyl 2 micrograms/kg intravenously (i.v.) before induction, followed by a standardized propofol anesthetic and 2 mL of saline or ketorolac 60 mg i.v. in a randomized double-blind fashion 30 min before the anticipated end of the operative procedure. Patients were assessed for postoperative pain via a 10-cm visual analog scale (VAS) (0 = no pain; 10 = severe pain) before analgesic treatment in the postanesthesia care unit (PACU). Severe postoperative pain (VAS or 5 or more) was treated with incremental doses of fentanyl, 25-50 micrograms i.v. by a blinded PACU nurse. Ibuprofen or acetaminophen with codeine was administered for pain control once the patient tolerated oral medications. This study showed that intraoperative ketorolac (60 mg i.v.) with fentanyl (2 micrograms/kg i.v.) administered at the induction of anesthesia resulted in significant opioid sparing and a diminution in pain in the DL sample but not in the TL sample. The analgesic regimen was also associated with a lower incidence of nausea and vomiting and resulted in earlier discharge, which was not seen after TL. These results demonstrate that pain after TL is far greater than that after DL, which suggests that these procedures should be considered separately when designing analgesic regimens.

A comparison of the efficacy of ketorolac and indomethacin for postoperative analgesia following laparoscopic surgery in day patients

The analgesia provided in the postoperative period by three regimens commonly used in our private anaesthetic practice were compared in a double-blind study of one hundred and thirty-seven women presenting for day-case laparoscopic procedures. After random allocation into three groups, all patients were similarly anaesthetized and then received both a rectal suppository and an IM injection. Group P received two placebos, Group I had an indomethacin suppository 100 mg and Group K an IM injection of ketorolac 30 mg. The trial showed a statistically significant reduction in pain at 180 minutes postoperatively in the group receiving ketorolac (visual analog pain score of 13.8 v 21.7). The parenterally administered ketorolac may be a useful analgesic supplement in these patients. However the trial was aborted following the appearance in the literature of case reports of postoperative renal failure. Further investigation of the efficacy and side-effect profile of reduced doses may be warranted.

Colonic ulceration associated with the systemic use of nonsteroidal antiinflammatory medication

We report the first case of colonic ulceration precipitated by the intramuscular administration of ketorolac. This report suggests a role for the systemic effects of nonsteroidal antiinflammatory agents in the development of gastrointestinal ulceration.

Effect of benzalkonium chloride/EDTA on the ocular bioavailability of ketorolac tromethamine following ocular instillation to normal and de-epithelialized corneas of rabbits

This study was designed to examine the effect of benzalkonium chloride/ethylenediaminetetraacetic acid (BAK/EDTA) on the ocular bioavailability (Focular) of ketorolac tromethamine after ocular instillation to normal and de-epithelialized corneas of rabbits both in vitro and in vivo. The in vitro Focular of the formulations was measured in flow-through perfusion chambers. For in vivo studies, a 35 microL dose of 0.5% ketorolac tromethamine with or without BAK/EDTA was instilled into rabbit eyes with intact or de-epithelialized corneas. At 0.5, 1, 2, 4, 6, and 8 h postdose, rabbits were euthanized, and the corneas and aqueous humor were collected from both eyes. The ketorolac concentrations from both in vivo and in vitro samples were quantified by reversed-phase high-performance liquid chromatography. The in vitro study results indicated that BAK/EDTA statistically significantly increased the Focular of ketorolac through de-epithelialized corneas but not through intact corneas. The in vivo study results showed that BAK/EDTA had no effect on the Focular of ketorolac in rabbits with intact corneas, based on the values of the area under the aqueous humor concentration versus time curves (AUC0-6h) of ketorolac. As expected, de-epithelialization of the corneas produced a faster and greater ocular absorption of ketorolac as evidenced by the smaller Tmax and larger AUC values compared to those for the intact corneas in vivo. However, BAK/EDTA decreased the ocular absorption of ketorolac in rabbits with de-epithelialized corneas. The half-lives (t 1/2) of ketorolac in corneal tissue and aqueous humor were longer in rabbits with intact corneas than those in rabbits with de-epithelialized corneas. In conclusion, the in vivo Focular of ketorolac was not altered by BAK/EDTA in rabbits with intact corneas, but it was decreased by BAK/EDTA in rabbits with de-epithelialized corneas. Therefore, the formulation with ketorolac alone may be better as a post-operative ocular analgesic.

Intravenous ketorolac vs diclofenac for analgesia after maxillofacial surgery

PURPOSE

To compare the efficacy of the non-steroidal antiinflammatory drugs (NSAID), ketorolac and diclofenac in prevention of pain after maxillofacial surgery.

METHODS

Sixty ASA I-II patients (30 in each group) received randomly, and double blindly either ketorolac 0.4 mg.kg-1 or diclofenac 1.0 mg.kg-1 iv after general anaesthesia induction, before surgical incision. In the ketorolac group, the same dose was repeated iv three times at six hour intervals. The diclofenac group patients received diclofenac 1.0 mg.kg-1 after 12 hr iv. Rescue analgesic medication consisting of oxycodone 0.03 mg.kg-1 iv, was administered by a patient controlled analgesia apparatus.

RESULTS

Two patients in the ketorolac and three patients in the diclofenac group did not need oxycodone during the study period. On average, 12 and 11 doses of oxycodone were needed in the ketorolac and the diclofenac groups, respectively (NS). Side-effects were similar in both groups. All patients except one were satisfied with the pain therapy.

CONCLUSION

Parenteral ketorolac (0.4 mg.kg-1 four times in 24 hr) and diclofenac (1 mg.kg-1 twice in 24 hr) were similar, but insufficient alone, for analgesia after maxillofacial surgery.

[Use of new elastomeric pumps and PCA in postoperative pain control in thoraco-abdominal surgery]

36 patients submitted to interventions for thoraco-abdominal surgery has been submitted to antalgic post-operatory therapy with elastomeric pump at a continuous intravenous infusion and patient controlled analgesia (PCA). The patients have been randomized in three groups. The patients of the 1 degree group received 30 minutes before of the end of the surgical intervention 30 mg of Ketorolac. At the end of the anesthesia came started an infusion of 150 mg of Ketorolac (5 vials) in 60 ml of isotonic chlorinated solution at the rate of 0.5 ml/h. The pump had besides the capability of disperse a maximum of 4 bolus/ h, everyone of 0.5 ml, on demand of the patient. The 2 degrees group received a solution containing 60 ml of Morphine in 60 ml of isotonic chlorinated solution with the same formality of administration. The 3 degrees group (placebo) received 60 ml of isotonic chlorinated solution in pumps from infusion and Ketorolac intramuscular on demand. To the times T0 (awakening), T1 (3 h), T2 (6h), T3 (12 h), T4 (24 h), T5 (30 h, was collected algometrical consequences according to VAS (Visual Analogous Scale of Sc modification of the PA increase, FC, FR, SatO2.. The obtained results have highlighted like in the 1 degree group, to the 1 degree algometric consequence (T0), there is a good sedative effect on the pain (intensity of the middle low pain 3.70 +/- 1.64); this antalgic effect has also continued in the other consequences effected in the post-operatory. In the 2 degree group to the awakening (T0), the pain was middle-tall (5.50 +/- 2.32) and an expressive reduction appeared at the time T2 (3.60 +/- 1.35 P < 0.005). In the 3 degrees group have not recorded a diminution of the pain if not after 24 hours from the end of the intervention deposit the intramuscular antalgic therapy. In conclusion, the system infusion + PCA represents an indubitable advantage in comparison with the traditional antalgic therapy as for concern the entity of the reduction of the pain as because it permits the use of a smaller quality of drugs.

Reduction of postburn hyperalgesia after local injection of ketorolac in healthy volunteers

BACKGROUND

Nonsteroidal antiinflammatory drugs may be particularly effective against prostaglandin-mediated, post-injury hyperalgesia and related inflammatory pain. However, their usefulness may be limited by their systemic side effects. The current study determined if local effectiveness can be achieved by low-dose intradermal nonsteroidal antiinflamatory drug administration.

METHODS

Ten healthy volunteers were asked to make magnitude estimations of the pain induced by a contact thermal stimulator at 1 degree C increments between 43 and 51 degrees C at three 1 x 1 cm study sites on each forearm during three study phases:(1) baseline; (2) after pretreatment with 10 microl 0.9% saline (n=1 site on each forearm), 0.3 mg ketorolac (n=1 on each forearm), or nothing (n=1 on each forearm); and (3) after "injury" by a mild burn at the ketorolac- and saline-treated sites on one arm or by injection of 10 nmol bradykinin at all three sites on the other arm. The effects of pretreatment on the pain induced by thermal testing were assessed using repeated-measures analysis of variance.

RESULTS

Pretreatment with ketorolac had a selective effect on the postburn injury hyperalgesia, reducing the increase in pain intensity (P<0.05) but not the decline in pain threshold. It had no effect on the responses to thermal stimuli before injury or on the pain of burning, which were similar at ketorolac- and saline-treated sites. The effect of pretreatment with ketorolac on bradykinin-induced hyperalgesia was not achieved after bradykinin injection at sites pretreated with saline as well as ketorolac.

Intraocular penetration of periocular ketorolac and efficacy in experimental uveitis

PURPOSE

To determine in rabbits whether periocular injection of ketorolac tromethamine effectively delivers the drug to the eye and, if so, whether this is efficacious in the treatment of experimental uveitis.

METHODS

Ketorolac was administered by anterior subconjunctival injection, posterior periocular injection, intramuscular injection, or topical eye drops. The aqueous and vitreous were assayed for ketorolac. Anterior subconjunctival and topical ketorolac were compared to control as well as topical and anterior subconjunctival steroid treatments in uveitis induced by the intravitreal injection of tumor necrosis factor.

RESULTS

Anterior subconjunctival injection led to high, though short-lived, levels of drug in the aqueous and vitreous. Posterior periocular injection led to much lower levels. Topical dosing led to relatively low aqueous and undetectable vitreous levels. No ocular levels were detected after intramuscular dosing. All tested antiinflammatory treatments were similarly effective in controlling uveitis.

CONCLUSIONS

Anterior subconjunctival injection of ketorolac produced high intraocular concentrations of drug and was beneficial in controlling the inflammation in this animal model of uveitis.

Comparative effects of three doses of intravenous ketorolac or morphine on emesis and analgesia for restorative dental surgery in children

PURPOSE

The optimal dose of intravenous ketorolac tromethamine (ketorolac), a non-steroidal anti-inflammatory drug has not been determined in children. There are only limited published data on the use of intravenous ketorolac for paediatric analgesia. This study compares the analgesic and emetic effect of three different doses of ketorolac with morphine in paediatric dental surgical out-patients.

METHODS

Following institutional approval and parental consent, 120 ASA I or II children, age 2-10 yr were randomized to four groups and received ketorolac 0.75, 1.0, and 1.5 mg.kg-1 or morphine 0.1 mg.kg-1 iv at induction of a standardized anaesthetic. At 15 and 30 min after arrival in the recovery room a blinded observer assessed pain using the Objective Pain Score (OPS). Twenty-four hours after surgery a telephone interview was carried out with a parent at home.

RESULTS

There were no differences in demographic data, anaesthesia time, recovery and day-care unit time, OPS and postoperative analgesic requirements in the four groups. Postoperative vomiting in the first 24 hr occurred more frequently in the morphine group than in the other groups (P < 0.0166). No patient had excessive surgical bleeding.

CONCLUSIONS

Ketorolac, in all doses studied (0.75, 1.0 and 1.5 mg.kg-1) was as effective an analgesic as morphine 0.1 mg.kg-1 given intravenously at induction to children having restorative dental surgery. Its use was associated with a significant reduction in the incidence of postoperative vomiting.

Is preoperative ketorolac a useful adjunct to regional anesthesia for inguinal herniorrhaphy?

BACKGROUND

Nonsteroidal antiinflammatory drugs (NSAIDs) have become a popular component of analgesia regimens, particularly in combination with narcotics. We questioned whether there might also be a place for their use in conjunction with regional anesthesia and whether there was a preferable route for NSAID administration.

METHODS

Ilioinguinal and field blocks were performed preoperatively on seventy patients undergoing outpatient inguinal hernia repair. Patients were divided into a control group who received no ketorolac and four study groups who received a preoperative dose of 30 mg ketorolac by one of the following routes: i.v., i.m., p.o., or intrawound (i.w.). The ketorolac in the i.w group was mixed in the syringe with the local anesthetic used for the field block. i.v. and i.m. groups also received ketorolac at the time of the preoperative regional anesthesia and the PO group received the dose at least one hour preoperatively. All patients received a similar general anesthetic intraoperatively.

RESULTS

Postoperative pain scores and analgesic requirements were lowest for the i.m., i.v., and i.w. groups. Pain scores and analgesic requirements for the PO group were less than for the control group but more than for the other three groups. Analgesic efficacy therefore ranked: i.m. = i.v. = i.w. > p.o. > control. Though no differences were found between groups in the time to discharge from the recovery room, the ease of nursing care paralleled the findings for pain scores and analgesia requirements.

CONCLUSION

Beyond the analgesia provided by the regional anesthesia of the ilioinguinal and field blocks, the preoperative use of ketorolac further reduced postoperative pain scores and the need for additional postoperative analgesic medication. Comparable outcomes for the i.v., i.m. and i.w. groups indicate the lack of any benefit to concentrating the non-steroidal anti-inflammatory drug at the wound (i.w.) or to achieving high blood levels rapidly (i.v.). In conclusion, ketorolac is a useful supplement to ilioinguinal plus field block regional anesthesia for hernia surgery and is most effective administered parenterally.