The effect of ketorolac as an adjuvant to local anaesthetic infiltration for analgesia in paediatric umbilical hernia surgery

After umbilical hernia surgery, and wound infiltration with bupivacaine 0.5%, 17 children were given ketorolac 0.5 mg.kg-1, with 18 controls receiving only the wound infiltration. No child experienced severe pain, but moderate pain was noted in patients in both groups. Objective and subjective pain scores were not different statistically at any point up to the morning after surgery.

Postoperative morphine requirements, nausea and vomiting following anaesthesia for tonsillectomy. Comparison of intravenous morphine and non-opioid analgesic techniques

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be as effective as opioid analgesia following tonsillectomy in children. Opioids are still frequently used but tonsillectomy is associated with a high incidence of vomiting. This study has attempted to assess postoperative analgesic consumption and nausea and vomiting after general anaesthesia for tonsillectomy using either paracetamol premedication, paracetamol plus a NSAID or intravenous morphine to provide postoperative analgesia. Some children required a rescue dose of morphine in the recovery room, including some who had received intravenous morphine at induction. Least supplementary morphine was required by those who had received paracetamol plus ketorolac. Postoperative nausea and vomiting was significantly less in the two groups which were not given intraoperative morphine. The number of vomiting incidents was also much less. We conclude that the preoperative administration of paracetamol alone provides satisfactory analgesia in many children but that supplementary analgesia is still required for some.

Absorption of transdermally delivered ketorolac acid in humans

Transdermal delivery of ketorolac acid, a potent analgesic, through human skin in vitro and in vivo was evaluated. The following three transdermal solutions were selected to study the in vitro skin permeation rate of ketorolac acid: formulation A, isopropyl alcohol: water: isopropyl myristate (IPA/water/IPM; 11:7:1); formulation B, ethanol: propylene glycol:isopropyl myristate (ET/PG/IPM; 11:7:2); and formulation C, IPM/capmul (glyceryl mono- and dicaprylate; Monoctanoin). The permeation of ketorolac acid through cadaver skin from a saturated drug solution was evaluated at 32 degrees C with a modified Franz diffusion cell. The in vitro skin fluxes were 180, 177, and 14 micrograms/cm2/h for formulations A, B, and C, respectively. The systemic bioavailability of ketorolac acid from three transdermal formulations was evaluated in nine healthy subjects in a randomized three-way crossover fashion. Hill Top chambers were used as prototype dermal delivery devices to load the drug solution. This procedure was followed by the immediate application of devices to human subjects for 24 h. Blood samples were collected at various time intervals up to 48 h, and the samples were assayed by HPLC. The basic pharmacokinetic parameters were derived from the drug plasma concentration versus time plot. The maximum drug plasma concentrations were 1.265, 0.696, and 0.092 micrograms/mL for formulations A, B, and C, respectively. Formulation A provided the highest in vitro and in vivo transdermal delivery rate among the three formulations studied. An excellent correlation between the in vitro steady-state skin flux and the area under the curve of in vivo plasma drug concentration versus time was observed for all the three formulations.

[Clinical use of ketorolac (ketrodole) for analgesia in the early postoperative period]

Ketrodole was administered to 30 patients operated on the abdominal organs, heart and major vessels, lungs and bronchi. The drug was used in a single dose of 30 mg, the maximal daily dose being 90 mg for 16 young patients and 60 mg for 14 elderly patients. Adequate analgesia depending on the time of ketrodole use was attained in 74 to 95% of patients. In 60% of patients with medium intensive pain ketrodole may replace potent opioid analgesics or reduce their daily dose two- or threefold. Ketrodole in the doses used is a relatively safe analgesic.

Effects of ketorolac tromethamine on erythropoietin levels in Sprague Dawley rats

Ketorolac tromethamine (KT) is a potent analgesic, most often used in its injectable form postoperatively. Similar to other nonsteroidal antiinflammatory drugs (NSAIDs), it inhibits prostaglandin (PG) synthesis. Prostaglandins have been shown to be involved in the regulation of renal function as well as erythropoietin (Ep) production. The intent of this study was to determine the effect of KT on plasma Ep levels in Sprague Dawley (SD) rats. Twenty rats received either 15 mg/kg/d or the KT vehicle IM for 5d. Blood samples (1 ml) were collected via tail vein each day of treatment. Plasma Ep levels were significantly higher in the KT rats than normal controls with the greatest difference occurring on d4 of treatment (70.1 +/- 10.8 vs 30.9 +/- 10.84 mU/ml, p < 0.01). This change in Ep corresponded with a significant reduction in hematocrit (KT, 29.5 +/- 2.2 vs C, 40.8 +/- 2.2%, p < 0.01). Presence of fecal blood was noted in the KT treated rats. A similar second experiment was designed to determine if blood loss was the cause of altered Ep production. In this experiment controls (HC) were bled via tail vein, to match the hematocrits of KT treated animals. Repeated administration of KT led to a steady reduction in hematocrit. When compared, hematocrit matched animals showed no difference in plasma Ep levels on all days of treatment (KT, 48.0 +/- 4.9 vs HC, 44.6 +/- 3.1 mU/ml, N.S.). In conclusion, repeated administration of KT showed no impairment of Ep production and release in response to reduced hematocrit, suggesting that in this instance, prostaglandin inhibition plays a minimal role in Ep production or release.

Topical ketorolac has no antinociceptive or anti-inflammatory effect in thermal injury

This study investigated the antinociceptive and anti-inflammatory effect of a topical non-steroidal anti-inflammatory drug in human thermal injury. Twelve healthy unmedicated volunteers had identical burn injuries produced on the medial side of both calves with a 49 degrees C 15 x 25 mm thermode. Ketorolac gel or placebo were randomly applied on the right or left calf 1.5 h before burn injury, immediately after burn injury and 6 and 12 h later in a double-blind trial where every subject served as his own control. Heat pain detection thresholds (HPDT), head pain tolerance (HPT), mechanical pain detection thresholds (MPDT) and the intensity of burn-induced erythema (erythema index, EI) were assessed in the area of the thermal injury, and areas of hyperalgesia to pin prick were determined outside the injury before and 3, 6 and 24 h after the burn injury. Burn injury led to a decrease in HPDT, HPT and MPDT, an increase in EI and development of mechanical hyperalgesia (P < 0.05). Ketorolac gel had no effect on any of the nociceptive or inflammatory variables studies (P > 0.2).

Comparison of morphine and ketorolac for intravenous patient-controlled analgesia in postoperative cancer patients

OBJECTIVE

To compare the effectiveness of intravenous patient-controlled (i.v.-PCA) ketorolac to i.v.-PCA morphine in the treatment of postoperative pain in cancer patients.

DESIGN

In a double-blind, prospective, randomized trial, patients received either morphine in 1 mg/ml concentration or ketorolac 5 mg/ml for postoperative pain control. On arrival to the postanesthesia care unit (PACU), the patients received 2 ml of medication every 5 min, until satisfactory analgesia was achieved. If pain persisted after 20 ml of study drug had been administered, 0.1 mg/kg morphine was given i.m. On discharge from the PACU, the patients were placed on an i.v.-PCA pump. All patients received a basal infusion of 1 ml/h with a 1-ml on-demand bolus and a lockout interval of 10 min. Patients were offered 0.1 mg/kg morphine IM every 6 h, which they could refuse.

SETTING

University Cancer Center.

PATIENTS

Seventy patients scheduled for abdominal or truncal cancer operations.

MAIN OUTCOME MEASURES

Visual analog pain scores (VAPS) and Visual analog sedation scores (VASS) were used to measure the quality of pain control achieved either with ketorolac or morphine. The incidence of side effects was documented.

RESULTS

The VAPS were comparable between the groups. Patients in the ketorolac group requested more supplemental i.m. morphine. However, the total morphine dose and incidence of side effects was significantly higher in patients receiving i.v.-PCA morphine.

CONCLUSIONS

These results indicate that ketorolac supplemented with small doses of morphine is associated with a lower incidence of nausea, vomiting, and pruritus compared to morphine alone. This combination should be considered where immunosuppression from operation and administration of morphine is undesirable.

A comparison of intramuscular ketorolac and pethidine in the alleviation of renal colic

OBJECTIVE

To compare the analgesic efficacy of a single 30 mg intramuscular dose of ketorolac with that of intramuscular pethidine 100 mg, in a double-blind, parallel-group investigation of patients presenting with pain suggestive of renal colic.

PATIENTS AND METHODS

Seventy-six patients (17 women, 15 men; mean age 45.2 years, range 20-80) were allocated by means of a pre-determined randomization schedule to receive ketorolac and 78 patients (20 women, 58 men; mean age 42.1, years range 18-70) to receive pethidine. Data from eight patients in the ketorolac group and six in the pethidine group were excluded from the efficacy analyses because of protocol violations. The severity of each patient's pain was assessed on a four-point verbal rating scale (VRS) and a 10 cm visual analogue scale at pre-dose and at 15 min intervals for the first hour post dosing. The time to first administration of rescue analgesic, up to 24 h following dosing with the study medication, was recorded. Adverse events were elicited by general questioning.

RESULTS

Eighty-eight per cent of patients in each treatment group had improved according to the VRS of pain severity 1 h after dosing; the summed pain intensity differences up to 1 h were statistically significantly different in favour of ketorolac (P < 0.05). Fifty-six per cent of patients who were receiving ketorolac required rescue analgesia during the study period compared with 74% receiving pethidine. The incidences of adverse events were lower in the ketorolac group (28%) than the pethidine group (51%).

CONCLUSION

Ketorolac can be considered a viable alternative to pethidine for the treatment of renal colic.

Combination of intramuscular Ketorolac and low dose epidural morphine for the relief of post-caesarean pain

Epidural morphine produces profound analgesia but also causes many adverse effects in a dose-dependent manner. This double-blind, randomized, prospective study evaluated the analgesic efficacy and safety of low dose (2 mg) epidural morphine in combination with 30 mg intramuscular (IM) Ketorolac, a non-steroidal anti-inflammatory drug with potent analgesic activity, in patients suffering pain after caesarean surgery. Ninety parturients who received epidural anaesthesia in the postoperative period were divided into 3 equal groups: group A received epidural morphine 2 mg plus IM placebo; group B received epidural morphine 2 mg plus IM Ketorolac 30 mg; and group C received epidural saline placebo plus IM Ketorolac 30 mg. All patients were observed for pain relief, vital signs and adverse effects for 24 hours post drug administration. Results showed that group B had statistically significant superior pain relief to that of the other 2 groups. The incidence of adverse effects was similar between those of group A and B. We concluded that the addition of Ketorolac by IM administration enhanced the analgesic effect of low dose (2 mg) epidural morphine in the relief of post-caesarean pain without potentiating its adverse effects.

Pharmacist empowerment: taking practice guidelines to the next level (Part 2)

Empowering pharmacists to have direct control and responsibility for institutional drug-use protocols can assist in reducing costs and improving the quality of patient care. This article examines pharmacist involvement in two drug use protocols in place at St. Luke's Episcopal Hospital in Houston. The first is a pharmacist conversion order protocol in which pharmacists are given the responsibility of flagging and monitoring IV to oral dosage conversions of selected medications; the second is a pharmacist screening program for parenteral ketorolac dosing.

Single-blind comparative analgesic and safety study of single doses of intramuscularly administered ketorolac tromethamine and pethidine hydrochloride in patients with pain following orthopaedic surgery

Ketorolac tromethamine, a potent non-narcotic prostaglandin synthetase inhibiting analgesic was compared with pethidine for relief of moderate to severe postoperative pain. Forty-eight patients received Ketorolac 0.5 mg/kg and 52 received pethidine 1.25 mg/kg. The degree of pain prior to the administration of the drug and pain relief that followed were quantified using a vertical visual analogue scale (VAS) and monitored at hourly intervals. The safety profile was also studied by recording all adverse events noted. The mean pain (VAS) score at medication for Ketorolac was 7.04 and for pethidine 7.09. The pain relief obtained in the first four hours following administration of the drugs was similar for pethidine and Ketorolac. Although Ketorolac showed a longer sustained pain relief, time to peak analgesia after administration of this drug was slower than that after pethidine. It took 30 to 50 min for pethidine compared to 75 to 150 min for Ketorolac to achieve peak analgesia. The latter is therefore inappropriate if rapid pain relief is required. The incidence of side effects was significantly greater with pethidine (40.4%) as compared to Ketorolac (10.4%). The similar analgesic efficacy to pethidine makes Ketorolac an appropriate drug for the relief of postoperative pain especially in day surgery settings where observation following administration of the drug as in the case of pethidine can be dispensed with and patients sent home earlier because of the minimal side effects associated with its use. Caution must be exercised with the use of large doses of Ketorolac especially if the drug is used for more than 5 days to avoid serious complications like renal failure and gastrointestinal bleeding.

Clinical experience with ketorolac in children

OBJECTIVE

To describe the use of parenteral ketorolac in a large population of children, focusing on dosing patterns, efficacy, and safety.

DESIGN

Observational, prospective study conducted over a four-month period.

SETTING

A 122-bed children's medical center located within an academic medical center hospital.

PARTICIPANTS

Children receiving ketorolac during their hospitalization.

MAIN OUTCOME PARAMETERS

Indications for treatment, dose, dosing interval, use of a loading dose, length of therapy, efficacy (subjective response and use of concomitant therapy), and adverse effects (bleeding, gastrointestinal ulceration or vomiting, and renal dysfunction).

RESULTS

Of 112 children evaluated, 110 received ketorolac for analgesia, and 2 were given ketorolac as an antipyretic. The children ranged in age from 6 months to 19 years. Doses of 0.5 mg/kg q6h were used for most children (range 0.17-1.0). The average length of therapy was 3.4 days (range 1-12). The most frequent reason for discontinuing ketorolac therapy was a change to oral therapy. Therapy was discontinued because of a lack of efficacy in only 2 children. Adverse reactions were unusual, with only 2 patients having bleeding potentially associated with ketorolac use.

CONCLUSIONS

Ketorolac appears to be a safe and effective therapy for children when given in appropriate doses for a limited duration.

[Double-blind placebo-controlled study of the effectiveness and tolerability of 10 and 30 mg ketorolac tromethamine suppositories in post-cholecystectomy pain]

OBJECTIVE

To evaluate the efficacy and tolerability of ketorolac tromethamine 10 mg and 30 mg suppositories in comparison to placebo, after single dose administration in patients suffering from post-operative pain after cholecystectomy.

DESIGN

Double-blind, randomized, controlled study.

SETTING

Anaesthesia Service.

PATIENTS

99 patients with severe pain following surgery.

INTERVENTIONS

Cholecystectomy.

MEASUREMENTS AND MAIN RESULTS

The analgesia activity of ketorolac tromethamine 10 mg and 30 mg suppositories were evaluated after single dose administration by assessing pain intensity and pain relief using a 4 point scale (VRS). At the end of the treatment period overall assessment of safety and efficacy were recorded by physician and patient. The results show that in both active groups after 30' and until 4 hours, pain intensity decreased significantly with respect to the baseline. However a statistically significant difference between groups of p < 0.02, p < 0.01 and p < 0.05 was found in favour of the 30 mg dose respectively at 30', 6 and 8 hours after administration. All the patients treated with placebo suppositories required another rescue analgesic drug and withdrew from the trial. Three patients complained adverse events not related to treatment: two on placebo and one on ketorolac 10 mg. The systemic and local tolerability of the drug was good.

CONCLUSIONS

This study shows that ketorolac 30 mg suppositories are effective in clinical conditions, such as after surgery, in which pain control must be achieved within the shortest time interval and maintained or improved by means of a single route of administration.

Evaluation of the antipyretic effect of ketorolac, acetaminophen, and placebo in endotoxin-induced fever

The authors studied the antipyretic effect of three intramuscular doses of ketorolac (15, 30, and 60 mg), acetaminophen 650 mg PO, and placebo in healthy male volunteers using an endotoxin-induced fever model. In this double-blind, double-dummy, parallel study, subjects were assigned randomly with equal probability to one of the above treatment groups. Thirty minutes after study medication administration, a 20 unit per kilogram dose of reference standard endotoxin (RSE) was administered intravenously, and temperature was determined every 15 minutes for an 8-hour period. Compared with placebo, all active treatment groups demonstrated a statistically significant reduction in both adjusted area under the temperature-by-time curve (AAUC) and the maximum increase over baseline temperature (dTmax). Furthermore, the 30 mg intramuscular dose of ketorolac demonstrated approximately the same antipyretic activity as the 650 mg oral dose of acetaminophen, and there was a statistically significant dose response across the three ketorolac doses studied (P < .0001). The majority of side effects reported during this study were symptoms associated with fever, including chills, headache, myalgia, and dizziness, all of which are effects of RSE. The frequency of side effects tended to be less in the treatment groups with the greatest antipyretic activity.

Tolerability, central effects and pharmacokinetics of intravenous ketorolac tromethamine in volunteers

The central effects, tolerability and pharmacokinetics of multiple intravenous doses of the analgesic ketorolac tromethamine (30 mg 4 times daily for 5 days) were studied in male volunteers. In this double-blind, randomized, parallel group study, 13 subjects received ketorolac tromethamine and 7 subjects received placebo (vehicle). To determine the effects of withdrawal all subjects were then given further dosing with placebo (4 times daily) for 2 days while maintaining the double-blind nature of the previous drug assignment. Physical examinations and laboratory tests were obtained prior to the drug administration and after completion of the study. Scales for assessment of anxiety, depression, sleep and opiate withdrawal were presented to the subjects on day 2, 5, 6, 7 and 8 of the study. After 5 days of multiple intravenous doses ketorolac showed overall good systemic tolerance and safety in comparison with placebo. Myalgia and taste perversion were more frequently reported in the ketorolac group. The frequency of injection site complaints, mostly transient pain, was about 80% for both ketorolac and placebo, indicating these were likely caused by the vehicle. There were no significant changes in the scales assessing anxiety, depression, sleep and opiate withdrawal during treatment with ketorolac and after its withdrawal, suggesting that the drug has neither any major central effects nor any clear addiction potential in this dose schedule. Pharmacokinetic parameters were derived from plasma samples collected after the first and last active doses.(ABSTRACT TRUNCATED AT 250 WORDS)

A multiple-dose, double-blind comparison of intramuscularly and orally administered ketorolac tromethamine and Ketogan in patients with pain following orthopaedic surgery

In this multiple-dose, double-blind study 100 patients with moderate, severe or very severe pain following orthopaedic surgery were randomly assigned to receive ketorolac, a non-steroidal anti-inflammatory drug with potent analgesic properties (10 mg), or the standard regimen of Ketogan (a combination product containing the narcotic analgesic, ketobemidone, plus a spasmolytic agent) by intramuscular injection every 1-6 h as needed for pain. When patients were able to tolerate an oral diet and were expected to respond to oral analgesic medication, based on overall pain sensitivity, they were switched to oral doses of the same medication every 4-6 h as needed. A maximum of four daily doses of medication was allowed for up to 10 days. The severity of pain was scored on a five-point scale and was recorded before the first intramuscular dose, at fixed time points thereafter for up to 6 h and at the end of each day. Both treatments were effective immediately after the first dose and during the subsequent multiple-dose phase. There were no statistically significant differences between ketorolac and Ketogan. The results show that 10-mg doses of ketorolac in intramuscular injections followed by 10-mg doses of oral ketorolac are as effective as Ketogan for the treatment of pain following orthopaedic surgery. Ketorolac appears to be better tolerated than Ketogan since significantly fewer patients reported adverse events (P = 0.004) when taking ketorolac.

Pain management for children following selective dorsal rhizotomy

Selective dorsal rhizotomy (SDR) is a neurosurgical procedure used for treating lower extremity spasticity in patients with cerebral palsy. The purpose of this paper is to present a review of our institution's first three years' experience with postoperative pain and spasticity management in patients who have undergone SDR. The medical records of the 55 patients who had an SDR during the study period were reviewed. The basis of postoperative analgesia was morphine, with the majority of patients receiving continuous morphine infusions (20-40 micrograms.kg-1.hr-1 (n = 49), 60 micrograms.kg-1.hr-1 (n = 1)). Four patients used a patient-controlled delivery system. One patient had successful analgesia with epidural morphine. Ketorolac (1 mg.kg-1 i.v. loading dose followed by 0.5 mg.kg-1 i.v. every six hr for 48 hr) was used as an adjunct to morphine in six patients. For management of postoperative muscle spasm, an intravenous benzodiazepine was used (diazepam 0.1 mg.kg-1 (n = 2), or midazolam infusion 10-30 micrograms.kg-1.hr-1 (n = 51)). All patients were cared for on a ward where nurses were familiar with the use of continuous opioid and benzodiazepine infusions. All patients received continuous cardiorespiratory monitoring as well as frequent nursing assessment. There were no episodes of postoperative apnoea or excessive sedation. We have found the use of continuous infusions of morphine and midazolam, along with adjunct ketorolac, to be effective in treating postoperative pain and muscle spasms following SDR.

Evaluation of intravenous ketorolac administered by bolus or infusion for treatment of postoperative pain. A double-blind, placebo-controlled, multicenter study

BACKGROUND

Ketorolac is a nonsteroidal analgesic that may provide postoperative analgesia without opioid-related side effects. This double-blind, randomized, multicenter study evaluated the analgesic efficacy and safety of intravenous ketorolac in 207 patients during the first 24 h after major surgery.

METHODS

Subjects were assigned to receive one of three analgesic regimens: a ketorolac infusion, ketorolac boluses, or placebo. All subjects had access to intravenous morphine via patient-controlled analgesia (PCA). Evaluations included PCA morphine used, pain assessment (categorical pain intensity scores and visual analogue pain scores), pain relief (categorical pain relief scores), sedation, presence of adverse events, and overall rating of regimens by study observers and patients.

RESULTS

Patients in the ketorolac infusion group (but not the ketorolac bolus group) used less morphine (average 33 mg) than did the placebo group (44 mg) (P = 0.009). Significant differences favoring both ketorolac groups were seen in the pain intensity and the categorical pain relief scores at various time points during the study. At the termination of the study, compared with the placebo group, categorical pain intensity scores were lower in the ketorolac bolus group; visual analogue pain scores were lower in both ketorolac groups; and pain relief scores were higher in the ketorolac bolus group. The incidence of vomiting was significantly greater in the placebo group (27%) than in the ketorolac infusion group (12%) or bolus group (9%) (P = 0.032 and P = 0.005, respectively). The incidence of postoperative fever was 10% in the ketorolac bolus group and 25% in the placebo group (P = 0.013). Study observers noted less nursing difficulty while caring for patients in the ketorolac infusion group (P = 0.015). Study observers and patients in both ketorolac groups reported statistically significant overall drug superiority compared with placebo.

CONCLUSIONS

It is concluded that intravenous boluses or infusions of ketorolac in conjunction with PCA morphine provide effective, safe analgesia after major surgery and improve on the response to PCA morphine alone.