Renal failure and hyperkalemia associated with ketorolac tromethamine

Three patients who were treated with ketorolac tromethamine (Toradol), an injectable nonsteroidal anti-inflammatory drug for pain management, developed acute renal failure or hyperkalemia or both. These complications were reversible in two cases after discontinuing the drug. Clinical conditions preexisted in each patient that rendered them susceptible to the renal complications of nonsteroidal anti-inflammatory use. It is well known that caution should be observed while using nonsteroidal anti-inflammatory drugs in patients whose renal function may be preserved through prostaglandin-mediated vasodilatory effects. The same cautions apply to ketorolac. Since its major marketed use is as an analgesic and its potent effect on prostaglandin synthesis may not be well recognized, those cautions must be emphasized.

Assessment of ketorolac as an adjuvant to fentanyl patient-controlled epidural analgesia after radical retropubic prostatectomy

BACKGROUND

Opioids, although effective postoperative analgesics, are associated with undesirable side effects. In an attempt to determine whether adjuvant, nonopioid medication would permit a reduction of the amount of fentanyl required for postoperative analgesia, the efficacy of ketorolac, an injectable nonsteroidal antiinflammatory drug, was studied as an adjuvant to fentanyl patient-controlled epidural analgesia (PCEA) for postoperative pain management following radical retropublic prostatectomy.

METHODS

Forty patients were randomized into two groups to receive fentanyl PCEA and either ketorolac 30 mg intramuscularly every 6 h after an initial dose of 60 mg (n = 20) or placebo (n = 20) for 72 h. Visual analogue scale pain scores (0-100 mm; 0 mm = no pain; 100 mm = worst pain), sedation, fentanyl usage, gastrointestinal function, complications, blood loss, and temperature were assessed four times each day.

RESULTS

Visual analogue scale (VAS) pain scores at rest were lower in the ketorolac group during the first 4 h (P < 0.01), but were similar thereafter. Global VAS pain scores with activity were lower in the ketorolac group on postoperative day 1 (23 +/- 4 vs. 39 +/- 6; P < 0.05) and postoperative day 2 (17 +/- 3 vs. 29 +/- 4; P < 0.05). Bladder spasm pain occurred less frequently in the ketorolac group (1 vs. 9 patients; P < 0.05). Fentanyl usage was less in the ketorolac group throughout the study (33 +/- 3 vs. 50 +/- 6 micrograms/h, 0-24 h; 20 +/- 2 vs. 36 +/- 6 micrograms/h, 24-48 h; 12 +/- 2 vs. 24 +/- 6 micrograms/h, 48-72 h; P < 0.05). Sedation scores and side effects were similar, except on postoperative day 3 when nausea was less frequent in the ketorolac group (0 vs. 6 patients; P < 0.05). Recovery of gastrointestinal function occurred sooner in the ketorolac group as determined by first bowel sounds (26 +/- 3 vs. 38 +/- 4 h; P < 0.05), first clear liquids (51 +/- 2 vs. 65 +/- 3 h; P < 0.01), and first regular meal (95 +/- 4 vs. 110 +/- 4 h; P < 0.05). There was no significant difference in blood loss, transfusion requirement, hematocrit, platelet count, or temperature. There was high overall satisfaction in both groups, but fewer patients in the ketorolac group rated pain with walking as usually or always painful (1 vs. 9 patients; P < 0.05).

CONCLUSIONS

Ketorolac is a beneficial adjuvant to fentanyl PCEA for postoperative pain management after radical retropubic prostatectomy.

Use of Toradol in anorectal surgery

Toradol (ketorolac tromethamine; Syntex Labs, Palo Alto, CA) is a nonsteroidal anti-inflammatory drug introduced for intramuscular injection to control postoperative pain. Its action is peripheral. Therefore, it seemed appropriate to inject it directly into the anal sphincter muscles when these are exposed during anorectal procedures. A total of 60 mg (2 cc) are used, divided among the quadrants resected. Four hours postoperatively, 30 mg are given intramuscularly, and the patient is discharged. Any patient who required medication stronger than Darvocet-N-100 (propoxyphene napsylate and acetaminophen; Eli Lilly and Co., Indianapolis, IN) for pain was considered a failure. Seventeen of 100 patients (17 percent) failed to have their pain controlled. Unexpectedly, only two patients (2 percent) needed catheterization for urinary retention. The usual incidence is 20 to 30 percent. To date we have seen none of the complications associated with the use of anti-inflammatory drugs.

Ketorolac in reflex sympathetic dystrophy

Treatment of reflex sympathetic dystrophy (RSD) is primarily surgical. Typically, regional sympathetic blockade or sympathectomy is employed. Alternatives to neurosurgery, such as pharmacotherapy, include systemic corticosteroids and antidepressants. However, side effects and nonresponders to these approaches are not uncommon. Recently, ketorolac was demonstrated to relieve pain in RSD patients when administered by intravenous regional block (IVRB), yet this method has obvious limitations in the outpatient setting. The following case demonstrates marked improvement in treatment-resistant RSD pain with intramuscular ketorolac.

Fatal fulminant autoimmune haemolytic anaemia associated with tolmetin use and gastric carcinoma. Case report and literature review

Presented is a case report of an 80-year-old man with dyspnoea and jaundice who died from autoimmune haemolytic anaemia (AIHA) within 12 hours of arrival at the emergency department. The patient had been taking tolmetin for osteoarthritis. On autopsy he was found to have a superficial gastric adenocarcinoma. A brief presentation on AIHA includes primary (idiopathic) and secondary types. Factors associated with AIHA include nonsteroidal anti-inflammatory drugs (NSAIDs) and gastric carcinoma, although a direct cause cannot be demonstrated. After a discussion of the autoimmune mechanism of drug-associated hemolysis of which methyldopa is the prototype, a review of NSAIDs associated with AIHA is presented. All (18) NSAID cases of immune haemolysis were reviewed to determine which were more likely due to an autoimmune mechanism. These included 3 cases with tolmetin use: one probable and one possibly having an autoimmune basis for haemolysis, while with the third case immune haemolysis was by the drug adsorption mechanism. A review of gastric carcinoma associated with AIHA reveals only 2 previously reported cases. The associations of tolmetin use, as well as gastric carcinoma with AIHA, both rare, are noteworthy but cannot be proven as causative factors with our current level of knowledge and technology.

Ketorolac injection use in a university hospital

A drug-use evaluation (DUE) of ketorolac injection is described. Pharmacists at a 663-bed university hospital saved all new orders for ketorolac injection (except those from the operating, recovery, and emergency rooms) for five weeks. If an order was not in compliance with the DUE criteria, the DUE pharmacist contacted the prescriber to recommend a change. Fifty-two orders were evaluated. The daily dose exceeded that in the criteria in seven patients (13%). Conditions under which the product should be used with extra caution were present in eight patients (15%). Twelve patients (23%) received the drug for more than five days. Five patients (10%) had possible ketorolac-associated adverse effects. The pharmacist's concurrent interventions improved prescribing for correct dosage and facilitated discontinuation of the agent in high-risk patients. After follow-up educational efforts, a second audit in 28 patients showed further improvements in prescribing for correct dosage, but 25% of the patients received the drug for more than five days. No adverse effects were reported. A 72-hour automatic stop-order policy was implemented, and the fraction of patients receiving the drug for more than five days fell to 3% (of 223 pharmacy profiles reviewed). Three patients had apparent ketorolac-induced adverse effects. Educational efforts and adoption of a 72-hour stop-order policy decreased the duration of ketorolac injection therapy and the use of inappropriately large dosages and may have decreased the frequency of ketorolac-induced adverse effects.

Gastric ulcer perforation associated with the use of injectable ketorolac

OBJECTIVE

To report a case of a perforated gastric ulcer associated with the use of injectable ketorolac tromethamine.

DATA SYNTHESIS

A 77-year-old woman with no previous history of peptic ulcer disease developed a perforated gastric ulcer after four days of treatment with ketorolac. To date, six other cases of gastrointestinal (GI) perforation associated with the use of ketorolac have been reported to the manufacturer.

CONCLUSIONS

Although ketorolac is an effective analgesic, it is a nonsteroidal antiinflammatory agent and thus has the propensity for causing GI ulceration. Caution should be used when administering this drug and patients should be monitored for GI adverse effects.

Morphine sulfate, transdermal fentanyl citrate and ketorolac tromethamine: effects on postoperative pulmonary function

The physiological effects of morphine sulfate and fentanyl citrate on postoperative pulmonary function demonstrate varying degrees of respiratory depression related to dose, route of administration and pre-existing pathologies. Current postoperative analgesic therapies that include concomitant use of narcotic agonists and nonsteroidal anti-inflammatory drugs require adjustment of drug dosages to provide adequate pain relief while avoiding drug-induced complications. Specific nursing considerations include understanding therapeutic and adverse effects of these agents on pain and ventilation, continuous pain assessment and early recognition and treatment of respiratory depression.

Comparison of intravenous ketorolac with morphine for postoperative pain in children

Ninety-two children from 3 to 12 years of age were given intravenous morphine or ketorolac by titration, or ketorolac by bolus injection for moderate or severe postsurgical pain in a double-blind randomized parallel-group study. Pain scores were assessed every 5 minutes until pain relief was complete, and then every 15 minutes for 8 hours or until pain returned. Twenty-nine of 30 patients receiving morphine and 25 of 30 patients in each group receiving ketorolac achieved pain relief. The subjects in the morphine group required statistically fewer doses for analgesia than the subjects in the ketorolac groups. The sums of pain intensity differences calculated from the start of the study numerically favored morphine, but the sum of pain intensity differences from pain relief until 50% withdrew were significantly better in the ketorolac groups. Median durations of analgesia from initial drug administration were 170, 190, and 225 minutes in the morphine, ketorolac titration, and ketorolac bolus groups, respectively. The most common side effect was injection site pain. Analgesia after intravenous ketorolac developed more slowly but was sustained better than morphine.

Anaphylactoid reaction following ketorolac tromethamine administration

OBJECTIVE

To report a case of an anaphylactoid reaction to injectable ketorolac tromethamine in a patient with no prior history of allergies or risk factors associated with nonsteroidal anti-inflammatory drug-induced hypersensitivity reactions.

CASE SUMMARY

A 37-year-old man without a significant medical history presented to an emergency department with vague, dull, left-sided chest pain. Myocardial infarction was ruled out based on an unremarkable electrocardiogram, chest X-ray, and laboratory data that were within normal limits. Sublingual nitroglycerin 0.4 mg, magnesium/aluminum hydroxide gel 30 mL, and intravenous ranitidine 50 mg were administered without resolution of symptoms. Ketorolac tromethamine 60 mg was administered intramuscularly with resolution of symptoms. The patient was discharged; however, within 30 minutes, he returned to the emergency department with facial swelling, shortness of breath, and chest tightness. Multiple doses of aerosolized albuterol and intravenous methylprednisolone and diphenhydramine were administered, resulting in a slight improvement of symptoms. The patient was admitted for a complete cardiac evaluation that proved negative. The allergic symptoms resolved and the patient was discharged without medication after a three-day hospitalization.

DISCUSSION

Ketorolac tromethamine is the first injectable nonsteroidal antiinflammatory drug approved for short-term pain management. A review of the literature revealed no similar cases of anaphylactoid reaction.

CONCLUSIONS

Healthcare professionals must be aware of the potential risks of anaphylactoid reactions, especially in light of the increased use of injectable ketorolac in the ambulatory setting and availability of the oral formulation.

Comparison of ketorolac and morphine for postoperative pain after major surgery

This study was designed to determine the relative analgesic efficacy and safety of single intramuscular injections of ketorolac (10 mg or 30 mg) and morphine (10 mg) in patients of either sex with moderate to severe pain after major surgery. In a single-dose, randomised, double-blind study of parallel design, pain was assessed immediately before injection of test medication and at regular intervals for 8 h thereafter. One hundred and seventeen patients (109 undergoing cardiac surgery; 8 lung surgery) were randomized to one of the three treatment groups. Pain intensity was assessed using a 5-point verbal scale before administration of study drugs. Postadministration, at 30 min and hourly for 8 h, pain intensity and pain relief were assessed, again using the 5-point verbal scale. Additionally, as a measure of analgesia, forced expiratory volume (FEV1) was obtained in all patients. Vital signs including blood pressure, pulse, temperature, respiratory rate and blood gases (PaCO2) were recorded prior to and after study medication. Based on hourly pain intensity differences and hourly pain relief observations, ketorolac 10 mg was generally more effective than morphine 10 mg, and ketorolac 30 mg was generally more effective than ketorolac 10 mg. The results of this study show that ketorolac is an effective and safe (with regard to arterial pressure, blood gases and lung function) analgesic for relief of postoperative pain after major surgery in stable patients. No clinically significant adverse effects occurred during the study. One cannot exclude an influence on patients with organ system dysfunction or on parameters not measured in this study.

Acute renal failure in an elderly woman following intramuscular ketorolac administration

OBJECTIVE

To report a case of ketorolac tromethamine-induced acute renal failure and to discuss the risk factors that make patients more susceptible to the renal effects of nonsteroidal antiinflammatory drugs (NSAIDs).

DATA SOURCES

Case reports and review articles identified by MEDLINE. Indexing terms included ketorolac, renal failure, and NSAIDs.

DATA EXTRACTION

Data were abstracted from pertinent published English-language sources and were reviewed by all authors.

DATA SYNTHESIS

Ketorolac is an intramuscularly administered NSAID with many of the same adverse effects associated with other oral NSAIDs. Although reversible depression of renal function has been associated with several NSAIDs, to date there have been no published reports of acute renal failure secondary to ketorolac administration. A 71-year-old woman received three doses of ketorolac to control the pain associated with pelvic and T11-T12 compression fractures. Over the next two days, the patient developed signs and symptoms of acute renal failure, including significant increases in blood urea nitrogen, serum creatinine, and peripheral edema. These signs and symptoms resolved over the next three to four days. Certain risk factors, several of which were present in this woman, make individual patients more susceptible to the renal affects of NSAIDs. These risk factors include advanced age, cirrhosis, volume depletion, congestive heart failure, gastrointestinal bleeding, and preexisting mild renal dysfunction.

CONCLUSIONS

Caution should be taken when initiating ketorolac or any NSAID therapy with specific attention to risk factors that predispose a patient to renal dysfunction.

A comparative study of intramuscular ketorolac and pethidine in labour pain

A single dose block randomised double-blind study comparing intramuscular ketorolac, 50 mg of pethidine and 100 mg pethidine was carried out in multiparous women. Pain intensity and sedation effect were recorded at inclusion to the study, half hourly for the first 2 h, then hourly until 6 h after delivery. Maternal and neonatal side effects were noted including the Apgar scores and the baby's requirements for resuscitation. All three treatments are relatively ineffective in relieving labour pain. There was no difference in the analgesic efficacy between the two doses of pethidine but both doses of pethidine were statistically more effective compared with ketorolac. There was no difference in the retrospective assessment of the three groups or when comparison was made with the previous labour. A similar number of patients required further analgesia in each group. In all three groups, no adverse effect occurred in the mother or fetus. Maternal sedation and fetal depression were statistically less in the ketorolac group. Although ketorolac had inferior analgesic effect, its use was not associated with clinically significant sequelae and it showed a superior safety profile compared with either dose of pethidine. The study was not powerful enough to detect a difference between 50 mg and 100 mg of pethidine.

Ketorolac versus meperidine and hydroxyzine in the treatment of acute migraine headache: a randomized, prospective, double-blind trial

STUDY OBJECTIVE

To compare the effectiveness of IM ketorolac with that of meperidine and hydroxyzine in the treatment of acute migraine headache.

DESIGN

Prospective, randomized, double-blind trial.

SETTING

Urban emergency department with an annual census of 42,000 patients.

PARTICIPANTS

Forty-seven adult patients with migraines enrolled on 50 visits.

INTERVENTIONS

Patients were randomly assigned to receive a single injection of either 60 mg ketorolac (group 1) or 100 mg meperidine and 50 mg hydroxyzine (group 2). Pain assessment was made using both visual-analog and verbal descriptor scales.

RESULTS

At 60 minutes, 15 patients (60%) from group 1 (25) and 14 patients (56%) from group 2 (25) reported a great deal of complete relief (P = .77) Sixty-minute mean pain relief scores (3.35 versus 3.37) were different (P = .76). Nine patients (36%) from group 1 and seven patients (28%) from group 2 required additional analgesia (P = .76).

CONCLUSION

Ketorolac is as effective as meperidine and hydroxyzine for the treatment of acute migraine headache.

Ketorolac: a new parenteral nonsteroidal anti-inflammatory drug for postoperative pain management

Providing adequate pain control with minimal side effects in inpatient and ambulatory settings is a continuous challenge to the PACU nurse. Ketorolac tromethamine (Toradol, Syntex, Palo Alto, CA) is a new parenteral nonsteroidal anti-inflammatory drug (NSAID) approved for use in the United States. Ketorolac is useful in the management of short term, moderate to severe postoperative pain. It is used by itself or as an adjunct to traditional opioid analgesics. Ketorolac, like other NSAIDs, has analgesic, anti-inflammatory, and antipyretic properties. Unlike morphine or meperidine, ketorolac does not bind to opioid receptors and is not a centrally acting agent. Administered intramuscularly, peak plasma levels are reached in 45 to 50 minutes. It is administered as a 30- or 60-mg intramuscular (IM) loading dose followed by 15- or 30-mg doses IM every 6 hours, with a maximum first-day dose of 150 mg and 120 mg on subsequent days up to a recommended maximum of 5 days. The lower dose range is recommended for elderly patients, patients weighing less than 50 kg, and patients with impaired kidney function. Initial studies show that use of ketorolac decreases the overall amount of opioid analgesia needed for postoperative pain control. To date, reported occurrence of side effects is low. A case study presents a healthy ambulatory surgical patient admitted for inguinal hernia repair using epidural anesthesia. Use of ketorolac has shown initial favorable results. More research is needed to further define its role and side effects in postoperative pain management.

A new method for rate of analgesic onset: two doses of intravenous morphine compared with placebo

A new method of frequent early pain assessments for 1 hour only was used to determine time of onset of analgesia after intravenous administration of 10 mg morphine, 5 mg morphine, or placebo in a double-blind study; 79 patients were randomized if they required parenteral analgesia in the early postoperative period. Pain intensity was determined by a four-point categoric verbal rating scale and on a verbal ordinal scale from 0 to 100 (0 = no pain, 100 = worst pain imaginable) during the first hour after analgesic administration. The onset time of analgesia, assessed by 50% of patients achieving 25% reduction from their baseline pain assessment, was significantly faster for 10 mg morphine compared with 5 mg morphine (p = 0.02) and placebo (p less than 0.01). More familiar analgesic efficacy measures, including the sum of pain intensity differences and time to next analgesic dose, similarly showed the superiority of 10 mg morphine to placebo in the first hour, confirming sensitivity according to the conventional paradigm.

Hyperkalemia associated with ketorolac

OBJECTIVE

To report and describe the apparent first case of hyperkalemia following intramuscular administration of ketorolac and to discuss the proposed mechanism of action.

PATIENT

The patient was a 59-year-old man who developed hyperkalemia following a right upper lobectomy; he had received an intramuscular injection of ketorolac 30 mg for incisional pain.

RESULTS

All possible causes of the hyperkalemia, including other drugs and intraoperative and postoperative events, were thoroughly evaluated and ruled out. Hyperkalemia has been reported in patients who have received other nonsteroidal antiinflammatory drugs (NSAIDs). The proposed mechanism of action for the occurrence of this hyperkalemia appears to be related to the suppression of prostaglandin synthesis.

CONCLUSIONS

Considering the temporal sequence of events and drugs administered prior to the hyperkalemia in this patient and the hyperkalemic potential associated with other NSAIDs, ketorolac appears to be the precipitating agent. The possibility of hyperkalemia associated with the parenteral use of ketorolac may warrant practitioners to closely monitor the blood chemistry of patients receiving this agent.

Comparison of the efficacy and safety of ketorolac and meperidine in the relief of dental pain

A single-dose, randomized, double-blind study of parallel design was conducted to determine the analgesic efficacy and safety of ketorolac tromethamine in patients who experience moderate or severe pain after the surgical removal of three or more third molars, one of which was a bony-impacted mandibular molar. Meperidine hydrochloride was used as the control analgesic. In this 8-hour study, assessments were made of pain intensity, pain relief, and overall rating of the medication in 145 patients, each of whom had received an intramuscular injection of 10 mg, 30 mg, or 90 mg of ketorolac, or 50 mg or 100 mg of meperidine. The summed pain intensity and total pain relief scores showed that, at 3 and 8 hours, the effectiveness of 30 mg of ketorolac was similar to that of 90 mg ketorolac and that both of these doses were significantly more efficacious than 10-mg ketorolac, 50-mg meperidine, or 100-mg meperidine. Patients who received 30 mg or 90 mg of ketorolac gave the study medication significantly higher ratings overall than did patients who received 50 mg or 100 mg of meperidine. Significantly fewer patients treated with ketorolac reported adverse events in comparison with those treated with meperidine (17% and 59%, respectively), which suggests that it possesses a better therapeutic index than meperidine. Thus, ketorolac appears to represent an important advance in analgesic therapy.