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

Nonsteroidal anti-inflammatory drugs associated acute kidney injury in hospitalized children: A systematic review and meta-analysis

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs) are regarded as nephrotoxins. Children commonly use NSAIDs and are susceptible to nephropathy, but the relationship between acute kidney injury (AKI) and use of NSAIDs is not well examined yet.

OBJECTIVE

To evaluate the relationship between AKI and use of NSAIDs in hospitalized pediatric patients who are susceptible to nephropathy.

METHODS

We conducted this systematic review and meta-analysis of observational studies by searching PubMed, Embase, and Cochrane Database for articles published up to June 1, 2020. Reports included involved children (age < 18 years) who used NSAIDs for various reasons and were admitted in the hospital. The main outcome measure was whether AKI occurred, and pooled odds ratio (OR) and 95% confidence intervals (CI) were calculated using generic inverse variance methods.

RESULTS

Seven studies reporting risk of AKI in the hospitalized pediatric patients receiving NSAIDs were included applying a random-effects model. In the hospitalized pediatric population, the pooled OR of AKI for present NSAID exposure was 1.55 (95%CI 1.26-1.92).

CONCLUSIONS

NSAID exposure was associated with an approximate 1.6-fold rise in the odds of developing AKI in hospitalized pediatric patients. Avoidance, cautious use of NSAIDs and further evidence are needed. This study was registered with PROSPERO (identifier: CRD42021219779).

Treatment of Pain in Pediatric Patients

A growing body of evidence demonstrates that untreated pain is associated with adverse consequences that can compromise clinical and developmental outcomes in children but that these adverse consequences can be prevented or attenuated by appropriate analgesic therapy. Thus, effective treatment of acute pain must be a clinical priority for children of all ages. Over the past 20 years, extensive pediatric research exploring pain assessment, developmental pharmacology of analgesics, and the clinical use of analgesics has dispelled many myths and misconceptions about pain management in pediatric patients; proven that analgesics can be used safely in neonates, infants, and children; and provided a framework for the development of pediatric pain management guidelines. This article reviews guidelines recommended for managing acute pain in pediatric patients and the treatment options for children experiencing acute pain. Contemporary issues regarding acetaminophen, nonsteroidal anti-inflammatory agents, and opioids are discussed.

Ketorolac is underutilized after ureteral reimplantation despite reduced hospital cost and reduced length of stay

OBJECTIVES

To examine patterns of ketorolac use and its association with hospital outcomes. Although ureteral reimplantation (UR) reliably corrects vesicoureteral reflux, postoperative pain and bladder spasm often occur. Multiple studies show that ketorolac markedly reduces postoperative pain after UR, but there is no information on whether ketorolac is routinely used.

METHODS

The Pediatric Health Information System is a national database collected by over 40 US children's hospitals. We identified children with primary vesicoureteral reflux who underwent UR between 2003 and 2008. Billing data were reviewed to identify patients who received ketorolac during hospitalization. Multivariate models were used to examine ketorolac use and postoperative outcomes including complication rates, length of stay, and hospital costs.

RESULTS

We identified 12,239 children undergoing UR, 6362 (52%) of whom received ketorolac postoperatively. Factors associated with ketorolac use include older age, female gender, and decreased disease severity (all P <.0001). Ketorolac use was associated with reduced length of stay (2 vs 3 days, P <.0001) and decreased hospital costs ($14,223 vs $16,382, P <.0001). Complication rates were slightly higher in patients not receiving ketorolac (4% vs 3%). After adjusting for confounding factors, ketorolac use remained highly associated with decreased length of stay (P = .01) and decreased costs (P = .002), with no significant differences in complication rates (P = .4).

CONCLUSIONS

In a contemporary nationwide sample, only half of children undergoing UR received ketorolac. Ketorolac use is independently associated with reduced procedure costs and reduced length of stay after UR, without increased complications. This suggests underutilization of ketorolac after UR.

Pharmacologic management of acute pediatric pain

The accurate assessment and effective treatment of acute pain in children in the hospital setting is a high priority. During the past 2 to 3 decades, pediatric pain management has gained tremendous knowledge with respect to the understanding of developmental neurobiology, developmental pharmacology the use of analgesics in children, the use of regional techniques in children, and of the psychological needs of children in pain. A wide range of medications is available to treat a variety of pain types. This article provides an overview of the most common analgesic medications and techniques used to treat acute pain in children.

Report of an Anaphylactoid and an Anaphylactic Reaction to Ketorolac in Two Pediatric Surgical Patients

Ketorolac is a potent analgesic drug that has been restricted in dosage and use because of its potential adverse effects. The diagnostic and ethical challenges of 2 children who had unpredictable adverse drug reactions to ketorolac are reported. Case 1: A 3-year-old boy received ketorolac 1 mg/kg for prevention of postoperative pain at the end of an orthopedic surgical procedure. Ten minutes later, he had bilateral palpebral edema, erythema in thorax, hypotension, and tachycardia. The adverse event was classified as a mixed reaction probably related to ketorolac. Case 2: A 7-year-old girl, who had previously received ketorolac in 2 different surgical procedures, underwent a third orthopedic surgery. She received ketorolac 1 mg/kg as pre-emptive analgesia at 1.5 hours of anesthetic time (approximately 1 hour of surgical time). The patient developed palpebral edema 5 minutes later in addition to erythema in thorax, hypotension, tachycardia, tachypnea, oxygen desaturation, and wheezing. The adverse event was classified as a systemic reaction probably related to ketorolac. The 2 patients were successfully treated with symptomatic therapy. Although rare in its frequency, ketorolac administration may be associated to anaphylactic and anaphylactoid reactions in children with or without history of previous exposure. Because ketorolac is off-licensed for pediatric patients, it should be administered only after the risks and benefits have been discussed with the child's parents in the preanesthetic consultation.

Analgesia and local anesthesia during invasive procedures in the neonate

BACKGROUND

Preterm and full-term neonates admitted to the neonatal intensive care unit or elsewhere in the hospital are routinely subjected to invasive procedures that can cause acute pain. Despite published data on the complex behavioral, physiologic, and biochemical responses of these neonates and the detrimental short- and long-term clinical outcomes of exposure to repetitive pain, clinical use of pain-control measures in neonates undergoing invasive procedures remains sporadic and suboptimal. As part of the Newborn Drug Development Initiative, the US Food and Drug Administration and the National Institute of Child Health and Human Development invited a group of international experts to form the Neonatal Pain Control Group to review the therapeutic options for pain management associated with the most commonly performed invasive procedures in neonates and to identify research priorities in this area.

OBJECTIVE

The goal of this article was to review and synthesize the published clinical evidence for the management of pain caused by invasive procedures in preterm and full-term neonates.

METHODS

Clinical studies examining various therapies for procedural pain in neonates were identified by searches of MEDLINE (1980-2004), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2004), the reference lists of review articles, and personal files. The search terms included specific drug names, infant-newborn, infant-preterm, and pain, using the explode function for each key word. The English-language literature was reviewed, and case reports and small case series were discarded.

RESULTS

The most commonly performed invasive procedures in neonates included heel lancing, venipuncture, IV or arterial cannulation, chest tube placement, tracheal intubation or suctioning, lumbar puncture, circumcision, and SC or IM injection. Various drug classes were examined critically, including opioid analgesics, sedative/hypnotic drugs, nonsteroidal anti-inflammatory drugs and acetaminophen, injectable and topical local anesthetics, and sucrose. Research considerations related to each drug category were identified, potential obstacles to the systematic study of these drugs were discussed, and current gaps in knowledge were enumerated to define future research needs. Discussions relating to the optimal design for and ethical constraints on the study of neonatal pain will be published separately. Well-designed clinical trials investigating currently available and new therapies for acute pain in neonates will provide the scientific framework for effective pain management in neonates undergoing invasive procedures.

Anesthesia and analgesia during and after surgery in neonates

BACKGROUND

Historically, the use of anesthetics and analgesics in neonates and infants has been based on extrapolations from studies performed in adults and older children. Over the past 20 years, there has been a growing body of research on the clinical pharmacology and clinical outcomes of these agents in neonates and infants.

OBJECTIVE

This article summarizes clinical pharmacology and clinical outcomes studies of opioids, opioid antagonists, sedative-hypnotics, nonsteroidal anti-inflammatory drugs and acetaminophen, and local anesthetics in neonates and infants to highlight gaps in the available knowledge, review some concerns about study design, and identify drugs that should receive high priority for future study.

METHODS

Relevant studies were identified through a search of MEDLINE and a review of textbooks, conference proceedings, and abstracts. The available literature was subjected to expert committee-based review.

CONCLUSIONS

There is a growing body of information on analgesic and anesthetic pharmacokinetics, pharmacodynamics, and clinical outcomes in neonates and infants, permitting safe and effective use in some clinical settings. Major gaps in knowledge persist, however. Future research may involve a combination of clinical trials and preclinical studies in suitable infant animal surrogate models.

Ketorolac after congenital heart surgery: does it increase the risk of significant bleeding complications?

BACKGROUND

The routine use of ketorolac after congenital heart surgery in infants and children is limited by concerns for postoperative bleeding complications. The object of this study was to determine if the use of ketorolac is associated with an increased risk of significant postoperative bleeding after congenital heart surgery in infants and children.

METHODS

A retrospective chart review was performed. The exposure of interest was postoperative use of ketorolac after congenital heart surgery in infants and children. The outcome measured was postoperative bleeding requiring surgical exploration. The patients who received ketorolac were compared with an age- and diagnosis-matched comparison group who did not receive ketorolac.

RESULTS

Records of 842 infants and children who underwent congenital heart surgery between July 2001 and October 2002 were reviewed. 94 (11.1%) patients were treated with ketorolac postoperatively. The comparison group consisted of 94 matched subjects selected from the patients that did not receive ketorolac. The mean age of patient in the ketorolac group was 8.5 (+/-6.1) years. No (0%) patients in the ketorolac group and four (4.2%) patients in the nonketorolac group developed postoperative bleeding requiring surgical exploration. The relative risk for postoperative bleeding that required surgical exploration in the ketorolac group compared with the nonketorolac group was 0.2 (95% CI 0.02-1.67).

CONCLUSIONS

The use of ketorolac after congenital heart surgery in infants and children does not significantly increase the risk of bleeding complications requiring surgical exploration.

Treatment of retinopathy of prematurity with topical ketorolac tromethamine: a preliminary study

BACKGROUND

Retinopathy of Prematurity (ROP) is a common retinal neovascular disorder of premature infants. It is of variable severity, usually heals with mild or no sequelae, but may progress to blindness from retinal detachments or severe retinal scar formation. This is a preliminary report of the effectiveness and safety of a new and original use of topical ketorolac in preterm newborn to prevent the progression of ROP to the more severe forms of this disease.

METHODS

From January 2001 to December 2002, all fifty nine preterm newborns with birthweight less than 1250 grams or gestational age less than 30 weeks of gestational age admitted to neonatal intensive care were eligible for treatment with topical ketorolac (0.25 milligrams every 8 hours in each eye). The historical comparison group included all 53 preterm newborns, with the same inclusion criteria, admitted between January 1999 and December 2000.

RESULTS

Groups were comparable in terms of weight distribution, Apgar score at 5 minutes, incidence of sepsis, intraventricular hemorrhage and necrotizing enterocolitis. The duration of oxygen therapy was significantly longer in the control group. In the ketorolac group, among 43 children that were alive at discharge, one (2.3%) developed threshold ROP and cryotherapy was necessary. In the comparison group 35 children survived, and six child (17%) needed cryotherapy (Relative Risk 0.14, 95%CI 0.00 to 0.80, p = 0.041). Adjusting by duration of oxygen therapy did not significantly change these results. Adverse effects attributable to ketorolac were not detected.

CONCLUSIONS

This preliminary report suggests that ketorolac in the form of an ophthalmic solution can reduce the risk of developing severe ROP in very preterm newborns, without producing significant adverse side effects. These results, although promising, should be interpreted with caution because of the weakness of the study design. This is an inexpensive and simple intervention that might ameliorate the progression of a disease with devastating consequences for children and their families. We believe that next logical step would be to assess the effectiveness of this intervention in a randomized controlled trial of adequate sample size.

Prospective randomized trial of ketorolac after congenital heart surgery

OBJECTIVE

Ketorolac is a potent nonsteroidal analgesic agent used to treat postoperative pain. It produces excellent analgesia without the sedating side effects of opioid analgesics. Routine use of ketorolac after cardiac surgery is limited by concerns of bleeding complications. The purpose of this study was to evaluate the risk of bleeding complications of ketorolac for treatment of pain after congenital heart surgery in infants and children.

DESIGN

Prospective randomized, controlled trial.

SETTING

Pediatric cardiac intensive care unit in tertiary teaching hospital.

PARTICIPANTS

Seventy infants and children, median age 10 months (range 2.5-174), who underwent congenital heart surgery requiring cardiopulmonary bypass were randomized in the trial.

INTERVENTION

Pain control was performed with ketorolac and opioid analgesics in one arm of the study and opioid analgesics alone in the other arm.

OUTCOME MEASURES

The main outcome evaluated was bleeding complications measured by chest-tube drainage and wound and gastrointestinal bleeding.

RESULTS

Thirty-five patients were randomized to each treatment arm. In the ketorolac group, the median chest-tube drainage was 13.3 (range 4-22) mL/kg/d, no patient had significant wound bleeding, and 1 (0.03%) patient had gastrointestinal bleeding. In the control group, the median chest-tube drainage was 16.5 (range 3-24) mL/kg/d, 1 (0.03%) patient had wound bleeding, and no patient had gastrointestinal bleeding.

CONCLUSION

Ketorolac can be used to treat pain after congenital heart surgery without an increased risk of bleeding complications.

Use of intravenous ketorolac in the neonate and premature babies

BACKGROUND

Ketorolac is a powerful nonsteroidal anti-inflammatory drug widely used for pain control in children and adults. The aim of this study was to evaluate its safety and analgesic efficacy in the neonate.

METHODS

Ketorolac was used in a group of 18 spontaneously breathing neonates presenting with chronic lung disease, for the control of postsurgical pain and pain from invasive procedures. Pain scores (Neonatal Infant Pain Scale) were assessed before and after i.v. administration of 1 mg.kg(-1) of ketorolac.

RESULTS

Total pain control was achieved in 94.4% of the neonates. None of the neonates had haematological, renal or hepatic changes prior to treatment, and these complications did not occur after treatment. No neonate had systemic haemorrhage or bleeding from injection and blood withdrawal sites.

CONCLUSIONS

Ketorolac could represent an efficacious analgesic alternative to opioids, particularly in neonates. It would avoid the side-effects associated with opioid analgesics, especially respiratory depression.

Pain management in children with sickle cell disease

Sickle cell disease (SCD) is one of the most common inherited diseases worldwide. The disease is characterized by chronic hemolytic anemia, as well as acute and chronic complications. One of the most intractable problems encountered by children with SCD is the painful episode that results from tissue ischemia due to vaso-occlusion. Pain related to SCD is unique among pain syndromes due to the unpredictable, recurrent, and often persistent nature of the disease, as well as the recurring and essential need for the use of opioids. Painful vaso-occlusive episodes (VOE) are a principal cause of morbidity and account for a significant number of emergency department and hospital admissions. When untreated or inadequately managed, the pain of VOE may cause both short- and long-term consequences. Despite the fact that pain is an almost universal feature of the disease, children with SCD may form one of the most undertreated and understudied populations. One of the factors contributing to poor pain management is conflicting perceptions between patients, their families, and healthcare professionals about pain that is reported and analgesia that is required. Pain management guidelines have recently been published in an effort to overcome barriers in the assessment and management of pain related to SCD. Although there is considerable variability in the way SCD pain is managed, the standard treatment protocol for painful episodes has been rest, rehydration, and analgesia. However, pain control for children with SCD is often a difficult and complex process, and one that requires frequent systematic pain assessments and continuous adjustment of comfort measures, especially analgesics. There are a variety of analgesic agents to choose from, such as acetaminophen (paracetamol), oral or parenteral nonsteroidal anti-inflammatory drugs, and oral or parenteral opioids. Each of these options has advantages and disadvantages to their use. Continuous infusions of analgesics and patient controlled analgesia have been shown to be effective and widely used in hospital settings to manage severe pain. However, the opioid dose required to achieve pain relief varies considerably within each painful episode, from one episode to another, and between individual patients. Although not yet curable in humans, pain related to SCD can be effectively managed in most patients by using a comprehensive approach that incorporates pharmacologic, psychologic, behavioral, and physical pain management strategies.

Time-contingent schedules for postoperative analgesia: a review of the literature

The management of pain reflects a history of myths and misconceptions often based on the "common sense" of the time. Evidence-based approaches to patient care are now strongly advocated. Recognizing that the accepted practice for administering postoperative analgesics has become the time-contingent or around-the-clock (ATC) regime, this article reviews the existing literature in search of empirical evidence supporting this practice. The review was conducted through MEDLINE, with the database limited to articles in the English language, involving human subjects, and published between 1960 and 2000. Database searches included each of the terms schedule, ATC, time, regime, administration, hour, dosing, qid, q6h, q4h, pro re nata, regular, and prn. Furthermore, common pain relieving drugs used in the postoperative period also were used as search words. Every database search was qualified by the terms post-operative or postoperative. The search showed sparse empirical work warranting endorsement of this dosing regimen. Although a great deal is known about specific drugs and dosage requirements, research is needed that clearly examines optimal scheduling regimens if we are to maximize patient care.

Age-stratified pharmacokinetics of ketorolac tromethamine in pediatric surgical patients

Published data suggest that ketorolac pharmacokinetics are different in children than in adults. We sought to better characterize ketorolac pharmacokinetics in children. Thirty-six children, aged 1-16 yr, were stratified into four age groups: 1-3 yr, 4-7 yr, 8-11 yr, and 12-16 yr. Each child received 0.5 mg/kg of ketorolac tromethamine IV after completion of elective surgery. A maximum of 16 venous blood samples (mean, 13 +/- 2) were collected at predetermined times up to 10 h after drug administration. Plasma ketorolac concentrations were measured by high-performance liquid chromatography after solid-phase extraction. Individual concentration-versus-time relationships were best fit to a two-compartment pharmacokinetic model by using SAAM II. Body weight-normalized pharmacokinetic variables did not differ among the age groups and were similar to those reported for adults, including a volume of distribution at steady state of 113 +/- 33 mL/kg (mean +/- SD) and an elimination clearance of 0.57 +/- 0.17 mL x min(-1) x kg(-1). Our study demonstrates that a single dose of ketorolac (0.5 mg/kg) results in plasma concentrations in the adult therapeutic concentration range for 6 h in most children. Our data provide no evidence that children require either larger weight-adjusted doses or shorter dosing intervals than adults to provide similar plasma drug concentrations.

IMPLICATIONS

The literature suggests that ketorolac disposition differs between children and adults. We characterized ketorolac pharmacokinetics in 36 children. Body weight-normalized two-compartment pharmacokinetic variables did not differ among pediatric patients <17 yr old and were similar to adult values.

Risks and benefits of nonsteroidal anti-inflammatory drugs in children: a comparison with paracetamol

Nonsteroidal anti-inflammatory drugs (NSAIDs) possess antipyretic, analgesic and anti-inflammatory effects. They are frequently used in children and have numerous therapeutic indications, the most common ones being fever, postoperative pain and inflammatory disorders, such as juvenile idiopathic arthritis (JIA) and Kawasaki disease. Their major mechanism of action is through inhibition of prostaglandin biosynthesis by blockade of cyclo-oxygenase (COX). The disposition of most NSAIDs has been mainly studied in infants > or = 2 years of age. Compared with adults, the volume of distribution and clearance of NSAIDs such as diclofenac, ibuprofen (infants aged between 3 months and 2.5 years), ketorolac and nimesulide were increased in children. The elimination half-life was similar in children to that in adults. These pharmacokinetic differences might be clinically significant with the need for higher loading and/or maintenance doses in children. Ibuprofen, acetylsalicylic acid (ASA) and acetaminophen are the most frequently used agents for fever reduction in children. Over the past 20 years, because of the association between ASA use and Reye's syndrome, most of the interest has been directed toward ibuprofen and acetaminophen. In view of its comparable antipyretic efficacy, but superior tolerability profile, acetaminophen, when used appropriately with age-adapted formulations, should remain the first-line therapy in the treatment of childhood fever. At the moment, there is no scientific evidence to recommend simultaneous use of these two antipyretic drugs. Most NSAIDs provide mild to moderate analgesia, with the exception of ketorolac which has a strong analgesic activity. The analgesic efficacy of ketorolac, ketoprofen, diclofenac and ibuprofen in the treatment of postoperative pain has been mainly studied following a single dose, in children of > or = 1 year of age undergoing minor surgeries. In this setting, when used either alone or in adjunct to caudal or epidural anaesthesia, they were associated with an opioid-sparing effect and were well tolerated. With the exception of ketorolac use in children undergoing tonsillectomy, where controversy exists regarding the risk of postoperative haemorrhage, NSAIDs have not been associated with an increased risk of perioperative bleeding. NSAIDs are the first-line therapy in JIA. They appear to be equally effective and tolerated, with the exception of ASA which is associated with more adverse effects. ASA has been used for many years in the treatment of Kawasaki disease and is part of the standard modality of treatment in combination with intravenous gammaglobulins. More recently, lung inflammation associated with cystic fibrosis (CF) has become a new target for NSAIDs. Despite promising preliminary results with ibuprofen, numerous questions need to be answered before this new strategy becomes part of the conventional treatment of patients with CF. In summary, NSAIDs are effective in reducing fever, alleviating pain and reducing inflammation in children, with a good tolerance profile. Pharmacokinetic studies are needed to characterise the disposition of NSAIDs in very young infants in order to use them rationally. To date, no studies have been published on the disposition, tolerability and efficacy of specific COX-2 inhibitors in children. Further clinical experience with these agents in adults is warranted before undergoing trials with specific COX-2 inhibitors in children.

Therapeutic uses of non-steroidal anti-inflammatory drugs in dentistry

The non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely used classes of drugs for the management of acute and chronic pain in dentistry. Their therapeutic efficacy and toxicity are well-documented and provide evidence that NSAIDs generally provide an acceptable therapeutic ratio of pain relief with fewer adverse effects than the opioid-mild analgesic combination drugs that they have largely replaced for most dental applications. The great many studies done with the oral surgery model of acute pain indicate that a single dose of an NSAID is more effective than combinations of aspirin or acetaminophen plus an opioid, with fewer side-effects, thus making it preferable for ambulatory patients. The combination of an NSAID with an opioid generally results in marginal analgesic activity but with an increased incidence of side-effects, which limits its use to patients in whom the NSAID alone results in inadequate analgesia. The selective COX-2 inhibitors hold promise for clinical efficacy with less toxicity from chronic administration and may prove advantageous for the relief of chronic orofacial pain. The use of repeated doses of NSAIDs for chronic orofacial pain should be re-evaluated in light of a lack of documented efficacy and the potential for serious gastrointestinal and renal toxicity with repeated dosing.

Analgesic efficacy of ketorolac 0.5% ophthalmic solution (Accular) in paediatric strabismus surgery

This prospective double-blind study was designed to assess the analgesic efficacy of ketorolac 0.5% ophthalmic solution compared with placebo in 30 healthy children undergoing extraocular muscle recession for correction of strabismus. After paracetamol 20 mg.kg-1 preoperatively, a standard anaesthetic was given. There were no significant differences in Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and faces pain scale (FPS) scores, requirement for supplementary analgesia or in postoperative vomiting between the two groups over the following 24 h. This study did not demonstrate improved postoperative analgesia when topical ketorolac eye drops were given in addition to paracetamol. This observed lack of efficacy may reflect difficulties in the use of CHEOPS and FPS in this age group with this pain model.

Ketorolac suppresses postoperative bladder spasms after pediatric ureteral reimplantation

We evaluated the efficacy of ketorolac in suppressing postoperative bladder spasms after ureteroneocystostomy (ureteral reimplantation). Twenty-four pediatric patients undergoing intravesical ureteroneocystostomy were enrolled prospectively to receive either ketorolac or placebo via double-blinded randomization. Twelve patients in each group shared similar preoperative characteristics. All were maintained on an epidural infusion of bupivacaine (0.1%) with fentanyl (2 microg/mL) throughout the study. Patients were given either ketorolac (0.5 mg. kg(-1). dose(-1)) or placebo (equivalent volume saline) IV after surgery and every 6 h thereafter for 48 h. Parents were instructed to record bladder spasm episodes prospectively by using a standardized time-flow diary. Three patients (25%) in the ketorolac group experienced bladder spasms, compared with 10 patients (83%) in the placebo group (two-sided P < 0.05). The median severity score for the ketorolac group was 1.2 (mild = 1.0, severe = 3.0), compared with 2.6 for the placebo group (P = 0.003). We conclude that IV ketorolac reduces the frequency and severity of postoperative bladder spasms after intravesical ureteroneocystostomy.

IMPLICATIONS

We studied the efficacy of ketorolac, a prostaglandin synthesis inhibitor, in the treatment of bladder spasm after ureteroneocystostomy (antireflux operation). Patients were randomized in a double-blinded manner to receive either ketorolac or placebo after the surgery. We demonstrate that ketorolac reduces the frequency and severity of postoperative bladder spasm.

A randomized comparison of ketorolac tromethamine and morphine for postoperative analgesia in critically ill children

OBJECTIVES

To evaluate the efficacy of a single dose of ketorolac compared with morphine for the relief of pain in children, and to determine the safety of ketorolac.

SETTING

Tertiary pediatric intensive care unit in a university-affiliated hospital.

DESIGN

Prospective, randomized, double-blind, parallel, single-dose, positive control study.

PATIENTS

Children admitted to the intensive care unit with postoperative pain.

INTERVENTIONS

Patients received a single dose of either morphine or ketorolac as the first postoperative analgesic when the pain score indicated significant pain. Blood pressure, heart rate, and urine output were recorded, as well as blood urea nitrogen, creatinine, bleeding time, hematuria or proteinuria, and aspartate aminotransferase. Side effects such as nausea and vomiting were noted. Morphine was used for rescue treatment if the patient continued to have significant pain > or =30 mins after study drug administration.

MEASUREMENTS AND MAIN RESULTS

Of the 102 children studied, 48 received morphine and 54 received ketorolac. The percentage of patients reporting pain relief in the first and second hours after drug administration was not different between groups. Likewise, the proportion of patients who met the criteria for pain relief during the entire evaluation period was not different between groups. There was a trend toward fewer patients who received ketorolac requiring remedication in the first 4 hrs compared with those who received morphine, but this trend did not reach statistical significance. More patients in the morphine group failed to achieve pain relief at any time after the dose compared with those who received ketorolac. There were no differences between the two groups in physiologic or laboratory variables. Vomiting was more common in patients who received ketorolac.

CONCLUSION

Ketorolac is comparable to morphine in relief of postoperative pain in children. A single dose of ketorolac does not result in abnormal postoperative bleeding or alter renal function. However, ketorolac may cause nausea and vomiting in some patients.

Minimizing hospital length of stay in children undergoing ureteroneocystostomy

OBJECTIVES

Shortening hospital stay yet not compromising quality of care can result in significant cost savings for children undergoing surgical correction of vesicoureteral reflux.

METHODS

We reviewed the medical records of pediatric patients who underwent ureteroneocystostomy between July 1995 and July 1997. A total of 43 patients, aged 0.2 to 18 years (mean 5.2) who all received identical postoperative care, except for their pain management and the time of bladder catheter removal, were included in the study. Twenty-three were treated with intravenous ketorolac tromethamine (Toradol); the remaining 20 received narcotics in the immediate postoperative period. The bladder catheter was removed in less than 24 hours in 22 children, and greater than 24 hours in 21.

RESULTS

Patients who received ketorolac tromethamine for postoperative analgesia had on average shorter hospital length of stays than those treated with narcotics (1.4 versus 2.5 days, respectively; P < 0.001). The average stay for children whose bladder catheter was removed within 24 hours postoperatively was significantly shorter than those whose catheter was removed after a 24-hour period (1.4 versus 2.4 days, respectively; P < 0.001). There were no reimplantation failures. One child presented 2 days postoperatively with anemia, which did not require transfusion.

CONCLUSIONS

Our review demonstrates that ketorolac tromethamine can be used safely and effectively in children for immediate postoperative analgesia, and that its proper use combined with early catheter removal can reduce the length of hospital stay for pediatric patients undergoing ureteroneocystostomy.

Post-operative pain management

For many years pediatric procedural and postoperative pain has been undertreated or not treated. In some areas this practice still exists and is a likely reflection of persistence of myths related to the infant's ability to perceive pain. Such myths include the lack of ability to perceive pain or remember painful experiences. New literature exists showing that these former beliefs do not hold true. The appropriate management of postoperative pain is contingent on a cooperative effort from pediatric surgeons, pediatric anesthesiologists, pediatricians, and parents. There are many ways to treat postoperative pain. The method of postoperative analgesia depends on the patient, underlying medical conditions, the type of surgery, the patient's disposition following surgery (inpatient vs. outpatient), and the physician's comfort level with a particular analgesic regimen. Many pediatric anesthesiologists and surgeons have excellent success with the utilization of regional anesthetic techniques as treatment for postoperative pain. Caudal epidural blocks, ilioinguinal/iliohypogastric nerve blocks, and penile nerve blocks are some of the commonly used blocks. These blocks not only provide excellent postoperative analgesia, but are great adjuncts to general anesthesia, thus, reducing the amount of general anesthesia required. Additionally, the use of epidural opioids is extremely useful in patients following major abdominal, thoracic, and orthopedic surgery. Traditional medications such as oral and parenteral narcotics, non-steroidal anti-inflammatory drugs, and acetaminophen (paracetamol), are much more commonly used to treat postoperative pain. Regardless of the analgesic regimen chosen, we must assure our pediatric patients the least painful perioperative experience possible.

Ketorolac. A reappraisal of its pharmacodynamic and pharmacokinetic properties and therapeutic use in pain management

Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) with strong analgesic activity. The analgesic efficacy of ketorolac has been extensively evaluated in the postoperative setting, in both hospital inpatients and outpatients, and in patients with various other acute pain states. After major abdominal, orthopaedic or gynaecological surgery or ambulatory laparoscopic or gynaecological procedures, ketorolac provides relief from mild to severe pain in the majority of patients and has similar analgesic efficacy to that of standard dosages of morphine and pethidine (meperidine) as well as less frequently used opioids and other NSAIDs. The analgesic effect of ketorolac may be slightly delayed but often persists for longer than that of opioids. Combined therapy with ketorolac and an opioid results in a 25 to 50% reduction in opioid requirements, and in some patients this is accompanied by a concomitant decrease in opioid-induced adverse events, more rapid return to normal gastrointestinal function and shorter stay in hospital. In children undergoing myringotomy, hernia repair, tonsillectomy, or other surgery associated with mild to moderate pain, ketorolac provides comparable analgesia to morphine, pethidine or paracetamol (acetaminophen). In the emergency department, ketorolac attenuates moderate to severe pain in patients with renal colic, migraine headache, musculoskeletal pain or sickle cell crisis and is usually as effective as frequently used opioids, such as morphine and pethidine, and other NSAIDs and analgesics. Subcutaneous administration of ketorolac reduces pain in patients with cancer and seems particularly beneficial in pain resulting from bone metastases. The acquisition cost of ketorolac is greater than that of morphine or pethidine; however, in a small number of studies, the higher cost of ketorolac was offset when treatment with ketorolac resulted in a reduced hospital stay compared with alternative opioid therapy. The tolerability profile of ketorolac parallels that of other NSAIDs; most clinically important adverse events affect the gastrointestinal tract and/or renal or haematological function. The incidence of serious or fatal adverse events reported with ketorolac has decreased since revision of dosage guidelines. Results from a large retrospective postmarketing surveillance study in more than 20,000 patients demonstrated that the overall risk of gastrointestinal or operative site bleeding related to parenteral ketorolac therapy was only slightly higher than with opioids. However, the risk increased markedly when high dosages were used for more than 5 days, especially in the elderly. Acute renal failure may occur after treatment with ketorolac but is usually reversible on drug discontinuation. In common with other NSAIDs, ketorolac has also been implicated in allergic or hypersensitivity reactions. In summary, ketorolac is a strong analgesic with a tolerability profile which resembles that of other NSAIDs. When used in accordance with current dosage guidelines, this drug provides a useful alternative, or adjuvant, to opioids in patients with moderate to severe pain.