What is the dose, mechanism of action, safe administration guidelines, and nursing considerations for Ketorolac (generic name: Ketorolac tromethamine)?

Ketorolac (Toradol): Comprehensive Medication Guide

Ketorolac (Toradol) is a potent NSAID with a maximum dosing duration of 5 days, requiring reduced dosing in elderly, renally impaired, or patients under 50kg, with administration rates not exceeding recommended timeframes to prevent serious adverse effects. 1

Mechanism of Action

Ketorolac is a non-steroidal anti-inflammatory drug (NSAID) that inhibits cyclooxygenase/prostaglandin synthesis, thereby reducing inflammation, pain, and fever. It has potent analgesic effects with relatively low incidence of adverse effects compared to opioids 2. Unlike opioids, ketorolac does not cause respiratory depression, sedation, nausea/vomiting, or urinary retention, making it valuable for acute pain management 2.

Dosage Guidelines

Adult Dosing (17-64 years)

• IV/IM Initial Dose: 30 mg
• IV/IM Maintenance: 30 mg every 6 hours (maximum daily dose: 120 mg)
• Oral Initial Dose: 20 mg once
• Oral Maintenance: 10 mg every 4-6 hours (maximum daily dose: 40 mg) 1

Special Populations

• Elderly (≥65 years), Renally Impaired, or <50kg:
  • IV/IM Initial Dose: 15 mg
  • IV/IM Maintenance: 15 mg every 6 hours (maximum daily dose: 60 mg)
  • Oral Initial Dose: 10 mg once
  • Oral Maintenance: 10 mg every 4-6 hours (maximum daily dose: 40 mg) 1

Pediatric Dosing

• Not FDA approved for oral formulation in children under 17
• For postoperative pain in children ≥1 year:
  • Initial: 0.5 mg/kg IV
  • Maintenance: Either 1.0 mg/kg IV every 6 hours or 0.17 mg/kg/hour IV infusion
  • Maximum daily dose: 90 mg
  • Maximum duration: 48 hours 1, 2

Safe Administration Guidelines

Administration Routes and Rates

• IV: Administer over at least 15 seconds to minimize pain at injection site
• IM: Deep intramuscular injection; avoid in patients with coagulation disorders
• PO: Administer with food to reduce GI irritation
• Maximum Duration: 5 days combined IV/IM and oral therapy 1

Contraindications

• History of peptic ulcer disease
• GI bleeding or perforation
• Advanced renal impairment or risk of renal failure
• Cerebrovascular bleeding
• Hemorrhagic diathesis/coagulation disorders
• Pregnancy or labor and delivery
• Concurrent use with aspirin or other NSAIDs 1

Nursing Assessment and Considerations

Baseline Assessment

• Obtain complete pain assessment (location, intensity, quality, onset, duration)
• Assess vital signs with focus on blood pressure
• Review baseline laboratory values:
  • Renal function tests (BUN, creatinine)
  • Liver function tests
  • Complete blood count
  • Coagulation profile
  • Fecal occult blood test 1

Ongoing Monitoring

• Monitor for signs of GI bleeding (black/tarry stools, hematemesis)
• Assess for edema, particularly in elderly patients
• Monitor urine output and renal function
• Evaluate pain relief using appropriate pain scale
• Assess for CNS effects (drowsiness, dizziness)
• Monitor for signs of bleeding or bruising 1, 3

Administration Precautions

• Use lowest effective dose for shortest duration possible
• Never administer oral formulation as initial dose; only use as continuation after IV/IM dosing
• Ensure adequate hydration before administration
• Discontinue if BUN or creatinine doubles or hypertension develops/worsens 1

Drug Interactions

• Increased bleeding risk with anticoagulants, antiplatelets, SSRIs
• Increased nephrotoxicity with ACE inhibitors, ARBs, diuretics
• Reduced efficacy of antihypertensives
• Monitor closely for toxicities in patients receiving chemotherapy due to potential additive nephrotoxicity 1

Important Nursing Considerations

• Ketorolac has a ceiling analgesic effect; doses above recommended amounts do not provide additional pain relief but increase adverse effect risk 1
• Ketorolac can be part of multimodal analgesia, showing synergistic effects with opioids, allowing for lower opioid doses 2
• Recovery of bowel function after abdominal surgery occurs sooner with ketorolac compared to opioid-treated patients 2
• Most serious adverse events occur with high doses, prolonged therapy (>5 days), or in vulnerable patients (elderly) 3
• Acute renal failure associated with ketorolac is usually reversible after discontinuation 3

By following these guidelines, ketorolac can be safely administered while minimizing the risk of adverse effects, providing effective pain management for acute pain conditions.