Guidelines for Ketorolac Use in Pediatric Postoperative Pain Management
Ketorolac is recommended for short-term postoperative pain management in pediatric patients at a dose of 0.5-1 mg/kg (maximum 30 mg) for a single intraoperative dose, followed by 0.15-0.2 mg/kg (maximum 10 mg) every 6 hours for a maximum duration of 48 hours. 1
Dosing Recommendations
IV Ketorolac Dosing
- Initial dose: 0.5-1 mg/kg up to 30 mg for a single intraoperative dose 1
- Maintenance dose: 0.15-0.2 mg/kg (maximum 10 mg) every 6 hours 1
- Maximum duration: 48 hours (short-term therapy only) 1, 2
- Age restriction: Not recommended for infants under 1 year of age 3
Role in Multimodal Pain Management
Ketorolac should be used as part of a multimodal approach to pain management:
- First-line agents: Scheduled NSAIDs (including ketorolac) and acetaminophen should form the foundation of postoperative pain management 2
- Breakthrough pain: Opioids should be reserved for breakthrough pain 2
- Synergistic effect: When combined with opioids, ketorolac demonstrates marked opioid-sparing effects, allowing lower opioid doses and reducing opioid-related adverse effects 3
Clinical Benefits
- Opioid-sparing: Reduces postoperative opioid requirements 3, 4
- Pain reduction: Significantly decreases postoperative pain scores (demonstrated in adenotonsillectomy with maximum FLACC score 4.3 ± 2.6 for ketorolac vs. 5.9 ± 3.0 for placebo) 4
- Avoids opioid side effects: Unlike opioids, ketorolac does not cause respiratory depression, sedation, urinary retention, or significant nausea and vomiting 3
- Faster recovery: Promotes earlier recovery of bowel function after abdominal surgery compared to opioid-only regimens 3
Precautions and Contraindications
Bleeding Risk
- Monitor for signs of bleeding when using ketorolac 2
- Bleeding time may be slightly increased but usually remains within normal values 3
- Evidence regarding increased surgical-site bleeding after tonsillectomy is conflicting 3, but a prospective randomized trial in congenital heart surgery showed no increased risk of bleeding complications 5
Renal Function
- Consider renal function when using NSAIDs 2
- Avoid in patients with renal impairment
Other Considerations
- Avoid intramuscular administration unless IV access is unavailable 3
- Transition to oral NSAIDs as soon as the patient can tolerate oral medication 1, 2
Procedure-Specific Recommendations
The European Society for Paediatric Anaesthesiology (ESPA) recommends ketorolac as part of multimodal analgesia for various procedures 1:
- Thoracoscopy/Thoracotomy: IV NSAIDs (including ketorolac) combined with regional anesthesia techniques
- Hypospadias Repair: IV NSAIDs during the entire postoperative period
- General postoperative care: IV NSAIDs as part of basic, intermediate, and advanced pain management protocols
Monitoring
- Regular assessment of pain using age-appropriate validated pain scales
- Monitor for signs of bleeding
- Monitor renal function with prolonged use
- Assess for adequate pain control and need for breakthrough medication
Common Pitfalls to Avoid
- Exceeding recommended duration: Limit ketorolac use to 48 hours maximum to reduce risk of adverse effects 1, 2
- Monotherapy for severe pain: Ketorolac should not be used alone for severe pain but as part of multimodal therapy 1
- Overlooking renal function: Always consider renal function before administering NSAIDs 2
- Inadequate dosing: Children may require relatively higher doses compared to adults due to pharmacokinetic differences (increased volume of distribution and plasma clearance) 3
- Missing the transition to oral medication: Aim for oral administration as soon as feasible 1
By following these evidence-based guidelines for ketorolac use in pediatric postoperative pain management, clinicians can effectively reduce pain while minimizing opioid requirements and their associated adverse effects.