Ketorolac Administration in a Patient with Significant Chest Tube Output
Ketorolac should not be administered to a patient with 300ml of chest tube output in one hour due to its antiplatelet effects and increased bleeding risk.
Bleeding Risk with Ketorolac
- Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that inhibits platelet aggregation, which can increase bleeding risk 1
- Studies have shown that ketorolac administration results in prolongation of bleeding time by approximately 50% in healthy volunteers 2
- The National Comprehensive Cancer Network recommends avoiding ketorolac in patients with active bleeding and using with caution in patients with compromised fluid status 3
Chest Tube Output Considerations
- Significant chest tube output (300ml in one hour) indicates active bleeding that could be exacerbated by ketorolac's antiplatelet effects 1
- In thoracic surgery patients, studies have shown higher volumes of blood in thoracic drains with ketorolac use compared to other analgesics (309ml vs. 273ml with paracetamol) 4
- While this difference might not be clinically significant in stable patients with minimal drainage, it becomes concerning with already significant chest tube output 4
Alternative Pain Management Options
- Paracetamol (acetaminophen) would be a safer alternative for this patient, as it provides effective analgesia without affecting platelet function 4
- Studies comparing ketorolac with paracetamol in thoracic surgery patients found no significant difference in pain scores or patient satisfaction, but less bleeding with paracetamol 4
- If stronger analgesia is needed, opioid analgesics would be preferable until chest tube output decreases 5
When Ketorolac May Be Reconsidered
- Ketorolac could potentially be reconsidered once chest tube output has decreased to minimal levels (<50ml/hour) for at least 4-6 hours 3
- When reintroducing ketorolac, use the lowest effective dose (15mg IV for adults) to minimize bleeding risk 3
- Continue close monitoring of chest tube output after ketorolac administration 1
Special Considerations
- In pediatric cardiac surgery patients with normal chest tube output, ketorolac has been used safely without increased bleeding complications 6
- However, this evidence cannot be extrapolated to patients with already significant chest tube output 6
- The risk of adverse events with ketorolac increases with high doses and in vulnerable patients 1
Remember that while ketorolac provides excellent analgesia without the sedating effects of opioids, patient safety must be prioritized when significant bleeding is present, as indicated by the high chest tube output.