What is the appropriate use of ketorolac (NSAID) for intravenous (IV) pain management?

IV Ketorolac for Acute Pain Management

For IV ketorolac administration in acute pain, use 30 mg IV over at least 15 seconds every 6 hours (maximum 120 mg/day) for patients under 65 years, or 15 mg IV every 6 hours (maximum 60 mg/day) for patients ≥65 years, those with renal impairment, or weighing <50 kg, with total treatment duration not exceeding 5 days. 1

Dosing Protocol

Standard Adult Dosing (Age <65 years)

• Single dose: 30 mg IV administered over minimum 15 seconds 1
• Multiple doses: 30 mg IV every 6 hours, maximum 120 mg/day 1, 2
• Onset: Analgesic effect begins in ~30 minutes, peaks at 1-2 hours, duration 4-6 hours 1

High-Risk Population Dosing

Reduce dose by 50% for patients who are: 1, 2

• Age ≥65 years
• Renally impaired
• Weight <50 kg (110 lbs)

Adjusted regimen: 15 mg IV every 6 hours, maximum 60 mg/day 1, 2

Duration Limits

• Maximum treatment duration: 5 days total (including any transition to oral ketorolac) 1
• This is a hard stop—exceeding 5 days dramatically increases risk of serious gastrointestinal bleeding and renal failure, particularly in elderly patients 1, 3

Absolute Contraindications

Do not administer ketorolac if ANY of the following are present: 1

• Active peptic ulcer disease or recent GI bleeding/perforation
• History of peptic ulcer disease or GI bleeding
• Advanced renal impairment or patients at risk for renal failure due to volume depletion
• Suspected or confirmed cerebrovascular bleeding
• Hemorrhagic diathesis, incomplete hemostasis, or high bleeding risk
• Coronary artery bypass graft (CABG) surgery setting
• Previous hypersensitivity to ketorolac, aspirin, or other NSAIDs
• Aspirin-induced asthma or NSAID-induced bronchospasm 4, 5
• Current use of aspirin or other NSAIDs (cumulative toxicity risk) 1
• Labor and delivery (inhibits uterine contractions, affects fetal circulation) 1
• Intrathecal or epidural administration 1

Critical Safety Considerations

Cardiovascular Risk

• NSAIDs increase risk of myocardial infarction and stroke, which may occur early in treatment 1, 4
• Discontinue ketorolac immediately in patients presenting with acute coronary syndrome 4

Gastrointestinal Risk

• Can cause peptic ulcers, GI bleeding, and perforation at any time without warning symptoms 1
• Risk increases markedly with high doses, duration >5 days, and age ≥65 years 3
• Consider proton pump inhibitor co-administration in high-risk patients 4

Renal Risk

• Contraindicated in volume-depleted patients—correct hypovolemia before administration 1
• Monitor baseline and periodic BUN, creatinine in patients on therapy 2
• Acute renal failure risk is particularly high in patients with marginal kidney function 6

Bleeding Risk

• Inhibits platelet function reversibly 7
• Avoid in patients on anticoagulants or with coagulopathy 1
• Contraindicated as prophylactic analgesic before major surgery 1

Hypersensitivity Risk

• Bronchospasm to anaphylactic shock can occur 1, 5
• Have appropriate counteractive measures available when administering first dose 1
• Asthmatics with aspirin sensitivity are at highest risk 5

Clinical Applications

Postoperative Pain

• Provides analgesia comparable to morphine and meperidine for moderate-to-severe postoperative pain 3, 8
• Opioid-sparing effect: Reduces opioid requirements by 25-50% when used in combination 3, 4
• May reduce opioid-induced nausea, vomiting, and sedation 3
• Effective for post-cesarean delivery pain: 30 mg IV at end of surgery, then 30 mg IV every 6 hours for 24 hours 2

Emergency Department Use

• Effective for renal colic, migraine, musculoskeletal pain 3, 6
• Limitation: 30-60 minute onset delays rapid relief; >25% of patients show inadequate response 8
• Consider supplementing with low-dose opioids for breakthrough pain 1

ICU Procedural Pain

• Single 30 mg IV dose shows comparable efficacy to morphine 4 mg IV for procedures like chest tube removal 2

Administration Technique

• IV bolus must be given over minimum 15 seconds (not as rapid push) 1
• Do not mix in syringe with morphine, meperidine, promethazine, or hydroxyzine (causes precipitation) 1
• Administer through dedicated line with minimum 10 ml/h saline flush 4
• Inspect solution for particulate matter before administration 1

Monitoring Requirements

Baseline assessment: 2

• Blood pressure
• BUN and creatinine
• Liver function tests
• Complete blood count
• Fecal occult blood (if long-term use anticipated)

Ongoing monitoring: 4

• Sedation levels and respiratory status
• Signs of GI bleeding (hematemesis, melena, abdominal pain)
• Renal function deterioration (decreased urine output, rising creatinine)
• Cardiovascular events (chest pain, dyspnea)
• Hypertension and heart failure exacerbation

Common Pitfalls to Avoid

1. Do not exceed 5-day duration—this is when serious adverse events spike dramatically 1, 3
2. Do not increase dose or frequency for breakthrough pain—instead add low-dose opioids 1
3. Do not use in dehydrated patients—correct volume status first 1
4. Do not combine with other NSAIDs or aspirin—cumulative toxicity 1
5. Do not assume safety in elderly—use half-dose and monitor closely 1, 2
6. Do not give as rapid IV push—must infuse over ≥15 seconds 1

Transition Strategy

• Switch to oral NSAIDs (ibuprofen 600 mg every 6 hours or naproxen) as soon as patient tolerates oral intake 2
• If transitioning to oral ketorolac, ensure combined IV + oral duration does not exceed 5 days 1
• For ongoing pain beyond 5 days, transition to alternative analgesic strategy (acetaminophen, different NSAID class, or multimodal approach) 4