What is the recommended ketorolac dosing for a 25‑kg, 11‑year‑old child with normal renal function and no contraindications?

Ketorolac Dosing for a 25 kg, 11-Year-Old Child

For this 25 kg child, administer ketorolac 0.5 mg/kg intravenously (12.5 mg) as a single intraoperative dose, with a maximum of 30 mg, and if postoperative continuation is needed, use 0.15–0.2 mg/kg IV every 6 hours (approximately 4–5 mg per dose, maximum 10 mg per dose) for no more than 48 hours. 1

Intraoperative/Initial Dosing

• Give 0.5–1 mg/kg IV as a single loading dose during surgery or for acute pain management 1, 2
• For this 25 kg child, this translates to 12.5–25 mg IV 1
• Do not exceed 30 mg for the single intraoperative dose, even though this child's weight-based calculation allows up to 25 mg 1, 3
• Administer the IV bolus over at least 15 seconds 3
• Analgesic effect begins in approximately 30 minutes, with maximum effect at 1–2 hours and duration of 4–6 hours 3, 2

Postoperative Maintenance Dosing (If Needed)

• Use 0.15–0.2 mg/kg IV every 6 hours for continued postoperative analgesia 1
• For this 25 kg child, this equals approximately 4–5 mg per dose every 6 hours 1
• Maximum single maintenance dose is 10 mg, regardless of weight-based calculation 1
• Limit total duration to 48 hours (not 5 days as in adults) to minimize renal and bleeding complications in pediatric patients 1, 2

Transition to Oral Therapy

• After 48 hours of IV ketorolac, transition to oral ibuprofen 10 mg/kg every 8 hours (250 mg per dose for this 25 kg child) 1
• Alternatively, oral ketorolac can be used at 0.25 mg/kg per dose (approximately 6 mg for this child), but IV-to-oral ketorolac transition is less commonly recommended than switching to ibuprofen 2

Multimodal Analgesia Integration

• Combine with acetaminophen 10–15 mg/kg IV every 6–8 hours (250–375 mg per dose for this child) to achieve synergistic analgesia and reduce opioid requirements 1
• Reserve opioids for breakthrough pain only; ketorolac reduces postoperative opioid consumption by 25–50% 1, 4
• Consider adjunctive dexamethasone 0.15–0.25 mg/kg (approximately 4–6 mg for this child) or ketamine 0.5 mg/kg intraoperatively to further enhance analgesia 1
• Regional anesthesia techniques (caudal block, wound infiltration) should be incorporated when appropriate 1

Critical Safety Screening Before Administration

Absolute contraindications (do not give ketorolac if any are present):

• Active or history of gastrointestinal bleeding or peptic ulcer disease 1, 5
• Renal impairment or compromised kidney function 1, 6
• Aspirin or NSAID-induced asthma 7
• Sickle cell disease, particularly during vaso-occlusive crisis (markedly elevated acute kidney injury risk) 1, 6
• Mastocytosis (fatal idiosyncratic reaction reported) 1

Baseline monitoring required:

• Blood pressure 1
• BUN and creatinine to assess renal function 1, 6
• Complete blood count 1
• Liver function tests 1

Advantages Over Opioids in This Age Group

• No respiratory depression, sedation, nausea/vomiting, urinary retention, or addiction potential 1, 2
• Can be discontinued abruptly without withdrawal symptoms 1
• Faster return of bowel function after abdominal surgery compared to opioid-only regimens 2
• Comparable analgesic efficacy to morphine for moderate to severe postoperative pain in children 2, 4

Common Pitfalls to Avoid

• Do not use adult dosing guidelines (adults receive 15–30 mg every 6 hours; children require weight-based dosing with lower per-dose maximums) 1, 3
• Do not exceed 48 hours of IV therapy in children (adult guidelines allow up to 5 days, but pediatric safety data support shorter duration) 1, 2
• Do not give intramuscular injections unless IV access is unavailable; IM administration is painful and not recommended in children 2
• Do not mix ketorolac in a syringe with morphine, meperidine, promethazine, or hydroxyzine, as this causes precipitation 3
• Do not use in infants <1 year of age; safety and efficacy are not established in this population 2

Monitoring During Therapy

• Monitor renal function for any deterioration during treatment 1, 6
• Watch for signs of GI bleeding (melena, hematemesis, abdominal pain) 5
• Assess for adequate hydration; correct hypovolemia before administering ketorolac 3
• Bleeding time may be slightly increased due to reversible antiplatelet effects, but this typically remains within normal limits and does not contraindicate use for most pediatric surgeries (tonsillectomy data are conflicting) 2, 5