Ketorolac (Toradol)

Anesthesia Implications

Classification: NSAID, COX 1-2 inhibitor (nonselective)
Therapeutic Effects: Analgesia
Time to Onset: 30 minutes

Duration: 4-6 hours

Contraindications

Avoid in patients with coagulopathies, renal failure, active peptic ulcer disease, GI bleeding, history of asthma, or high risk for bleeding.

Avoided in parturients that are past their first trimester as it can cause closure of the fetal ductus arteriosus.

Avoided in PEDs patients undergoing a tonsillectomy as it has been shown to increase postoperative bleeding complications by 2 – 5 times. Acetaminophen and/or tramadol should be considered as alternatives.

Primary Considerations

Very effective agent for mild to moderate pain. Specifically, ketorolac is especially effective at pain related to inflammation.

Common suggested doses are 15-30 mg. HOWEVER, recent studies show that the therapeutic ceiling is achieved with only 10mg, which is just as effective as 15-30mg. Higher doses DO contribute to a higher incidence of side effects and MAY extend the duration of Toradol (duration extension is yet to be studied).

By the textbook, 30 mg is roughly equivalent to 12 mg of Morphine. This drug is typically given as an adjuvant to traditional opioids.

The advantage is that ketorolac works synergistically with opioids with very little incidence of nausea and vomiting and no respiratory depression. This makes it ideal for cases where avoiding opioids is desirable (laparoscopic and pediatric dental cases).

Contributes to reversible platelet dysfunction.

Ketorolac is on the list of drugs that CAN cause ototoxicity by direct and indirect mechanisms.  The reports are rare, but when they do happen, it is often irreversible.  Ketorolac has an additive ototoxic effect when combined with other ototoxic drugs (aminoglycosides, erythromycin, vancomycin, loop diuretics, salicylates, antineoplastic agents, and other NSAIDs).

Some clinicians believe that NSAIDs delay bone healing (inhibition of normal prostaglandin function), so asking the surgeon is always important.

Prostaglandins also play a part in embryo implantation, so NSAIDs like ketorolac are avoided in the artificial reproductive technology (ART) patient.

The addition of ketorolac to local anesthesia solutions has shown to be effective in reducing tourniquet pain.

6 mg of ketorolac added to 1% lidocaine for dermal anesthesia prior to epidural placement has shown to be effective at reducing incidence and severity of postpartum back pain.

PEDs:  Ketorolac is an effective treatment for postoperative bladder spasms. Also very effective as an adjuvant to opioids in infants and children of all ages.

IV push dose

New Research: 10mg (just as effective as the most common dose below)
Most common: 15-30 mg
Textbook: 0.5 mg/kg

May be redosed every 6 hours

maximum of 2mg/kg every 24 hours (5 days max) in PEDs patients under 60 kg in weight.

IM dose

Same as IV push

Method of Action

Inhibition of COX-1, COX-2, and prostaglandin synthesis

Metabolism

Hepatic