AACN Advanced Critical Care
Volume 25, Number 1, pp.23-30
Ketorolac as an Analgesic Agent
for Infants and Children After
Cardiac Surgery
Safety Profile and Appropriate Patient Selection
Meredith K. Jalkut, RN, MSN, CRNP
ABSTRACT
Ketorolac has been used safely as an analge-
sic agent for children following cardiac sur-
gery in selected populations. Controversy
exists among institutions about the risks
involved with this medication in this patient
group. This article reviews the current litera-
ture regarding the safety of ketorolac for
postoperative pain management in children
after cardiac surgery. Specifically, concerns
about renal dysfunction and increased bleed-
ing risk are addressed. Additionally, the arti-
cle details pharmacokinetics and potential
benefits of ketorolac, such as its opioid-
P ain management following cardiac sur-
gery is an important element of postoper-
ative management in infants and children. A
large percentage of children who have cardiac
surgery are infants younger than 1 year.1 This
population often experiences dramatic hemo-
dynamic changes after cardiac surgery, and
achieving adequate pain management can be a
challenge.2 Inadequate pain control for patients
of any age following cardiac surgery can lead
to increased metabolic demand and oxygen
consumption, which can subsequently cause
inadequate cardiac output and decreased venti-
lation.2 In addition to limiting physiological
stress, appropriate pain management following
cardiac surgery allows patients to perform age-
appropriate tasks that aid in the recovery pro-
cess (ie, eating, getting out of bed, walking).3
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NCI-D-13-00024R1.indd 23
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sparing effect. The literature reflects that the
use of this medication is not well studied in
certain pediatric cardiac patients such as
neonates and those with single-ventricle
physiology, and the safety of this medication
in regards to these special populations is
reviewed. In conclusion, ketorolac can be
used in specific pediatric patients after car-
diac surgery with minimal risk of bleeding or
renal dysfunction with appropriate dosing
and duration of use.
Keywords: cardiac surgery, children, ketorolac,
pain management
The most common pain management strat-
egy for pediatric patients who have undergone
cardiac surgery is a combination of opioids
and acetaminophen for analgesia and benzodi-
azepines for agitation and anxiety.3 Continu-
ous administrations of fentanyl and midazolam
are frequently used for patients who remain
intubated postoperatively.3 Intermittent mor-
phine and rectal or intravenous (IV) acetami-
nophen are often used for patients who have a
natural airway until they are able to take
Meredith K. Jalkut is Pediatric Nurse Practitioner, Children’s
Hospital of Philadelphia, 1519 S Clarion St, Philadelphia, PA
19147 (meredith.jalkut@gmail.com).
The author declares no conflicts of interest.
DOI: 10.1097/NCI.0000000000000002
06/01/14 4:40 PM
 JA LK UT
enteral nutrition, at which time they are started
on enteral acetaminophen and oxycodone.3
The use of dexmedetomidine is becoming a
frequent practice for the periextubation and
early postoperative periods.4
Ketorolac, a nonsteroidal anti-inflamma-
tory drug (NSAID), is frequently used as an
analgesic medication in both adult and pediat-
ric populations for postoperative pain manage-
ment.5 Use of this medication for children
following heart surgery is controversial
because of concern for renal dysfunction, gas-
trointestinal (GI) bleeding, and surgical
bleeding.3 The objective of this article is to
review the pharmacokinetics of ketorolac, the
current literature on the safety profile of this
medication, and the benefits seen with reduc-
tion in opioid use with concurrent use of
ketorolac. Review of the current literature will
help advanced practice nurses in selection of
pain medications for pediatric patients follow-
ing cardiac surgery.
Pharmacological Properties
of Ketorolac
In the reviewed literature, ketorolac was dosed
at 0.5 mg/kg administered intravenously (IV)
every 6 hours for less than 4 days; most
patients received the drug for less than 48 hours.
In only 1 study were patients given a loading
dose of 1 mg/kg.6 Ketorolac produces analgesia
by acting as a nonselective inhibitor of the
cyclooxygenase enzyme that is implicated in
pain receptors. This drug is highly bound in
the plasma and undergoes very little metabo-
lism before being excreted almost entirely by
the kidneys.7,8 Some literature hypothesizes
that infants have higher clearance of drug
because of their relatively high volume of body
water and lower plasma protein than adults.8
Other authors7 have suggested that the
opposite is true based on overall lower renal
clearance in infants. These opposing theories
present a challenge for providers to make an
informed decision about prescribing this medi-
cation to neonates and patients with abnormal
renal clearance.
Two studies evaluated the pharmacokinetics
of ketorolac on infants from the neonatal
period to 11 months of age. Cohen and
colleagues7 concluded that the clearance rate of
ketorolac after a single dose of 0.5 mg/kg IV
was similar to that of adults. The mean half-
life of the drug was 233 minutes. On the basis
of a goal serum concentration of ketorolac
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NCI-D-13-00024R1.indd 24
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shown to provide analgesia in 50% of the
population in adults, they recommended that
the drug be dosed every 4 to 6 hours.7 By con-
trast, in a different study, clearance of the drug
was found to be higher for neonates and young
infants compared with reported clearance rates
for older children and adults.8 Both studies
were limited by small cohort size, and each
patient received only 1 dose of the drug with
serial blood sampling for plasma concentra-
tion. In addition, exclusion criteria for each
cohort included cardiac, renal, hepatic, and
hematologic disease, prematurity, low birth
weight, and use of aspirin. Further data are
needed on the clearance and pharmacokinetics
of ketorolac in relation to neonates and infants,
especially those with cardiac disease or follow-
ing cardiac surgery.
Renal Toxicity With Use of
Ketorolac
Renal toxicity has been reported as an adverse
side effect in the safety profile of ketorolac. As
with other NSAIDs, the risk to the kidneys
involves inhibition of prostaglandin-mediated
renal function. Prostaglandins serve to vasodi-
late renal vessels; inhibition by an NSAID can
reduce renal blood flow.9 Reduction in renal
blood flow can be seen clinically with decreased
urine output and elevated serum creatinine
level from baseline.9 The drug was first intro-
duced in Europe several decades ago with
higher dosing recommendation and duration
of therapy.9 Many cases of severe adverse
effects, including renal toxicity, GI bleeding,
and surgical site bleeding, were reported in
adults. Since the time of these events, the man-
ufacturer has reduced the recommended dos-
ing range and duration of therapy.9 Renal
injury persists as a concern for patients who
receive this medication, despite multiple large
studies of adults receiving this drug at current
recommended dosing, which is 30 mg IV every
6 hours for up to 96 hours.9
Children undergoing cardiac surgery may
have increased risk for renal injury for several
reasons. Children presenting for cardiac surgery
may have compensated or uncompensated heart
failure, which can lead to reduction in renal per-
fusion in the preoperative state.10 In addition, car-
diopulmonary bypass surgery can be followed by
a low cardiac output state during which renal
perfusion is decreased.1 Finally, patients fre-
quently receive loop diuretics following cardiac
surgery, which may predispose them to a prerenal
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state.11 Some clinicians are reluctant to expose
patients to an NSAID concurrently with a loop
diuretic while renal function as measured by
urine output and serum creatinine may be unpre-
dictable.11 Providers are challenged to determine
exactly which patients are at risk for renal dys-
function with the use of ketorolac based on other
clinical issues.11
To date, a few prospective studies and sev-
eral retrospective studies have evaluated the
renal safety of ketorolac in children who have
undergone cardiac surgery.6 One study included
a retrospective chart review of 62 pediatric
patients who had received ketorolac for pain
control following cardiac surgery. All of the
patients studied were younger than 6 months;
11 (18%) were younger than 1 month. Surgical
intervention ranged from arterial switch opera-
tion to atrial septal defect closure. Eighty-three
percent of the patients underwent cardiopulmo-
nary bypass during the surgery. Serum creati-
nine level was compared with baseline after
patients received ketorolac 0.5 mg/kg IV every
6 hours for 48 hours The group found that 16
patients had a statistically significant increase in
serum creatinine and blood urea nitrogen
(BUN) levels, including 2 of 11 neonates. The
largest increase in creatinine level for any
patient was 0.3 mg/dL. The peak serum creati-
nine and BUN levels were still within the range
of normal for age for each patient, and the
authors of this study did not think that eleva-
tion of this value after patients received
ketorolac was clinically significant. All patients’
serum creatinine and BUN levels returned to
baseline, indicating that no long-term renal
injury occurred.6 Urine output and creatinine
clearance were not evaluated in this study. The
authors do not comment on the concurrent use
of furosemide or other diuretics in these patients
but note that patients with a statistically signifi-
cant increase in creatinine also had a negative
fluid balance.6
Similarly, other studies suggest that
ketorolac does not pose a risk to renal function
in young cardiac surgical patients. Another ret-
rospective study also concluded that ketorolac
does not cause a significant rise in serum cre-
atinine levels in infants younger than 6 months
with biventricular physiology.12 The authors
of this study completed a chart review of
19 patients who had received ketorolac
for postoperative pain management. These
patients were matched to control group by age.
Infants with NSAID allergies, single-ventricle
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NCI-D-13-00024R1.indd 25
KE TOROLAC IN P OSTOP E RAT IVE CA RD IAC P E D IAT RICS
physiology, preoperative renal impairment
defined as serum creatinine level greater than
0.6 mg/dL, or BUN level greater than 15 mg/
dL were excluded. Data analysis demonstrated
that these patients did not have statistically sig-
nificant change in renal function as measured
by serum creatinine and BUN levels.
A retrospective study evaluated 248 children
between the ages of 5 months and 18 years who
received ketorolac following cardiac surgery.13
The authors of this study evaluated serum cre-
atinine level, BUN level, and urine output, in
addition to the use of furosemide. Patients who
were included in this study were categorized as
having low-risk cardiac surgery, such as repair
of atrial septal defect and ventricular septal
defect repairs or right ventricle to pulmonary
artery conduit revisions, and were compared
with patients of similar age and clinical condi-
tion following the same cardiac surgeries who
did not receive ketorolac. The authors found
that patients who had received ketorolac com-
pared with those who had not had no increase in
serum creatinine or BUN level and no decreased
urine output. They also found that those patients
who received ketorolac for pain management
received on average less furosemide than patients
who did not receive ketorolac for reasons that
were unclear to the authors.13 Table 1 summa-
rizes the current literature on risk of renal dys-
function with the use of ketorolac.
The current literature demonstrates safety in
the use of ketorolac in patients with biventricu-
lar repairs and no preoperative renal dysfunc-
tion, with minimal risk of postoperative renal
dysfunction or renal insufficiency as evidenced
by serum creatinine levels and urine output. As
previously described, prospective randomized
control studies are lacking. Studies including
children with single-ventricle physiology and
neonates have small cohorts.6,14 The effects of
ketorolac on patients in high-risk categories,
such as those with single-ventricle physiology or
those with more complex cardiac surgeries requir-
ing longer bypass times, are not well-studied.
Therefore, this medication can be recommended
only for nonneonates with biventricular physio-
logy undergoing cardiac surgery.
Bleeding Risk With Use of
Ketorolac
As with all of the drugs in the NSAID class,
ketorolac is associated with a theoretical
increased risk of bleeding caused by thrombox-
ane A2 inhibition. Thromboxane is a mediator
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 JA LK UT W W W.A ACNA DVA NCE D CRIT ICA LCA RE .COM

Table 1: Summary of Literature Review of Renal Insufficiency With Use of Ketorolac

Patient Population/ Outcomes
Reference Study Design Measured Results Ketorolac Dosing
Dawkins et al12 Infants younger than BUN, serum No significant 0.5 mg/kg IV every
6 months, status creatinine increase in serum 6 h for average
postcardiac surgery, creatinine or BUN of 3.1 d
biventricular physiol- compared with
ogy/retrospective nonketorolac
chart review group
Inoue et al13 Infants and children Serum creatinine, No significant 0.5 mg/kg IV every
post low-risk cardiac BUN, urine increase in serum 6 h for average
surgery/retrospec- output creatinine and 36 h
tive chart review BUN or decrease
in urine output
compared with
nonketorolac
group
Moffett et al6 Infants younger than Serum creatinine, No significant Mean 0.44 mg/kg
6 mo postcardiac BUN increase in serum IV every 6 h
surgery/retrospec- creatinine or BUN
tive chart review compared with
nonketorolac con-
trol group
Abbreviations: BUN, blood urea nitrogen; IV, intravenous.

of platelet aggregation that is altered with the
prostaglandin inhibition caused by all NSAIDs.9
In addition, ketorolac and other NSAIDs inhibit
prostaglandin-dependent suppression of gastric
acid, causing an increased risk of GI bleeding.9
Providers historically have been resistant to giv-
ing this drug for pain management in postopera-
tive patients because of the risk of bleeding, both
at the surgical site and in the GI tract. A study of
healthy, adult volunteers showed that bleeding
times were significantly prolonged compared
with baseline after a dose of intramuscular
ketorolac, but platelet aggregation was similar
after the dose compared with the baseline,15
which may have a relevance to surgical site
bleeding postoperatively for patients receiving
ketorolac after cardiac surgery.
This drug is well-studied in the adult popu-
lation and is routinely given as an analgesic
agent for postoperative patients, although
some controversy persists about using it after
cardiopulmonary bypass surgery because of
concern for low cardiac output syndrome and
compromised renal perfusion.11 Existing stud-
ies in children are sparse and have small sam-
ple sizes. A prospective randomized study
examined bleeding risk associated with
ketorolac after cardiac surgery as measured by
chest tube drainage, wound bleeding as meas-
ured by visual observation and dressings, and
GI bleeding measured by emesis or output
from a gastric decompression tube.14 Patients
were aged 2 days to 18 years, and all under-
went cardiopulmonary bypass surgery. The
authors excluded patients with history of
recent GI bleed, bleeding in the first 6 postop-
erative hours requiring reoperation/explora-
tion or blood product transfusion, cardiac
transplantation, or delayed sternal closure.
The study included a total of 70 patients
divided between the ketorolac and nonke-
torolac groups. The patients in the ketorolac
group received 0.5 mg/kg per dose every 6
hours starting 12 hours after surgery for up to
48 hours total. Patients in both groups had
similar amounts of chest tube drainage, and
the patients in the ketorolac group had no
wound bleeding compared with 1 patient in
the nonketorolac group who had wound bleed-
ing. One patient in the ketorolac group had GI
bleeding seen as small-volume coffee ground
nasogastric drainage with no change in hemo-
globin or hematocrit. These authors concluded
that short-term use of ketorolac after cardiac
surgery did not increase the risk of postopera-
tive bleeding in their study.

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Several retrospective studies have evaluated
the risk of bleeding in children receiving
ketorolac after cardiac surgery. Another study
compared postoperative bleeding as measured
by hemoglobin, hematocrit, platelets, and
frank bleeding. Chest tube output was not
included as a measure of bleeding in this study.6
A total of 4 of 53 patients had episodes of
bleeding; none of the episodes were at the sur-
gical wound site, and none of the patients
experienced a decrease in hemoglobin, hema-
tocrit, or hemodynamic stability. The authors
of this study concluded that, in their patients,
ketorolac therapy for less than 48 hours in
neonates and infants does not increase the risk
of bleeding compared with the patients who
did not receive ketorolac.
Another retrospective study by Gupta et al16
evaluated the risk of bleeding for patients
receiving this drug after cardiac surgery by per-
forming a chart review and controlling for
diagnosis and degree of illness severity in the
nondrug group. The patients in this study were
infants to older teenagers with a mean age of 8
years. The authors do not comment on the
inclusion or exclusion of neonates or those
with cyanotic heart disease. The authors
defined clinically significant bleeding as
bleeding requiring surgical exploration. They
found no association between clinically signifi-
cant postoperative bleeding and exposure to
ketorolac (0.5 mg/kg IV every 6 hours follow-
ing 1 mg/kg loading dose) for an average of 44
hours. The limitations of this study include
small sample size, retrospective design, and an
absence of measurement of chest tube output,
blood counts, or any bleeding that did not
require surgical exploration.
The current literature suggests a low risk of
bleeding with the use of ketorolac for children
following cardiac surgery. Various studies used
different measures of bleeding, making it diffi-
cult to evaluate what level of bleeding is clini-
cally significant. For example, bleeding requiring
blood transfusion should be categorized as clini-
cally significant because blood transfusions
carry risk.17 In addition, these studies do not
describe concurrent medications such as other
anticoagulation medications, NSAIDs, or H2-
blockers for GI prophylaxis. Risk of bleeding
with the use of ketorolac based on current litera-
ture is summarized in Table 2. Although the lit-
erature supports minimal increased risk of
postoperative bleeding with the use of ketorolac,
this conclusion is limited to short-term dosage.
The manufacturer recommends that the drug be

Table 2: Summary of Literature Review of Bleeding Risk With Use of Ketorolac

Reference Patient Population Outcomes Measured Results Ketorolac Dosing
Dawkins et al12 Infants younger Hemoglobin, No significant dif- 0.5 mg/kg IV every
than 6 mo, status hematocrit, platelet ference in hemo- 6 h for average of
postcardiac surgery, count, the number globin, hematocrit, 3.1 d
biventricular of blood transfu- platelet count,
physiology sions or the number of
blood transfusions
compared with
nonketorolac group
Gupta et al14 Neonates, infants, and Chest tube drainage, No significant 0.5 mg/kg IV every
children postcardiac wound bleeding, GI increased risk of 6 h for < 48 h
surgery/prospective bleeding bleeding compared
randomized control with control group
study
Gupta et al16 Infants and children Postoperative bleed- No significant 0.5 mg/kg IV every
postcardiac surgery/ ing requiring surgi- increased risk of 6 h for < 48 h
retrospective chart cal reoperation bleeding compared
review with nonketorolac
group
Moffett et al6 Infants younger than Signs and symptoms No significant Mean 0.44 mg/kg IV
6 mo postcardiac of bleeding, hemo- increased risk of every 6 h
surgery/retrospec- globin, hematocrit, bleeding compared
tive chart review platelets with nonketorolac
control group
Abbreviation: GI, gastrointestinal.

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 JA LK UT
discontinued after 5 days as a result of
significantly increased risk of GI bleeding and
renal dysfunction with dosing more than 5 days.
Special Populations
Many of the studies previously discussed are
retrospective in design and rely on chart review
for patient cohorts. These studies reviewed
patient data for those who had received
ketorolac postoperatively and then created a
comparison group matched for criteria such as
diagnosis, age, surgical intervention, and sever-
ity of illness, which created a selection bias for
each study and excludes many groups of
patients who were not given the drug. In addi-
tion, the prospective, randomized control
study excluded patients who were at high risk
for renal dysfunction or bleeding.14 Conse-
quently, little information or research is avail-
able about the safety profile of this drug in
special populations such as neonates, children
with single-ventricle physiology, and those
receiving concurrent medications that could
increase the risk of bleeding or renal dysfunc-
tion with ketorolac.
Neonatal cardiac surgery accounts for a
large portion of pediatric cardiac surgery.18
These patients are a high-risk group for several
reasons, including the complexity of their heart
disease, length of cardiopulmonary bypass
time, increased amount of time spent with
invasive support and monitoring, and altered
volume of distribution and pharmacokinetics.1
The reviewed literature does not clearly indi-
cate that it is safe to give these patients
ketorolac following cardiac surgery.
According to some reports, patients with
single-ventricle physiology receive ketorolac
after undergoing the Blalock-Taussig shunt, the
Glenn surgery, or the Fontan surgery, but the
sample sizes are quite small.16 In addition, these
patients are commonly taking low-dose aspirin
at baseline prior to surgery and are restarted
on this medication shortly after surgery.19 Little
discussion is found in the literature about the
use of ketorolac in patients who are taking
another NSAID. Further studies need to be
done to evaluate the safety of this medication
in these patients. Many postoperative cardiac
patients are often started on a form of antico-
agulation (eg, heparin, enoxaparin, warfarin)
for their anatomy or implanted foreign devices.
None of the literature reviewed here addressed
patients receiving ketorolac who are also
receiving anticoagulation therapy.
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Finally, patients who undergo orthotopic
heart transplants are excluded from ketorolac
studies because of the renal toxicity associated
with immunosuppressive medications. This
patient group should not receive ketorolac at
any time.9 Patients who take tacrolimus have a
risk of acute nephrotoxicity with concurrent
use of NSAID medication.20 Pediatric cardiac
patients in the intensive care unit who are tak-
ing tacrolimus or other similar immunosup-
pressive medications are not candidates to
receive ketorolac and should avoid all NSAIDs.
Opioid-Sparing Effect
As previously mentioned, the most common
medications for pain control for children who
have undergone cardiac surgery are opioids
and acetaminophen.3 Opioids have well-
known dose-dependent adverse effects such as
respiratory depression, hypotension, nausea/
vomiting, GI hypomotility, and pruritis.21
These adverse effects can be significant for
infants and children who have undergone car-
diac surgery, given their potentially tenuous
hemodynamics. Often patients are receiving
these medications in the periextubation time
period when respiratory sufficiency is of vital
importance to avoid reintubation.22
Patients who remain intubated following
surgery commonly receive continuous adminis-
tration of fentanyl with as-needed dosing for
breakthrough pain. Extubated patients often
receive intermittent morphine or fentanyl for
breakthrough pain.3 Researchers hypothesize
that the concurrent use of ketorolac will reduce
the need for opioids and therefore reduce nega-
tive adverse effects of opioids while still pro-
viding adequate analgesia.23 In one study, adult
patients after surgery received either ketorolac
and morphine or morphine only for break-
through pain.24 Patients who received dual
therapy had a decreased need for morphine,
but no significant difference in adverse effects
from opioids was reported. Another study of
adults had similar findings. Patients who
received ketorolac in addition to morphine for
postoperative pain had a 48% reduced need
for morphine. No evidence of reduction of opi-
oid-associated adverse effects is reported in
this study.25 The authors from both of these
studies concluded that the duration of time for
which the patients were evaluated for opioid-
associated adverse effects was inadequate.
A small prospective trial evaluated the
opioid-sparing effect of ketorolac on children
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 VOL UME 2 5 • N U MBER 1 • JANUARY–M ARCH 2014
following general surgery.23 The authors found
a significant opioid-sparing effect for children
receiving concurrent ketorolac and morphine
particularly on postoperative day 1 along with
a reduction in adverse effects from morphine,
including nausea and vomiting and respiratory
depression. Few studies to date describe the
opioid-sparing effect of ketorolac for children,
and no studies were able to describe the opioid-
sparing effect for patients who had undergone
cardiac surgery.
Implications for Advanced
Practice Nurses
Pain management for children undergoing
cardiac surgery is a critical element of the
postoperative period. Adequate analgesia
reduces physiological and psychological stress
of infants and children. Use of ketorolac
for 24 to 72 hours postoperatively can reduce
breakthrough pain and the number of neces-
sary rescue medications.23 Reduction in
adverse effects of opioid medications
could also reduce the necessity of additional
medications such as stool softeners, laxatives,
antiemetics, and antihistamines. Finally,
decreased use in opioid medications may pre-
vent the need for opioid taper and adverse
effects of withdrawal.
For advanced practice nurses in the pediat-
ric cardiac intensive care unit, pain manage-
ment for patients following cardiac surgery
should be diligent and analgesic agents should
be selected thoughtfully. Although institutions
may have protocol-driven pain management
pathways, being familiar with the current
Table 3: Considerations in Dosing Ketorolac in Infants and Children
Dosing and Duration of
Therapy Monitoring Parameters
0.5 mg/kg IV every 6 h Hemoglobin, hematocrit,
24-48 h of therapy platelet count
Signs and symptoms of
Initiate therapy 6-24 h
surgical site bleeding,
postoperatively
chest tube output,
gastric bleeding
Serum creatinine, blood
urea nitrogen
Urine output
Abbreviations: IV, intravenous; NSAID, nonsteroidal anti-inflammatory drug.
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KE TOROLAC IN P OSTOP E RAT IVE CA RD IAC P E D IAT RICS
literature on a particular pain medication and
how it applies to a specific patient or patient
population is imperative. Knowledge of the
safety profile of ketorolac based on pediatric
specific evidence allows advanced practice
nurses to appropriately and safely select
ketorolac for certain patients and educate oth-
ers in regard to its use in this population.
Table 3 highlights some considerations for pro-
viders who are prescribing ketorolac and gives
dosing recommendations.26
Conclusion
The use of ketorolac as an adjunct for the
treatment of pain in pediatric patients follow-
ing cardiac surgery is currently a controversial
topic. Institutional standards vary considerably
in regard to pain management strategies and
protocols for this patient population. Current
literature supports the safe use of this medica-
tion at 0.5 mg/kg per dose IV every 6 hours for
48 hours following cardiac surgery. Little evi-
dence is available about the efficacy or safety
of a loading dose or dosing for longer than 48
hours in pediatrics. Ketorolac is contraindi-
cated in those with a history of renal failure;
taking concurrent nephrotoxic, NSAID, or
anticoagulation medications; with clinically
significant bleeding during or immediately fol-
lowing the surgery; or with a history of GI
bleeding. Not enough literature is available to
support safe use in patients younger than
28 days or with single-ventricle physiology.
Further studies need to be completed to assess
the risk factors associated with ketorolac in
these special populations.
Patient Selection Special Considerations
Infants older than 28 d Avoid in patients with
and children intracardiac catheters or
Biventricular physiology pacing wires with high
risk of bleeding in situ
Patients without immedi-
ate postoperative Initiation of H2-blocker
bleeding requiring Avoid in patients receiving
blood transfusion or other NSAIDs or forms
reoperation of anticoagulation
Patients without history
of renal failure or
receiving nephrotoxic
medications
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 JA LK UT
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