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Intravenous Ketorolac in the Emergency Department Management of Sickle Cell Pain and Predictors of Its Effectiveness
James L. Beiter, Jr, MD;
Harold K. Simon, MD;
C. Robert Chambliss, MD;
Thomas Adamkiewicz, MD;
Kevin Sullivan, PhD
Arch Pediatr Adolesc Med. 2001;155:496-500.
Objectives To evaluate the effectiveness of intravenous (IV) ketorolac tromethamine
in the treatment of children with sickle cell disease with moderate to severe
acute vaso-occlusive pain (VOP) and to develop a predictive model that would
determine who would need additional IV analgesics.
Design A prospective case series.
Setting The emergency department of an urban children's hospital in the southeastern
United States.
Patients A convenience sample of 51 children aged 6 to 18 years, representing
70 distinct episodes of VOP requiring IV analgesics.
Intervention All patients were given 0.5 to 1 mg/kg IV ketorolac and IV fluids.
Main Outcome Measures Patients, parents, nurses, and physicians assessed pain before and after
ketorolac using a standard 100-mm visual analog scale (VAS).
Results Of the 70 episodes of VOP, 37 (53%) adequately resolved with IV ketorolac
and IV fluids and required no IV opioids (group A). Thirty-one episodes (47%)
required the addition of an IV opioid (group B). Group B had a significantly
greater proportion of episodes reporting 4 or more painful sites than group
A, 43% (12/28) vs 9% (3/33), respectively (P<.01).
Group B also had significantly higher mean initial VAS scores than group A
as assessed by the patient (81 vs 60; P<.01),
parent (71 vs 54; P<.01), nurse (78 vs 51, P<.01), and physician (69 vs 53; P = .01). Of the patient assessments with an initial VAS score greater
than 70, 69% (18/26) required the addition of an opioid.
Conclusions First-line therapy with IV ketorolac and IV fluids resulted in adequate
resolution of pain in 53% of episodes with acute VOP. A reported 4 or more
painful sites and an initial VAS score greater than 70 were predictors of
the likelihood to need additional IV analgesics.
From the Department of Pediatrics (Drs Beiter, Simon, Chambliss, Adamkiewicz,
and Sullivan), the Division of Emergency Medicine (Drs Beiter and Simon),
the Division of Critical Care Medicine (Dr Chambliss), and the Division of
Hematology/Oncology (Dr Adamkiewicz), Hughes Spalding Children's Hospital,
Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston,
Atlanta, Ga.
Corresponding author: James L. Beiter, MD, 5643 Glenrich Dr, Atlanta,
GA 30388 (e-mail: jbeiterjr{at}aol.com).
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