Published online February 1, 2007
PEDIATRICS Vol. 119 No. 2 February 2007, pp. 421-422 (doi:10.1542/peds.2006-3249)
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LETTER TO THE EDITOR

Ketorolac and Renal Compromise in Neonates

Prabhakar Devavaram, MBBS
Department of Anesthesia
Children's Hospital Boston
Boston, MA 02115

To the Editor.—

I read the policy statement on prevention and management of pain in neonates with interest,1 and I would like to make a comment on the subsection "Reducing Pain From Surgery."

The role of ketorolac and nonsteroidal antiinflammatory drugs (NSAIDs) in treating postoperative pain was discussed but not recommended for use as an adjuvant. However, the possibility of renal failure with its use was not mentioned. Since its introduction in 1992, there have been many reports of renal failure. Postoperative ketorolac use in infants and neonates has been described.2,3 However, the risk of renal failure or insufficiency is not known. If the incidence of postoperative renal failure is assumed to be 1 in 1000 (0.1%), and we wish to know if ketorolac would double the risk, 63 000 patients would need to be recruited.4 Such studies have not been performed in neonates. Alternatively, if we were to compare an intermediate measure of renal function, such as creatinine clearance decrease, it would require ~300 patients.4 One area in neonates where NSAIDs have been used is in the treatment of closure of patent ductus arteriosus. A comparison of ibuprofen and indomethacin for closure of patent ductus arteriosus indicated oliguria as an adverse effect, occurring more in the indomethacin group.5 Renal blood flow depends on prostaglandins, especially during stressful periods (as in neonates in the postoperative course). Studies in premature neonates have shown that the glomerular filtration rate decreases in neonates with use of ibuprofen.6 With the evidence currently available, ketorolac and other NSAID use is associated with risk of renal compromise in the neonatal period.

REFERENCES

  1. American Academy of Pediatrics, Committee on Fetus and Newborn and Section on Surgery; Canadian Paediatric Society and Fetus and Newborn Committee. Prevention and management of pain in the neonate: an update. Pediatrics. 2006;118 :2231 –2241[Abstract/Free Full Text]
  2. Moffett BS, Wann TI, Carberry KE, Mott AR. Safety of ketorolac in neonates and infants after cardiac surgery. Paediatr Anaesth. 2006;16 :424 –428[CrossRef][Medline]
  3. Burd RS, Tobias JD. Ketorolac for pain management after abdominal surgical procedures in infants. South Med J. 2002;95 :331 –333[ISI][Medline]
  4. Myles PS, Power I. Does ketorolac cause postoperative renal failure: how do we assess the evidence? Br J Anaesth. 1998;80 :420 –421[Free Full Text]
  5. Van Overmeire B, Smets K, Lecoutere D, et al. A comparison of ibuprofen and indomethacin for closure of patent ductus arteriosus. N Engl J Med. 2000;343 :674 –681[Abstract/Free Full Text]
  6. Allegaert K, Cossey V, Debeer A, et al. The impact of ibuprofen on renal clearance in preterm infants is independent of gestational age. Pediatr Nephrol. 2005;20 :740 –743[CrossRef][ISI][Medline]
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics




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