Ketorolac use in the emergency department in children: a systematic review and meta-analysis

Acute pain is a frequent reason for pediatric patients visiting the emergency department (ED). Non-steroidal anti-inflammatory drugs (NSAIDs) and opioids are often used to manage pain in this setting. This systematic review and meta-analysis evaluates the effectiveness of ketorolac, a NSAIDs, in managing acute pain in children in the ED, comparing its efficacy and potential advantages over other pain management options. The search was conducted in PubMed and Web of Science, for English-language articles published from 1991 to February 2023. Only randomized controlled trials (RCTs) evaluating the analgesic effect of ketorolac in commonly painful conditions such as migraine, traumatic and non-traumatic musculoskeletal pain, abdominal pain, and renal colic treated in the ED were included. Pediatric studies were specifically selected. A meta-analysis was subsequently conducted to compare efficacy of ketorolac with other analgesic medications. Eight RCTs have investigated the efficacy of ketorolac for acute pain in children in the ED, reflecting limited pediatric evidence. Ketorolac showed variable effectiveness for conditions such as migraine, musculoskeletal trauma, acute abdominal pain, renal colic, and vaso-occlusive crisis in sickle cell disease. The meta-analysis revealed no significant differences in analgesic performance between ketorolac and other drugs, including opioids and other NSAIDs. The risk of bias across the studies was evaluated. However, the evidence remains insufficient to confidently recommend a specific intervention, highlighting the need for further research to guide clinical decision-making.Conclusion: Despite its limitations, the systematic review highlights that ketorolac seems effective for managing acute pain in pediatric ED patients, but not superior to other analgesic drugs. It emphasizes the necessity for further research to define optimal dosing, administration methods, and its comparative effectiveness with other analgesics across various clinical scenarios.