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368 Sickle cell crisis
One potentially useful advantage to ketorolac (or any other NSAID) would
be if its administration had an opioid-sparing effect. The question has been
assessed in studies, which gave mixed results. A pediatric RCT of ketorolac
(0.9 mg/kg IV) versus placebo for adjunctive analgesia (to morphine) found
no ketorolac-associated benefit in total opioid dose, reduction in pain
severity, rate of hospitalization, or (for discharged patients) rate of return to
the ED. 21 Two studies in adults report opposite findings. A trial with limited
applicability to current ED practice suggested that ketorolac may provide
clinical synergism with IM meperidine (pethidine). 22 A more methodologically
rigorous ED RCT found no opioid-sparing effect associated with IM
ketorolac. 23 Consensus reviews tend to conclude that there is some opioidsparing
effect from ketorolac, and that the injectable NSAIDs have a role in
the initial therapy of VOC. 13,14 The reviews are consistent in their recommendations
that ketorolac be used for no more than three to five days in a
given episode of VOC. 13
Like other NSAIDs, ketorolac is not without risk in VOC. The patient may be
at increased risk for NSAID-associated effects on renal blood flow and platelet
function. 12 Close attention to renal function should accompany ketorolac use
in VOC patients, but the NSAID side effects do not preclude occasional utility
of this class in VOC – especially when therapy is limited to a few initial doses
to help to get pain under control. 24
OPIOIDS
Although the NSAIDs may be occasionally used as monotherapy, and may
have some efficacy as adjuvant therapy, the cornerstone of VOC treatment in
the ED is opioids. Administered by a variety of methods, opioids can safely
and effectively relieve VOC pain. As is the case with many chronic disease
states, there are inevitable issues with respect to opioid dependency. The role
of the acute care provider is to act within the patient’s longitudinal care plan,
coordinating opioid care with outpatient providers where possible. However,
the prime goal of the ED provider remains relief of the patient’s pain using
whatever means are possible; physicians should err on the side of opioid
administration when other choices are unavailable.