Report of an anaphylactoid and an anaphylactic reaction to ketorolac in two pediatric surgical patients.

Ketorolac is a potent analgesic drug that has been restricted in dosage and use because of its potential adverse effects. The diagnostic and ethical challenges of 2 children who had unpredictable adverse drug reactions to ketorolac are reported. Case 1: A 3-year-old boy received ketorolac 1 mg/kg for prevention of postoperative pain at the end of an orthopedic surgical procedure. Ten minutes later, he had bilateral palpebral edema, erythema in thorax, hypotension, and tachycardia. The adverse event was classified as a mixed reaction probably related to ketorolac. Case 2: A 7-year-old girl, who had previously received ketorolac in 2 different surgical procedures, underwent a third orthopedic surgery. She received ketorolac 1 mg/kg as pre-emptive analgesia at 1.5 hours of anesthetic time (approximately 1 hour of surgical time). The patient developed palpebral edema 5 minutes later in addition to erythema in thorax, hypotension, tachycardia, tachypnea, oxygen desaturation, and wheezing. The adverse event was classified as a systemic reaction probably related to ketorolac. The 2 patients were successfully treated with symptomatic therapy. Although rare in its frequency, ketorolac administration may be associated to anaphylactic and anaphylactoid reactions in children with or without history of previous exposure. Because ketorolac is off-licensed for pediatric patients, it should be administered only after the risks and benefits have been discussed with the child's parents in the preanesthetic consultation.