Pain management in fulminating ulcerative colitis

BACKGROUND: Toxic megacolon is a life-threatening complication of ulcerative colitis (UC) characterized by systemic toxicity, loss of blood per rectum and severe pain. Pain management is challenging in these patients because nonsteroidal anti-inflammatory drugs may exacerbate bleeding and opioids are contraindicated because they adversely affect bowel peristalsis causing an increased risk of colonic perforation. METHODS: We describe three episodes of fulminating UC in two children in whom ketamine analgesia was used. Our protocol for a low-dose continuous ketamine infusion with either nurse-controlled analgesia (NCA) or patient-controlled analgesia (PCA) bolus administration is presented and a review of the literature regarding the use of ketamine analgesia in children is discussed. RESULTS: Low-dose ketamine N/PCA with a continuous background infusion provided satisfactory analgesia and none of our children reported adverse effects. CONCLUSIONS: We have demonstrated the safe and effective use of ketamine analgesia in children with toxic megacolon, a condition in which the child is in severe pain and morphine is contraindicated.