Kelowna General Hospital
Low Dose Ketamine Infusion
Self Learning Package
Self Learning Package Section Contents
Learning Objectives......................................................................................................... 3
Pharmacology of Ketamine ............................................ 4Error! Bookmark not defined.
Indications for Use................................................................................................................ 5-7
Short Term Side Effects…………………………………………………..............................5
Contraindications of Use………………………………………………………………………5
Benefits …………………………………………………………………………………………6
Risks, Adverse Effects, and Disadvantages…………………………………………………6
Nursing Responsibilities ................................................... 6-10Error! Bookmark not defined.
Summary ....................................................................................................................... 10
Post Test ....................................................................................................................... 11
References .................................................................................................................... 12
Answer Keys ................................................................................................................. 12
Self Learning Package Evaluation ................................................................................ 14
Low Dose Ketamine Infusion Self-Learning Package
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Learning Objectives
This Self-Learning Package has been developed to ensure that you have the
knowledge and skills necessary to care for a patient prescribed a low dose ketamine
infusion.
At the end of this Learning Package, you will:
1. Describe the pharmacology of ketamine.
2. State the most common effects of low dose ketamine.
3. Describe the benefits of low dose ketamine.
4. State potential risks and disadvantages of low dose ketamine.
5. Describe the nursing actions required when an adverse effect occurs.
6. Describe the indications for low dose ketamine use.
7. Describe the nursing responsibilities required for a patient on a low dose ketamine
infusion.
LEARNING INSTRUCTIONS
1. Read the learning objectives
2. Study the information contained in this Self-Learning Package
3. Complete the Post-Test
4. Check the answers to the Post-Test
5. Review the information as needed
Definitions and Abbreviations
Hyperalgesia: uncontrolled increasing pain
Dysphoria: disquiet, restlessless
PAR: Post Analgesic Recovery Room
MAR: Medication Administration Record
RN: Registered Nurse
POSS: Pasero Opioid Sedation Scale
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Pharmacology of Ketamine
Ketamine hydrocholoride is a white, crystalline powder that has a slight, characteristic
odour. In high doses, it is used as a potent anesthetic agent. However, prescribed and
administered in sub-anesthetic doses (2-30 mg/hour), ketamine can be used to
control acute and neuropathic pain. Patients receiving ketamine infusions also require
concomitant multimodal pain management strategies, such as epidural pain
management, systemic opioids such as PCA, NSAIDs, acetaminophen, and
antineuropathic drugs such as gabapentin and pregabalin.
If used pre-emptively, ketamine may block the development of hyperalgesia and is also
helpful in restoring opioid sensitivity in opioid tolerant patients.
Ketamine is rapidly absorbed following parenteral administration and has a rapid onset,
usually within 30 seconds with a duration of 5 to 10 minutes. Side effects commonly
seen at higher, anesthetic dose range are infrequent. However, euphoria, dysphoria,
illusions, vivid dreams, nightmares, and salivation may occur and require
discontinuation of the infusion or co-administration of protective agents such as
benzodiazepines (i.e. LORazepam). Ketamine preserves respiratory drive and selfprotective muscles; therefore respiratory depression is minimal. Ketamine is primarily
excreted in urine.
Refer to the ketamine monograph located in the Medication Manual (Parenteral Drugs)
for further information.
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Indications for Use of Low Dose Ketamine
Low dose (2 to 30 mg/hour) ketamine infusions are used to treat:

Hyperalgesia (uncontrolled increasing pain not responsive to opioids)

Incident pain associated with painful conditions such as multiple bone
metastases or from a painful procedure such as major abdominal surgery

Neuropathic pain
Short Term Side Effects
Potential side effects to watch for with an IV ketamine infusion include:
Tachycardia
Dysphoria (disquiet or restlessness)
Hypertension
Salivation
Nausea
Emergence phenomena which include the following:

Dysphoria

Vivid dreams

Excitement/agitation

Irrational behavior

Confusion

Hallucinations
However when low dose ketamine is used these potential side effects are infrequent.
The co-administration of protective agents such as benzodiazepines (i.e. LORazepam)
helps minimize and prevent side-effects.
Contraindications of Use
o Hypersensitivity to ketamine
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o Conditions where a significant elevation of blood pressure is hazardous (e.g.,
patients with poorly controlled hypertension, aneurysms, acute right- or left-sided
heart failure, angina, cerebral trauma, recent myocardial infarction)
o Pregnant women
Benefits of Low Dose Ketamine Infusion
Ketamine preserves respiratory drive and self-protective muscles; therefore respiratory
depression is minimal.
Risks and Disadvantages of Low Dose Ketamine Infusion
There are no antagonists to ketamine.
Ketamine is metabolised in the liver and hepatic clearance is required for termination of
clinical effects. Prolonged duration of action may occur in patients with cirrhosis or
other type of liver impairment; dose reductions should be considered in these patients.
Nursing Considerations
Adminstration of Low Dose Ketamine Infusion

Low dose ketamine infusions can be administered by Registered Nurses
knowledgeable in pharmacology, pain management, appropriate use of infusion
pumps, and who have successfully completed the Low Dose Ketamine Infusion
self-learning package

These infusions may be administered intravenously in Medical, Surgical,
Palliative Care, and Critical Care areas.

Acute Pain Service (APS) physician must manage ketamine infusions.

Ketamine is only administered as a continuous infusion using a Sigma IV
Pump. No boluses are to be administered.
o Pharmacy will supply ketamine in 1 mg/mL bags.
o The medication bag must be contained in a lock box on the IV pole
obtained from PAR.
o Programming is in mg/hr. Refer to dosing chart for rate of infusion.

Two RNs must perform an Independant Double Check to verify drug
concentration and infusion rate in mL/hr and co-sign the MAR at time of
initiation and any bag changes.
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


Prior to administration, review potential side effects with the patient and let
them know that you require them to report their level of pain so that we can
keep their discomfort at a level suitable to them.
Use pain scale (see below) to assess the patient during the infusion
Use POSS sedation scale (see below) to assess the patient during the
infusion
Monitoring the Patient with a Low Dose Ketamine Infusion
A) Baseline:
 Pulse, blood pressure, respiratory rate, sedation scale (see POSS below),
orientation to date-time-place-person, and pain scale (see below).
B)



Ongoing:
Q1H x 4 hours: BP, pulse, sedation scale, RR, pain score, then
Q4H and PRN: BP, pulse, sedation scale, RR, pain score
Monitor for potential side effects every 4 hours
NOTE: Notify Acute Pain Service if:
 Inadequate pain control (i.e. pain rating greater than patient’s desired comfort
level for 3 consecutive pain ratings)
 POSS Sedation Score = 3 or greater (see below)
 Respiratory rate less than 8/min
 Patient has dysphoria
If a patient experiences dysphoria, it may be treated by:
 Administering lose dose benzodiazepines (i.e. LORazepam)

Encouraging the patient to listen to music of their choice or engage in a pleasant
activity.
 Reassuring the patient that these side effects will subside.
Patient and Family Education:
1. Review the potential rare side effects of dysphasia, vivid dreams, salivation,
cardiac stimulation (tachycardia with the patient)\
2. Let the patient know that we need their help reporting their level of pain so that
we can try to keep their discomfort within his/her comfort zone.
Pasero Opioid-Induced Sedation Scale (POSS)
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Interior Health Pain Scale
Documentation

Medication Administration Record (MAR)

Graphic Clinical Record (801432)

Acute Pain Management Flow Sheet (809182)
- Document only on the “Patient Assessment” portion of the flow sheet
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Summary
CONGRATULATIONS
You have just completed the Low Dose Ketamine Infusion self learning module. If you
have any questions about indications for use, administration, or monitoring
requirements contact your Educator or pharmacy.
Now all that you now need to do is to complete the post test and the evaluation form.
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Post Test
1. When administering a low dose ketamine infusion, what are two potential side
effects?
2. Who can order a low dose ketamine infusion?
3. Which infusion device should be used to administer ketamine?
4. Name 3 situations when you would notify a physician regarding a patient
receiving a low dose ketamine infusion?
5. Name one indication for low dose ketamine?
6. What is a benefit of low dose ketamine infusion?
7. What sedation scale is used with patients on a low dose ketamine infusion?
8. What baseline monitoring parameters must be obtained prior to starting a
ketamine infusion?
9. Where can you find additional information on low dose ketamine infusions?
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References
1. Laskowski, K. (2011). A systematic review of intravenous ketamine for postoperative analgesia.
Canadian Journal of Anesthesia. Oct 58(10), 911-923.
2. Bell, R.F. (2006). Perioperative ketamine for acute postoperative pain. Cochrane Database of
Systematic Reviews. Jan 25 (1): CD004603.
3. Zakine, J. (2008). Postoperative ketamine administration decreases morphine consumption in major
abdominal surgery: a prospective, randomized, double-blind, controlled study. Anesthesia and
Analgesia. Jun 106(6), 1856-61.
4. Granot, R.; Day, R.O.; Cohen, M.L.; Murion, B.; & Garrick, R. (2007). Targeted pharmacotherapy of
evoked phenomena in neuropathic pain: a review of the current evidence. Pain Medicine, 6, 48-64.
6. Polomano, K.; Buckermaier, C.C. (3rd); Kwon, K.H.; Hanion, A. L.;Rupprecht,C.; Goldberg, C. &
Gallagher, R. M. Effects of low-dose IV ketamine on peripheral and central pain from major limb injuries
sustained in combat. Pain Medicine, 14 (7), 1088 to 1100.
7. Visser, E. & Schug, S.A. (2006). The role of ketamine in pain management. Biomedical and
Pharmacotherapy, 60(7),341-348.
8. Medication Manual (Parenteral Drugs)
Answer Keys
Post-Test Answer Key
1
Dysphoric symptoms (hallucinations, illusions, and unpleasant dreams)
tachycardia, hypertension, salivation, nausea
2
Anesthesiologist
3
Sigma Spectrum
4
- Inadequate pain control
- Sedation Score = 3 or greater
- Respiratory rate less than 8/min
Analgesic in refractory neuropathic pain, incident pain from a painful procedure or
hyperalgesia
5
6
Minimal respiratory depression
7
Pasero Opiod-Induced Sedation Scale (POSS)
8
Pulse, blood pressure, respiratory rate, sedation scale, orientation to date-timeplace-person, and pain scale
9
Medication Manual (Parenteral Drugs)
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Self Learning Package Evaluation
Your feedback is very important, so please fill out.
1. What did you like about the learning module?
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2. What did you not like about the learning module?
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3. In your opinion, what could be done to improve it?
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4. What was your overall impression of this learning module? (Circle only one)
Poor
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Excellent
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5. Do you have any further comments?
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Thank you for taking the time to complete this survey!
Please return to Staff Development Education
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