South Western Sydney Local Health District
Policy No: SWSLHD_GL2014_007
Date Issued:
Guideline: Critical Care
Ketamine
Document Number:
SWSLHD_GL2014_007
Functional Sub-Group:
Clinical
Summary:
This guideline has been developed to ensure
Approved by:
Clinical Quality Council
Publication (Issue) Date:
July 2014
Next Review Date:
July 2017
standardized preparation and administration of ketamine
throughout the SWSLHD.
Replaces Existing Guideline: No
Previous Review Dates:
Guideline SWSLHD_GL2014_007
None
Ketamine
Page 1 of 10
South Western Sydney Local Health District
Policy No: SWSLHD_GL2014_007
Date Issued:
Contents:
1. Introduction
2. Aims/Expected Outcomes
3. Principles
4. References and Links
Appendices
Appendix 1 – Richmond Agitation-Sedation Score
Appendix 2 – Pain Assessment
Guideline SWSLHD_GL2014_007
Ketamine
Page 2 of 10
South Western Sydney Local Health District
1.
Policy No: SWSLHD_GL2014_007
Date Issued:
Introduction:
Ketamine is a rapid acting (non-barbiturate) anaesthetic agent that also produces good
analgesic effects.
The risk addressed by this policy:
Patient Safety
2. The Aims / Expected Outcome of this policy:
Ketamine will be administered safely and without adverse side effects.
.
Related Standards or Legislation
NSQHS Standard 1 Governance
National Standard 4 Medication Safety
Related Policies (if relevant)
PD2013_043 Medication Handling in NSW Public Hospitals
http://www0.health.nsw.gov.au/policies/pd/2013/pdf/PD2013_043.pdf
3. Principles











All care provided within SWSLHD will be in accordance with infection control, manual
handling and minimisation and management of aggression guidelines.
Medications are to be prescribed and signed by a medical officer/authorised nurse
practitioner (NP) unless required during an emergency.
All drugs administered during an emergency (under the direction of a medical
officer/authorised nurse practitioner) are to be documented during the event, then
prescribed and signed following the event.
Medications are to be given at the time prescribed (as close to the time as is possible
when multiple drugs require ‘same time’ administration and, when the nurse is caring
for more than one patient, recognition is given to a possible short delay to
administration – antibiotics and other lifesaving drugs are to be prioritised) and are to
be signed by the administering nurse.
Parenteral medication prescriptions and the drug are to be checked with a second
registered or endorsed enrolled nurse prior to administration. The “rights of drug
administration” must be followed: right: patient, drug, dose, route, administration, time,
reason for the drug and documentation.
Adverse drug reactions are to be documented and reported to a medical officer.
Medication errors are to be reported using the hospital electronic reporting system:
IIMS.
Guidelines are for adult patients unless otherwise stated.
Ketamine is a Schedule 8 drug, requiring storage and administration as per the Poisons
Act 1994.
All patients receiving a ketamine infusion must have a pain score and sedation score
attended and documented.
This guideline is for administration of drugs in critical care areas only.
Actions1,2,3
 Ketamine produces dissociative anaesthesia due to dissociation between the cortical
and limbic system. It is an NMDA receptor antagonist
Guideline SWSLHD_GL2014_007
Ketamine
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South Western Sydney Local Health District


Policy No: SWSLHD_GL2014_007
Date Issued:
It interacts with opioid receptors and produces good analgesic effects at subanaesthetic
doses.
It is a rapid acting (non-barbiturate) anaesthetic, characterised by profound analgesia,
normal pharyngeal /laryngeal reflexes, normal or slightly enhanced skeletal muscle
tone, cardiovascular and respiratory stimulation and occasionally a transient and
minimal respiratory depression.
Indications1,2,3
Use for acute pain:
 In subanaesthetic doses it can be used to control acute pain. It is used as an adjunctive
agent along with other analgesic / sedation agents.
 In persistent pain, it can be effective when given in short bursts of 3 to 5 days, then
ceased and recommenced if pain returns or increases.
Use for procedural sedation:
 It can be used as an anaesthetic agent for diagnostic and surgical procedures, where
cardiovascular stability is crucial.
 In patients with severe asthma it is used as an anaesthetic agent for endotracheal
intubation, in view of its bronchodilation properties.
Contraindications1,2,3
Ketamine should be avoided in patients the following conditions:
 Severe hypertension and tachycardia.
 Acute stroke, intracranial haemorrhage or mass
 Acute myocardial infarction, acute coronary syndrome, stenotic valve disease,
tachyarrhythmias.
 Hyperthyroidism
 Raised intraocular pressure, including penetrating eye injuries.
 History of hallucinations.
Precautions1,2,3
Use with caution in patients with the following conditions:
 Seizure disorders, cerebral trauma, raised intracranial pressure, intracranial metastases
or history of cerebrovascular accident.
 Ischemic heart disease, hypertension, cardiovascular disease.
 Impaired renal and hepatic function.
 Use with caution in patients with hypotension, myocardial depression and in those
patients who are septic or in hypovolemic shock.
Significant Interactions1,2,3
 Concomitant use of antihypertensive agents and ketamine increases the risk of
hypotension.
 When administered rapidly in high doses along with halogenated anaesthetics it can
potentiate bradycardia, hypotension and decreased cardiac output.
 When ketamine is administered to patients who are taking thyroxine, they are at
increased risk of developing hypertension and tachycardia..
 Ketamine can potentiate the neuromuscular blocking effects of any muscle relaxant.
 Barbituates and ketamine are chemically incompatible and should not be administered
in the same line.
Adverse Effects1,2,3
 Hallucinations, nightmares, confusion, delirium (benzodiazepines can be used to treat
these adverse effects).
 Tachycardia, hypertension and increased intracranial pressure.
 Severe depression of the respiratory system or apnoea may occur following
intravenous administration of high doses.
 Reduction of seizure threshold.
Guideline SWSLHD_GL2014_007
Ketamine
Page 4 of 10
South Western Sydney Local Health District
Policy No: SWSLHD_GL2014_007
Date Issued:
Presentation1,2,3
 200mg /2ml vial
Administration Guidelines1,4
Dose for procedural sedation

0.5 to 2mg/kg administered as IV bolus, produces anaesthesia in 30seconds
and lasts 5-10minutes.
IVI Infusion dose for analgesia
• Dilute 200mg vial of ketamine with sterile 0.9% sodium chloride in a syringe, to
give a total volume of 50mL . 200mg/50ml = final concentration of 4mg/mL.

Infusion rate = 5 to 20mcg/kg/min
Example for 70kg patient: (Infusion concentration 4mg/ml)
5mcg/kg/min = 350mcg/min
= 21,000mcg/hr
= 21mg/hr
Rate of infusion = 5.25ml/hr
20mcg/kg/min
= 1400mcg/min
= 84000mcg/hr
= 84mg/hr
Rate of infusion = 21ml/hr
Clinical Considerations1,3,5,7
 Assess and document pain scores and sedation scores 2nd hourly on the ED / ICU flow
chart. The desired RASS sedation score should be documented on the flow chart.
 Daily sedation vacations or interruption of analgesia / sedation should occur to allow for
neurological assessment.
 Monitor patients heart rate and blood pressure as hypertension and tachyarrhythmias
can occur.
 Monitor respiratory function for signs of respiratory depression, apnoea or
laryngospasm.
 Monitor for spontaneous limb movements, which can be treated with benzodiazepines.
 Dose of the infusion should be titrated to desired sedation and analgesia effect on the
patient.
 Benzodiazepines may need to be used to treat the delirium and hallucinations that are
side effects of ketamine administration.
5. References and links
1.
2.
3.
4.
5.
6.
7.
8.
MIMS Online, CIAP: NSW Health Department, Copyright MIMS Australia Pty Ltd. August 2012.
http://www.use.hcn.com.au
The Society of Hospital Pharmacists of Australia 2011, The Australian Injectable Drugs
th
Handbook, 5 Edition, SHPA publications, Australia.
eTherapeutic Guidelines: CIAP 2012, http://www.tg.org.au/
th
Thomas Reuters, Micromedex 2.0, http://www.micromedex.com/, viewed 27 August 2012.
Young J, Siffleet j, Nikoletti S and Shaw T. 2006. Use of a Behavioral Pain Scale to assess pain
in ventilated, unconscious and/or sedated patients. Intensive & Critical Care Nursing. 22(1)32-39.
Ashley E and Given J. 2008. Pain management in the critically ill. Critical Illness 18(11):504-509.
Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, Tesoro EP and Elswick
RK. 2002. The Richmond agitation-sedation scale. Validity and reliability in adult intensive care
unit patients. American Journal of Respiratory and Critical Care Medicine 166:1338-1344.
Liverpool Hospital Intensive Care Unit Guidelines. 2013. Ketamine, SWSLHD
Guideline SWSLHD_GL2014_007
Ketamine
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South Western Sydney Local Health District
Author:
Reviewers:
Policy No: SWSLHD_GL2014_007
Date Issued:
Clinical Nurse Consultant, ICU, Liverpool Hospital, SWSAHS, LHD
(Sharon-Ann Shunker).
Grant Isedale (Clinical Manager, Critical Care & Surgical Specialties SWSLHD),
SWSLHD Drug Advisory Committee
Bankstown ICU: Grant Bennet (ICU Director), Ruth Tabvuma (NUM), Kathleen
Brennan (NP).
Bankstown ED: Matthew Smith (ED Director), (NUM), Jenny Morris (CNC), Angela
Duncan (CNE)
Bowral ICU: William Quinn & Simon Grant (Physicians), Gail Hanger (NUM),
Elizabeth Longhurst (CNE).
Bowral ED: Matthew Bragg (ED Director), Daryn Mitford (NUM), Maie Pikkat
(CNE).
Campbelltown ICU: Gillian Bishop (ICU Director), Bruce Nicholson (NUM), David
Sanchez (CNC), Steve Goodall (CNE).
Campbelltown ED: Sellappa Prahalath (ED Director), Stewart Watkins (Deputy
Director), Kelly-Ann Paddock (NUM), Ron Wilson (CNC), Ray Morgan (CNC), Ann
Dillon (CNC).
Fairfield ICU: Jyotsna Dwivedi (ICU Director), Belinda Lloyd (NUM), Jane Gibson
(CNE).
Fairfield ED: Harry Doan (ED Director), Belinda Pellizzon (NUM), Glenda Austin
(CNC), Deborah Raymond (CNC).
Liverpool ICU: Michael Parr (ICU Director), Linda Williams (NM), Sharon Shunker
(CNC), Paula Nekic (CNE), Karla Lopez (CNE), Tony Bogdanovski (CNE).
Liverpool ED: Ian Ferguson (ED Director), Penny Weir (Deputy Director), Lyndal
Marlow (NM), Carlie Tighe (CNC), Kathryn Spears (CNE), Amanda Hawkins (CNE).
Pharmacicts: Madeline Eves, Eugenia Fiakos, Shivon Singh, Sue-Ellen Brown,
Guideline SWSLHD_GL2014_007
Ketamine
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South Western Sydney Local Health District
Policy No: SWSLHD_GL2014_007
Date Issued:
APPENDIX 1: Richmond Agitation-Sedation Score
Instructions
 Obtain a sedation score goal at handover/ward round; document this in the health
care record.
 Assess a sedation score every 2-4 hours and as clinically indicated. Conduct a
sedation score even if there is no apparent drug in use that would contribute to
sedation.
 A ‘sedation – vacation’ from sedative drugs must be prescribed when the sedation
score is deemed ‘moderate sedation: ‘- 3’, and this degree of sedation is not the
goal of therapy.
Assessment
The use of a sedative aims to:
 Enable the patient to cooperate with ventilation and treatments, and
 Produce a desired amnesia to the Intensive Care environment.
 Document which drugs the patient is taking to produce a sedative effect
Richmond Agitation-Sedation Score (RASS)
Score
7
Term
Description
+4
Combative
Overtly combative, violent, immediate danger to self, staff,
others
-
+3
Very agitated
Pulls or removes tube(s) or catheter(s); aggressive
-
+2
Agitated
Frequent non-purposeful movement, fights ventilator
-
+1
Restless
Anxious but movements are not aggressive/vigorous
-
0
Alert and calm
-
-1
Drowsy
Not fully alert, has sustained awakening (eye-opening/eye
contact) to voice (≥ 10 seconds)
Verbal
-2
Light sedation
Briefly awakens with eye contact to voice (< 10 seconds)
Verbal
-3
Moderate sedation
Movement or eye opening to voice (but no eye contact)
Verbal
-4
Deep sedation
No response to voice but movement or eye opening to physical
stimulation
Physical
-5
Unrousable
No response to voice or physical stimulation
Physical
Procedure
• Observe patient

Patient is alert, restless or agitated
•
Stimulus
(score 0 to + 4 )
If not alert, state patient’s name and say to open eyes and look at speaker

Patient awakens with sustained eye opening and eye contact
(score – 1 )

Patient awakens with eye opening and eye contact, but not sustained (score – 2 )

Patient has any movement in response to voice but no eye contact (score – 3 )
When no response to verbal stimulation, physically stimulate the patient by shaking
shoulder and / or using the trapezius pinch or applying supra-orbital pressure, as
appropriate

Patient has any movement to physical stimulation
(score – 4 )

Patient has no response to any stimulation
(score – 5 )
Guideline SWSLHD_GL2014_007
Ketamine
Page 7 of 10
South Western Sydney Local Health District
Policy No: SWSLHD_GL2014_007
Date Issued:
APPENDIX 2: Pain Assessment
Aw ake an d respon sive:
Use "Faces Pain Scale - Revised" 5 adapted for ICU - get the patient to point to the face
that matches their pain level or ask the patient: 0 = none, 10 = worst pain.
0
0
2
4
6
8
10
2
4
6
8
10
No pain
Mild pain, discomfort only with moving
Continuous mild pain
Continuous moderate pain
Continuous severe pain
Excruciating pain
Assess for pain at least every 4 hours:
•
•
•
•
•
If pain score < 4, consider analgesia effective, reassess frequently as ongoing analgesia may
need to continue.
If pain score  4, increase analgesia to relieve pain
Maintain prescribed sedation score, report any issues to the M.O. and document.
Document score on the flowchart.
If the patient has no pain and they are able to cough easily, deep breathe and move easily,
the ongoing need for analgesia is assessed.
Patients who are sedated, mechanically ventilated and unresponsive
Use the “Behavioural Pain Scale”7 or the Critical-Care Pain Observation Tool (CPOT)10
Behavioural Pain Scale
ITEM
Facial Expression
Behavioural Pain Scale
DESCRIPTION
Relaxed
Partially tightened (eg, brow lowering)
Fully tightened (eg, eyelid closing)
Grimacing
SCORE
1
2
3
4
Upper Limb Movements
No movement
Partially bent
Fully bent with finger flexion
Permanently retracted
1
2
3
4
Compliance with
mechanical ventilation
Tolerating movement
1
Coughing but tolerating ventilation for
most of the time
Fighting ventilator
Unable to control ventilation
TOTAL SCORE
Score ranges from 3 (no pain) to 12 (maximum pain).
Guideline SWSLHD_GL2014_007
2
3
4
3 TO 12
Ketamine
Page 8 of 10
South Western Sydney Local Health District
Policy No: SWSLHD_GL2014_007
Date Issued:
11
The Critical-Care Pain Observation Tool (CPOT) .
Directives of use of the CPOT
1. The patient must be observed at rest for one minute to obtain a baseline value of the CPOT.
2. Then, the patient should be observed during nociceptive procedures (e.g. turning, wound
care) to detect any changes in the patient’s behaviours to pain.
3. The patient should be evaluated before and at the peak effect of an analgesic agent to
assess whether the treatment was effective or not in relieving pain.
4. For the rating of the CPOT, the patient should be attributed the highest score observed
during the observation period.
5. The patient should be attributed a score for each behaviour included in the CPOT and
muscle tension should be evaluated last, especially when the patient is at rest because the
stimulation of touch alone (when performing passive flexion and extension of the arm) may
lead to behavioural reactions.
Observation of patient at rest (baseline).
The nurse looks at the patient’s face and body to note any visible reactions for an observation period
of one minute. She gives a score for all items except for muscle tension. At the end of the oneminute period, the nurse holds the patient’s arm in both hands – one at the elbow, and uses the
other one to hold the patient’s hand. Then, she performs a passive flexion and extension of the
upper limb, and feels any resistance the patient may exhibit. If the movements are performed easily,
the patient is found to be relaxed with no resistance (score 0). If the movements can still be
performed but with more strength, then it is concluded that the patient is showing resistance to
movements (score 1). Finally, if the nurse cannot complete the movements, strong resistance is felt
(score 2). This can be observed in patients who are spastic.
Observation of patient during turning.
Even during the turning procedure, the nurse can still assess the patient’s pain. While she is turning
the patient on one side, she looks at the patient’s face to note any reactions such as frowning or
grimacing. These reactions may be brief or can last longer. The nurse also looks out for body
movements. For instance, she looks for protective movements like the patient trying to reach or
touching the pain site (e.g. surgical incision, injury site). In the mechanically ventilated patient, she
pays attention to alarms and if they stop spontaneously or require that she intervenes (e.g.
reassurance, administering medication). According to muscle tension, the nurse can feel if the
patient is resisting to the movement or not. A score 2 is given when the patient is resisting against
the movement and attempts to get on his/her back.
Guideline SWSLHD_GL2014_007
Ketamine
Page 9 of 10
South Western Sydney Local Health District
Policy No: SWSLHD_GL2014_007
Date Issued:
Th~ C ritica l-C a1·~
Pain
Obs~l'Yation
T ool (CPOT)
(Gelinas et a!. 2006)
Indicator
Score
F ~ti:. l upre s~ioo
·-·~-·.......
·--
-"<·
~·
'
-
-· . ' ·-;:: :::i-. ~
.;;
--
.
..
Reb ..xed . neun"ll
0
No mu~d e ten -:.1on ob-:.elYed
Ten -;.e
1
Pre!.ence of frownlllg. brow lowering. orbit
tightening and ~entor c onn-action
~
·- '
e ye~
or m y other chl.nge (e.g. operung
aWing nocicepnn procea.W·e-:.)
...
~ :::::
..r r...:"'
~;·r•
Demiplion
or tu n ng
GrirnlCUlf
2
All previou-:. fac1aJ monme.nt-:. phl-:. eye!id tight!y
do-:..e-d {the parient may pre~e.nt w1th mouth open or
b1ting the e.ndorncheal rube)
Ab<:.ence of moYe.men.r..
or no1m1l po:.ition
0
D oe~ not mon .u all (doe~n ' t nece~:..uily mean
.tb:.ence o f pain) or normal po:.-irion (movement:.
'
CJJ·oline Albow·. &'I. B.Sc ..
PbD(~nt)
S.cbool of Nu.">inf. ).{cG111 Ulli\'m iry
Bod y m oH mto ts
not :umed toward the p:un <:.i te or not uude for the
pwJ>O:.e o f protection)
Protecnon
1
Slow. cautiotu movemem:.. touching or JUbbing the
pl in ~ite . -:.eekmg lttennon tluough
Complbnc e "ith the nnribtor
(in tuba te-d p :u ien ts)
monment~
Re-.-t~e~e~~'A pu tion
2
Pulling rube. l nempnng to '.·it up . mot-ing
limb1./th:ra':.b.U1g. not follou-ing coll.Ulll.llcb. -.mkUlg
l t :.tlff. O) -ing to d unb out of bed
To1enting ventil.uor or
movement
0
Abnn~
Coughing 'but tolenriD;
1
Coughw.g, .3lanw· may be .tctin ttd bu1~top
not a ctin ted. u-.~· n nrih non
-..pontm eou -:.ly
Fighnng ventih tor
2
A!.~1lchron y:
bloc.kUlg ventihrion. l hrm-.
frequ ently acrinted
OR
\ 'oc-a liutioo (u rub :u e-d p, rin u )
~ ~ u ~ d• teo ~ iou
Talking in norml 1 tone
Talking Ul normal tone or no -..ound
or no ~ound
0
S1ghing. moming
1
Sighing. m o.ming
CJ}-ing out. -.obbing
2
Crying out. -..obbmg
Reb .xed
.
0
No re~ i-:.o.nce to pl ~~lYe m ovement~
1
Re~i.,.t lnce
2
Strong r e!.l'.-tl.llc e to pa -:.~i ve moYem ent!. or
inc lplcity to comp lete them
En hu .non by pl ~'.·lYe flexton l.lld Ten -:.e. rigid
e:tten~ion of upper limb~ when plrient
1~ l t r e!.t or en l ulnon when pl rient 1~ Very ten:.e or npd
beUlg turned
TOTAL
to pa-:.:.iYe movement~
-- 18
Assess Pain Scale every 4 hours. Self-reporting of pain should be used whenever appropriate.
Patient is in significant pain if BPS > 5; CPOT > 3
Guideline SWSLHD_GL2014_007
Ketamine
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