Ketamine Infusion
Prescription and Observation Chart - adult
Education Slide Presentation
A presentation prepared by the
Pain Interest Group Nursing Issues
in association with the Agency of Clinical Innovation
Pain Management Network
Please direct comments to:
Emily Edmonds
Coordinator State Pain Forms
Pain Interest Group Nursing Issues
CNC Acute Pain Service Blacktown Hospital
Phone: 9881 7649
Email: emily.edmonds@swahs.health.nsw.gov.au
OR
March 21, 2013
Jenni Johnson
Manager
Pain Management Network
Agency for Clinical Innovation (ACI)
Phone: 9464 4636
Email: jenni.johnsons@aci.health.nsw.gov.au
Ketamine infusion
Prescription and observation- adult
The ketamine infusion prescription and observation chart for adult patients has been
developed by a team of experts in the field of acute pain including clinical nurse
consultants, anaesthetists and pharmacy representatives.
This chart has been designed for the administration of subcutaneous or intravenous
ketamine infusions for patients who may have acute or chronic pain. The chart may
not be appropriate for ketamine infusion administration in palliative care.
Standardisation of this chart promotes best practice in pain assessment and
management of adverse effects in those patients who are receiving a ketamine
infusion for pain management.
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Aim of this presentation:
This presentation aims to explain
 how to use the chart to record the prescription,
administration and discarding of ketamine as a
continuous infusion.
 how to complete the clinical observations.
 guidelines on the management of patients who are
receiving ketamine as a continuous infusion including
the management of adverse effects.
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Ketamine infusion
Prescription and observation chart - adult
-
Front page:
- Ketamine Infusion
Management Guidelines &
Clinical Review Criteria
Page 2 and Page 3:
Left side: prescription (valid for 4 days)
Right side: administration & discard
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Inside pages:
Observation space for up to
4 days
Prescription page:
Patient allergy status
and patient label
Ketamine prescription:
- Route
- Amount
- Additional drug & amount (if used)
- Diluent
- Total volume
- Concentration
- Infusion rate
- Infusion range (if used)
- Date, prescriber, pharmacy
Two revised
prescription options
for alterations to
ketamine prescription
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Prescription: Patient identification
Handwrite patient details
or affix patient label
Prescriber to complete
patient allergy and
ADR section in full
(First prescriber to check patient
label is correct)
Private patients:
require a
signature from
the referring
Doctor to the Pain
Service

The frequency of observations
(2 hourly or 4 hourly)
must be determined by the
medical officer
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Prescription is valid for a
maximum of 4 days unless
ceased earlier
Ketamine prescription:
Options: set rate OR infusion range
PLEASE REFER TO YOUR LOCAL HOSPITAL POLICY OR
PROCEDURE FOR PREFERRED KETAMINE DELIVERY OPTIONS
Ketamine
IV
4
4 mg
0.9% sodium
chloride
NIL
200 mg
1
15/04/13
TSmith
4
8
1
2
50mL
SMITH
Two further prescription boxes are provided for when alterations are indicated for the ketamine dose,
concentration or infusion rate.
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Administration and discard of ketamine:
15/04/13
16/04/13
10:00
20:00
Any ketamine remaining
from a syringe or bag
MUST be recorded on the
corresponding row from
its administration
15/04/13
17/04/13
20:00
NIL
09:00
5 mL
IF a ketamine syringe or bag is
empty when the next is
commenced,
document ‘NIL’ discarded
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There are 12 more rows
provided for more than
one syringe or bag of
ketamine that is
commenced
Clinical Review Criteria
and
Management Guidelines:
Clinical
Review
Criteria
Ketamine
Infusion
Management
Guidelines
Ketamine
infusion
cessation
prompt
(check local policy for use
of this prompt)
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Observations
The ketamine chart can provide
observations for a maximum of 4 days.
If the infusion continues beyond 4
days, a new chart must be started and
a new prescription written.
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A patient label must be
affixed or details written
on each page that has
recorded observations
01/03/2013
15/04/13
10 14 18
00 00 00
22
00
Pain assessment:
R = Rest
M = movement
02
00
(If a PCA chart is in use – record
pain score on the PCA chart)
M
R
M M
R R
M
R
M
R
Dysphoric adverse effects
assessment
(A score in the Yellow Zone requires a
Clinical Review by the pain service)





8
6 6
8 8
mg
mg mg mg mg
SH
KL
NH
SH
KL
NH
Infusion rate (in mg or mL)
Ketamine pump program check
Subcutaneous or IV site check
Comments for free text

SH SH
KL
/ SH KL
AT
Initial prompt
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The standardisation of this chart promotes best practice in
prescribing, pain assessment and management of adverse
effects in those patients receiving a ketamine infusion.
Comments or questions can be directed to your
implementation officer or the project leaders
Emily Edmonds or Jenni Johnson.
(contact details introduction slide)
The feedback register can be located on the ACI website:
http://www.aci.health.nsw.gov.au/networks/pain-management/acute-pain-forms
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