CLINICAL GUIDELINE FOR NURSING CARE OF PATIENT WITH
INTRAVENOUS KETAMINE INFUSION
1. Aim/Purpose of this Guideline
1.1. Nursing Guidelines for the safe administration of Intravenous Ketamine
Infusion
2. The Guidance
2.1. Definition
2.2. Ketamine is an anaesthetic agent with analgesic properties.
2.3. A low dose Ketamine infusion provides safe and effective analgesia.
2.4. Ketamine may be used as a separate infusion alongside other opioids
[morphine,fentanyl] to improve pain relief.
2.5. A low dose Ketamine infusion may cause some sedation. However,
respiratory depression is minimal and severe dysphoria or hallucinations are
uncommon.
2.6. Professional responsibility

A Ketamine infusion must only be prescribed on the advice of an anaesthetist or
Pain Team.

The infusion must only be set up and changed within the prescribed limits by a
Registered Nurse competent in the administration of IV drugs and the use of
Mckinley pumps.

Prescriptions may only be altered by an anaesthetist or Pain Team.

Only an anaesthetist may deliver a Ketamine bolus.

Ketamine must be ordered from pharmacy on a named patient order form.

Ketamine is a controlled drug, recorded and stored in the controlled drug
cupboard as per RCHT guidelines.

Competent staff need to maintain their competency and attend a mandatory pump
update and practical sessions 3 yearly.
2.7. Indications for use


Where pain is inadequately controlled by opioids alone.
When opioid tolerance has developed; i.e. patient requiring increasing doses of
opioids.
Intravenous Ketamine Infusion: Nursing Guidelines
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2.8. Contraindications
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

Patient not consenting.
Previous adverse effects to Ketamine.
Patients who have unstable heart disease, psychosis or raised intracranial
pressure.
Severe hypertension
Allergy
Raised intraocular pressure
Known ischemic heart disease
2.9. Equipment








Only designated Mckinley infusion pumps 595 [Grey Front] labelled Specialist
Analgesia in red and dedicated clear BodyGuard microset anti siphon infusion
lines must be used.
A Mckinley 595 ‘Specialist Analgesia’ pump and dedicated clear BodyGuard
microset anti siphon infusion line can be located from general recovery.
Lines should be changed after 48hrs.
The asset number on the Ketamine/Specialist Analgesia pump must be recorded
on pink acute pain form in recovery or Pain Services must be informed
of the commencement of infusion as to ensure timely review.
The infusion bag must be labelled with a; ‘Drugs added to this infusion’ label.
The Ketamine infusion line must be clearly labelled.
A dedicated venous line should be used.
Care of IV cannula as per RCHT guidelines.
2.10. PROTOCOLS





Ketamine should be prescribed as: 500mg Ketamine in 100ml saline to give
a concentration of 5mg per ml at a rate of 1- 5ml/hr (see below).
Protocol A must be used on the pump.
If weight >50kg the infusion rate should not be increased more frequently than
hourly and should never exceed 5ml/25mg per hour.
If weight<50kg the infusion rate should not be increased more frequently than
hourly and should never exceed 3ml/15mg per hour.
Infusions should be commenced at 1ml per hour (5mg/hr) and titrated to effect
(see above for maximal infusion rates) or until side effects are experienced.
2.11. Monitoring and Management

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Patient should be nursed in an area where there is adequate monitoring and
competent staff.
Patients should remain on prescribed oxygen.
Naloxone must be prescribed see below or on RCHT Analgesia assessment
chart.
Patients may mobilise.
Ketamine Mckinley 595 pump keys should be kept with the controlled drug keys.
Review the need for the Ketamine infusion daily.
Regular paracetamol and NSAIDs [unless contra- indicated] should continue.
Intravenous Ketamine Infusion: Nursing Guidelines
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

Pain scores and observations must be recorded on RCHT NEWS charts and
Analgesic Assessment Chart.
Adequate alternative analgesia must be available prior to discontinuing infusion.
2.12. Observation Frequency
st
Monitoring
parameter
Respiratory Rate
1
hour
Every 15 mins
Following 2
hours
Every 30 mins
Blood Pressure
Every 15 mins
Every 30 mins
Heart Rate/Sats
Every 15 mins
Every 30 mins
Pain score at rest
Every 15 mins
Every 30 mins
Pain score on
movement
Every 15 mins
Every 30 mins
Sedation
Dysphoria and
Hallucinations
Every 15 mins
Every 30 mins
thereafter
Hrly for 24 hrs,
then 2hrly until
cessation
Hrly for 12 hrs if
stable then 2hrly
until cessation
Hrly for 12 hrs
then 2hrlyif
stable until
cessation
Hrly for 24 hrs
then 2hrly until
cessation
Hrly for 24 hrs
then 2hrly until
cessation
Hrly for 24 hrs
then 2hrly until
cessation
2.13. Infusion Monitoring
2.14.Ketamine infusion rate recorded on RCHT Analgesia assessment chart. Drug
wastage to be recorded in the ward wastage book as per hospital guidelines.
2.15.Drug to be disposed of in a denaturing kit.
2.16. TREATMENT OF PROBLEMS
2.17.Blood Pressure
2.18.Ketamine stimulates the cardiovascular system, so usually causes a rise in
blood pressure.
2.19.If systolic BP < 90mmHg seek medical assistance.
2.20.Exclude haemorrhage, sepsis, acute cardiopulmonary event.
2.21.Give colloid 250ml over 15 minutes.
2.22.If BP < 90 mmHg persist call the Acute Pain Team / Anaesthetist on
call/Critical Care Outreach.
Intravenous Ketamine Infusion: Nursing Guidelines
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2.23.Respiration
2.24.Low dose Ketamine does not usually depress respiration. If respirations < 8
breaths a minute and sedation score 3, stop infusion.
2.25.Give 100% oxygen via reservoir mask whilst waiting for medical review.
Consider giving Naloxone.
2.26.If respiratory rate <5 and sedation score 3, give Naloxone. Naloxone should
be given in increments of 100mcg every 5 minutes.
2.27.Seek urgent medical assistance.
2.28.Sedation
2.29.If sedation score of 3, stop Ketamine infusion and seek medical assistance. If
opioid is used as well as Ketamine, consider giving Naloxone. See NEWS chart.
2.30.Call the Acute Pain Team / Anaesthetist on call urgently.
2.31.If mild; stop Ketamine infusion.
2.32.If severe; stop ketamine infusion and call Acute Pain Team / Anaesthetist
on call.
2.33.Nausea
2.34.Give regular anti-emetics.
2.35.If persistent nausea and vomiting after 2 anti-emetics, seek medical review
and consider addition of dexamethasone.
2.36.Avoid the use of neuroleptic drugs such as droperidol or chlorpromazine.
2.37.If persistent despite anti-emetics, stop infusion or decrease rate and
review.
2.38.Support Mechanisms.


Pain Services Mon-Fri 8.30pm-4.30pm. Pain Specialist Nurses on Bleep 2613.
Out of hours; 4th on call anaesthetist via switchboard.
3. Monitoring compliance and effectiveness
Element to be
monitored
Lead
Tool
All elements
Pain Service
1. RCHT National Early Warning System [NEWS], Clinical
Observations, pain scoring. Analgesic Assessment Chart
2. Training/records. Medical Devices Training form MD07
3. Trust Patient Experience Survey
Intravenous Ketamine Infusion: Nursing Guidelines
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Frequency
1. Monitor each infusion individually.
Complete and share report findings as necessary depending
on each individual outcome.
2. 3 yearly updates via Pain Services and Medical Devices
training.
Medical Devices compile rolling records on training
3. RCHT Patient Experience Survey Repeated by RCHT.
Pain Service notified on, in- patient pain experience from
results and acts accordingly.
4. Monitor each infusion individually.
Complete and share report findings as necessary depending
on each individual outcome.
Pain Services acute pain meetings.
Datix
Acting on
Document recommendations made, acted on and amended within
recommendations a specific time frame.
and Lead(s)
Practice changes be implemented
Change in
practice and
Required changes to practice will be identified and actioned within
lessons to be
a specific timeframe allowed depending on the changes required.
shared
A lead member of the team will be identified to take each change
forward where appropriate.
Lessons will be shared with all the relevant stakeholders
Reporting
arrangements
4. Equality and Diversity
4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service
Equality and Diversity statement.
4.2. Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Intravenous Ketamine Infusion: Nursing Guidelines
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Appendix 1. Governance Information
Document Title
Intravenous Ketamine Infusion: Nursing
Guidelines
Date Issued/Approved:
8 Apr 13
Date Valid From:
8 Apr 13
Date for Review:
8 Apr 16
Directorate / Department responsible
(author/owner):
Pain Services
Contact details:
01872 252792/ 2839
Brief summary of contents
Guidelines for nursing care of patient with
Intravenous Ketamine Infusion
Suggested Keywords:
As above.
RCHT

Target Audience
PCT
CFT
Executive Director responsible for
Policy:
Medical Director
Date revised:
8 Apr 13
This document replaces (exact title of
previous version):
Intravenous Ketamine Infusion: Nursing
Guidelines
Pain services RCHT
Learning and Development RCHT
Dr Paul Upton Medical Director
Governance RCHT
Approval route (names of
committees)/consultation:
Divisional Manager confirming
approval processes
Name and Post Title of additional
signatories
Signature of Executive Director giving
approval
Publication Location (refer to Policy
on Policies – Approvals and
Ratification):
Duncan Bliss
Not required.
{Original Copy Signed}
Internet & Intranet
Document Library Folder/Sub Folder
Clinical / Pain
Links to key external standards
None
Related Documents:
 Intranet Only

RCHT: Guidelines for use of Ketamine
as an Adjuvant Analgesic [for anaesthetic
use only] 2011

Pasero C. and McCaffery M [2005]
Ketamine. American Journal of Nursing
April 105 [4]: PP 60-64.

Schmid R.L.Sandler A.N. and Katz
Intravenous Ketamine Infusion: Nursing Guidelines
Page 6 of 9
J. [1999]. Use and efficacy of low dose
Ketamine in the management of acute
post-operative pain: a review of current
techniques and outcomes. Pain, August
82: PP111-25.

RCHT. Rules Relating to all Activities
Involving Controlled Drugs. RCHT
Document Library.
Registered Nurse competent in
administering intravenous medication.
Training Need Identified?
Registered Nurse competent in the use of
McKinley infusion pumps and maintain
competency by regular use and attending
3 yearly update.
Version Control Table
Date
20 Jul 12
08/04/13
Version
No
V2.0
V3.0
Summary of Changes
Previous version history not known
Amended page 2 and 3

A Mckinley 595 ‘Specialist Analgesia’
pump and dedicated clear BodyGuard
microset anti siphon infusion line can be
located from general recovery.

Added Pain Assessment Chart to Pain
scores and observations
Section 2.10 protocol and prescription has
been simplified to one prescription and
protocol.
MEWS chart changed to NEWS chart or
Analgesia assessment chart where
appropriate.
Changes Made by
(Name and Job Title)
Sharon Dunstan
Senior Pain
Specialist Nurse.
Jayne Thomas
Pain specialist
nurse.
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of
printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS
Trust Policy on Document Production. It should not be altered in any way without
the express permission of the author or their Line Manager.
Intravenous Ketamine Infusion: Nursing Guidelines
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Appendix 2.Initial Equality Impact Assessment Screening Form
Name of service, strategy, policy or project (hereafter referred to as policy) to
be assessed: Guidelines for nursing care of patient with a Ketamine
Intravenous Infusion.
Directorate and service area:
Is this a new or existing
Pain Services
Procedure? Existing
Telephone: 01872 252792
Name of individual completing
assessment: Sharon Dunstan
1. Policy Aim*
Administration of intravenous Ketamine via a Mckinley
Bodyguard 595 pump.
2. Policy Objectives*
Available to nursing staff and medical staff.
3. Policy – intended
Outcomes*
4. How will you
measure the outcome?
5. Who is intended to
benefit from the Policy?
6a. Is consultation
required with the
workforce, equality
groups, local interest
groups etc. around this
policy?
b. If yes, have these
groups been consulted?
To standardise practice and safe management.
Administration of intravenous Ketamine via a Mckinley
Bodyguard 595 pump.
Reduced datix reports received.
Patient satisfaction regards to pain control.
Patients, medical and nursing staff.
No
N/A
c. Please list any groups
who have been consulted Previously practice development and infection control.
about this procedure.
*Please see Glossary
7. The Impact
Please complete the following table using ticks. You should refer to the EA guidance notes
for areas of possible impact and also the Glossary if needed.



Where you think that the policy could have a positive impact on any of the equality
group(s) like promoting equality and equal opportunities or improving relations within
equality groups, tick the ‘Positive impact’ box.
Where you think that the policy could have a negative impact on any of the equality
group(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box.
Where you think that the policy has no impact on any of the equality group(s) listed
below i.e. it has no effect currently on equality groups, tick the ‘No impact’ box.
Intravenous Ketamine Infusion: Nursing Guidelines
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Equality
Group
Age
Positive
Impact
Negative
Impact
No
Impact

Disability

Religion or
belief

Gender

Transgender

Pregnancy/
Maternity
Race

Sexual
Orientation

Marriage / Civil
Partnership

Reasons for decision

You will need to continue to a full Equality Impact Assessment if the following have
been highlighted:
 A negative impact and
 No consultation (this excludes any policies which have been identified as not
requiring consultation).
8. If there is no evidence that the policy
promotes equality, equal opportunities
or improved relations - could it be
adapted so that it does? How?
Full statement of commitment to policy of
equal opportunities is included in the policy
Please sign and date this form.
Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights, c/o
Royal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean House,
Penventinnie Lane, Truro, Cornwall, TR1 3LJ
A summary of the results will be published on the Trust’s web site.
Signed ____________ Sharon Dunstan _________
Date _____________ 20/07/2012 _______________
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