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Child Health Guideline Identifier

Pain - Ketamine Infusion

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Introduction

Ketamine infusions are generally used in combination with opioids that are being administered via a PCA/NCA when the analgesic effect the opioids are providing is inadequate. Ketamine in these circumstances is best delivered via a continuous infusion and is used to manage moderate to severe pain.

In some circumstances Ketamine infusions may be used alone.

Responsibility

Registered nurses that have attended the paediatric pain study day can care for a patient on a Ketamine Infusion.

Ketamine Infusions are charted by an anaesthetist or pain specialist and managed by the acute pain service (APS). Patients on a Ketamine infusion will be reviewed daily by the APS and all decisions around the infusion will be made by the service.

A small number of patients suffering from complex pain may require Ketamine infusions as determined by their complex pain consultant. These patients will be managed by the prescribing Complex Pain Service (CPS) consultant with after-hours support provided by the acute anaesthetic/pain registrar on-call.

Patients under the palliative care team may also be placed on ketamine infusions. These patients will be managed by palliative care in partnership with the APS.

The pain nurse specialists can be contacted for advice for any child (acute or complex) on a Ketamine infusion during normal working hours, Monday to Friday.

Prescription

Ketamine infusions are charted on the intravenous analgesia preparation and prescription form (CR9003). The recommended dosage parameters can be found on this form also.

Prescriptions may only be altered by an anaesthetist or pain specialist if under the APS or complex pain consultant if under the CPS.

Indications for use

  • When pain is not being sufficiently managed with an opioid PCA/NCA and a neuropathic pain component is present. 
  • When the patient is requiring increased opioid doses due to the development of opioid tolerance and/or side effects. 
  • Specific complex pain conditions.

Set up & Management

Prescription

Ensure Ketamine is prescribed correctly by an anaesthetist or pain specialist on the prescription paperwork (CR9003). It must include appropriate charting and correct parameters for the age of the child.

A patient name label must be attached to the medication bag with the time, date and initials of the two registered nurses completing the check.

Ensure drug and patient checking procedures are completed as per medication administration policy.

Equipment

  • CADD solis pump (sourced from Equipment pool)
  • CADD solis lockbox key (kept with the controlled drug keys)
  • CADD Administration set

Tubing (CADD administration set)

The single line CADD tubing should be attached to a bifurcated Y extension set. One lumen of the Y-extension set will have the CADD  tubing attached and the other lumen will have intravenous fluid running as charted by the primary medical team (at least a minimum of TKVO rate).

 Pain PCA

Programming

A Registered nurse, who has attended the Pain Study Day and had their CADD Pump competency signed off, can set up and programme a ketamine infusion. This must be done with a second registered nurse both of whom must sign the Prescription.

Ensure the pump is programmed as per the prescription (CR9003):

  • Select new patient
  • Infusion Paediatric programme
  • Continuous dose correct
  • Correct reservoir volume

The programme should be re-checked when taking over a new patient or after a bag or line change. This can be done by a single registered nurse. Before commencing a ketamine infusion and after any programme changes two registered nurses are required to complete the programme checks.

Alterations to the programme can be made post commencement if needed as long as the alterations fall within the prescribed parameters. A code (supplied to all registered nurses) will be required to make any changes. All changes must be checked by two registered nurses.

Priming the line

Once the CADD pump is programmed and the settings have been reviewed it will prompt you to prime the CADD administration set line. Ensure all clamps are unlocked and the line is not attached to the patient before commencing the prime. When you are confident the line is completely primed click the button below the words 'stop priming'

Commencement

Once pump settings have been reviewed against the prescription and tubing line primed and connected to the patient via the appropriate peripheral or central access point the infusion may be commenced.

Changing medication bag and tubing

The medication bag if made up must be changed every 24hrs.

The tubing line must be changed every 72hrs. A sticker with the date and time the line was changed should be applied to the tubing.

Documentation

Commencement and cessation of the infusion should be documented on the back of the Intravenous analgesia preparation and prescription (CR9003) form.

The following should also be documented on this form:

  • Rate changes
  • Bag changes (and bag volume discards)
  • Checks when taking over patient care

The modality continuation forms (CR8986) can be attached to the CR9003 if additional space is needed for documenting these details.

Observations required should be documented on the paediatric early warning signs (PEWS) chart where sections allow for it. All other details should be documented in the patient's clinical notes.

Line changes should be documented in the clinical notes by the nursing staff. If the patient has a central access line the line change should be documented on their CLAB form (CR4032).

Volume administered should be read and documented hourly in the fluid balance chart. This volume should be cleared every 24hours at 0700.

Safety

Patients with a ketamine infusion should not leave the ward environment without a registered nurse in attendance.

Observations

Details are outlined on the Intravenous Analgesia Preparation and Prescription form (CR9003). They are as follows:

Hourly 4 Hourly Observe and document every shift
HR, RR, SP02 - Any observations >1 on Paediatric Early Warning Score (PEWS) chart, a full set of PEWS is required.
BP - hourly for 1st 4 hours
Level of consciousness
Pain Assessment
PEWS - as per Starship Child Health Observation and Monitoring Guidelines.
Nausea/Vomiting
Urinary retention,
Itching
Continuous oximetry for patients 'at risk' or requiring oxygen
• If asleep and PEWS are stable for over 6hrs: document level of consciousness and pain assessment 4 hourly.
• Continue observations for 4hrs after stopping intravenous analgesia infusion.

Additional analgesia

Non-opioid analgesics such as Paracetamol and non-steroidal anti-inflammatory drugs (if not contraindicated) can be administered in conjunction with a Ketamine infusion.

Morphine or Oxycodone PCA/NCA may run in conjunction with ketamine infusions if charted specifically by the APS.

With the exception of tramadol, no other opioid analgesia should be administered unless discussed with an anaesthetist, pain specialist, or the pain service.

Precautions

Some patients receiving Ketamine infusions may experience dysphoria, hallucinations and/or vivid dreams. Patients and their families should be informed of these potential side effect prior to commencement of the Ketamine infusion.

A member of the APS should be contacted if the patient is experiencing any of these symptoms. If the adverse effects being experienced become problematic or distressing then the Ketamine infusion rate may need to be decreased or the infusion ceased.

The patient may be at increased risk of sedation or respiratory depression if receiving other medications that have a sedative effect. If an opioid PCA/NCA is running in conjunction with a ketamine infusion the rates may need to be decreased to avoid over sedation, the APS will make decisions around the starting doses of the ketamine because of this potential interaction.

Ceasing ketamine infusion

When Ketamine is used in combination with an opioid PCA/NCA the order in which to wean the infusions should be discussed with the APS.

The APS will decide when the ketamine infusion is to be discontinued and will document in the patients clinical notes and sign the authorised discontinuation section of the CR9003 form.

The same documentation process applies to ketamine infusions being managed by the CPS with the charting consultant deciding when it is discontinued.

References

  • McGrath, J, P., Stevens, J, B., Walker, M, S., & Zempsky, T, W. (2014) Oxford Textbook of Paediatric Pain. Oxford, United Kingdom: Oxford University Press.
  • Oakes, L, L. (2011). Compact Clinical Guide to Infant and Child Pain Management. An Evidence-Based Approach for Nurses. New York, United States of America: Springer Publishing Company.

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Document Control

  • Date last published: 02 August 2017
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Pain Service
  • Author(s): Andrew Liley, Taryn Mannix, Ross Drake
  • Owner: Paediatric Pain Service
  • Editor: Greg Williams
  • Review frequency: 2 years

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