Practice Information

IV Drug Administration of Ketamine for the Treatment of Intractable Pain


To: Interested Parties

From: Barbara Zittel, RN, Ph.D, Executive Secretary, State Board for Nursing

Subject: IV Drug Administration of Ketamine for the Treatment of Intractable Pain

Date: June 2011

A number of inquiries have recently been received by the Board for Nursing questioning the Board’s October 2006 position on the intravenous administration, by Registered Professional Nurses (RNs), of drugs classified as anesthetic agents (most specifically ketamine), to patients experiencing pain. The Board’s 2006 position indicated that RNs, meeting certain conditions, could administer such drugs but only to patients in critical care, hospice, or palliative care areas. Recent inquiries have requested that a re-examination of this position consider the use of low-dose ketamine infusion in patient care areas where a low patient to nurse ratio is not the norm.

As background information, ketamine is identified by the Federal Drug Administration as an intravenous anesthetic agent. It has been used for this purpose since the 1960s. However, because of its psychomimetic reactions which include: feeling light-headed, floating, having "out of body" experiences, visual hallucinations, "tripping", delusions, and delirium, ketamine’s use as an anesthetic agent has had limitations.3,8,9 In contrast, these central nervous effects have made ketamine attractive as a drug of abuse.2,8

Within the last ten years, although not licensed for this purpose, low-dose ketamine has found utility as an aid in providing analgesia for the treatment of post-operative pain, neuropathic pain, and chronic pain especially related to patients with opioid tolerance. Clinical studies suggest that in the majority of patients, the use of low-dose ketamine is a useful adjunct to standard practice opioid analgesia resulting in: a decrease in opioid requirements in both surgical and non-surgical patients,1,3,4,6,7,10,12,13 fewer physician interventions to manage severe pain12, a positive impact on knee mobilization after total knee arthroplasty1, a decrease in post-operative nausea and vomiting3, and reduced pain scores for as long as one-year after surgery. The literature also cautions that prescribers must be vigilant, and that further study is warranted to determine optimal dosages of low-dose ketamine administration2,3,11.

Because ketamine is licensed as an anesthetic agent that must be administered by anesthesia providers, because of the "complexity of patient assessment, treatment decision-making and initial monitoring,2" because of a legitimate concern for the potential for abuse, and because of the possibility of distressing side effects, the Board is cautious in considering the administration of low-dose ketamine infusion by RNs in general patient care areas. Thus, the Board continues to affirm its 2006 position but, based on current research evidence, adds the following modification:

Within the first 24 hours of initiation of low-dose ketamine administration, RNs, with demonstrated competence, can administer and monitor patients on this regimen only to patients in recovery rooms, critical care, hospice, step-down or palliative care areas, that is, in patient care units with low patient to nurse ratios. Following this time period, and with no evidence of untoward side effects, such patients can be cared for by RNs, with demonstrated competence, on general patient units.

The following conditions must also be met:

  • Candidates for low-dose ketamine administration must be evaluated by Acute Pain Service or Anesthesiology and assessed for appropriateness before initiation of therapy.
  • A patient-specific order for a low-dose ketamine infusion must be provided by and is restricted to Acute Pain Service or Anesthesiology.
  • Low-dose ketamine infusions must be prepared only by the pharmacy.
  • Low-dose ketamine should be infused through its own dedicated IV line (when possible) or via the most proximal port of a carrier solution.
  • Low-dose ketamine should be infused through portless IV tubing to avoid inadvertent bolusing.
  • Low-dose ketamine should NOT be bolused as a treatment for pain except by an anesthesia provider.
  • Low-dose ketamine should be infused using an IV infusion control device with a locked control panel.
  • Vital signs should be monitored as well as alertness, orientation, evidence of nystagmus, bad dreams and unpleasant hallucinations.
  • The prescriber should be notified of a heart rate greater than 100 beats per minute, a systolic B/P less that 90 mmHg, a respiratory rate less than 10 breaths per minute, oxygen saturation of less than 93% and symptoms of emergence reactions such as bad dreams, hallucinations and nystagmus.
  • The facility must provide a written policy and procedure that documents an RN’s role in the administration of low-dose ketamine.

We hope this clarification is helpful. If you have questions or need additional information, please contact the New York State Board for Nursing by phone 518-474-3817 ext. 1-120, or by e-mail nursebd@nysed.gov.

References:
  • 1. Adam F, et al. [2005] Small-Dose Ketamine Infusion Improves Postoperative Analgesia and Rehabilitation After Total Knee Arthroplasty. Anesth Analg: 100:475–80.
  • 2. Akporehwe, N. A, et al.[2006] Ketamine: a misunderstood analgesic? BMJ: 332:1466.
  • 3. Bell RF, Dahl JB, Moore RA, Kalso E. [2005] Peri-operative ketamine for acute post-operative pain: a quantitative and qualitative systematic review (Cochrane review). Acta Anaesthesiol Scand: 49:1405—1428.
  • 4. Elia N, & Tramer MR. [2005] Ketamine and postoperative pain – a quantitative systematic review of randomised trials. Pain: 113: 61–70.
  • 5. Grande LA, et al. [2008] Ultra-Low Dose Ketamine and Memantine Treatment for Pain in an Opioid- Tolerant Oncology Patient. Anesth Analg: 107:1380 –3.
  • 6. Guillou N, et al. [2003] The Effects of Small-Dose Ketamine on Morphine Consumption in Surgical Intensive Care Unit Patients After Major Abdominal Surgery. Anesth Analg: 97:843–7.
  • 7. Lahtinen, P, et al. [2004] S(+) Ketamine as an Analgesic Adjunct Reduces Opioid Consumtpion After Cardiac Surgery. Anesth Analg: 99:1295-1301.
  • 8. Rakie, A. & Golumbiewski, J. [2009] Low-Dose Ketamine Infusion for Postoperatice Pain Management. J. of PeriAnesthesia Nursing: 24, 4:254-257.
  • 9. Slatkin, N & Rhiner, M. [2003] Ketamine in the Treatment of Refractory Caner Pain: Case Report, Rationale , and Methodology. Journal of Supportive Oncology: 1.4:287-293.
  • 10. Subramaniam K, Subramaniam B, Steinbrook RA. [2004] Ketamine as Adjuvant Analgesic to Opioids: A Quantitative and Qualitative Systematic Review. Anesth Analg: 99:482–95.
  • 11. Suzuki M, et al. [2006] Low-dose Intravenous Ketamine Potentiates Epidural Analgesia after Thoracotomy. Anesthesiology: 105:111–9.
  • 12. Webb AR, et al. [2007] The Addition of a Small-Dose Ketamine Infusion to Tramadol for Postoperative Analgesia: A Double-Blinded, Placebo-Controlled, Randomized Trial After Abdominal Surgery. Anesth Analg: 104:912–7.
  • 13. Yamauchi M, et al. [2008] Continuous Low-Dose Ketamine Improves the Analgesic Effects of Fentanyl Patient-Controlled Analgesia After Cervical Spine Surgery. Anesth Analg: 107:1041–4.
Last Updated: January 31, 2013