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Low Dose Ketamine for Pain Relief in the ED

History / Summary of Article(s) / New Practice / Community Practice
Ketamine, which is classified as an N-methyl d-aspartate (NMDA) receptor antagonist or dissociative
anesthetic, is a well known medication utilized in both human and veterinary medicine used to induce
and maintain general anesthesia. Ketamine has commonly been used in the Emergency Department
(ED) alone or as an adjunct for the induction of intubation or procedural sedation.
An alternative off label use of Ketamine is for pain control, using sub-anesthetic doses. Low Dose
Ketamine (LDK) has been shown to provide effective analgesia in patients with both acute and chronic
pain. LDK allows for effective analgesia with lower doses of opioids, thereby reducing the risks
associated with opioid overdose/overuse (e.g. hypotension and respiratory depression). Ketamine
administered as a solo agent or as part of multimodal analgesia (in combination with drugs such as
opiates and NSAIDS) to manage the pain of critically injured soldiers has been used extensively by the
U.S. Military. According to several studies coming out of the U.S. Military, LDK and multimodal analgesia
has improved the ability of the military’s healthcare to provide safe and effective analgesia. 1,4,5,7
A survey of ten Bay Area Emergency Departments revealed the use of LDK to be minimal and when it is
used, to be MD specific. Two strong supporters of LDK use in the ED for pain relief include, Emergency
Medicine pain experts, James Ducharme, MD, CM, FRCP, McMaster University, Ontario and Peter
Viccellio, MD, FACEP, Stony Brook University Medical Center, New York. Both experts have had success
using LDK as a single agent and in combination with an opioid for over a decade. 11,12

Proposed New Practice / Committee Recommendations
Low Dose Ketamine may be used in the ED as an agent for analgesia in patients with acute or chronic
pain, either alone or in combination with additional pain relieving drugs.

Administration Guidelines / How-To
IM/SQ
10-30 mg IM/SQ
*Maximum Dose: 60-100 mg in a 24 hour period
SIVP
5-20 mg SIVP over 1 minute
*Maximum Dose: 60-100 mg in a 24 hour period
To Decrease Likelihood of Dissociative Effects Consider:
Administering LDK over 5-10 minutes
IV Drip (pump required)
0.1-0.3 mg/kg/hr on a pump [Ketamine 50mg/50mL D5W or NS (conc = 1mg/mL)]
*Maximum Dose: 700 mg in a 24 hour period
Optional Loading Dose Prior Starting IV Drip:
Administer 0.2-0.3 mg/kg over 10 minutes on a pump 12

Indications for Use
LDK may be administered to patients who fall within the inclusion criteria and who have received the
required patient education from the MD, MLP &/or RN, prior to administration.
2/2013 ED-ARC

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Low Dose Ketamine for Pain Relief in the ED
Inclusion Criteria
Patients > 18 years of age
Patients in the ED complaining of acute or chronic pain
Patients with pain but intolerant to opioids
Patients in the ED requiring a painful procedure
Exclusion Criteria
Patients < 18 years of age
Uncontrolled seizure activity
Severe symptoms related to elevated intracranial pressure
Allergy to Ketamine
Renal &/or liver failure
Women who are pregnant or are breastfeeding

Who May Administer Medication
Licensed MDs, Mid-Level Practitioners MLP) / Advanced Practice Provider (APP) and RNs

Considerations / Special Precautions / Contraindications
Before administering LDK, consider opioid dose reduction by 25-50%
In the elderly, LDK dose reduction would be prudent 9
LDK should be used with caution in patients with severe hypertension, heart failure, coronary artery
disease, and/or tachycardia – consider placing on cardiac monitor with regular vital signs 13,14
At higher doses (>0.3-0.5 mg/kg), slight dissociative effects such as dysphoria, sedation, and
dizziness have been noted 7,9
Consider a reduction in dose or discontinuation of LKD if the patient complains of dissociative
effects
A low dose benzodiazepine should be considered as a reversal agent to decrease the dysphoric
effects of LDK (example: Midazolam 0.5-1mg IM or SIVP)

Monitoring Requirements
Continuous pulse oximetry is required for all LKD infusions. For IM and SIVP administration, continuous
pulse oximetry is required for 30-60 minutes post administration.

Locations in the ED Where Medication May Be Administered
Anywhere in the ED that has pulse oximetry capabilities
NOTE: LDK IV Drips must be discontinued prior to the patient leaving the ED

Alternatives to Using This Medication for this Practice
Opioids and/or non-steroidal anti-inflammatory drugs (NSAIDs) may be considered for analgesia.

New Practice Proposed By
Andrew Herring, MD

ED-ARC Members that Reviewed and Came to Consensus for this New Practice
Janis Farnholtz Provinse, MS, RN, CNS, CEN
Sarah Graffman, RN
2.2013 ED-ARC

Nicole Mendoza-Martens, RN
Tina Liu, PharmD

Charlotte Wills, MD

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Low Dose Ketamine for Pain Relief in the ED
References
1. Bell, R., Dahl, J., Moore, R., Kalso, E. (2006). Perioperative Ketamine for acute postoperative pain.
Cochrane Database of Systematic Reviews, 2006(1), Article CDC004603.
2. Ducharme, J. (2001). Ketamine: Do what is right for the patient. Emerg Med. 13:7-8.
3. Fitzgibbon, E.J., Hall, P., Schroder, C., Seely, J., Viola, R. (2002). Low dose Ketamine as a analgesic
adjuvant in difficult pain syndromes: a strategy for conversion of parenteral to oral Ketamine. J Pain
Symptom Mgmt, Feb;23(2):162-170.
4. Galinski, M., Dolveck, F., Combed, X., Limoges, V., Smail, N., Pommier, V., Templier, F., Catineau, J.,
Lapostoaolle, F., Adnet, F. (2007). Management of severe acute pain in emergency setting:
Ketamine reduces morphine consumption. Am J Emerg Med, 25:385-390.
5. Lester, L., Braude, D., Niles, C., Crandall, C. (2010). Low-dose Ketamine for analgesia in ED: a
retrospective case series. Am J Emerg Med, 28:820-827.
6. Malchow, R., Black, I. (2008). The evolution of pain management in the critically ill trauma patient:
emerging concepts from the global war on terrorism. Crit Care Med, 36(7):S346-S357.
7. Schmid, R., Sandler, A., Katz, J. (1999). Use and efficacy of low-dose ketamine in the management of
acute postoperative pain: a review of current techniques and outcomes. Pain, 82:111-125.
8. Subramaniam, K., Subramaniam, B., Steinbrook, R. (2004). Ketamine as an adjunct analgesic to
opioids: a quantitative and qualitative systematic review. Anesthesia and Analgesia, 99(2):482-495.
9. Vissers, E., Schug, S.A. (2006). The role of ketamine in pain management. Biomedicine and
Pharmacology, 60:341-348. Retrieved Feb 2, 2012 from CINAHL.
10. Herring, A.A., Ahern, T., Stone, M.B., Frazee, B.W. (2012). Emerging applications of low-dose
ketamine for pain management in the ED. Am J Emerg Med, 2012 Nov 16. Epub ahead of print.
11. Viccellio, P. Personal communication. Dec 11, 2012.
12. Ducharme, J. Personal communication. Dec 4, 2012.
13. LexiComp Drug database. Ketamine. Accessed 2/13/13.
14. Fitzgibbon, E.J. & Viola, R. (2005). Parenteral ketamine as an analgesic adjuvant for severe pain:
development and retrospective audit of a protocol for palliative care unit. J Palliat Med,
Feb;8(1):49-57.
15. Ahern, T.L., Herring, A., Stone, M.B., Frazee, B.W. (in press). Effective analgesia with low-dose
ketamine and reduced-dose hydromophone in emergency department patients with acute severe
pain.

To Be Reviewed Again
Six months after implementation date - please address all comments / concerns to ED-ARC members
Date effective:

SCHEDULED REVIEW DATE:

3/1/13

9/1/13

2/2013 ED-ARC

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