Affix STAT sticker touching top& left edge of paper.

PHYSICIANS ORDER SHEET Instructions:

1. 2. 3. 4. 5. Identify patient name, date of birth, and MR#. The order must contain date, time, prescriber ID# and signature. Write only in the spaces provided. Check boxes when applicable. Scan/Fax to pharmacy.

ALLERGIES:

______________________ WEIGHT: Ketamine LOW DOSE Adjunctive Analgesia (Adult) Infusion Orders

lb.

kg.

Ketamine is used for the induction and maintenance of general anesthesia. However, this

medication provides analgesia by acting on central and peripheral sites through the NMDA receptor (uncouples pain from awareness of pain) which may also be useful in the management of acute and chronic pain and for those patients who are opioid-tolerant. Ketamine is generally used only when other more traditional methods of pain management are ineffective, for instance, in patients who have received high dose opioid therapy and no longer benefit from increasing opioid doses. Additionally, those patients with a large component of neuropathic nerve pain may also benefit. Ketamine may be used for patients with a variety of conditions, such as cancer, postoperative pain, and chronic pain. Use with caution in patients with coronary artery disease, hypertension, tachycardia, psychosis, and elevated intracranial pressure. Side Effects are not common with low dose ketamine infusions. Adverse effects that have been reported, typically at higher doses include: hypertension, tachycardia, tremors, tonic-clonic movements, fasciculations, increased intracranial pressure, hypersalivation, vomiting, increased skeletal tone diplopia, nystagmus, increased intraocular pressure, increased airway resistance and depression of cough reflex. Reassure patients that they may experience a dream like feeling, especially those who cannot adequately communicate. Prescribing is Restricted to Acute Pain Service or Anesthesiology saline well Vascular Access Device. Flush per protocol. Nursing scan Addendum C to pharmacy. Other:___________________________________________________ If not already on maintenance IV fluid, Normal Saline (0.9%) IV at 125ml/h

1. Discontinue Alcohol Detoxification orders and Opiate Withdrawal orders if ordered. 2. IV Access:

3. IV Fluid:

4. Ketamine (Ketalar) IV Infusion at: 0.05mg/kg/h 0.075mg/kg/h 0.1mg/kg/h. Do not titrate. 5. Assess pain, vital signs and pulse oximetry q4h. 6. Notify prescriber for: heart rate >100bpm SBP < 90mmHg respiratory rate < 10 breaths/min oxygen saturation < 93% symptoms of emergence reactions (bad dreams, unpleasant hallucinations)

Acute Pain Service/Anesthesia

Prescriber Signature:______________________________________ ID #:_____________Date:________Time:________ Transcriber Signature:___________________________Print Name:_________________ Date:________Time:________ RN Signature:_________________________________Print Name:_ ________________ Date:________Time:________ KLDAAIO (11/10 Rev. 12/10) Orders sent to Pharmacy: ________(initials)