Unique Plan Description: Ketamine Infusion Subphase
Plan Selection Display: Ketamine (Mechanical Vent) Infusion
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2025-06-10 13:15:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-06-11 11:06:21
Available at all facilities: Yes

Ketamine Infusion Subphase
Vital Signs
	Vital Signs
		T;N, (heart rate, blood pressure, respiratory rate, and oxygen saturation)
			Comment: Prior to Initiation, and then every 15 minutes x 4 after a bolus dose or initiation of infusion, then hourly and prn any dose adjustments (per provider order) while on continuous infusion.
IV Solutions
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.10570.1001(NOTE)*
		(Choose only 1 indication)(NOTE)*
Pain
	ketamine 200mg/NS 250mL Premix IV
		200 mg, EVERY BAG, 0.05 mg/kg/hr
		250 mL, IV, Routine, T;N
			Comment: Titrate to target pain goal (CPOT 0-3).  Incremental dose increase 0.02 mg/kg/hr. Incremental dose decrease 0.02mg/kg/hr. Incremental frequency q 30 min. Max dose 0.3 mg/kg/hr. Comment: Contact ordering LIP if unable to titrate up or down or if max dose is reached and the desired pain goal is not reached. Reorder from pharmacy 1 hr before needed. Notify provider for excessive oral and/or airway secretions.Stop infusion and notify provider if HR< 50 or >120, or SBP <90mmhg, or for CNS effects (Hallucinations, paranoia, tremors, diplopia, confusion.  After one hour if symptoms resolve, restart infusion at rate prior to symptom onset. If symptoms persist after infusion held for one hour, notify provider for next steps; could consider treatment of CNS Reaction with Midazolam.  * Dosing to IBW
	ketamine IVPB
		0.25 mg/kg, INT, IVPB, Once, STAT
			Comment: IVPB loading dose (max 50mg) once for Pain. Dose using ideal body weight (IBW).
Sedation
		(if unable to tolerate other agents)(NOTE)*
	ketamine 200mg/NS 250mL Premix IV (Sedation)
		250 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 0.25 mg/kg/hr, Incremental Decrease: 0.25 mg/kg/hr, Incremental Freq: 30 min(s), Max Dose: 3 mg/kg/hr
			Comment: Notify ordering LIP if unable to titrate up or down or if max dose is reached and the desired RASS sedation goal OR BIS goal is not achieved. Reorder from pharmacy 1 hr before needed.Stop infusion and notify provider if HR< 50 or >120, or SBP <90mmhg, or for CNS effects (Hallucinations, paranoia, tremors, diplopia, confusion.  After one hour if symptoms resolve, restart infusion at rate prior to symptom onset. If symptoms persist after infusion held for one hour, notify provider for next steps; could consider treatment of CNS Reaction with Midazolam. Dosing to IBW
		200 mg, EVERY BAG, 0.5 mg/kg/hr
	ketamine IVPB
		0.5 mg/kg, INT, IVPB, Once, STAT
			Comment: loading dose (max 150mg) once for Sedation followed by infusion. Dose using ideal body weight (IBW)
Medications

	glycopyrrolate
		0.2 mg, Injection, IV Push, Q6H, PRN secretions
			Comment: as needed for hyper-salivation
	midazolam
		1 mg, Injection, IV Push, Q15MIN, PRN see comment
			Comment: prn CNS Emergence Reaction (Hallucinations, paranoia, tremors, diplopia, nystagmus, confusion). After 4 doses (4mg total) notify provider.
Patient Care
	Assess RASS
		T;N, Q15MIN, 4, Dose(s)/Time(s)
		T;N+60, Q1H
			Comment: While on continuous infusion and PRN for any dosage adjustments as directed by provider.
	Pain Assessment
		T;N, Q15MIN, 4, Dose(s)/Time(s)
		T;N+60, Q1H
			Comment: While on continuous infusion and PRN for any dosage adjustments as directed by provider
	Monitor for CNS effects
		T;N, Q15MIN, 4, Dose(s)/Time(s), Monitor for Hallucinations, paranoia, tremors, diplopia, nystagmus and confusion
			Comment: while on continuous infusion and prn any dosage adjustments. If symptoms noted, Stop infusion for one hour and notify provider. Consider treatment of CNS emergence Reaction with Midazolam (per provider order). After one hour if symptoms resolve, restart infusion at rate prior to symptom onset.  If symptoms still persisting after pausing infusion for one hour, continue to hold infusion and notify provider for further direction
		T;N+60, Q1H, Monitor for Hallucinations, paranoia, tremors, diplopia, nystagmus and confusion
			Comment: while on continuous infusion and prn any dosage adjustments. If symptoms noted, Stop infusion for one hour and notify provider. Consider treatment of CNS emergence Reaction with Midazolam (per provider order). After one hour if symptoms resolve, restart infusion at rate prior to symptom onset.  If symptoms still persisting after pausing infusion for one hour, continue to hold infusion and notify provider for further direction
	Notify MD
		If SBP <90 or >180 mmHg, MAP < 65, HR< 50bpm or >120bpm, RASS < -2.
		For excessive oral and/or airway secretions.
Therapies
	Perform Spontaneous Awakening Trial
		T;N, DAILY
			Comment: If on Ketamine, turn infusion off. If the patient should complain of or demonstrate sign/symptoms of pain, the RN may administer bolus doses of analgesics as ordered. If the patient would develop or demonstrate CNS symptoms (Hallucinations, paranoia, tremors, confusion, nystagamus), while the infusion is off, notify the provider for further direction. If the patient fails the SAT and the need to resume the continuous infusion exists, it will be restarted at ½ the previous dose.
Consults/Follow-up
	Pharmacy Consult
		T+1;N, After initiation of Ketamine, review pain and sedation medications for possible adjustments.

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase