IV ketamine for Depression - Protocol?

[Blitz2006]

I want to start treating a patient for treatment resistant depression with IV ketamine.

Any idea of dosing? Frequency?

Is there a reputable protocol/guideline I can follow online?

Thanks!

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[NontradCA]

I want to start treating a patient for treatment resistant depression with IV ketamine.

Any idea of dosing? Frequency?

Is there a reputable protocol/guideline I can follow online?

Thanks!

2019 Fall Conference

www.wapsychiatry.org

 

[Blitz2006]

Thanks!

Great source, but it seems to focus mainly on ECT, not ketamine?

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[NontradCA]

Thanks!

Great source, but it seems to focus mainly on ECT, not ketamine?

Sent from my SM-N970U using Tapatalk

I edited it sorry, full conference materials should be there now.

 

[NontradCA]

Also, there's more relative contraindications to ketamine than what's on those protocols. If you are using it for first time, I'd read up on it more. Zarate's book is something I'd recommend as well as his papers.

 

[Blitz2006]

I edited it sorry, full conference materials should be there now.

Any suggestions on maintenance?

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[Shufflin]

I want to start treating a patient for treatment resistant depression with IV ketamine.

Any idea of dosing? Frequency?

Is there a reputable protocol/guideline I can follow online?

Thanks!

Are you airway trained? Do you have a crash cart and do you know how to use it? do you know how much ketamine is too much when someone is not responding to tx? do you know how to control BP that keeps rising? theses are a few things to think about before you go down the IV ketamine path. but props for wanting to help the person.

 

[liquidshadow22]

Are you airway trained? Do you have a crash cart and do you know how to use it? do you know how much ketamine is too much when someone is not responding to tx? do you know how to control BP that keeps rising? theses are a few things to think about before you go down the IV ketamine path. but props for wanting to help the person.

You were trained to intubate? Have you ever actually done one? Is there a course for this for a practicing psychiatrist?
Also do you have access to iv BP meds, or a Cardine gtt?

 

[Stagg737]

You were trained to intubate? Have you ever actually done one? Is there a course for this for a practicing psychiatrist?
Also do you have access to iv BP meds, or a Cardine gtt?

I mean, if you've ever been ACLS certified you've been trained to intubate. No, it's not the the same as doing a gas residency but the basics aren't very hard to learn. Feeling competent enough to do it yourself in a clinical setting when you could have someone who does it regularly present is a different story, but on straightforward patients it's not particularly difficulty. Saying this from experience as an EMT before med school.

 

[liquidshadow22]

I mean, if you've ever been ACLS certified you've been trained to intubate. No, it's not the the same as doing a gas residency but the basics aren't very hard to learn. Feeling competent enough to do it yourself in a clinical setting when you could have someone who does it regularly present is a different story, but on straightforward patients it's not particularly difficulty. Saying this from experience as an EMT before med school.

Ok then is the expectation to have an up to date acls certification and an ability to call 911 Stat if someone loses their airway from a ketamine complication? Or is the expectation for you to hire a anesthesia trained nurse for a private practice? Or just depends on your risk tolerance?

 

[NontradCA]

Are you airway trained? Do you have a crash cart and do you know how to use it? do you know how much ketamine is too much when someone is not responding to tx? do you know how to control BP that keeps rising? theses are a few things to think about before you go down the IV ketamine path. but props for wanting to help the person.

This. You can read about this in the literature, which will include several protocols for induction and maintenance. You could likely do this in an office on your own, without anesthesia or even nursing. That’s how most psychiatrists do it. That being said if something were to go wrong and you’re doing something off label, you can kiss your career and wallet goodbye.

You could also find a list of ketamine providers in your city or state and contact them. Some will be willing to show you what they’re doing for a price.

 

[NontradCA]

Ok then is the expectation to have an up to date acls certification and an ability to call 911 Stat if someone loses their airway from a ketamine complication? Or is the expectation for you to hire a anesthesia trained nurse for a private practice? Or just depends on your risk tolerance?

If you’re asking this question then you really have no business giving anyone IV Ketamine. Call 911 for airway problem? So they can collect the body?

 

[liquidshadow22]

If you’re asking this question then you really have no business giving anyone IV Ketamine.

LOL I don't think ANY psychiatrist has business giving iv ketamine with 4 months of medicine floors. We are not EM, Gas or critical care. Bottom line is if something goes wrong you will be liable for giving a general anesthetic in an outpatient office.

My whole point is that being acls trained isnt going to cut it in my opinion. If you are going to go this alone, one needs to accept that you are practicing out of your scope of training and take that risk. From a liability perspective, would patients be safer with nurse or anesthesia Dr around? The answer is yes and anyone who says no is letting $$ blind their judgment.

I understand the doses for ketamine are not anesthetic doses but let's not act like this is the safest care model because we all know it's not.

 

[NontradCA]

LOL I don't think ANY psychiatrist has business giving iv ketamine with 4 months of medicine floors. We are not EM, Gas or critical care. Bottom line is if something goes wrong you will be liable for giving a general anesthetic in an outpatient office.

My whole point is that being acls trained isnt going to cut it in my opinion. If you are going to go this alone, one needs to accept that you are practicing out of your scope of training and take that risk. From a liability perspective, would patients be safer with nurse or anesthesia Dr around? The answer is yes and anyone who says no is letting $$ blind their judgment.

I think patients should have access to more interventional treatments in general, and I feel like psychiatrists should be the ones doing it. I’m of the opinion we should all be trained on it, among other things. Adequate training.

“Don’t worry if something goes wrong an Anesthesiologist helped me intubate someone 8 years ago.”

 

[liquidshadow22]

I think patients should have access to more interventional treatments in general, and I feel like psychiatrists should be the ones doing it. I’m of the opinion we should all be trained on it, among other things. Adequate training.

“Don’t worry if something goes wrong an Anesthesiologist helped me intubate someone 8 years ago.”

I'm all for it, but I'm really not sure the current psychiatry residency requirements allow for this. I'm curious what kind of postgraduate training exists for this setup. Would be nice if there were a course like there is for ECT

 

[NontradCA]

I'm all for it, but I'm really not sure the current psychiatry residency requirements allow for this. I'm curious what kind of postgraduate training exists for this setup. Would be nice if there were a course like there is for ECT

The link that I provided is a presentation by a former PGY4 in Yales Interventional Chief year. It is legit. A few programs have this.

 

[TexasPhysician]

Why not IN ketamine?

 

[NontradCA]

Why not IN ketamine?

It has more barriers to treatment, similar efficacy. Talking about money grabbing

 

[Blitz2006]

Just to follow-up. I was planning on working with an Anesthesiologist to do the infusions...

But I just wanted more information on dosing protocol 🙂

 

[birchswing]

Is lower dose ketamine different acting than doses used for general anesthesia?

The reason I ask is you would think if higher doses used for general anesthesia were effective for depression, there would be case reports of someone with depression having sudden improvement after surgery under general anesthesia.

By different acting, I guess I mean does it hit receptors differently in a way that is changed when the dose is high enough for general anesthesia.

Edit:

I found something after a quick google search. Sounds like it's related to electrical activity at higher doses:

"
In their research the team were surprised to find that some drugs, including ketamine, actually activate rather than suppress brain activity. This is why ketamine can trigger hallucinations at low doses. But at higher doses the excess brain activity leads to unconsciousness by creating disorganized patterns and “blocking any coherent signal,” similar to the experience of seizure-induced unconsciousness.

Low doses of ketamine may even be of help for people with depression, according to Brown. It acts quickly and could help “bridge the gap” between different types of antidepressant. He believes that the drug’s effects are comparable to electroconvulsive therapy."

Brain Effects of General Anesthesia

New research is shedding light on the effects of general anesthesia on the brain and the body. In the United S

psychcentral.com

 

[romanticscience]

I want to start treating a patient for treatment resistant depression with IV ketamine.

Any idea of dosing? Frequency?

Is there a reputable protocol/guideline I can follow online?

Thanks!

Andrade, C. (2017). Ketamine for Depression, 4: In What Dose, at What Rate, by What Route, for How Long, and at What Frequency? The Journal of clinical psychiatry 78(7), e852-e857. Ketamine for Depression, 4: In What Dose, at What Rate, by What Route, for How Long, and at What Frequency? |J Clin Psychiatry

 

[Circle10]

According to the 5 studies done so far, ketamine is equal with placebo when it comes to treating depression, same as current antidepressants. BUT, it has almost no side effects, zero withdrawal effect, and, unlike current antidepressants, has a bigger than 0$ street value. It produces a beautiful euphoric effect. The only problem is driving on it, slightly increased suicide rate and bladder problems in 20% of users.

It's a super clean drug that will hopefully completely replace current antidepressants that have gone out of patent. The company manufacturing it has modified ketamine by 1 molecule, put an "Es" in front of it, patented it and now sells it for 5400$/month instead of 5$ in USA, covered by insurance. The company estimates that EsKetamine will cover 20% of the antidepressant market in just 5 years.

This is an incredible development for psychiatry but nothing compared to what will come in 5 - 20 years. Magic mushrooms are the next drug on the line, a drug that will very probably crush placebo when it comes to depression and is also the antidote for autism. It has zero side effects and is impossible to abuse. They are already used in a couple of countries where they are legal and some USA cities. The scientist that are studying them at the moment have claimed that "illegalizing magic mushrooms has been the biggest censorship that ever happened in modern science" and I perfectly agree. There is no such thing as psychiatry without magic mushrooms, the current era is the pre-psychiatry era. All psychiatric drugs combined probably don't have the clinical utility that magic mushrooms have. If you really want to help that person recover from depression, give him magic mushrooms if you're in one of those cities where it's legal.

PS: As an alternative, dextrometanphan is almost the same thing as Ketamine, costs nothing, and is legal everywhere. Since beating placebo does not seem to be a concern at the moment when it comes to treating depression, the lack of studies on DXM and depression is not a problem. Side effects are similar to Ketamine, meaning they almost do not exist.