Ketamine infusion protocols

[BloodySurgeon]

I was wondering what everyones starting protocol for in-office ketamine infusions? Would you alter your dosage base on indication CPRS vs central pain vs chronic neuropathic pain?

Dosage:
10-22mg/hr?
0.35mg/kg/hr?

Duration:
4 hours?

Length:
1 day?
5 consecutive days?

Do you ever combine medications such as ketamine + lidocaine + midazolam? If so what is your cocktail? Please share.

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[stsa84]

I can only share what I've seen, from what my attendings do in fellowship. Not endorsing this method...

One guy gives 500mg of ketamine, the rest give 250mg, injected into a 500cc bag of NS, infused over 5-6 hours. For most people it would be around 50-100 mg/hr, or .5-1 mg/kg/hr. Everyone gets a few mg of midazolam up front, as well as zofran, with phenergan injected into the infusion bag as well. Ketamine doses are adjusted down if the patient is significantly smaller than the average patient. Also, if the patient is over 70 or so, the first infusion may be reduced by about half. Again, not an endorsement of method...

 

[BloodySurgeon]

I can only share what I've seen, from what my attendings do in fellowship. Not endorsing this method...

One guy gives 500mg of ketamine, the rest give 250mg, injected into a 500cc bag of NS, infused over 5-6 hours. For most people it would be around 50-100 mg/hr, or .5-1 mg/kg/hr. Everyone gets a few mg of midazolam up front, as well as zofran, with phenergan injected into the infusion bag as well. Ketamine doses are adjusted down if the patient is significantly smaller than the average patient. Also, if the patient is over 70 or so, the first infusion may be reduced by about half. Again, not an endorsement of method...

Thank you for sharing and i agree there are a lot of different protocols out there including inpatient vs outpatient dosages. Does your program bring the patient back for multiple days or require cash per session? Also, do you see a lot of side effects with the high ketamine dosages? Im worried about hallucinations in the office setting.

 

[stsa84]

Thank you for sharing and i agree there are a lot of different protocols out there including inpatient vs outpatient dosages. Does your program bring the patient back for multiple days or require cash per session? Also, do you see a lot of side effects with the high ketamine dosages? Im worried about hallucinations in the office setting.

They usually set people up for a series of 3 infusions, set a week or so apart. If someone is nearly pain free after the first one, however, then we just hold there and have them come back for another session if they request it. I've been surprised at the minimal side effects I've seen with these higher doses. We do probably 5-8 infusions per week, and give additional versed once or twice a week, usually for mild agitation/restlessness, and labetalol once every two weeks or so. We require the patient have a support person present in the room with them the entire time. The patients usually just lay there in the dark and fly high I guess. Haven't seen anyone truly freak out. Usually the support person is able to do an excellent job of helping orient them if they 'wake up' and are disoriented or agitated. Unsure about requiring cash per session. I don't think so. Patients who have to self pay prior to having a procedure done are noted as such on the schedule, and I haven't seen any of our ketamine infusions noted this way. But unsure.

 

[callmeanesthesia]

I think people got .5-1 mg/kg/h but they were hospitalized for a week for it because insurance would only cover it inpatient. All had PRN Benzo and zofran. We rarely did them and I hated them because the n of 2 I saw didn’t work and had terrible toxicity. It also felt like the most massive waste of resources because they had to be in the ICU due to hospital policy, because they were on an anesthetic drip. What labs are you checking before/after? Comprehensive metabolic panel?

 

[Baron Samedi]

On inpatient side we did starting dose 10mg/hr max dose 40mg/hr. Infusion would usually last 5 days. PRN benzo and Zofran.

 

[BloodySurgeon]

Do they have to be admitted to have insurance coverage? Can you please share your experience with insurance approval. I have inpatient and ambulatory privileges with a set up that would work very well for infusion sessions as an ambulatory outpatient procedure.

 

[deleted131481]

We used to do 0.5 mg/kg/hr for 1 hour first time, then up to 1mg/kg/hr for 1 hour 2nd time. PRN zofran and versed. It seemed to work for a couple hours to a couple weeks max. I haven't seen any literature beyond a couple weeks.

If successful we'd try namenda or dextromethorphan - both worked poorly.

Anyone trying intranasal ketamine?

 

[Baron Samedi]

We used to do 0.5 mg/kg/hr for 1 hour first time, then up to 1mg/kg/hr for 1 hour 2nd time. PRN zofran and versed. It seemed to work for a couple hours to a couple weeks max. I haven't seen any literature beyond a couple weeks.

If successful we'd try namenda or dextromethorphan - both worked poorly.

Anyone trying intranasal ketamine?

Those doses seem really low. Most protocols for outpatient infusions I've seen range between 100-500mg total.

 

[Ferrismonk]

I've never seen Ketamine work long term or get covered by insurance.

In my opinion it's either an academic plaything or a unscrupulous outpatient money grab.

Never Rx'd intranasal Ketamine for home use either. Too much abuse potential if you ask me.

I did have a new patient once who was vaping ketamine powder from his PCP if that counts...

 

[Ducttape]

be careful with "inpatient" treatment.

some states require 1:1 monitoring and ICU level care for inpatients