Ketamine Infusions while doing cases at ASC

[WDP05]

We are considering doing ketamine infusions at an ASC where we are working. I would like opinions on whether or not it is permissible to monitor these infusions while medically directing 2-3 ORs with CRNAs. Our plan is to have a the nurses start the IV, etc. and we speak with the infusion patients and are of course available at all times. Would there be an issue of compliance in that case? I know we have always been told we cannot do an epidural blood patch while medically directing, which seems similar.

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[caligas]

We are considering doing ketamine infusions at an ASC where we are working. I would like opinions on whether or not it is permissible to monitor these infusions while medically directing 2-3 ORs with CRNAs. Our plan is to have a the nurses start the IV, etc. and we speak with the infusion patients and are of course available at all times. Would there be an issue of compliance in that case? I know we have always been told we cannot do an epidural blood patch while medically directing, which seems similar.

I think you are ahead of the rule book on this one.

 

[Ezekiel2517]

Easy simple straightforward patients. Clean simple straightforward drug. What could possibly go wrong? Go for it.

 

[Aether2000]

If the BP is not out of control, the hallucinations are not overwhelming to the patient causing them to try to get out off the stretcher, and if the tachycardia is controlled, it is a relatively easy procedure. In an office setting, a controlled infusion that does not exceed 200-250mg over several hours is well tolerated by most patients. We do multitask during these infusions. But we also strap them to the stretcher.

 

[lobelsteve]

Any reason to do these infusions? Any insurance paying for it?

 

[Aether2000]

Insurance does not pay.

 

[AdmiralChz]

Any reason to do these infusions? Any insurance paying for it?

Great question. My residency shop stopped doing them about 2-3 years ago (previously did them commonly, like 5-10 every couple weeks), from why I understand a lack of reimbursement was the primary driver. We used to use "extra" space in the block area for these cases, they were staffed by an MD covering 2 resident or CRNA rooms, now that space is used for Botox by the pain group.

Anecdotally, the attendings that did the infusions didn't really have good things to say about them and weren't optimistic about the (lack of) results they were seeing.

 

[cchoukal]

We do them for patients with refractory depression, and it seems to be helpful. We are a VA, however, so we don't have the same issue around billing (I have no idea if this would get paid for). In terms of supervision, we have decided, together with the psychiatrists and PACU staff, that this "case" amounts more to moderate procedural sedation than MAC w/ sedation. We (a CRNA under medical direction, or an MD) meets the patient, has a pre-op (usually done well ahead of time), and starts the infusion, and then immediately "hands-off" the patient to a PACU RN. The doses are fairly low (0.5 mg/kg over 40 minutes), and our experience has been that patients have not had notable psychomotor, hemodynamic, or respiratory/airway issues.

Our approach, we believe, solves the supervision/direction aspect, in that the case is handed over the the PACU RN, and the MD can go about their business and start/direct other cases, but I can't tell you whether this would be suitable for billing purposes.

 

[Noyac]

Why?

 

[Noyac]

Why?

Let me correct my previous comment.

Why in the world?

 

[WDP05]

Let me correct my previous comment.

Why in the world?

What we plan to do are infusions for refractory severe depression. The psychiatrists in town have expressed an interest in someone providing these. Most clinics are stand alone and charge cash, as ketamine for depression isn't FDA approved and thus is not covered by insurance.
So why? The data is mounting, it's in demand and it's profitable. I'm just not sure we could do it while simultaneously running rooms. Though what we are thinking is essentially what cchoukal said above.

 

[anbuitachi]

What we plan to do are infusions for refractory severe depression. The psychiatrists in town have expressed an interest in someone providing these. Most clinics are stand alone and charge cash, as ketamine for depression isn't FDA approved and thus is not covered by insurance.
So why? The data is mounting, it's in demand and it's profitable. I'm just not sure we could do it while simultaneously running rooms. Though what we are thinking is essentially what cchoukal said above.

Dont some places do them for headaches too?

 

[WDP05]

Dont some places do them for headaches too?

Yes. Some also do infusions for anxiety, PTSD, and CRPS.

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[acidbase1]

Does anyone have any literature supporting ketamine infusions? I hear about them all the time and am skeptical of their efficacy

 

[AdmiralChz]

Does anyone have any literature supporting ketamine infusions? I hear about them all the time and am skeptical of their efficacy

Quick Pubmed search. Looks like the 24-hour efficacy hovers around 50%.

Low-dose ketamine for treatment resistant depression in an academic clinical practice setting. - PubMed - NCBI

Safety and efficacy of repeated-dose intravenous ketamine for treatment-resistant depression. - PubMed - NCBI

https://www.ncbi.nlm.nih.gov/pubmed/28790825

These studies seem to follow cchoukal's protocol of 0.5 mg/kg over 40 minutes. I'd dig more, but I'm tired.

 

[Ezekiel2517]

What we plan to do are infusions for refractory severe depression. The psychiatrists in town have expressed an interest in someone providing these. Most clinics are stand alone and charge cash, as ketamine for depression isn't FDA approved and thus is not covered by insurance.
So why? The data is mounting, it's in demand and it's profitable. I'm just not sure we could do it while simultaneously running rooms. Though what we are thinking is essentially what cchoukal said above.

cchoukal practices in an academic setting. Far different than an ASC where you may do this while covering multiple rooms and with who on earth knows watching these patients.

 

[Noyac]

What we plan to do are infusions for refractory severe depression. The psychiatrists in town have expressed an interest in someone providing these. Most clinics are stand alone and charge cash, as ketamine for depression isn't FDA approved and thus is not covered by insurance.
So why? The data is mounting, it's in demand and it's profitable. I'm just not sure we could do it while simultaneously running rooms. Though what we are thinking is essentially what cchoukal said above.

When you aid "at ASC" I assumed it was for surgeries.
But I think you will find that it isn't the holy grail. But go for it!

 

[Noyac]

What we plan to do are infusions for refractory severe depression. The psychiatrists in town have expressed an interest in someone providing these. Most clinics are stand alone and charge cash, as ketamine for depression isn't FDA approved and thus is not covered by insurance.
So why? The data is mounting, it's in demand and it's profitable. I'm just not sure we could do it while simultaneously running rooms. Though what we are thinking is essentially what cchoukal said above.

Also, I have done them for CRPS pts. I would place them in our hospital preop clinic and run the infusion for an 1-2 i believe (we have a protocol that I can't remember any longer since it's been years since I did it). It worked fairly well. But the pts kept coming back. It didn't resolve the issue. Now I just do blocks for these pts.
If you are trying to treat PTSD you could try stellate ganglion blocks right side only.

 

[anbuitachi]

Also, I have done them for CRPS pts. I would place them in our hospital preop clinic and run the infusion for an 1-2 i believe (we have a protocol that I can't remember any longer since it's been years since I did it). It worked fairly well. But the pts kept coming back. It didn't resolve the issue. Now I just do blocks for these pts.
If you are trying to treat PTSD you could try stellate ganglion blocks right side only.

i dont think ketamine will be a cure for CRPS or depression or anything. but at least for depression perhaps improved symptoms for x weeks, which isn't too bad for a a hr or 2 of infusion. it will be a chronic treatment

 

[deleted162650]

My group's ketamine clinic has been up and running for almost a year now. We have the pts take Depression scales before treatment and again after the first few infusions. If they haven't shown any real improvement, we tell them they probably are non-responders and recommend they don't continue with the full course. Our protocol sounds similar to what @cchoukal is doing.

I was pretty skeptical at the start, but the patients do seem to be doing well with significant improvements. I agree it's not a cure, but rather another treatment option for people with severe symptoms that have been refractory to everything else. So either it works, or it's just so expensive (all cash) that they don't want to admit to themselves that it's not working??

 

[Shimmy8]

Do you all have referrals from your psych department or just advertise it on own? Is it only for refractory folks? How do you determine refractory? Before/after ECT?

Just curious.

 

[WDP05]

Do you all have referrals from your psych department or just advertise it on own? Is it only for refractory folks? How do you determine refractory? Before/after ECT?

Just curious.

I think that's another great question. To me it seems you should get a referral if only to be sure someone is following along who can adjust medications, etc. If they are relying on ketamine with no counseling or further followup, we aren't helping anyone.

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[okayplayer]

My group's ketamine clinic has been up and running for almost a year now. We have the pts take Depression scales before treatment and again after the first few infusions. If they haven't shown any real improvement, we tell them they probably are non-responders and recommend they don't continue with the full course. Our protocol sounds similar to what @cchoukal is doing.

I was pretty skeptical at the start, but the patients do seem to be doing well with significant improvements. I agree it's not a cure, but rather another treatment option for people with severe symptoms that have been refractory to everything else. So either it works, or it's just so expensive (all cash) that they don't want to admit to themselves that it's not working??

How do you guys staff this?

How profitable is it after expenses?

 

[deleted162650]

1 doc staffs it (MD only group). we can run up to 4 pts at a time, and typically have at least a couple. We partnered with the hospital in the system that does a lot of pysch. They provide the space, a nurse, the monitors, and drugs. We just show up and do our thing. We split the fee 50/50 with the hospital. Essentially no expenses at this point.