Spravato Should Be Held at Least 2 Days Before Abdominoplasty
I strongly recommend discontinuing Spravato (esketamine) at least 2 days prior to abdominoplasty due to significant perioperative safety concerns related to cardiovascular effects, sedation, and dissociation.
Primary Safety Concerns
Cardiovascular Risk
Spravato causes significant blood pressure elevations that peak at approximately 40 minutes post-administration 1. The FDA label explicitly contraindicates Spravato when "an increase in blood pressure or intracranial pressure poses a serious risk" 1. Abdominoplasty involves:
- Significant tissue manipulation and potential for bleeding
- Risk of hematoma formation that could be exacerbated by hypertension
- Prolonged surgical time requiring hemodynamic stability
The cardiovascular effects of esketamine are unpredictable and could compromise surgical hemostasis and wound healing.
Sedation and Dissociation
Spravato causes sedation in 48-61% of patients and dissociative symptoms in 61-84% of patients 1. These effects:
- Require 2-hour post-dose monitoring until clinical stability is achieved 1
- Can include loss of consciousness (0.3-0.4% of patients) 1
- May persist beyond the immediate dosing period
Residual sedative or dissociative effects within 48 hours of surgery could complicate anesthetic management and increase perioperative risk.
Rationale for 2-Day Hold Period
This recommendation aligns with the SPAQI consensus guideline approach to perioperative medication management. The guideline specifically recommends holding ergotamine "at least 2 days prior to operation" due to cardiovascular concerns and drug interactions with anesthetics 2. Spravato shares similar concerns:
- Cardiovascular instability: Like ergotamine, esketamine causes vasoactive effects
- Anesthetic interactions: Both agents interact with perioperative medications
- CNS depression: Additive effects with general anesthetics 2
Pharmacokinetic Considerations
While the provided evidence doesn't specify esketamine's elimination half-life, the 2-day window allows for:
- Clearance of active drug and metabolites
- Resolution of cardiovascular effects
- Normalization of CNS function
- Reduced risk of drug-drug interactions with anesthetic agents
Clinical Algorithm for Decision-Making
If surgery is scheduled:
- >2 days away: Hold Spravato dose; proceed with surgery as planned
- <2 days away: Consider delaying elective abdominoplasty until 2-day clearance achieved
- Patient on maintenance dosing: Last dose should be ≥2 days before surgery
Coordinate with the prescribing psychiatrist regarding:
- Timing of next scheduled dose
- Risk of depression relapse with brief interruption
- Post-surgical resumption plan
Important Caveats
Psychiatric Stability
Spravato is prescribed for treatment-resistant depression or acute suicidal ideation 1. Brief interruption for elective surgery requires:
- Assessment of current psychiatric stability
- Coordination with mental health provider
- Plan for monitoring depressive symptoms perioperatively
However, patient safety during surgery takes precedence over maintaining the exact dosing schedule, particularly for elective cosmetic procedures like abdominoplasty.
Anesthetic Considerations
If esketamine was administered within 2 days of surgery despite recommendations:
- Inform anesthesiologist immediately
- Expect potential for hemodynamic instability
- Anticipate altered anesthetic requirements
- Plan for extended monitoring
- Consider increased risk of CNS depression with general anesthetics 2
Post-Surgical Resumption
The evidence supports perioperative use of esketamine/ketamine for enhanced recovery and pain management 3, 4, 5, but this refers to intraoperative administration by anesthesiologists, not continuation of outpatient Spravato nasal spray. These are distinct clinical scenarios.
Bottom Line
Hold Spravato for at least 2 days before abdominoplasty. The cardiovascular effects, sedation risk, and potential for anesthetic interactions outweigh any benefit of maintaining the exact dosing schedule for this elective cosmetic procedure. This approach prioritizes surgical safety and optimal outcomes while minimizing morbidity risk.