What kind of monitoring is required for patients with mental health conditions undergoing intravenous (IV) ketamine infusion?

Monitoring Requirements for IV Ketamine Infusion in Mental Health Settings

For IV ketamine infusion centers treating mental health conditions, continuous vital sign monitoring during the 40-minute infusion and post-infusion observation for approximately 2 hours is required, including blood pressure every 10 minutes during infusion, continuous pulse oximetry, heart rate monitoring, and capnography when available. 1, 2

Pre-Treatment Assessment and Baseline Monitoring

Baseline Laboratory Testing

• Obtain baseline liver function tests (LFTs), including alkaline phosphatase and gamma glutamyl transferase, before initiating ketamine treatment with recurrent dosing protocols. 1
• Monitor LFTs at periodic intervals during ongoing treatment due to risk of hepatobiliary dysfunction with repeated ketamine administration 1

Pre-Infusion Vital Signs

• Document baseline blood pressure, heart rate, oxygen saturation, and respiratory rate before each infusion 1, 2
• Screen for contraindications including uncontrolled hypertension, ischemic heart disease, cerebrovascular disease, and elevated intracranial pressure 1

During-Infusion Monitoring (Standard 40-Minute Protocol)

Vital Sign Monitoring Frequency

• Measure blood pressure every 10 minutes throughout the infusion period 3
• Continuous pulse oximetry to maintain oxygen saturation >93% on room air 2
• Continuous heart rate monitoring 1, 2
• Capnography when available 2

Expected Hemodynamic Changes

• Peak blood pressure elevations occur at approximately 30 minutes into the infusion (mean increase: systolic 3.28 mmHg, diastolic 3.17 mmHg) 3
• Transient increases in heart rate and cardiac index are frequently observed 1
• These hemodynamic changes are typically small, well-tolerated, and clinically insignificant when ketamine is administered at 0.5 mg/kg over 40 minutes 3, 4
• Patients with pre-existing hypertension may experience higher blood pressure peaks but still within tolerable ranges 3

Neuropsychiatric Monitoring

• Observe for dissociative and psychotomimetic symptoms, which occur in approximately 12% of patients during recovery 1, 4
• These symptoms are almost always mild, transient, and very seldom responsible for treatment discontinuation 4
• Minimize verbal, tactile, and visual stimulation during recovery to reduce emergence reactions 1

Post-Infusion Monitoring

Observation Period Duration

• Monitor patients for approximately 2 hours post-infusion before discharge 5, 6
• This aligns with esketamine REMS requirements for mandatory 2-hour post-treatment monitoring 5
• Average recovery time is approximately 84 minutes (range: 22-215 minutes) 7

Post-Infusion Vital Signs

• Measure blood pressure every 15 minutes during the post-infusion period 3
• Blood pressures typically return to baseline during post-infusion monitoring 3
• Continue pulse oximetry and heart rate monitoring throughout recovery period 2

Discharge Criteria

• Patient is alert and oriented with stable vital signs 7
• Resolution of any dissociative or psychotomimetic symptoms 1, 4
• Blood pressure has returned to near-baseline values 3

Safety Considerations and Emergency Preparedness

Respiratory Monitoring

• Maintain equipment for airway management and supplemental oxygen readily available 1
• Respiratory depression may occur with overdosage or rapid administration 1
• Have bag-valve-mask ventilation capability on-site 2

Cardiovascular Monitoring

• Ketamine is contraindicated in patients for whom significant blood pressure elevation would constitute a serious hazard 1
• Monitor for arrhythmias and cardiac decompensation, particularly in patients with suspected catecholamine depletion 1
• Decreases in blood pressure and heart rate can also occur, requiring individualized clinical assessment 1

Neurological Monitoring

• Patients with elevated intracranial pressure should be in a monitored setting with frequent neurologic assessments 1
• Monitor for emergence delirium, which may include confusion, excitement, and irrational behavior 1

Special Monitoring for Serial Infusion Protocols

Repeated Dosing Considerations

• For patients receiving twice-weekly or three-times-weekly infusions, monitor LFTs periodically throughout the treatment course 1
• No tolerance develops to blood pressure elevating effects between first and sixth infusions 3
• Continue same monitoring protocol for each subsequent infusion 3

Common Pitfalls to Avoid

• Do not discontinue infusions for mild, transient blood pressure elevations that are expected and clinically insignificant 3, 8
• Avoid aggressive antihypertensive management for asymptomatic, transient blood pressure increases during ketamine infusion 8
• Do not discharge patients prematurely before the 2-hour post-infusion observation period is complete 5, 6
• Ensure continuous monitoring equipment is functioning properly throughout the entire infusion and recovery period 2, 1