What are the requirements for administering IV (intravenous) ketamine to an adult patient with treatment-resistant depression in a psychiatric office?

Requirements for Administering IV Ketamine in a Psychiatric Office

To safely administer IV ketamine for treatment-resistant depression in a psychiatric office, you must have emergency airway equipment immediately available, continuous vital sign monitoring capability, trained staff for patient observation during and for 2 hours post-infusion, proper dilution equipment, and protocols for managing dissociative symptoms and hemodynamic changes. 1

Essential Equipment and Safety Infrastructure

Emergency Preparedness

• Emergency airway equipment must be immediately available at the point of care, as ketamine can cause respiratory depression with rapid administration 1
• Continuous monitoring equipment for blood pressure, heart rate, and oxygen saturation throughout the 40-minute infusion and recovery period 1, 2
• Resuscitation equipment and medications for managing cardiovascular complications, as ketamine produces dose-dependent increases in heart rate, blood pressure, and cardiac output 3

Medication Preparation Capabilities

• The 100 mg/mL concentration must never be administered IV without proper dilution 1
• For the standard 0.5 mg/kg dose: dilute with equal volume of Sterile Water, Normal Saline, or 5% Dextrose and use immediately after dilution 1
• Sterile preparation area with appropriate IV supplies and infusion pumps capable of delivering precise rates over 40 minutes 1

Clinical Protocols and Monitoring

Patient Selection Criteria

• Verify at least 2 failed adequate antidepressant trials (minimum 4-6 weeks at therapeutic doses) to confirm treatment resistance 4, 5
• Confirm moderately severe depression using standardized rating scales 5
• Screen for contraindications: ischemic heart disease, cerebrovascular disease, or uncontrolled hypertension, as ketamine stimulates the sympathetic nervous system 3

Standard Treatment Protocol

• Administer 0.5 mg/kg IV infused over 40 minutes (not faster, as rapid administration causes respiratory depression and enhanced vasopressor response) 4, 1
• Frequency: twice weekly until remission or completion of 4-6 total infusions 4, 5
• Consider antisialagogue administration prior to induction due to potential for salivation 1

Post-Administration Monitoring

• Mandatory observation for at least 2 hours post-infusion to monitor for dissociative symptoms, hemodynamic changes, and psychotomimetic effects 3
• Approximately one-third of patients experience protocol-defined hemodynamic changes requiring monitoring 2
• Common immediate side effects include drowsiness, dizziness, poor coordination, blurred vision, and feeling strange or unreal in the first 4 hours 2

Staffing Requirements

Training and Competencies

• Clinicians must acquire necessary training and experience before implementing a ketamine program 3
• Staff trained to recognize and manage dissociative symptoms (occur transiently in some patients) and emergence reactions (floating sensations, vivid dreams, hallucinations, delirium in 10-30% of adults) 3, 2
• Personnel capable of assessing response using standardized scales (≥50% reduction in depressive symptoms at 24 hours post-infusion) 4, 5

Supervision Capacity

• Sufficient staff to provide continuous observation during infusion and 2-hour post-treatment period 3
• Ability to manage psychotomimetic effects: hallucinations occur in ~20% and nightmares in ~12% of patients at 0.5 mg/kg 4

Regulatory and Documentation Requirements

Clinical Documentation

• Protocols for documenting baseline depression severity, treatment response at 24 hours, and adverse events 5, 2
• Systems for tracking response rates, remission rates, and time to relapse (average 19 days post-treatment, range 6-45 days) 6
• Documentation of informed consent addressing off-label use, potential for dissociative symptoms, and limited long-term safety data 3

Quality Assurance

• Protocols for managing the 1.95% of infusions that may require discontinuation due to adverse events 2
• Systems for identifying patients requiring cessation if genitourinary pain develops (reported in chronic ketamine users) 1

Common Pitfalls to Avoid

• Never administer the 100 mg/mL concentration without dilution - this is the most critical safety error 1
• Do not infuse faster than 40 minutes to avoid respiratory depression and enhanced vasopressor response 1
• Avoid use in patients with ischemic heart disease, cerebrovascular disease, or hypertension without careful risk-benefit assessment 3
• Do not use as initial treatment - ketamine is reserved for patients who have failed at least 2 adequate antidepressant trials 3
• Do not discharge patients before adequate observation period, as dissociative and psychotomimetic effects require monitoring 2