Overview of Ketamine Infusion Therapy
By Philip Getson, DO
By Philip Getson, DO
Patricia Curiale led an active life until an auto accident in 1998 triggered CRPS. After five years of living with pain that she rates “50 on a scale of 10,” she was enrolled in our outpatient program that uses ketamine to treat CRPS when other conventional treatments fail. Ketamine is an anesthetic previously used in the operating room and for emergency situations in patients with unknown medical history (eg, traffic accidents).
Ms. Curiale frankly credits the ketamine with saving her life. “I can understand putting a gun to your head to stop the pain,” she says. Although she currently rates her pain at “about a 5,” she can live with that. Plus, she has been able to get out of her wheelchair and walk, something a previous physician swore would never happen.
She is one of many people who have CRPS and who have taken part in a program that I run with Robert J. Schwartzman, MD, Drexel University College of Medicine in Philadelphia. Currently we are collecting data on an outpatient “awake” ketamine protocol for patients who have tried more conventional therapies without long-term benefit.
Elena King-Stoltz, who has full-body CRPS, had tried Bier blocks, spinal blocks, an intrathecal pump and other treatments since being diagnosed in 1992, but still experienced high levels of pain. She has been on the ketamine program for almost a year now. “I mowed my lawn for the first time in 10 years,” she says.
The program can be done on both an inpatient and outpatient basis. Before beginning either therapy, we do laboratory, cardiac, and psychological evaluations.
While we have had NO significant adverse events, we have been extremely cautious in screening patients with concurrent medical problems. The two most common reasons a patient would be eliminated are a psychiatric history of note (apart from the depression due to chronic pain) and cardiopulmonary disease.
Hospital-based infusions
The hospital-based infusions require a five-day in-patient stay. An intravenous (IV) line is inserted and the patient is started on a dose of 20mg of ketamine per hour, which is increased by 5mg increments to a maximum of 40mg per hour. As an adjunct, we are using clonidine, 0.1 mg (per FDA). We use small doses of lorazepam (Ativan®), 1-to-2 mg, for any dysphoria or hallucinations. Other medications are utilized to treat such problems as nausea and vomiting, headache etc.
The most common adverse event is fatigue. There have been some instances of short-term hallucinations related to dosage, but these have disappeared within an hour of lowering the dosage.
The accumulated data over three years has heretofore shown no significant lasting adverse events. Dr. Schwartzman and I have treated more than 100 patients. We had one patient with bradycardia in which the 5-day infusion was terminated.
Following discharge from the hospital, patients enroll in an outpatient infusion program of varying degrees and lengths. Initially, they are treated 1-to-2 times a week for a 4-hour IV infusion of 100 mg to 200 mg of ketamine. The frequency of outpatient treatments is weaned over time. Currently, we are using a protocol that consists of two outpatient treatments a week every other week for one month, then one treatment every other week for a month then monthly for three months then every three months. This protocol is merely a general guideline however and varies at times. Then one outpatient treatment the following month, after which we reassess the patient. Outpatient visits are then monthly, or at 3-month intervals, depending on the patient.
Outpatient protocol
Alternatively, the patients are given therapy only on an outpatient basis. They are given 10 daily treatments initially in two consecutive weeks in an outpatient infusion suite. They are administered from 70 mg-to-200 mg of ketamine per day in titrating doses over the 10-day timeframe and then they are placed in the outpatient program as described above. Again, there have been few adverse events and most of them have been dosage related. As before, the most common is fatigue on the day of the infusion. There have been NO long term side effects. Most patients are given 2 mg of midazolam and sleep through the procedure. Other medications are given as needed for side effects such as nausea and headache.
Okay, well, there is so much discussion, I will let the chips fall where they may.
This is a repost-In the spirit of intending to educate, not to do anything more: on the CORRECT administration of ketamine, as opposed to surgical centres that opreate on numbers I can't even begin to think of... And then??? Whamo! It implodes on you when you find out that the doc you paiid hundreds of thousands?? He didn't do it right: THAT IS WHY I POST THE ARTICLE
AND Link my SOURCES!!!
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