Ketamine: risks and advantages

In October 2023, Hollywood was shocked by the death of “Friends” star Matthew Perry. Perry had struggled with drug addiction for many years and was undergoing ketamine infusion therapy for depression and anxiety. Toxicology reports stated that his death was attributable to the “acute effects of ketamine” (Dalton, 2023). The use of ketamine to treat depression has increased over the past decade, and although research has shown that it may rapidly alleviate treatment-resistant depression (Thase and Connolly, 2023), Perry’s death reminds us that ketamine is a robust drug and that its effects can’t be disregard. Let’s take a take a look at ketamine, its effects, risks and advantages, and what nurses should find out about this powerful drug.

What is ketamine?

Ketamine hydrochloride is a “dissociative anesthetic hallucinogen” that produces sedation, immobility, pain relief, and amnesia (United States Drug Enforcement Administration [DEA], n.d.). It changes the perception of sight and sound and makes the person feel disconnected from the pain and surroundings. Ketamine is approved by the Federal Drug Administration (FDA) as a short-acting injectable anesthetic, used alone or together with other drugs. Esketamine (Spravato®), a derivative of ketamine, was approved by the FDA in 2019 as a nasal spray for the treatment of refractory depression in adults, together with an oral antidepressant (DEA, n.d.; Facts and Comparisons, 2023b), in addition to the drug antidepressant. symptoms in adults with major depressive disorder with suicidal thoughts or actions.

Unregistered uses of ketamine (facts and comparisons, 2023a)

Ketamine has been studied and really useful by skilled medical societies for off-label use within the treatment of a wide range of disorders that include:

• Severe agitation and aggressive behavior
• Pain (neuropathic, peripheral nerve damage, fibromyalgia, cancer, musculoskeletal damage)
• Depressive episode (severe, treatment-resistant) related to major depression (unipolar): ketamine produces an antidepressant response lasting roughly 7 days.
• Analgesia/sedation/agitation in mechanically ventilated patients within the intensive care unit (ICU)
• Rapid sequential intubation outside the operating room
• Status epilepticus, proof against treatment

Ketamine and Esketamine Dosage (Facts and Comparisons, 2023a)

Dosage will vary depending on the specified effect, the patient’s age and underlying diseases. Children metabolize ketamine faster than adults and may have the next dose. Elderly patients metabolize ketamine slowly, requiring a lower dose. When used together with other drugs similar to intravenous benzodiazepines or narcotics, dose adjustment is vital. Please seek advice from your facility’s policy or reputable drug references for specific dosing information and necessary clinical considerations.

Esketamine (Spravato®) may only be administered in healthcare settings certified within the Spravato® Risk Evaluation and Mitigation Strategies (REMS) program as a consequence of its high risk of sedation and dissociation and potential for abuse and misuse (FDA, 2019).

Nursing Considerations (Facts and Comparisons, 2023a; Thace and Connolly, 2023)

• • Patients taking any drug must be under the care of a psychiatrist to evaluate the suitability of the drug and monitor the effectiveness of treatment; should only be administered by experienced personnel
  • Contraindicated in conditions where a rise in blood pressure could be dangerous (aortic dissection, uncontrolled hypertension, myocardial infarction or aneurysm)
  • Use with caution in patients with
    • Increased intraocular pressure (IOP)
    • Increased cerebrospinal fluid (CSF) pressure.
    • Chronic alcohol use disorder
  • Both drugs are Schedule III controlled substances under the US Controlled Substances Act. Illegal use of ketamine includes snorting or inhaling it and consuming it with food.
• • When administering ketamine, prepare for intubation.
  • To reduce the danger of respiratory depression and apnea, intravenous bolus doses must be administered over 30 to 60 seconds.
  • Avoid or use with caution in patients with substance use disorders.
  • Before administration, the patient’s risk of abuse or misuse, psychosis, and consideration of cardiovascular and cerebrovascular problems must be assessed.
  • For the treatment of refractory unipolar depression, administer ketamine intravenously over 40 minutes.
  • Ketamine could also be useful in patients with hypotension or in patients who may develop hypotension.
  • Emerging delirium could also be alleviated by reducing the really useful dose, using it together with benzodiazepines, and/or limiting noise and tactile stimulation during administration. Diazepam at a dose of two to five mg intravenously over 1 minute can reduce the onset of delirium (Rosenbaum, Gupta, Patel, & Palacios, 2023).
    • Do not mix ketamine directly with barbiturates or diazepam as precipitation may occur.
• • The patient must be advised to avoid eating for at the very least 2 hours and drinking fluids for at the very least half-hour before administration.
  • Do not administer medications similar to intranasal steroids or decongestants inside 1 hour of intranasal administration.
  • Patients self-administer the nasal spray under the supervision of a healthcare skilled, and the spray can’t be taken home.
  • Esketamine may worsen suicidal ideation/behavior, psychosis, ulcerative or interstitial cystitis, and liver dysfunction.
  • Patients shouldn’t drive, operate heavy machinery or engage in other hazardous activities for as much as 24 hours after administration.

Monitoring

• Vital signs: heart rate, blood pressure, respiratory rate, oxygen saturation
  • Esketamine: Monitor respiratory status for at the very least 2 hours after each treatment.
• Level of sedation
• Heart function
• Liver function tests (LFT), alkaline phosphatase and gamma-glutamyltransferase (initial and periodic)
• Pain control (when treating pain)
• Monitor closely for worsening depression and signs of suicidal thoughts and behavior.

Full details about ketamine and esketamine will be present in the medication’s package leaflet or within the Nursing2024 Medicines Manual + medicines updates.

Dalton, A. (2023, December 15). The autopsy report concluded that Matthew Perry died from the consequences of ketamine. Related press. https://apnews.com/article/matthew-perry-death-cause-054e67f7495845804f801c57a1ae2522

Facts and Comparisons (2023a, December 18). Ketamine injection. https://fco.factsandcomparisons.com/lco/action/doc/retrieve/docid/fc_dfc/5549394?cesid=4QjeBb46v2i

Facts and Comparisons (2023b, December 18). Intranasal esketamine. https://fco.factsandcomparisons.com/lco/action/doc/retrieve/docid/fc_dfc/6778130?cesid=5L6lYpfQbWI

Federal Drug Administration. (2019, March 5). FDA Approves New Nasal Spray Drug for Treatment-Refractory Depression; available only in certified doctor’s offices or clinics. FDA press release. https://www.fda.gov/news-events/press-announcements/fda-approves-new-nasal-spray-medication-treatment-responsive-depression-available-only-certified

Rosenbaum, S. B., Gupta, V., Patel, P., & Palaces, J. L. (2023, May 26). Ketamine. [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470357/

Thase, M., & Connolly, K. R. (2023, August 24). Ketamine and esketamine for the treatment of unipolar depression in adults: administration, effectiveness, and unwanted side effects.
https://www.uptodate.com/contents/ketamine-and-esketamine-for-treating-unipolar-depression-in-adults-administration-efficiacy-and-adverse-effects

United States Drug Enforcement Administration (n.d.). Ketamine. Retrieved December 28, 2023 from https://www.dea.gov/factsheets/ketamine