Appendix F: Position Statements
i. Ketamine clinics Ketamine administration for severe depression as either a standalone therapy or in combination with electroconvulsive therapy (ECT) has been widely accepted in South Africa and worldwide as an evidence-based treatment modality. Anaesthesiologists are increasingly being asked to assist with delivering ketamine as therapy in these specific situations. Typically, the psychiatrist
i. Ketamine clinics
Ketamine administration for severe depression as either a standalone therapy or in combination with electroconvulsive therapy (ECT) has been widely accepted in South Africa and worldwide as an evidence-based treatment modality.
Anaesthesiologists are increasingly being asked to assist with delivering ketamine as therapy in these specific situations.
Typically, the psychiatrist treating the patient will prescribe and monitor the effects of ketamine on the patient’s general mood and condition, using the anaesthesiologist to administer the ketamine therapy after organising a suitable facility for the therapy to take place.
Initially, this was a hospital-based treatment provided only in standard operating theatres. Over time there has been a proliferation of satellite and “stand-alone” clinics offering ketamine infusions.
SASA has addressed this development with patient safety as a primary concern.
Ketamine is classified as an anaesthetic drug, and as a result, its use requires qualified sedationists.
The use of ketamine in this manner falls under the practice of procedural sedation and anaesthesia.
The SASA Sedation Guidelines published in April 2020 clearly address the conditions necessary for the use of anaesthetic drugs during procedural sedation. The Society believes the same should be extrapolated to the use of ketamine infusions.
General anaesthesia induction agents (propofol, ketamine, etomidate, dexmedetomidine) and short-acting opioids (fentanyl, alfentanil, sufentanil, remifentanil) should only be used by those formally trained in anaesthesia or intensive care medicine, or by experienced sedation practitioners with experience in anaesthesia who are trained in specific advanced sedation techniques. Sedation practitioners using these drugs must have at least a qualification in advanced life support.
Any practitioner involved in these ketamine infusions must ensure that the facilities in which they practice comply with SASA Sedation Guidelines, SASA Practice Guidelines and SASA Private Practice Guidelines.
The monitoring, equipment needed, safety requirements and staff needed for these therapy sessions are dealt with in the SASA sedation guidelines and are typically the same as those needed for routine ECT.
Proper history taking, examination and consent should be standard practice. Appropriate monitoring should be utilised. The dose quoted in the literature ranges from 0.10–0.75 mg/ kg, administered over about 40 minutes. Repeat sessions are common and guided by the psychiatrist.
A responsible adult must accompany the patient home, and only once the patient meets the required discharge criteria. Sedation must not be administered if an escort is not available. Carers must be advised to seek immediate help in case of complications.
Contact details of a physician, hospital, and ambulance service in case of any procedure- or sedation-related adverse events in the first 24 hours after sedation must be included in the information package on discharge.
Patient safety, avoidance of adverse events and the appropriate response should they occur underline the recommendations around the use of ketamine infusions for depression.
Essential
1. Adherence to SASA sedation guidelines in terms of monitoring and equipment
2. One patient at a time per sedationist
3. Sedationists must at least have a qualification in advanced life support
South African Society of Anaesthesiologists (SASA) Practice Guidelines_2022