Informed Consent

INFORMED CONSENT FOR KETAMINE INFUSION

Since the early 1960s, the Food and Drug Administration (FDA) has required drugs used in the United States be both safe and effective. The label information on the container, in the package insert, in the Physician’s Desk Reference (PDR) and in any advertising can indicate a drug’s use only in certain “approved” doses and routes of administration for a particular condition. The use of a drug for a disease not listed on the label, or in a dose, or by a route not listed on the label is considered to be an “off- label” use of the drug. Physicians, based on their knowledge and on available current information, may use a drug for a use not indicated in the “approved” labeling if it seems reasonable or appropriate.

Ketamine has not been approved by the FDA to treat depression, bipolar disorder, or PTSD.

  1. PROCEDURE – KETAMINE INFUSION THERAPY
    An intravenous line (IV) will be started in an extremity so you can receive ketamine. Your blood pressure, heart rate, and oxygen saturation will all be monitored throughout the infusion under the supervision of a physician.
  2. RISKS/SIDE EFFECTS
    Risk of ketamine: Side effects normally depend on the dose and how quickly the injection is given. The dose being used is lower than anesthetic doses and will be given slowly over 40-60 minutes. These side effects often go away on their own.
    Common side effects, greater than 1% and less than 10%:

    • hallucinations
    • nausea and vomiting
    • increased saliva production
    • dizziness
    • blurred vision
    • increased heart rate and blood pressure during the infusion -out of body experience during the infusion
    • change in motor skills

    These symptoms dissipate when the infusion is stopped. If they are severe, another medication such as a sedative can be used to treat the symptoms. You should not drive the day of an infusion and can resume driving the following day.
    Uncommon side effects, greater than 0.1% and less than 1%:

    • rash
    • double vision
    • pain and redness in the injection site -Increased pressure in the eye
    • jerky arm movements resembling a seizure

    Rare side effects, greater than 0.01% and less than 0.1%:

    • allergic reaction
    • irregular or slow heart rate
    • arrhythmia
    • low blood pressure
    • cystitis of the bladder: inflammation, ulcers, and fibrosis

    Other Risks:

    • Ketamine can cause various symptoms including but not limited to flashbacks, hallucinations, feelings of unhappiness, restlessness, anxiety, insomnia and disorientation.
    • There is a potential risk of dosing error or unknown drug interaction that may require medical intervention including intubation (putting in a breathing tube), or hospitalization.
    • The risk of venipuncture may include temporary discomfort from the needle stick, bruising, or infection. Fainting may also occur.
    • Risk of discomfort in answering questionnaires about your mental health and drug and alcohol use.
    • Risk of other medications interacting with ketamine. It is very important that you disclose all medications, both prescription and over the counter, that you are taking.
    • Ketamine may not help your depression, bipolar disorder, or PTSD

    Benefits:
    Ketamine infusion for refractory Major Depressive Disorder with Suicidal Ideation has been shown to be as effective as ECT (electro convulsive therapy). Ketamine has been associated with a decrease in depression, bipolar, and PTSD symptoms with results lasting for days to weeks to months. There is no way to predict how any single person will respond to ketamine infusion therapy. These effects may not be long lasting and will most likely require further infusions.
    Post Infusion Instructions:
    You must report any unusual symptoms or side effects at once to the medical staff
    On the day of the infusion, you should NOT engage in any of the following up to 12 hours after the infusion:

    • driving
    • drinking alcohol or using drugs
    • conducting business
    • participating in activities which require you to rely on motor skills or memory

    If your IV has been left in place do not allow the dressing to become wet. If you need to bathe, cover the entire extremity with a plastic bag and use tape and/or rubber bands to seal it.
    If your IV has been removed, keep a Band-Aid or other sterile dressing on the puncture site and keep it dry for twelve hours. Thereafter, inspect the site for any unusual signs of inflammation or infection and notify our clinic if this present.
    Ketamine infusions may help with your depression but are not intended to be a substitute for regular care by your mental health professional. Therefore, maintain any regularly scheduled visits with your primary care physician, psychiatrist, and /or therapist. If you have thoughts of suicide or any medical emergencies, call 911 or go directly to an emergency room and contact your mental health professional and / or primary care physician.

  3. VOLUNTARY NATURE OF THE TREATMENT
    You are free to choose to receive or not receive the ketamine infusion. Please tell the doctor if you do not wish to receive the infusion.
  4. WITHDRAWAL OF TREATMENT
    Your doctor has the right to stop the infusion at any time. They can stop the infusion with or without your consent for any reason.
  5. PATIENT CONSENT
    • I know that ketamine is not an FDA approved treatment for depression, bipolar disorder, or PTSD.
    • I know that my taking part in this procedure is my choice.
    • I know that I may decide not to take part or to withdraw from the procedure at any time.
    • I know that I can do this without penalty or loss of treatment to which I am entitled.
    • I also know that the doctor may stop the infusion without my consent.
    • I also know that ketamine infusion therapy may not help my depression, bipolar, or PTSD.
    • I have had a chance to ask the doctor questions about this treatment.
    • They have answered those questions to my satisfaction.
    • The nature and possible risks of a ketamine infusion have been fully explained to me.
    • The possible alternative methods of treatment, the risks involved, and the possibility of complications have been fully explained to me.
    • No guarantees or assurances have been made or given to me about the results that may be obtained.

Informed Consent

I have read and understand the Informed Consent for Ketamine Infusion

Signature Section