In 2005, at the urging of Dr. Robert Schwartzman, Dr. Prager performed the first ketamine infusion for chronic pain in California.  Dr. Schwartzman, one of the world leaders in treatment and research related to complex regional pain syndrome had performed research initially in Germany and later in the United States regarding the use of ketamine for complex regional pain syndrome.  

In Germany, they induced ketamine coma for 5 days on the most difficult cases with remarkable short-term results.  This prompted Dr. Schwartzman to begin research on outpatient ketamine treatment and in 2005 his important work was published (See reference).  Dr. Schwartzman contacted Dr. Prager who had a thriving complex regional pain syndrome practice and indicated to Dr. Prager that if he wanted to have a state of the art CRPS practice he had to include ketamine infusions in his treatment options for patients.  

Dr. Prager started using ketamine extremely conservatively according to the same protocol that Dr. Schwartzman had published.  However, as an anesthesiologist, he felt comfortable increasing the dosages, monitoring for side effects and achieved impressive results.  The program has increased in volume in the time since 2005 and has now performed approximately 7000 infusions.  

Ketamine is administered by intravenous infusion in a state-of-the-art licenses outpatient surgical facility recovery room.  The ketamine patient are staffed by a physician, who is board certified in Pain, as well as highly skilled nurses. All nurses have extensive cardiac care unit, intensive care unit or emergency room experience and have worked with Dr. Prager for decades.   There is one physician supervisor at all times and the care is carried out by these critical care nurses.   

Because ketamine is known to have potential side effects, for the first 10 years of performing infusions, all side effects were cataloged and pharmacological solutions were determined to be successful. 

Before committing to a full course of ketamine infusion treatment, the patient is given a 3 consecutive day trial of ketamine.  Doses are started modestly and increased daily during the 3 day trial.  Adjuvant medications are provided.  The purpose of the trial is two fold: 

1. To determine whether at the end of 3 days the patient will potentially benefit from full ketamine treatment.  
2. To determine if all side effects can be managed so that the patient can tolerate a 10 day infusion.  

The 10-day infusion is performed Monday through Friday during 2 consecutive weeks for patients who have had a successful 3 day trial.  Doses are escalated on a daily basis, depending on how well the patient is tolerating the infusion.  

Most of our patients after the 10 day infusion, receive at least 3 months of relief and are able to assume normal activities of daily living.  At the end of 3 months, approximately half the patients do not need further ketamine and the remaining half return for booster treatment.  We have found the patients who participate in our comprehensive interdisciplinary functional rehabilitation program have a greater chance of not requiring ketamine at the end of 3 months.  The rehabilitation program, for those who participate, commences the week after the 10 ketamine infusions are completed.  

The potential benefits of ketamine infusion is pain relief, possibly reduced swelling and often vast improvements in mood.  

The side effects of ketamine are numerous.  We spent more than a decade analyzing patients who had side effects from ketamine in order to develop a pharmacological regimen to vent or significantly diminish these side effects.  Side effects include: 

Post infusion medication is administered that usually significantly diminishes the headache.  

Nausea is a common side effect of ketamine that can be minimized by providing a variety of anti-nausea medicines.  There is one class of medications that is often used for chemotherapy patients that is found to be considerable effective.  If this medication is not effective there is a stronger medication from the same family that is more effective.  Sometimes, the nausea maybe caused by some dysequilibrium that temporarily is caused by the ketamine.  When this occurs, medications that are used for sea sickness either has a patch or a pill are used.  We note that patients who ride in a car for a considerable distance after ketamine infusions are more likely to have nausea so for this reason we do not recommend commuting from a great distance. 

Hallucinations have traditionally been a significant side effect for ketamine when used as an anesthetic in the operating room.  From a pharmacological standpoint, we have developed a regimen that we deliver before the ketamine infusion starts that significantly diminishes or eliminates hallucinations during the treatment.  

We prescribe medications before sleep for the 7 days after ketamine treatment.  In addition, we may provide some medication at the time of treatment that would minimize the possibility of nightmares.  Nightmares have not been a problem in our practice in many years. 

With the use of intermittent pressure to the legs, thrombus in the legs has been eliminated as a problem.  We also provide patients with one baby aspirin per treatment to help prevent blood clots from forming while lying still for the length of the time of the infusion.  

With the use of intermittent pressure to the legs, thrombus in the legs has been eliminated as a problem.  We also provide patients with one baby aspirin per treatment to help prevent blood clots from forming while lying still for the length of the time of the infusion.  

These are extremely rare and we monitor for this by drawing blood work to see if liver function tests have changed.  We have not had a significant case where it was necessary to discontinue treatment.

Ketamine infusion can leave a patient somewhat disoriented.  This can last up to a day or two after the 10th infusion.  The disorientation goes away by itself without the use of any medication.  There is only a small percentage of patients that experience this and it is a self limited phenomena.

Ketamine infusions for pain generally require a stay of 7 hours at the surgical facility. In the first hour, preparations for the infusions are made, and paperwork is completed. Monitors are applied, and intravenous line is established and preoperative medications are provided.

For the next 4 hours ketamine infusion is performed. Once the infusion is completed, patients stay an average of 2 additional hours to recover from the ketamine. If side effects are noted at the completion of the ketamine infusion, medications are provided to ameliorate the side effects.

Thus, with 1 hour of preparation, 4 hours of infusion and 2 hours of recovery, the entire process for ketamine infusions is approximately 7 hours.

Regarding the stay for ketamine infusions we highly recommend against long periods of transportation following the ketamine infusion because it causes nausea. For this reason, we have arranged a contract with a quality local hotel to provide a discounted rate of less than $100 per day. Most patients from out of town choose to reside at this hotel during the infusions.

Should a patient request nursing care immediately following the infusion, private nurses are available to be contracted to provide services for the several hours after the infusion for patients who desire to use this service.

We have been performing ketamine infusions for depression for more than a decade in collaboration with local psychiatrists.