Table 1 Summary of protocol for administering IV Ketamine for severe alcohol use disorder at Moi Teaching and Referral Hospital

Review of each case by the Hospital Ethics Committee

Determination by the Hospital Ethics Committee that the use of IV ketamine off-label is justified and adheres to ethical principles

To ensure that the benefits to the patient outweigh the risks and all available approved options have been tried unsuccessfully

To ensure that all necessary information on risks and benefits will be given to the patient

Review of each case by the Drug and Therapeutics Committee

Determination by the Drug and Therapeutics Committee that it is safe to use IV ketamine for a particular patient

To ensure safety issues are addressed and to limit the occurrence of adverse events

Consenting procedures

Determination of decisional capacity using validated and standardized tools

To ensure that the patient has the mental capacity to understand the risks and benefits of the intervention and can give informed consent

Obtain written consent from the patient after a detailed discussion of the risks and benefits of the treatment

To ensure that the patient voluntarily agrees to undergo treatment after an explanation of the risks and benefits

Psychoeducation to family and Obtaining concurrence of family or other significant Next of Kin

To ensure that important support systems for the patient understand the goal of the intervention and are willing to support the patient

Patient preparation

Perform the following laboratory tests: complete blood count, liver function tests, renal function tests, random blood sugar

To limit the occurrence of adverse events and to allow for adverse events monitoring. Ketamine use may result in adverse renal and hepatic events and may cause hypoglycemia [26, 27]

Conduct a drug toxicology screen

To rule out ketamine abuse and avoid ketamine overdose which could result in serious adverse events such as cardiovascular and respiratory depression [28]

Perform an electrocardiogram (EKG)

To allow for adverse events monitoring. Ketamine can cause conduction abnormalities and arrhythmias [26, 27]

Perform a head computed tomography scan

To rule out head injury, often associated with heavy alcohol use or alcohol withdrawal

Conduct substance use and other psychiatric assessments as indicated using standardized and locally validated assessments

To facilitate objective assessments of improvement in substance use and comorbid psychiatric symptoms

Admission for procedure 1–2 days prior

To allow for the above investigations and preparations to be conducted

Dosing

Administer a single infusion of low-dose ketamine as follows: a 2-min 0.11-mg/kg bolus in saline followed by a 50-min slow-drip IV infusion of 0.6 mg/kg

The dosing schedule is informed by a study conducted by Dakwar et al. [20]

Patient monitoring during and after infusion

Monitor blood pressure, conduct cardiac monitoring (EKG), pulse oximetry, and assessment for level of consciousness

Perform monitoring of the above parameters before infusion, periodically, or continuously throughout the infusion. Do not discontinue monitoring until any adverse effects (respiratory, cardiac, neurologic, or psychiatric symptoms) have resolved

Ensure availability of pulse oximetry in the event of respiratory depression requiring an airway intervention to assure adequacy of respiration

We adapted these guidelines from the Pennsylvania Guidelines for Safe administration of Low-dose Ketamine [27]. The guidelines recommend that at the minimum, the patient monitoring requirements indicated here are fulfilled [27]

Psychosocial support

Offer psychosocial support pre and post administration including education to family

The use of medication off-label may be stressful and cause anxiety to patients and families. It is important to offer psychosocial support so that the emotional and mental health needs of patients and families are met throughout the process

Follow-up

Follow-up and repeat laboratory investigations and substance use and other psychiatric assessments (as indicated) at months 1,3 and 6

To monitor both the long and short-term outcomes of the intervention