Ketamine and hypertension - Kata Canada
Ketamine and hypertension - Kata Canada

Ketamine and Hypertension - What matters to Patients?

Ketamine produces a sympathomimetic response, typically leading to tachycardia and hypertension. Most often this elevation is modest, in keeping with light exercise. Concerns have been raised that ketamine therapy should be denied to those with hypertension, or those with cardiovascular risk factors. Some physicians advocate for the emergent treatment of ketamine associated hypertension (KIH) when it occurs during Ketamine Assisted Therapy (KAT).

Epidemiology Moment

Fundamental to evidence based medicine are the concepts of patient oriented outcomes versus disease oriented outcomes.  Patient oriented outcomes are the things that matter to people; mortality, loss of a limb, hospitalizations, days sick. Disease oriented outcomes are surrogate markers that may correlate to clinical outcomes, such as cholesterol levels predicting heart attacks or uric acid for gout. However, disease oriented outcomes are often of less importance to patients than patient oriented outcomes – a drug that lowers cholesterol numbers but leads to painful leg cramps is unlikely to be acceptable.

Returning to hypertension, the initial recommended treatment is diuretics or ace inhibitors, medications that have both been shown to reduce blood pressure, and more importantly, to decrease long term mortality. Beta blockers are used only later in therapy, because despite being very effective in lowering blood pressure, they produce little to no effect on mortality. This represents a problem when a disease oriented outcome (blood pressure number) does not correlate with a primary patient oriented outcome (mortality).  We have long realized that there is little point in treating a number if there is no benefit to the patient.

Another Epidemiology Moment

Number needed to treat (NNT) – Simply put, this is the inverse of the number of people who got better out of the number given the medication or treatment.  A very effective medication is dexamethasone, which has an NNT of 7 in the treatment of croup; for every 7 children treated, one gets better. On the other hand, antibiotics for sinusitis are not recommended because the NNT for benefit is 17, higher than the NNH of 8 for harms, which means that one in eight had significant side effects, while only one in 17 was helped.

The treatment of hypertension has a surprisingly high NNT. In 125 people who take blood pressure medication for five years, one fewer will die. Even when taking blood pressure medication to prevent stroke, 67 people must take medication for five years to avert 1 stroke.  The difficulty in treating hypertension is managing the side effects which are much more common than the benefits, with an NNT of 10 for harms or stopping medication.  While the benefits to the individual are relatively low, we know that by treating people on a population basis, we can avert significant numbers of heart attacks and strokes.  But, it is important to understand that the majority of people taking these medications are not helped.

Hypertension and end-organ damage

The reason for treating hypertension is that over the long term, years to decades, persistent elevated blood pressure produces damage to blood vessels and increases the risk of heart attack, stroke, and other cardiovascular diseases. End organ damage is the term used for the pathology caused by persistent elevated blood pressure and is manifested as retinopathy and vision loss, kidney failure, heart failure, atherosclerosis, and cerebral ischemia. However, all of these take considerable time to develop.  A Canadian study followed over 30,000 people who presented with asymptomatic high blood pressure for 2 years and found that there was no increased risk for cardiovascular outcomes, even in the group that presented with BP >180/110. 

From exercise physiology, it is also understood that transient increases in blood pressure do not result in adverse outcomes by themselves.  Under heavy resistance, athletes can generate systolic blood pressure greater than 300 mm Hg with no adverse effects.  

This evidence suggests that transiently acutely elevated blood pressure without end organ damage is a very poor surrogate marker for acute events. 

A hypertensive emergency is defined as significantly elevated blood pressure accompanied by signs of end organ damage, such as confusion, chest pain, shortness of breath or visual loss. Hypertensive emergency is very rare, while asymptomatic hypertension (AHT) is very common. In the absence of end organ damage, the American College of Emergency Physicians recommends that patients who present with AHT be discharged, with or without treatment, to be seen by their primary care provider.  For AHT, acute treatment with antihypertensive medication is discouraged as this can lead to acute harms.

The American College of Cardiology notes that recreational drugs such as cocaine, amphetamine and “bath salts” have the potential to increase blood pressure. They do not recommend acute treatment with hypertensives in the absence of end organ damage, but rather waiting until the effects of these substances wear off. This is consistent with general practice in the emergency room, where the elevated blood pressure is a recognized side effect of these substances, rather than representing pathology.

While blood pressure is recognized as a vital sign, low blood pressure is more highly associated with acute pathology than high blood pressure.

In order to calculate the number needed to harm (NNH) from elevated blood pressure due to ketamine, we would need to express this as the number of acute harms associated with acute ketamine administration over the number of patients who have received ketamine (this could be in any setting, including the emergency department). The harms should be patient oriented rather than disease oriented, particularly in that we have shown that transient AHT is a poor surrogate for acute disease. In a recent systematic review of side effects associated with the use of ketamine depression, there were no reports of myocardial infarction or stroke in 60 studies of almost 900 patients. While it is likely that there could be some unreported episodes of bad cardiovascular outcomes from ketamine therapy, based on the evidence, the NNH is a very large number, approaching infinity.

Although it makes sense to avoid ketamine use in those with poor cardiac reserve (i.e. unable to climb two flights of stairs), mistaking elevated blood pressure for a bad outcome is likely to unnecessarily limit access to ketamine therapy. More concerning are protocols for the treatment of elevated blood pressure due to ketamine; these are likely to outlast the effects of the ketamine and rapid lowering of blood pressure is associated with bad outcomes in a way that acute elevations of blood pressure are not.

job posting: Executive Director Administrative assistant

Start Date: July 30, 2020
Job Title: Administrative Assistant
Reports To: Exucutive Director

Are you on the hunt for a new and dynamic challenge? Do you thrive in an organization committed to growth and innovation? Are you looking to grow your organizational skills while contributing to positive community and policy change in the field of mental health?

Ketamine Assisted Therapy Association of Canada

The Ketamine Assisted Therapy Association of Canada (KATA) is an interdisciplinary, not-for-profit organization that advances ketamine clinical practice by providing high level practice standards through the development of resources, education and policy recommendations. KATA is a member-based organization that consists of Psychiatrists, Emergency Physicians, Family Medicine Physicians, Naturopathic Doctors, Psychologists, Registered Counselors, Registered Nurses, Social Workers, Researchers, Policy Makers and patient partners – it was established in 2019 in the province of B.C., Canada.

 

KATA protects the public interest by supporting practitioners and physicians to gain appropriate ketamine training and experience that is aligned with current best evidence of safety and ethical recommendations. KATA supports ketamine providers to deliver ketamine assisted therapy in a safe and transparent manner that respects patient values.

The Administrative Assistant role will report to the Executive Director and work with the Working Groups and Board to grow our current member base and organizational reach by providing administrative support for our internal and external communication, public relations, member recruitment and organization activities. This is an organizational development role, therefore we are seeking an entrepreneurial, keen individual that loves to uncover opportunities, promote our offerings and ultimately convert conversations into members.

KATA is committed to fostering justice, equity, diversity and inclusion (JEDI) principles. We will not discriminate in our employment or membership practices due to an applicant’s race, age, color, religion, sex, national origin, immigrant and newcomer status, sexual orientation, gender identity, gender expression and/or disability

Duties and responsibilities:

  • Not-for-Profit Relationship Management: Strengthen customer relationships by fielding questions regarding programs and services and following up with program participants.
  • Member communication, data compilation and analysis: Implement and manage member communications, onboarding and communications systems, event management, email and newsletter communication systems. Set guidelines related to data collection and ongoing management to ensure accuracy and integrity. Compile and analyze data and prepare reports
  • Partnerships: Manage tracking and reporting requirements of partnerships with other organizations, government agencies and regulatory bodies
  • Organizational Development: Provide support to the Executive Director in managing Board and Working Group communications, meeting rhythms, agendas and notes, preparing policy and external communication briefs
  • Meeting Support: KATA Canada sometimes holds meetings and events for members outside of regular work schedule hours so some weekday evening availability is required
  • Perform a variety of tasks and other duties, as required.

Qualifications:

  • Communication skills: Excellent written and verbal client service and communication skills. Relationship-building is a key component of this position.
  • Technical Knowledge: Comfort with technology including Member Organization & Communication Platforms and Content Management Systems. Excellent skills with MS Office Suite and Google Drive. Aptitude for and interest in learning new technology and social media as the organization grows.
  • Adaptive Capacity: Passionate, entrepreneurial spirit with capacity to take risks and manage change. Ability to work within and foster a “learning organization”.
  • Job Knowledge: Clearly understand the mission and demonstrate the values of the organization. Understands volunteerism and the not-for-profit sector, and keeps job knowledge up-to-date.
  • Dependability: Possesses initiative, ability and commitment to producing high quality work independently and as part of a team. Ability to multitask and manage details with excellence while ensuring the organization’s goals and strategies are met.
  • Initiative: Can think critically and act logically to evaluate situations and generate required steps to ensure success. A self-starter who can set and achieve goals, and organize and manage a high-volume workload

WORKING CONDITIONS AND BENEFITS:

  • This is a Part-time Hourly Contractor position starting July 30th, 2021
  • Hourly rate for the role is $20/h for 15 – 25 hours per month.
  • If you are interested in this position, please email your resume and cover letter to
    [email protected] with the subject line: Administrative Assistant. We look forward to
    connecting with you.

“Parenteral Use of Ketamine for the Treatment of Mood Disorders” – COLLEGE OF PHYSICIANS AND SURGEONS OF BC FEEDBACK REQUEST DEADLINE PASSED

The College of Physicians and Surgeons of British Columbia’s Non-Hospital Medical and Surgical Facilities Accreditation Program recently put out a set of draft standards for “Parenteral use of Ketamine for the Treatment of Mood Disorders.”  This document will eventually become the mandatory guidelines for Ketamine IV/IM/SC therapies for depression.  They accepted feedback in the form of letters and surveys ending on Feb 17, 2021.  

The draft standards outline that IV/IM/SC ketamine treatments must be conducted in a “non-hospital accredited facility” with an anaesthesiologist present on site. This standard does not apply to intranasal esketamine (SPRAVATO®) administered in non-accredited facilities. 

Below is a summary of the most important standards by section, please see the CPSBC website for most up to date information at www.CPSBC.ca

Summary of Proposed College Guidelines on Ketamine

Pre-admission and Evaluation:

  •  Ketamine should only be considered when standard conventional pharmacological treatment(s) and psychotherapy (e.g. cognitive behavioral therapy, interpersonal therapy) have been unsuccessful.
  • Patients must be screened and have a pre-admission evaluation including laboratory and diagnostic testing (ECG, renal function and liver function tests). Screening process includes sleep apnea screening using a validated tool (e.g. STOP-BANG)

Psychiatric Assessment Documentation:

  • Includes comprehensive psychiatric and medical history, allergies, drug sensitivities, medication history, substance use history.
  • Physical exam must be documented including mental status and review of systems
  • A management plan including clinical impression, treatment and follow-up plan including the rationale for ketamine therapy, and documentation of consent discussion (consent discussion must inform the patient of the off-label status of ketamine therapy).

Admission and Pre-treatment Care:

  • Admission and pre-treatment care must be in accordance with the Admission and Pre-Procedure Care standard with the exception of surgical marking and pre-operative checklist
  • Patients should be fasting prior to ketamine administration.  For IN esketamine patients should refrain from eating for 2 hours prior and avoid drinking fluids for 30 mins prior.
  • IV access is established (Including all routes of administration of ketamine in a NHMSFAP)

Consent:

  • Both the psychiatrist and anesthesiologist administering treatment are required to have a consent discussion with the patient.  This must be documented on the chart, consent must be written.

Dosing limits are:

  • Intravenous (IV)  infusion dosing is restricted to a weight-based dose limit of 0.5 mg/kg IV over 40 minutes **can be initiated by an RN with a patient specific order as long as there are no bolus doses and infusion is run using an infusion control device
  • Intramuscular (IM) dosing is restricted to a weight-based dose limit of 0.1-0.4 mg/kg **must be administered by an anesthesiologist
  • Subcutaneous (SC)  dosing is restricted to a weight-based dose limit of 0.1-0.5 mg/kg SC **must be administered by an anesthesiologist
  • Intranasal (IN) esketamine dosing is restricted to the dosage recommendations per the product monograph for SPRAVATO® **doses administered under direct supervision of anesthesiologist, psychiatrist or registered nurse. 

Anesthesiologist qualifications:

Registered Nurse qualifications:

  • Each registered nurse must have current BLS/ACLS and additional critical care or post anesthesia care training or equivalent experience

Appropriate Staffing:

  • Two registered nurses or one registered nurse and one anesthesiologist are present in the treatment unit/area/room at all times when a patient is receiving care.
  • One-to-one (1:1) regulated health professional to patient ratios are observed.
  • There is a third regulated health professional immediately available
  • Prescribing psychiatrist must be available at minimum by telephone 

Treatment Room and Equipment:

  • Each treatment chair/bed/stretcher is equipped with cardiac monitoring, capnography, automatic BP monitoring, pulse oximetry, suction, oxygen and equipment, a bag mask valve device, artificial airways.
  • Clinical support supplies (IV supplies, stethoscope, medications etc.) and temperature monitoring equipment is readily available

Patient Assessment Supports Safety:

  • Continuous cardiac and pulse oximetry monitoring in place during and post-monitoring phase
  • ETCO2 monitored if sedation scale ≥ 2.
  • Oxygen saturation frequently assessed during and after treatment
  • Blood Pressure, respiratory rate, and level of consciousness assessed and documented at baseline, then every 5 mins x3, then every 15 mins.
  • Patient remains in the treatment room/area/unit for 30 mins after IV discontinued or after IM/SC injection and 2 hours after IN.
  • Patient remains in the facility for an additional 60-90 mins after the initial minimum length of stay.

Medical and Non-Medical Emergencies:

  • Emergency cart is stocked in accordance with NHMSFAP Class 1 General Anesthesia Facility Emergency Cart with the exception of succinylcholine.

For further information on: safe discharge, medical record keeping, safe medication practices, medical patient and care equipment, infection prevention and control, facility design/ layout, human resources, policies and procedures, and quality improvement strategies sections of this standard please visit the Parenteral Use of Ketamine for Mood Disorders standard.

KATA wrote to the CPSBC in response to this draft standards document to inform the college that we are preparing policy recommendations and are looking to discuss and provide consultation in regards to the regulation of ketamine therapies in BC. Thank you to those who submitted feedback.