Discharge Criteria After Ketamine Therapy: What We Look For Before You Leave

Why discharge isn’t time-based

It is tempting to assume that recovery from a ketamine infusion runs on a timer. The drug has a short half-life, the dissociation fades quickly once the drip stops, and most people feel reasonably normal within thirty minutes. So why not just hold everyone for a fixed window and send them out the door?

Because feeling ready and being ready are not the same thing. Residual effects after sedation are notoriously hard to self-assess. Patients consistently overestimate their own clarity in the first hour after a procedure, which is exactly why anesthesia developed objective discharge scoring in the first place. Ketamine is FDA-approved as an anesthetic; its use for depression, anxiety, PTSD, and chronic pain is off-label, but the post-dose monitoring framework is the same one used across every PACU in the country.

At Music City Ketamine, we run our discharge process the way an outpatient surgery center runs theirs. We are not improvising. We are using validated tools, applied by a CRNA, in a setting designed for safe sedation recovery.

The Aldrete and PADSS scoring frameworks in plain English

Two scoring systems dominate post-anesthesia discharge in the United States, and you will find both referenced in nearly every outpatient sedation policy.

The Modified Aldrete Score, developed by J. Antonio Aldrete and described in the Journal of Clinical Anesthesia in 1995, scores five domains zero to two: activity (movement of extremities), respiration, circulation (blood pressure relative to baseline), consciousness, and oxygen saturation. A total of nine or ten is the standard threshold for leaving the post-anesthesia care unit. Eight may be acceptable in some protocols if oxygen saturation is the only deficit and supplemental O2 is no longer needed.

The Post-Anesthetic Discharge Scoring System (PADSS), published by Frances Chung and colleagues in Anesthesia & Analgesia in 1995, is designed specifically for outpatient discharge to home. It scores vital signs, ambulation, nausea and vomiting, pain, and surgical bleeding. A score of nine or higher, with a present escort, is the standard for sending someone home. PADSS is the more relevant of the two for ketamine outpatient practice because it explicitly includes the ride-home requirement and the ability to walk.

The American Society of Anesthesiologists, in its 2013 Practice Guidelines for Postanesthetic Care, recommends that every facility performing sedation use documented discharge criteria covering consciousness, vital signs, oxygenation, pain, nausea, and the presence of a responsible adult escort. That is exactly what we do.

Mental status: alert, oriented, conversational

The first thing we assess is whether you are mentally back. Not partially back. Back. That means you can tell us your name, where you are, the day or approximate time, and why you came in. You can hold a normal conversation, follow simple instructions, and respond to questions without long pauses or word-finding trouble.

For some patients, this returns within fifteen minutes of the infusion ending. For others — particularly those who experienced deeper dissociation — it takes longer. Lingering dissociative phenomena like a sense of distance, mild visual drift, or the feeling that the world is “a little soft around the edges” are not necessarily a barrier to discharge if you are otherwise oriented and stable. Persistent confusion, however, is.

Our companion piece on what a ketamine infusion feels like covers the dissociative experience in more detail. Recovery from that experience is part of what we are watching for.

Vitals: back to your own baseline, not “textbook normal”

Ketamine reliably bumps blood pressure and heart rate during the infusion. That is expected. What we watch for in recovery is a return toward your pre-infusion baseline, not toward an arbitrary textbook range. A patient whose normal resting BP is 138/86 does not need to drop into the 110s before discharge — we just need to see the numbers settle into a stable trend that matches their own starting point.

We continue continuous pulse oximetry, blood pressure cycling, and heart rate monitoring throughout the infusion and into recovery. The Aldrete circulation score uses a 20% deviation from baseline as the threshold; we generally want to see numbers within that band, trending in the right direction, before we move toward discharge.

Marla Peterson, CRNA, oversees every infusion. If you would like more context on what a CRNA actually does and why anesthesia-level monitoring matters, we wrote a piece on what a CRNA is and one on whether ketamine therapy is safe that go into the broader monitoring picture.

Ambulation: the walk to the door is part of the exam

You don’t leave sitting down. You leave walking. The walk from the recovery chair to the front door is part of the discharge assessment, not a formality after it.

We are watching for steady gait, the ability to stand without orthostatic dizziness, and reasonable balance. PADSS specifically scores ambulation because it integrates several systems at once: cerebellar function, blood pressure regulation, proprioception, and basic motor coordination. A wobbly walk often signals a vital sign or neurological issue that has not been picked up sitting still.

If you stand up and feel lightheaded, we sit you back down, recheck pressures, and wait. That is normal and not a cause for alarm — it just means the assessment caught something the chair didn’t.

Nausea, pain, and lingering dissociation

Significant nausea is uncommon with our IV protocols, but when it happens we treat it before discharge. Vomiting in a moving car is not a small problem. We give an antiemetic, wait, reassess, and only release once it is genuinely controlled.

For patients on chronic pain protocols, we want to confirm that any acute infusion-related discomfort — back stiffness from sitting, a sore IV site, a tension headache — is at a manageable level. We are not promising you arrive home with zero discomfort. We are confirming nothing has worsened in a way that needs attention.

Lingering dissociation is the ketamine-specific addition to a standard PADSS assessment. Most patients describe a soft, dreamlike quality that fades over the recovery period. If that quality is still pronounced — if you are still feeling unanchored, if depth perception is off, if the room feels distant — we wait. Releasing someone who is still functionally dissociated is unsafe regardless of their numerical vitals.

The driver requirement — why it’s non-negotiable

You cannot drive yourself home from a ketamine session. Not the same day. Not even if you feel fine. Reaction time, judgment, and divided attention can be impaired for hours after the dissociative effects feel resolved. Our article on driving and ketamine covers the pharmacology of why.

The FDA’s Spravato (esketamine) REMS program, the only ketamine-related psychiatric treatment with a formal regulatory monitoring requirement, mandates a minimum two-hour post-dose observation period and a confirmed driver before discharge. That is the regulatory floor for the most regulated form of ketamine therapy in the country. We apply the same standard to IV ketamine even though it is not legally required to.

Our policy is that the driver must be a known, competent adult — a partner, family member, friend, or hired companion. Rideshare drivers do not qualify. This is consistent with most reputable ketamine clinics nationwide and with ASA guidance on responsible escorts. Plan the ride before you book the session. It is the one piece of preparation we cannot do for you.

What “discharge to home” actually means and what comes next

Discharge is not the end of the recovery period — it is just the point at which the rest of the recovery can safely happen at home with a competent adult nearby. The standard guidance, which mirrors what most surgery centers tell their outpatients, is:

• No driving for 24 hours, regardless of how clear-headed you feel.
• No heavy machinery, power tools, or anything else where impaired reaction time matters.
• No legally or financially binding decisions for the rest of the day. Don’t sign contracts, don’t close on a house, don’t commit to anything you wouldn’t commit to first thing in the morning.
• No alcohol or recreational substances for the rest of the day, and ideally that evening.
• Hydrate, eat normally when you’re hungry, and rest if you want to. Most patients are fully back to baseline by the next morning.

We cover this terrain in more detail in the article on what to do after a ketamine session and the first-infusion guide. The neuroplasticity work continues for hours after you leave the chair; the safety rules just protect that window from preventable problems.

When we keep someone longer

It happens. Not often, but it happens, and we treat it as a normal part of running a careful clinic rather than as a failure of the protocol.

The most common reasons we extend recovery: blood pressure that has not yet trended back toward baseline, persistent mild nausea, ongoing dissociation that has not cleared, an unsteady gait on standing, or — most commonly — a ride that hasn’t arrived. None of these are emergencies. They are simply criteria that have not yet been met.

We would much rather hold you for an additional thirty or sixty minutes than discharge someone who is not ready. That decision is made by Marla, on-site, using the same scoring framework we started with. There is no schedule pressure that overrides discharge criteria. The criteria are the criteria.

If you want a closer look at how the whole arc of a session fits together — from arrival through the infusion to discharge — our how it works page lays out the full process.