Spravato is given as supervised intranasal sprays in a certified clinic, with monitoring for at least 2 hours.
Below is a practical, clinic-ready walkthrough for administering Spravato (esketamine) nasal spray. It reflects current labeling, REMS requirements, and real-world workflow so a new team member can step in with confidence. Patients self-spray under direct observation; the care team sets up, times each spray, tracks vitals, and manages recovery and discharge.
How To Administer Spravato: Session Workflow
Spravato administration follows a repeatable pattern: pre-session checks, device setup, supervised self-administration, observation, then discharge planning. This section gives the fast map; deeper details and safeguards follow.
Pre-Session Setup
- Verify indication and enrollment in the REMS program; confirm the site and prescriber are certified.
- Confirm that the dose for today matches the plan (56 mg or 84 mg on treatment days).
- Ask the patient to blow their nose; avoid food for 2 hours and liquids for 30 minutes before dosing.
- Check blood pressure and pulse; baseline vitals guide monitoring and readiness to start.
- Review recent meds, alcohol, or sedatives that could raise sedation risk.
Spravato must never be dispensed for home use; administration occurs under direct observation with a post-dose observation period of at least 2 hours.
Device Basics You’ll Use All Day
Each single-use nasal spray device delivers two sprays totaling 28 mg esketamine. A 56 mg dose uses two devices; an 84 mg dose uses three. The device has visual dots that cue one spray per nostril. Discard each device after use.
Spravato Dosing And Visit Cadence
This table summarizes common dosing schedules and cadence used in practice for the approved indications. Always pair Spravato with an oral antidepressant when required by labeling and reassess response after the initial phase.
| Phase Or Indication | Typical Dose | Visit Frequency |
|---|---|---|
| Treatment-Resistant Depression (Week 1) | 56 mg or 84 mg | Twice weekly |
| Treatment-Resistant Depression (Weeks 2–4) | 56 mg or 84 mg | Twice weekly |
| TRD Maintenance (Weeks 5–8) | 56 mg or 84 mg | Once weekly |
| TRD Maintenance (After Week 8) | 56 mg or 84 mg | Every 1–2 weeks |
| MDD With Acute Suicidal Ideation/Behavior (Weeks 1–4) | 84 mg; may use 56 mg if not tolerated | Twice weekly |
| Reassessment Point | Evaluate benefit and tolerability | At 4 weeks |
| Device Math For Dose | 56 mg = 2 devices; 84 mg = 3 devices | All sprays supervised |
Labeling sets the above cadence; teams tailor within those ranges based on response and tolerability.
Administering Spravato Safely: Step-By-Step
These steps map to what a patient sees and what staff document. Use a timer. Keep a calm space. Dim lights if the patient wants it.
1) Position And Prime
- Seat the patient upright with slight head tilt forward.
- Open the blister; confirm device integrity and expiration.
- No priming sprays are needed; the device is ready to use.
Each device delivers two metered sprays; teach the rhythm before the first spray.
2) First Device (28 Mg)
- Instruct the patient to insert the tip just inside the first nostril; seal gently.
- Press the plunger firmly once for a full spray. The patient should sniff gently, not hard.
- Switch to the other nostril and deliver the second spray from the same device.
Coach slow breathing. Offer tissues. Keep the head slightly forward to reduce drip to the throat.
3) Dosing Interval Between Devices
- Wait at least 5 minutes before the next device to allow absorption and reduce runoff.
- Recheck the patient’s comfort and orientation; many feel dissociation or dizziness early.
- If today’s plan is 56 mg, repeat with one more device; if 84 mg, repeat twice.
Common effects include sedation and dissociation; keep a staff member present and speaking in short, reassuring sentences.
4) Observation Window
- Monitor for at least 2 hours from the last spray.
- Track vitals, mental status, and gait; use pulse oximetry per REMS guidance.
- Offer a dim room, eye mask, or soft music if the patient prefers.
The REMS requires direct observation, documented monitoring, and a safe discharge plan.
Key Safety Checks During And After Dosing
Blood Pressure And Sedation
Esketamine can raise blood pressure and cause marked sedation. Take baseline readings, repeat during observation, and delay dosing if baseline is high per clinical judgment. If symptoms escalate, pause, reposition, and notify the prescriber.
CNS Depressants And Alcohol
Combining with benzodiazepines, opioids, or alcohol can amplify sedation. Coordinate timing with the prescribing clinician; reduce or space sedatives when safe, or plan a longer observation window.
Pregnancy And Reproductive Planning
Spravato is not recommended during pregnancy; discuss contraception and pregnancy testing workflows before starting. Refer to the prescribing information for fetal risk language.
Who Should Not Receive Spravato Today
Do not give Spravato when an increase in blood pressure or intracranial pressure poses a serious risk, such as with certain aneurysms or a history of intracerebral hemorrhage. Screen for hypersensitivity to esketamine or ketamine.
Clinic-Ready Administration Checklist
Use this table as a compact checklist for each session—from triage to discharge. It pairs a practical cue with the why and a simple action line.
| Checkpoint | What To Verify | Action If Off-Track |
|---|---|---|
| REMS Enrollment | Site, prescriber, and patient are active | Pause; resolve in the REMS portal |
| Indication | TRD or MDD with acute suicidal ideation/behavior | Confirm diagnosis and oral antidepressant plan |
| Contraindications | No high-risk BP/ICP conditions or allergy | Hold dose; alert prescriber |
| Baseline Vitals | BP/pulse within clinic parameters | Delay; recheck; manage per protocol |
| Recent Substances | No alcohol or extra sedatives taken | Extend observation or reschedule |
| Device Count | 2 devices for 56 mg; 3 for 84 mg | Match order; document kit lot |
| Observation | At least 2 hours post-dose | Continue until clinically ready |
| Discharge Plan | No driving or operating machinery until the next day | Arrange ride; give written aftercare |
Patient Experience Tips That Reduce Dropouts
Setting And Sensory Comfort
Offer a quiet room, dim lighting, and a blanket. Simple breathing cues help during onset. Keep a small emesis bag nearby; some patients feel nausea.
Nasal Technique That Works
Ask the patient to blow their nose before dosing. During sprays, a gentle sniff improves mucosal contact. Hard sniffs push medicine backward and lower absorption. Space devices by at least 5 minutes to limit runoff.
Clear Rules For The Ride Home
Advise no driving, bike riding, or operating machinery until the next day after a restful sleep. Document the ride-home plan before the first device is opened.
Documentation That Protects Care And Compliance
- Pre-dose: indication, consent status, baseline vitals, device lot numbers, and planned dose.
- During dose: timestamps for each device, interim vitals, observed effects, interventions.
- Post-dose: end-time of observation, gait check, discharge criteria met, ride-home confirmation, next appointment.
Use the program’s patient monitoring forms or your EHR template so entries are consistent across staff and visits.
When The Plan Needs Adjustment
Excess Sedation
Keep the patient in a chair or recliner; add time, dim light, and calm coaching. Notify the prescriber; plan the next dose at the lower device count if needed.
Hypertensive Readings
Pause before the next device. Recheck in several minutes. If symptoms rise—severe headache, chest pain, visual changes—seek medical evaluation and defer further dosing today.
Nausea Or Dissociation That Feels Unsettling
Slow the room, offer a cool cloth, and speak in short, steady phrases. Some clinics pre-plan antiemetics on an as-needed basis per prescriber orders.
External References You Can Trust
For staff training and policy writing, link your clinic SOP to the FDA prescribing information and the REMS program overview. Both outline device specifics, dosing cadence, monitoring, and discharge essentials.
FAQ-Free Closing Notes For The Team
Keep the room calm, keep the timing tight, and keep the checklist visible. With the right pattern—screen, supervise, and document—Spravato sessions run smoothly and patients feel cared for from first spray to safe ride home.