Ongoing Observation
The following observations should be considered on an on-going basis from the time the patient has cleared the intake process until the patient is ready for discharge. Detailed record keeping throughout this entire process is important (Ch. 1).
General Observations
General observations of breathing, behavior, skin color and elasticity should be monitored. Fluid and food intake should be noted consistently. Patients should be instructed to notify supervisors if they experience any palpitations, chest pain, shortness of breath, or faintness.
Hydration
All patients will be well hydrated prior to administering ibogaine. About 1 fl. oz. per kg of body weight throughout the day is recommended, or more for physically active people. All hydration done during 24 hours prior to treatment, during treatment, and for at least 72 hours after treatment, should be done with fluids that contain electrolytes such as coconut water or other electrolyte preparation, and not with plain water or other fluids. This will help to maintain electrolyte levels.
Screening Tests
Further electrocardiograms or other tests should be administered as needed, or before the beginning of any follow-up treatment episode. At all times, the same exclusion criteria and risk considerations should be observed (Ch. 2).
Pre-Treatment Diet
Prior to treatment all intensive fasts and cleanses should be avoided. Patients should eat healthy whole foods in the days prior to treatment, and should make sure to eat well the day before. However, during treatment, in order to avoid nausea, patients should have an empty stomach. It is advised to avoid eating for at least 8 to 12 hours prior to dosing in order to minimize the risk of vomiting and medicine loss.
Immediately Prior to Dosing
The guidelines laid out in the rest of this chapter supervision include considerations for the acute phase of ibogaine administration. Some clinicians have made exceptions only when risks are assessed as minimal and the measures cause extreme discomfort.
Intravenous Port Access
Dehydration and loss of electrolytes is a serious risk with ibogaine treatment. Although it is possible to hydrate with fluids orally, this can be problematic in cases of chronic vomiting, especially when cardiac concerns become acute enough to make IV anti-nausea medication an added risk factor (Ch. 13).
In order to avoid these risks, and to provide access for emergency medicines in case of arrhythmia or seizure, an intravenous port should be inserted until the physician has confirmed cardiac risks have passed.
In the absence of sufficient vein access to establish an IV port, a central line can be inserted on the chest to the same effect. This procedure, as well as it’s subsequent removal post-session, should be done in a hospital unless sufficiently equipped and sterilization can be ensured.
Preparatory Fluids
Administering 1 liter of lactated ringer or normal saline, along with 1 ampule of magnesium sulphate produces a beneficial fluid overload that decreases hypotension and protects the patient from developing toursades de pointes. This should be administered beginning 1 hour before a flood dose, until 2 hours after the dose is administered.
Anti-Nausea Medication
In patients with extreme physical tension, vomiting can provide a release and help the patient to relax. However, in general, most patients find this experience to be uncomfortable and physically tiring. In some cases it can also influence the onierogenic effects.
Administering anti-nausea medication prior to treatment can help to counteract this experience. It is important to note that many common anti-emetic medications, including metoclopramide (which is also centrally acting) are known to prolong the QT interval, or like palonesetron, cause a drop in heart rate after IV administration. Pay particular attention to the cardiac effects of anti-nausea medications.
The preferred intervention is 25-50mg of diphenhydramine (IM) administered prior to ibogaine.1In places where diphenhydramine is not available, the same dosages of promethazine or other anti-nausea with low cardiac risks can be substituted.
In some cases it may be sufficient to use milder remedies, such as ginger extracts or tea, and only to use anti-nausea medication when there is a significant risk of dehydration from repeated vomiting, or at the suggestion of the attending physician.
Supervision
The supervision periods recommended here are considered to begin after the administration of a single large dose of ibogaine hydrochloride. For recommendations about supervisors see Chapter 1.
Close Supervision (First 12-24 hours)
In order to minimize cardiac risks, patients should be connected to a 3 lead heart monitor and under close supervision with at least one ACLS trained staff member present to monitor cardiac changes, and a second ACLS attendant closely on hand to respond in case of emergency. The quality and rate of respiration should also be monitored closely.
Patients should remain under close supervision until the ACLS attendant has confirmed that the t-wave morphology changes have normalized for at last 1 hour. This generally takes between 12-15 hours, but can take as long as 24 hours.
Regular Supervision (First 72 hours)
After the period of close supervision, patients should remain under regular but less intensive supervision for at least 72 hours after the initial dose.
During this period, although the patient may be alert and mobile, there are still remaining cardiac risks evidenced by reports of adverse events (Alper 2012). In order to minimize the remaining risks, blood pressure, pulse and blood oxygen levels should be taken at least every 4 hours while the patient is awake, and whenever possible between sleep. At least 1 ACLS trained staff member should remain on hand in case of emergency.
Acute Confusional State
In rare instances where clients experience an acute confusional state in which they seem to have a psychological break from reality that persists after the acute effects of the ibogaine have subsided, the patient should be kept in a secure environment and under constant regular supervision until the effects of the acute confusional state have passed. Refer to the section on acute confusional state intervention (Ch. 15).
