Ketamine / Methadone audit proforma- for patients commencing Ketamine or Methadone
ICN
Patient age Sex Diagnosis
Setting: SPC inpatient Hospital Home Outpatient
Are you starting the patient on Ketamine or Methadone?
- Ketamine Please fill in section 1
- Methadone Please fill in section 2
Section 1- Ketamine
Is this the patients’ first use of ketamine?Yes No
If no please describe previous uses (including when, what regime):
What was the indication for commencing Ketamine?
Complex neuropathic painIncident Pain
Bone pain Visceral Pain
Other, please state:
Prior to commencing ketamine what checks were performed?
U&E LFTs BP PulseOther
What was the route used? Oral S/C Mouthwash
Why did you choose this route?
What regimen did you use?
Burst ketamine Subcutaneous infusion Oral Ketamine Other
Please describe your regimen (including time scales and titration):
What was the starting dose prescribed? :
What was the maximum dose prescribed?
Was any additional medication co-prescribed?
Midazolam Haloperidol Diazepam None
Other (please state) Please state dose and route
If given S/C what diluent was used? Saline Water
Were any side effects observed? Yes No
If Yes please specify:
Cystitis Sedation Hallucinations Vivid dreams
Confusion HypertensionOther (please state)
What dose of opioid was the patient on prior to commencing ketamine? (Please state name and dose)
Did this change following initiation of Ketamine? Yes No
If yes please state change:
Was the patient on any adjuvant analgesics? Yes No
If Yes please describe name and dose:
Whilst the patient was on ketamine what checks were performed?
U&E LFTs BP PulseOther
How often were these checks repeated?
Was the patient discharged on Ketamine? Yes No N/A (if outpatient)
If Yes was this: Oral s/c
If no why was it stopped?
Was the patient converted from s/c to oral ketamine? Yes No N/A
If Yes what was the conversion (please state both dosages)
Was written information provided to the patient or HCP regarding the use of Ketamine?
Patient:Yes No
GP:Yes No
Other HCP: Yes No
Community Pharmacist: Yes No
If on oral ketamine in the community did you have any problems obtaining it for the patient? Yes No
If Yes please state:
What follow up was arranged for the patient?
Was pain control maintained at 4 weeks? Yes No Don’t know
Section 2 – Methadone
What was the indication for commencing Methadone for pain control?
Complex neuropathic painIncident Pain
Bone pain Visceral Pain
Other, please state:
Was this indication documented in the case notes? Yes No
What previous opioids have been used?
Morphine Oxycodone Hydromorphone Alfentanil
Other, please specify:
Is the patient on any adjuvant analgesics? Yes No
If Yes please specify:
Route for methadone administration: Oral Subcutaneously
If S/C what diluent was used? Water Saline N/A
What regimen was used for oral titration of methadone (please describe)?
Total daily dose of current opioid:
Fixed dose of Methadone prescribed:
Was this prescribed in: mls mgs Both
Number of days before changed to bd regimen:
BD dose prescribed:
Were any side effects observed? Yes No
If Yes please specify:
Drowsiness Opiate toxicity Nausea Confusion Hallucinations
Other(please state):
Was the patient discharged home on Methadone? Yes No
If no please specify why:
If Yes what dose was the patient discharged on?
If Yesdid the discharge letter include a named contact and telephone number should further advice be needed? Yes No Don’t know