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MRN FAMILY NAME GIVEN NAME D.O.B. _______ / _______ / _______ ALL OBSERVATIONS MUST BE GRAPHED LOCATION COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE { Assess pain both at rest and with relevant movement. Document “R” for rest and “M” for movement 10 Severe pain 9 8 7 6 Moderate pain 5 4 3 Mild pain 2 1 No pain 0 { { Dysphoric adverse effects present 10 9 8 7 6 5 4 3 2 1 0 Yes Yes No No Cumulative dose mg or mL (circle one) Ketamine program checked (initial) once per shift, on patient transfer and on change of bag or syringe Subcutaneous or IV cannula site secure, no signs of inflammation (check 8 hourly) LOCATION / WARD Ketamine Infusion Management Guidelines (For detailed information regarding PCA prescribing and management refer to local hospital PCA policy) ● Observations on this form to be recorded either 2 hourly or 4 hourly as indicated on the prescription section of this form or more frequently if patient’s clinical condition warrants. - If PCA (Patient controlled analgesia) in use, document pain scores on the PCA chart only. Record observations according to PCA management guidelines. ● Infusion pump settings to be checked at the commencement of each shift, on patient transfer and when the syringe or bag is changed. ● The cannula site (subcutaneous or intravenous) must be checked each shift for signs of redness, swelling or tenderness. ● Managing dysphoric effects such as hallucinations, unpleasant dreams or visual disturbances: contact the relevant pain service or equivalent medical officer. A medical officer may consider a dose reduction of the ketamine infusion or the addition of a benzodiazepine. (e.g. midazolam) REFER TO YOUR LOCAL CLINICAL EMERGENCY RESPONSE SYSTEM (CERS) PROTOCOL FOR INSTRUCTIONS ON HOW TO MAKE A CALL TO ESCALATE CARE FOR YOUR PATIENT APPROPRIATE CLINICAL CARE FOR PATIENTS WITH YELLOW ZONE OBSERVATIONS: • ENSURE THAT THE ACUTE PAIN SERVICE OR EQUIVALENT MEDICAL OFFICER IS CONTACTED YELLOW ZONE RESPONSE IF YOUR PATIENT HAS ANY YELLOW ZONE OBSERVATIONS YOU MUST FOLLOW THE YELLOW ZONE RESPONSE INSTRUCTIONS ON THE NSW STANDARD OBSERVATION CHARTS AND INITIATE APPROPRIATE CLINICAL CARE AS STATED ABOVE COMMENTS KETAMINE INFUSION (ADULT) Two initials for change of ketamine program M.O. Managing Adverse Effects Holes Punched as per AS2828.1: 2012 mg or mL per hour (circle one) FEMALE COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE BINDING MARGIN - NO WRITING INFUSION RATE KETAMINE INFUSION (ADULT) SMR130028 If PCA in use, document pain scores on PCA chart only TIME MALE ADDRESS ADDRESS DATE PAIN SCORE D.O.B. _______ / _______ / _______ Facility: ¶SMRÊ-Î<6Ä Altered Calling Criteria M.O. BINDING MARGIN - NO WRITING KETAMINE INFUSION (ADULT) MRN GIVEN NAME FEMALE Holes Punched as per AS2828.1: 2012 Facility: MALE FAMILY NAME 130217 NH606624 NO WRITING SMR130.028 ¶SMRÊ-Î<6Ä SMR130028 INITIAL: Page 8 of 8 ACUTE PAIN SERVICE or equivalent medical officer CONTACT: BUSINESS HOURS page/phone: OUT OF HOURS page/phone: NO WRITING Page 1 of 8 FAMILY NAME Attach ADR Sticker GIVEN NAME ALLERGIES & ADVERSE DRUG REACTIONS (ADR) Nil known Drug (or other) Unknown (tick appropriate box or complete details below) Reaction/Type/Date Reaction/e Initials MALE D.O.B. _______ / _______ / _______ GIVEN NAME FEMALE Facility: M.O. ADDRESS First Prescriber to Print Patient Pain specialist referral Name and Check Label Correct: Referring doctor name: ......................... ...................................................... Signature: ................................................ Date: ........................................................ Prescription is valid for a maximum of 7 days unless ceased earlier. Refer to local hospital policy for standardised Ketamine solutions Observations for this patient to be recorded: 2 hourly OR Drug (print ‘ketamine’) Amount (mg) Diluent (mg per mL) FROM: …..mg per hour = …..mL per hour TO: …..mg per hour = …..mL per hour Prescriber’s signature Print your name Contact Pharmacy Amount (mg) Diluent Total Volume (mL) Concentration Sodium chloride 0.9% Infusion start rate Infusion range (if applicable) …...mg per hour = ……mL per hour Date (mg per mL) FROM: …..mg per hour = …..mL per hour TO: …..mg per hour = …..mL per hour Prescriber’s signature Print your name Contact Pharmacy Revised prescription is valid until this chart is completed unless ceased earlier Route Drug (print ‘ketamine’) Amount (mg) Diluent ADDRESS LOCATION COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE { Assess pain both at rest and with relevant movement. Document “R” for rest and “M” for movement 10 Severe pain 9 8 7 6 Moderate pain 5 4 3 Mild pain 2 1 No pain 0 { { 10 9 8 7 6 5 4 3 2 1 0 Yes Yes No No mg or mL per hour (circle one) Cumulative dose mg or mL (circle one) Two initials for change of ketamine program Ketamine program checked (initial) once per shift, on patient transfer and on change of bag or syringe Subcutaneous or IV cannula site secure, no signs of inflammation (check 8 hourly) COMMENTS (mg per mL) Infusion range (if applicable) …...mg per hour = ……mL per hour Date M.O. INFUSION RATE Total Volume (mL) Concentration Sodium chloride 0.9% Infusion start rate Holes Punched as per AS2828.1: 2012 Drug (print ‘ketamine’) FEMALE TIME Dysphoric adverse effects present BINDING MARGIN - NO WRITING Revised prescription is valid until this chart is completed unless ceased earlier Route If PCA in use, document pain scores on PCA chart only BINDING MARGIN - NO WRITING Date PAIN SCORE Infusion range (if applicable) …...mg per hour = ……mL per hour MALE DATE Total Volume (mL) Concentration Sodium chloride 0.9% Infusion start rate ALL OBSERVATIONS MUST BE GRAPHED 4 hourly. Holes Punched as per AS2828.1: 2012 Route Altered Calling Criteria SMR130028 Ketamine Infusion (Adult) COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE D.O.B. _______ / _______ / _______ KETAMINE INFUSION (ADULT) ¶SMRÊ-Î<6Ä LOCATION / WARD Sign..............................Print..............................Date................ MRN FAMILY NAME MRN FROM: …..mg per hour = …..mL per hour TO: …..mg per hour = …..mL per hour Prescriber’s signature Print your name Contact Pharmacy Revised prescription is valid until this chart is completed unless ceased earlier Amount (mg) Diluent Total Volume (mL) Concentration Sodium chloride 0.9% Infusion start rate Infusion range (if applicable) …...mg per hour = ……mL per hour Date (mg per mL) FROM: …..mg per hour = …..mL per hour TO: …..mg per hour = …..mL per hour Prescriber’s signature Print your name Contact Pharmacy ¶SMRÊ-Î<6Ä Drug (print ‘ketamine’) SMR130028 Route CEASE KETAMINE ACCORDING TO INSTRUCTIONS IN THE MEDICAL RECORD Refer to entry in the medical record written on Page 2 of 8 INITIAL: Date:…............…. Time:......…… NO WRITING NO WRITING Page 7 of 8 MRN FAMILY NAME GIVEN NAME D.O.B. _______ / _______ / _______ ALL OBSERVATIONS MUST BE GRAPHED COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE PAIN SCORE If PCA in use, document pain scores on PCA chart only TIME { Assess pain both at rest and with relevant movement. Document “R” for rest and “M” for movement 10 Severe pain 9 8 7 6 Moderate pain 5 4 3 Mild pain 2 1 No pain 0 { { Dysphoric adverse effects present 10 9 8 7 6 5 4 3 2 1 0 Yes Yes No No Cumulative dose mg or mL (circle one) Two initials for change of ketamine program Ketamine program checked (initial) once per shift, on patient transfer and on change of bag or syringe Subcutaneous or IV cannula site secure, no signs of inflammation (check 8 hourly) LOCATION / WARD Record of ketamine administration and ketamine discarded Record of ketamine administration Time Record of ketamine discarded Signature Signature 1 2 Date Time Total ketamine discarded (mL or mg) Signature 1 Signature 2 1 2 3 4 Holes Punched as per AS2828.1: 2012 mg or mL per hour (circle one) M.O. COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE Date BINDING MARGIN - NO WRITING INFUSION RATE KETAMINE INFUSION (ADULT) SMR130028 DATE FEMALE ADDRESS ADDRESS LOCATION MALE D.O.B. _______ / _______ / _______ Facility: ¶SMRÊ-Î<6Ä Altered Calling Criteria M.O. BINDING MARGIN - NO WRITING KETAMINE INFUSION (ADULT) MRN GIVEN NAME FEMALE Holes Punched as per AS2828.1: 2012 Facility: MALE FAMILY NAME 5 6 7 8 9 10 11 COMMENTS 12 13 14 ¶SMRÊ-Î<6Ä SMR130028 INITIAL: Page 6 of 8 NO WRITING NO WRITING Page 3 of 8 MRN FAMILY NAME GIVEN NAME D.O.B. _______ / _______ / _______ ALL OBSERVATIONS MUST BE GRAPHED ADDRESS LOCATION COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE PAIN SCORE If PCA in use, document pain scores on PCA chart only TIME { Assess pain both at rest and with relevant movement. Document “R” for rest and “M” for movement 10 Severe pain 9 8 7 6 Moderate pain 5 4 3 Mild pain 2 1 No pain 0 { { Dysphoric adverse effects present 10 9 8 7 6 5 4 3 2 1 0 Yes Yes No No Cumulative dose mg or mL (circle one) Two initials for change of ketamine program Ketamine program checked (initial) once per shift, on patient transfer and on change of bag or syringe Subcutaneous or IV cannula site secure, no signs of inflammation (check 8 hourly) Holes Punched as per AS2828.1: 2012 mg or mL per hour (circle one) ALL OBSERVATIONS MUST BE GRAPHED MALE FEMALE M.O. ADDRESS LOCATION COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE DATE PAIN SCORE If PCA in use, document pain scores on PCA chart only TIME { Assess pain both at rest and with relevant movement. Document “R” for rest and “M” for movement 10 Severe pain 9 8 7 6 Moderate pain 5 4 3 Mild pain 2 1 No pain 0 { { Dysphoric adverse effects present BINDING MARGIN - NO WRITING INFUSION RATE Altered Calling Criteria SMR130028 DATE D.O.B. _______ / _______ / _______ KETAMINE INFUSION (ADULT) ¶SMRÊ-Î<6Ä Altered Calling Criteria Facility: M.O. BINDING MARGIN - NO WRITING KETAMINE INFUSION (ADULT) GIVEN NAME FEMALE Holes Punched as per AS2828.1: 2012 Facility: MALE MRN FAMILY NAME 10 9 8 7 6 5 4 3 2 1 0 Yes Yes No No INFUSION RATE mg or mL per hour (circle one) Cumulative dose mg or mL (circle one) Two initials for change of ketamine program Ketamine program checked (initial) once per shift, on patient transfer and on change of bag or syringe Subcutaneous or IV cannula site secure, no signs of inflammation (check 8 hourly) COMMENTS COMMENTS ¶SMRÊ-Î<6Ä SMR130028 INITIAL: Page 4 of 8 INITIAL: NO WRITING NO WRITING Page 5 of 8