Adult Ambulatory Infusion Order Form - Cho Intravenous Immune Globulin (Ivig)
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4Oregon Health & Science University
Hospital and Clinics Provider’s Orders
ACCOUNT NO.
*PO7071*
MED. REC. NO.
NAME
BIRTHDATE
ADULT AMBULATORY INFUSION ORDER
CHO:INTRAVENOUS IMMUNE
GLOBULIN (IVIG)
Page 1 of 4
Patient Identification
ALL ORDERS MUST BE MARKED IN INK WITH A CHECKMARK ( ) TO BE ACTIVE.
Weight: ___________kg
Height: ___________cm
Allergies:
Diagnosis Code: ____________________________________________________________________
Treatment Start Date:
Patient to follow up with provider on date:
**This plan will expire after 365 days at which time a new order will need to be placed**
GUIDELINES FOR PRESCRIBING:
1. Send FACE SHEET and H&P or most recent chart note.
2. Intravenous Immune Globulin (IVIG) is approved by the OHSU P&T Committee for use in patients
in whom there is literature/UHC/FDA documented effective uses. The OHSU Department of
Pharmacy Services will reconstitute and prepare IVIG, rounding to the nearest 5 gram vial size to
minimize wastage. Based on the supply and availability of products, Pharmacy has the authority to
select the most cost effective IVIG product.
3. In patients who may be at risk of renal failure, a decrease in dose, rate, and/or concentration
should be considered. IVIG should be given at a rate of less than 2 ml/kg/hr for the 10% solution.
Avoid use in patients with CrCl less than 10 ml/min.
4. Ideal Body Weight (IBW) will be used to dose IVIG. Adjusted Body Weight will be used when a
patient has an Actual Body Weight (ABW) greater than 130% IBW.
a. IBW Males (kg) = 50 + (2.3 x (height in inches – 60))
b. IBW Females (kg) = 45.5 + (2.3 x (height in inches – 60))
c. If height < 60 inches, use 50 kg (male) and 45.5 kg (female) to calculate IBW
d. Adjusted Body Weight= IBW + 0.4 (Actual Body Weight- IBW)
LABS: (must check to order)
Basic Metabolic Set, Routine, ONCE every
(visit)(days)(weeks)(months) – Circle One
IGG, Serum, Routine, ONCEevery
(visit)(days)(weeks)(months) – Circle One
Labs already drawn. Date:
PRE-MEDICATIONS: (Administer 30 minutes prior to infusion)
Note to provider: Please select which medications below, if any, you would like the patient to
receive prior to treatment by checking the appropriate box(s)
1. Acetaminophen oral, ONCE, every visit
650 mg tablet
325 mg tablet
500 mg tablet
1000 mg tablet
DiphenhydrAMINE oral, ONCE, every visit
25 mg capsule
50 mg capsule
Loratadine oral, ONCE, every visit (Choose as alternative to diphenhydramine if needed)
10 mg tablet
5 mg tablet
PO
-8064
ONLINE 06/2015 [supersedes 07/2014]
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