Western Maryland Health System Physician Orders Doctors Orders Intravenous Immune Globulin (Ivig) For Adults And Pediatrics printable pdf download

Western Maryland Health System Physician Orders Doctors Orders Intravenous Immune Globulin (Ivig) For Adults And Pediatrics

WESTERN MARYLAND HEALTH SYSTEM

Physician Orders

REMINDER: ALL MEDICATION ORDERS REQUIRE DOSE, ROUTE, FREQUENCY

DO NOT USE ABBREVIATIONS

Page 1 of 1

DOCTORS ORDERS

CHECK OFF/

INTRAVENOUS IMMUNE GLOBULIN (IVIG) FOR ADULTS AND PEDIATRICS

INITIALS

1. INDICATION:____________________________________________

2. PRE-MEDICATION-To be given 30 minutes before each infusion:

 Acetaminophen (Tylenol

) ____________mg by mouth times 1 dose (15mg/kg; up to 650mg)

 Diphenhydramine (Benadryl

) ________mg intravenous times 1 dose (0.5mg/kg; up to 25mg)

 Diphenhydramine (Benadryl

)__________mg by mouth times 1 dose (0.5mg/kg; up to 25mg)

 Other________________________________________________

3. INTRAVENOUS IMMUNE GLOBULIN ORDERS:

a. Height__________ Inches

Actual Weight:__________ kg Ideal Body Weight:________ kg

Ideal Body Weight for Males = 50 kg + 2.3 kg for each inch over 60 inches

Ideal Body Weight for Females = 45.5 kg + 2.3 kg for each inch over 60 inches

Adjusted Body Weight = (Actual Body weight – IBW) times 0.5 + IBW

b. DOSE= __________grams / kg X _______ Kg = ____________GRAMS



Use Ideal Body Weight (IBW) or adjusted body weight if greater than 40% over

IBW.



Dosage will be rounded to the nearest 6 grams.

c. FREQUENCY:____________________________________

d. FOR FIRST DOSE IVIG IS TO BE DILUTED TO 3% CONCENTRATION

e. FOR SUBSEQUENT DOSES IVIG IS TO BE DILUTED TO 6% CONCENTRATION

f. RATE OF ADMINISTRATION (Check one box):

STANDARD DOSE RATE

CUSTOMIZED RATE

RENAL DOSE RATE

(CrCl < 30 ml/min)

____mg/kg/min times 15 min, if

0.25 mg/kg/min times 30 min, then

0.5 mg/kg/min times 30 min, then

tolerated

____mg/kg/min times 30 min, if

0.5 mg/kg/min times 30 min, then

1 mg/kg/min times 30 min, then

tolerated

____mg/kg/min times 30 min, if

1 mg/kg/min times 30 min, then

2 mg/kg/min times 30 min, then

tolerated

3 mg/kg/min until complete

____mg/kg/min until complete

2 mg/kg/min until complete

Maximum infusion rate must not exceed 3mg/kg/min, unless otherwise indicated by MD.

VITAL SIGNS every 15 minutes times 2, then every 30 minutes times 2, then every hour until

infusion completes.

h. Draw BUN and Creatinine if not done within the last 72 hours.

LABS:________________________________________________

Western Maryland Health System Physician Orders Doctors Orders Intravenous Immune Globulin (Ivig) For Adults And Pediatrics

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