Immune Globulin Infusion Therapy Plan Orders
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2Name: ______________________________________
Immune Globulin (Gammagard Liquid) - IVIG
Group Health Member I.D. # ____________________
Infusion Therapy Plan Orders
Date of Birth ________________________________
Page 1 of 2
Instructions to Provider
Review orders and note any changes. All orders with will be placed unless otherwise noted. Please fax completed order
form to the infusion center where the patient will be receiving treatment (see fax numbers page 2).
Lab orders are not included on this form – place orders via usual method. Lab monitoring is the responsibility of the ordering
physician.
Please complete all of the following:
Pre-Service Authorization has been obtained by Group Health
Fax: 1-888-282-2685 Voice: 1-800-289-1363
Diagnosis:
________________
ICD-10 code (REQUIRED):
Order Date: _____________
ICD-10 description
__________________________________________________________
Weight: _________kg
___________________________________________________________________________
General Plan Communication
•
Special instructions/notes: __________________________________________________
Provider Information
•
Infusion rates should not go beyond 3.2 mg/kg/min for
•
Patients at risk for thrombotic event or
•
Patients with risk factors for renal dysfunction (over 65 years old, diabetes, abnormal renal function tests)
Infusion Therapy
Immune globulin-human (GAMMAGARD LIQUID) 10% IV infusion
Dose: _______ grams/dose (will be rounded the nearest 1 gm)
Route: Intravenous
daily x 2 doses_______
every _____ weeks x 6 months
Frequency:
daily x 4 doses_______
_________________________________________
Infusion Rate: T itrate per Group Health Nursing Protocol – IV Immune Globulin
___________________________________________
Note any changes to above regimen:
Pre-Meds
acetaminophen (TYLENOL) tablet
Dose: 650 mg
Route: Oral
Frequency: Once, 30 minutes prior to IVIG infusion.
May also be given once as needed during infusion for fever, headache or myalgia to infusion.
cetirizine (ZYRTEC) tablet
Dose: 10 mg
Route: Oral
Frequency: Once, at least 60 minutes prior to IVIG infusion (if not taken at home).
Other: ________________________________
Dose: _______
Route: Oral
Frequency: Once, 30 minutes prior to IVIG infusion
No routine pre-medications necessary. Above pre-meds may be given if patient has reaction and requires pre-
medications for future doses.
Provider Signature: ____________________________________________ Date: _______________
Printed Name: ______________________________________ Phone: ___________ Fax: ___________
HIM
Revision Date: 9/30/2015 Group Health Cooperative <Reference#115112>
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