Looking for a Medical Forms And Templates? Download it for free!

Form # 8729 (10/14)

AUTHORIZATION IS GRANTED TO DISPENSE AND ADMINISTER AN ALTERNATE DRUG PRODUCT ACCEPTABLE TO THE MEDICAL STAFF'S

PHARMACY COMMITTEE UNLESS THE DRUG PRODUCT IS SPECIFICALLY CIRCLED.

Allergies / Sensitivities (include types of reactions)________________________________________________________

________________________________________________________________________________________________

Height:__________________cm

Actual Weight:__________________kg

INDICaTIoN

Hypogammaglobulinemia

Idiopathic Thrombocytopenic Purpura - ITP

Hereditary

Kawasaki Disease (Mucocutaneous Lymph Node Syndrome)

Nonfamilial

Common Variable Immunodeficiency - CVID

with predominant abnormalities of B-cell numbers & function

Other__________________________________________

with autoantibodies to B or T-cells

other common variable immunodeficiencies

unspecified

IVIG is dosed using Ideal Body Weight (IBW). Use the following formula to calculate IBW.

•

For children LESS than 152cm tall use actual body weight.

•

For children 152cm or taller

•

IBW (males) = 39 + 0.9 (H - 152), where H is height in centimeters and IBW is weight in kilograms

•

IBW (females) = 42.2 + 0.9 (H - 152), where H is height in centimeters and IBW is weight in kilograms

LaBoRaToRY

IgG Level - Draw level prior to starting IVIG infusion (Recommended to evaluate level each year).

IgG Level with Subclasses - Draw level prior to starting IVIG infusion.

PRETREaTMENT and MoNIToRING - Give the following pre-medications 30 minutes prior to the start of infusion.

None

Acetaminophen (15 mg/kg) _____________ mg PO (Maximum: 650 mg/dose)

Acetaminophen (15 mg/kg) _____________ mg PR (Maximum: 650 mg/dose)

Diphenhydramine (1.25 mg/kg) __________ mg PO (Maximum: 50 mg/dose)

Diphenhydramine (1.25 mg/kg) __________ mg IV (Maximum: 50 mg/dose)

Hydrocortisone (2.5 mg/kg) _____________ mg IV (Maximum: 100 mg/dose)

•

Nursing to assess hydration. Call prescribing physician if patient may be volume depleted prior to beginning infusion.

•

Obtain baseline vital signs (BP, pulse, respirations, temperature) pre-infusion, then Q15 minutes until maximum delivery rate is reached. Then every

hour times 2, then Q2 hours until completed and 15 -30 minutes after the completion of the infusion.

DoSING of IVIG

IVIG (______ mg/kg) IV Frequency ____________

Total Dose: _____________ grams (Round to the nearest 5 gm +/- 5%. If rounding to

nearest 5 gm exceeds +/- 5% call provider for approval.)

Duration__________doses or ______weeks (Maximum duration of 1 year) - if not specified, the order will be considered as a one-time order and must be

rewritten. Refer to back page for specific infusion instructions.

7. aDMINISTRaTIoN and MoNIToRING

Gammagard (IVIG) Liquid

•

Begin infusion at 0.8 mg/kg/min for 30 minutes, if tolerated continue to increase every 30 minutes: 2 mg/kg/min, then 4 mg/kg/min, then

6 mg/kg/min, then to maximum rate of 8 mg/kg/min. (Max rate for pre-existing renal insufficiency or thrombotic risk is 3.3 mg/kg/min).

•

Use of an inline filter is optional.

•

Patients who have underlying renal disease or who are judged to be at risk of developing thromboembolic events should not be infused rapidly

with any IVIG product. Maximum infusion rate for pre-existing renal insufficiency or thrombotic risk is 3.3 mg/kg/min.

•

IVIG is to be administered with a separate infusion line with no other medications.

•

Patients who are on long term IVIG therapy may have physician orders with a more rapid titration rate to decrease total infusion time.

Monitoring

•

For common reactions (including fever, nausea, or vomiting)

- Temporarily stop or slow infusion rate to that previously tolerated by patient and treat symptoms as required

•

For chills or rigors decrease infusion rate to that previously tolerated by patient and notify physician

•

For serious reactions including hypotension, angioedema, bronchospasms, dyspnea, and anaphylaxis

- Stop infusion, notify physician, and treat symptoms as required.

- Begin IV of 0.9% Sodium Chloride to keep line open.

- Administer diphenhydramine 1.25 mg/kg IVP (max 50mg), hydrocortisone 2.5mg/kg IVP (max: 100mg), epinephrine 0.01mg/kg IM (max: 0.3mg)

The physician's full signature, date & time is to follow the order -

Patient ID Label

Abbreviations for names are not acceptable.

Signature

Date

Time

IVIG PEDIATRIC ORDERS

Form 8729 - Authorization Is Granted To Dispense And Administer An Alternate Drug Product

Related Articles

Related forms

Related Categories