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Patient weight = _______ kg
Patient height = ________ cm
Special instructions: Please place on separate order sheet.
A. Indication/Usual dosage. Weight basis for dose calculation is actual body
weight (ABW) for patients up to 120% ideal body weight (IBW). Adjusted dosing
weight (DW) of DW = 0.4(ABW-IBW) + IBW will be used for patients >120% IBW.
Prescribers must check one below for inpatient use.
Autoimmune hemolytic anemia or neutropenia – 1 gm/kg x 2 days
Guillain-Barre syndrome – 400 mg/kg x 5 days
Humoral rejection post solid organ transplant – 500 mg/kg dose, to maximum
of 2 gm/kg over three weeks: cumulative dose: _____ mg/kg
Immune – Mediated Thrombocytopenia – 1 gm/kg max dose once
Immunodeficiency associated with multiple myeloma, chronic lymphocytic
leukemia, or hematopoietic stem cell transplantation (defined as IgG level of
<400 mg/dL) – 500 mg/kg weekly until IgG > 400 mg/dL
Kawasaki Disease – 2 gm/kg once
Myasthenia gravis medically unstable with failed/contraindicated plaspheresis –
500 mg/kg per day, infused over 24 hours x 4 days
Peri-operative desensitization / prevention of humoral rejection - 500 mg/kg
dose with 2 gm/kg cumulative dose between POD -1 and POD +21
Parvovirus-related anemia in patient requiring hospitalization - 500 mg/kg
dose, to maximum of 2 gm/kg over three weeks
Medication order (pharmacy to calculate/round to nearest whole vial)
Immune globulin (intravenous) standard (containing sucrose)
__________ gm/kg IV every _______ X _______doses
Standard Infusion Rate - start at 30 mL/hr x 15 minutes, if tolerated may
increase by 30 mL/hr every 15 minutes to a final rate of 150 mL/hr. If
faster titration rates are desired for subsequent infusions, consult with
provider for a supplemental order. Maximum rate is 150 mL/hr
Immune globulin (intravenous) restricted (without sucrose)
__________ gm/kg IV every _______ X _______doses
Renal dysfunction (Estimated creatinine clearance ≤ 30 mL/minute)
Immune globulin dose ≥ 1 gm/kg/dose
Immune Globulin Order Form/PILOT/UNIV only/051011
Post-renal transplant or renal transplant anticipated within next 7 days
Sucrose free product infusion rate - start at 0.5 mL/kg/hr x 30
minutes, then 1 ml/kg/hr x 30 minutes, then increase by 0.5 ml/kg/hr
every 15 minutes to a maximum of 4 mL/kg/hr.
C. Premedications (Give 30 minutes prior to start of infusion except for
Acetaminophen 650 mg PO once
Diphenhydramine 50 mg PO once
Diphenhydramine 50 mg IV once
Hydrocortisone 100 mg IV once
Pre-hydrate with the following fluid: _________________ at ______
ml/hr for _____ mls.
Other: ______________________________________________
D. PRN medications during infusion
Acetaminophen 650 mg PO Q 4 hours prn headache, myalgias, or
temperature > 38 degrees C
Diphenhydramine 50mg IV x1 prn severe dyspnea, hives, angioedema, or
itching. Notify Physician STAT.
Epinephrine 1:1000 (1 mg/ml). Administer 0.3ml IM for severe dyspnea,
angioedema, or hypotension. Notify Physician STAT.
Hydrocortisone 100mg IVx1 prn severe dyspnea, hives, angioedema, or
hypotension. Notify Physician STAT.
E. General patient care
1. Make sure Emergency/Resuscitative Equipment (Crash Cart) is available in
2. Vital signs
• With the first dose: Monitor vital signs pre-infusion, during infusion (Q15
min x 4, Q30 min x 2, then Q1H) and post-infusion.
• With subsequent infusions: Monitor pre-infusion and during the infusion at
the discretion of the nurse, based on patient tolerance.
3. Infusion reactions
• Major reactions - STOP infusion and notify MD immediately for:
- HR > 120 bpm or < 50 bpm
- Respiratory rate > 20 or < 8 breaths/min
- Temperature > 38.3 degrees C
- BP > 185 or < 90 mmHg
- Symptoms of wheezing, chest pain, angioedema, or urticarial skin
reaction (hives).
• Minor reactions (back pain, rigors, fever < 38.3, headache, mild shortness
of breath): HOLD infusion for 30 minutes, then restart at 50% of the
previous rate. Contact MD if symptoms persist or recur.
Physician signature: ________________________________ ID #: ______________
Date: _______________
Time: _______________
Immune Globulin Order Form/PILOT/UNIV only/051011