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Patient weight = _______ kg Patient height = ________ cm IMMUNE GLOBULIN (INTRAVENOUS) ORDER FORM – Adult Inpatient 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 Other: B. Medication order (pharmacy to calculate/round to nearest whole vial) Immune globulin (intravenous) standard (containing sucrose) __________ gm/kg IV every _______ X _______doses Dose interval 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 Dose interval CRITERIA FOR SUCROSE-FREE PRODUCT (must check one): Renal dysfunction (Estimated creatinine clearance ≤ 30 mL/minute) Immune globulin dose ≥ 1 gm/kg/dose Immune Globulin Order Form/PILOT/UNIV only/051011 *111* 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 prehydration) 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 area. 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