Physicians's Orders - Intravenous Immunoglobulin
TACO BELLVIEW HOSPITAL
PHYSICIAN'S ORDERS
INTRAVENOUS IMMUNOGLOBULIN
PROVIDER TO SIGN AND PLACE PAGER NUMBER LEGIBLY UNDER EACH ORDER
* signifies requred fields
PATIENT INFORMATION *Height Units:
*Weight Units:





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NON-MEDICAL ORDERS
ATTENDING
DATE TIME
IVIG PRODUCT SELECTION GUIDE

Carimmune NF is the preferred IVIG formlation at TBH. It provides enhanced patient protection against a broader range of pathogens (i.e. enveloped viruses, parasites, etc.) Subtle differences exist between IVIG products with respect to osmolarity. IgA and sucrose content. Although the risk for developing renal insufficiency is low with IVIG, the following product selection criteria are recommended:

Select Carimuno NF if:
  • Normal renal function (adult serum creatinine (SCr) ≤ 1.8mg/dl for adult males. ≤ 1.5mg/dl for adult females, or age appropriate normals for pediatric patients) OR
  • On chronic dialysis OR
  • For patients with adequate renal function and any of the following risk factors for developing renal insufficiency, the RENAL SPARING INFUSION PROTOCOL is recommended:
    • Age > 65
    • On concurrent highly nephrotoxic agents
    • Volume depletion
    • Diabetes
    • Sepsis
    • Paraproleinemia

Insuring adequate hydration (example: 1/2NS or D51/2NS at 1 ml/kg/hr 6 hrs. NS bolus)
pre-, peri-, and post infusion should also be considered.

Select Polygam S/D only if:
  • lgA deficiency (Carimmune NI contra-indicated)
  • Renal Impairment defined as an adult mate with a SCr > 1.8 mg/dl. Female SCr > 1.5 mg/dl or a comparable degree of renal insufficiency in pediatric patients (excludes chronic dialysis patients)
  • Documented intolerance to Carimmune NF
IVIG AUTOMATIC DOSAGE
dose carimune nf polygam s/d
5-15 Gms closest 1 Gm vial no rounding
>15Gms closest 3 Gm vial closest 2.5 Gm vial
* doses will be rounded either up or down by the pharmacist
to the nearest vial size
MEDICAL ORDERS ONLY
A. DIAGNOSIS
B. PRODUCT SELECTION *Carimune NF 6% (6 Gms/100MLS)
*Polygam S/D 5% (5 Gms/100MLS)



grams*IV every 24 hrs
*dose(s)
* (dose automatically rounded by pharmacy per protocol)

C. INFUSION RATE: check one Carimune NF 6%
* STANDARD PROTOCOL: Begin infusion at 0.5 mls/kg/hr × 15 mins. If tolerated, double the rate q 15-30 minutes till a maximum infusion rate of 4 mls/kg/hr. Monitor and document vital signs (HR, BP, RR, temperature) with each infusion rate dose escalation, and then q1-2 hrs during infusion.
* RENAL SPARING INFUSION PROTOCL: Begin infusion at 0.5 mls/kg/hr × 15 mins. If tolerated, double rate q15-30 minutes till a maximum infusion rate of 1.8 mls/kg/hr. Monitor and document vital signs (HR, BP, RR, temperature) with each infusion rate dose escalation, and then q1-2 hrs during infusion.
Polygam S/D 5%
* STANDARD PROTOCOL: Begin infusion at 0.5 mls/kg/hr × 15 mins. If tolerated, double the rate q 15-30 minutes till a maximum infusion rate of 4 mls/kg/hr. Monitor and document vital signs (HR, BP, RR, temperature) with each infusion rate dose escalation, and then q1-2 hrs during infusion.
*OTHER:



D. PRETREATMENT:





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