/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/inpatient/,/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/,

/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98212-en.cckm

201712349

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Hospital-wide

IP - Immune Globulin Infusion - Adult - Supplemental [1317]

IP - Immune Globulin Infusion - Adult - Supplemental [1317] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Immune Globulin Infusion - Adult - Supplemental [1317]
for Adult Patients OnlyIntended
Patient Care Orders
Vital Signs [18126]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Monitor vital signs at initiation of Immune Globulin
infusion, with each rate change, and then hourly with
maximum rate until one hour post-infusion. Hold for
signs of an infusion reaction (flushing, hives, dyspnea,
wheezing, hypotension) and notify provider. When
symptoms resolve resume infusion at half of the rate
at which the reaction occurred. If signs of an infusion
reaction reoccur, stop infusion and notify provider.
Contingency Parameters [18129]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg): ***
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Patient develops signs of an infusion reaction
(flushing, hives, dyspnea, wheezing)
Medications - Pre-Infusion
Analgesics (Single Response) [17266]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, ONCE For 1 Doses
Prior to immune globulin
Antihistamines (Single Response) [17268]
diphenhydramine (BENADRYL) cap [36791] 25 mg, Oral, ONCE For 1 Doses
Prior to Immune globulin.
diphenhydramine (BENADRYL) injection [800106] 25 mg, Intravenous, ONCE For 1 Doses
Prior to Immune globulin.
cetirizine (ZYRTEC) tab [44602] 10 mg, Oral, ONCE For 1 Doses
Prior to Immune Globulin
Steroids (Single Response) [17269]
dexamethasone (DECADRON) intraVENOUS
[800037]
4 mg, Intravenous, ONCE For 1 Doses
Prior to immune globulin
dexamethasone (DECADRON) tab [36586] 4 mg, Oral, ONCE For 1 Doses
Prior to immune globulin
Page 1 of 2
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 6:57:14 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Medications - Infusion Agent
Infusion Agent (Single Response) [17272]
UWHealth Criteria for Use of Intravenous Immune
Globulin (IVIG)
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/medications/name-97580-
en.cckm
immune globulin 10% (GAMMAGARD LIQ) bag
[143798]
Intravenous, ONCE For 1 Doses
Does NOT require filter for administration
See IVIG Guideline to determine rate of infusion.
immune globulin 10% (GAMMAGARD S/D LOW
IGA) bag - NOTE: Reserved for use in patients
with IgA levels less than or equal to 7 mg/dL or a
history of hypersensitivity to Gammagard Liquid
[45390]
Intravenous, ONCE For 1 Doses
Use 15 micron filter for administration.
See IVIG Guideline to determine rate of infusion.
Medications - Adverse Reaction
Medications - Adverse Reaction (Single Response) [17274]
Diphenhydramine [242489]
diphenhydramine (BENADRYL) injection
[800106]
25 mg, Intravenous, PRN For 1 Doses, infusion
reaction
Dexamethasone [242490]
dexamethasone (DECADRON) intraVENOUS
[800037]
4 mg, Intravenous, PRN For 1 Doses, Infusion
Reaction
diphenhydramine - dexamethasone [242491]
diphenhydramine (BENADRYL) injection
[800106]
25 mg, Intravenous, PRN For 1 Doses, infusion
reaction
dexamethasone (DECADRON) intraVENOUS
[800037]
4 mg, Intravenous, PRN For 1 Doses, Infusion
Reaction
Page 2 of 2
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 6:57:14 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org