/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-98213-en.cckm

201708216

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 – Pediatric – Supplemental [4161]

IP – Immune Globulin Infusion – Pediatric – Supplemental [4161] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Immune Globulin Infusion - Pediatric - Supplemental [4161]
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 - Premedications
Analgesics (Single Response) [112030]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Maximum dose 650 mg
[800005]
15 mg/kg, Oral, ONCE For 1 Doses
Prior to immune globulin
acetaMINOPHEN (TYLENOL) tab - NOTE:
Recommended Dose = 15 mg/kg Maximum Dose
= 650 mg [34149]
Oral, ONCE For 1 Doses
Administer prior to infusion.
Antihistamines (Single Response) [112031]
cetirizine (ZYRTEC) syrup [54047] Oral, ONCE For 1 Doses
Administer prior to infusion. (Dose based on age: 2-6
years: 2.5 mg; 6-12 years: 5 mg; Greater than 12
years: 10 mg.)
Page 1 of 2
Printed by WILLIAMS, HEATHER R [HRS0] at 8/1/2017 11:56:41 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

cetirizine (ZYRTEC) tab [51071] Oral, ONCE For 1 Doses
Administer prior to infusion. (Dose based on age: 6-12
years: 5 mg; Greater than 12 years: 10 mg.)
diphenhydramine (BENADRYL) elixir - NOTE:
Maximum dose 50 mg [36793]
1 mg/kg, Oral, ONCE For 1 Doses
Prior to immune globulin
diphenhydramine (BENADRYL) injection - NOTE:
Maximum dose 50 mg [800106]
1 mg/kg, Intravenous, ONCE For 1 Doses
Prior to immune globulin
diphenhydramine (BENADRYL) cap - NOTE:
Recommended dose 1 mg/kg Maximum Dose =
50 mg [36791]
Oral, ONCE For 1 Doses
Administer prior to infusion
Steroids (Single Response) [112032]
dexamethasone (DECADRON) intraVENOUS -
NOTE: Maximum dose 4 mg [800037]
0.2 mg/kg, Intravenous, ONCE For 1 Doses
Prior to immune globulin
methylprednisolone sodium succ. (SOLU-
MEDROL) intraVENOUS [800058]
1 mg/kg, Intravenous, ONCE For 1 Doses
Prior to immune globulin
Medications - Infusion Agents
Immune Globulin (Single Response) [112258]
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
[45390]
Intravenous, ONCE For 1 Doses
See IVIG Guideline to determine rate of infusion.
Medications - Adverse Reactions
Analgesics (Single Response) [192939]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Maximum dose 650 mg
[800005]
15 mg/kg, Oral, ONCE PRN For 1 Doses, pain/fever,
infusion reaction
acetaMINOPHEN (TYLENOL) suppository -
NOTE: Maximum dose 650 mg [43994]
Rectal, ONCE PRN For 1 Doses, pain/fever, For
infusion reaction, if unable to take orally
Antihistamines [192941]
diphenhydramine (BENADRYL) elixir - NOTE:
Maximum dose 50 mg [36793]
1 mg/kg, Oral, ONCE PRN For 1 Doses, Infusion
Reaction, If unable to take orally.
diphenhydramine (BENADRYL) injection - NOTE:
Maximum dose 50 mg [800106]
1 mg/kg, Intravenous, ONCE PRN For 1 Doses,
Infusion Reaction
Steriods (Single Response) [192943]
dexamethasone (DECADRON) intraVENOUS -
NOTE: Maximum Dose 4 mg [800037]
0.5 mg/kg, Intravenous, ONCE PRN For 1 Doses,
infusion reaction
dexamethasone soln (ORAL) - NOTE: Maximum
dose 10 mg [800221]
0.5 mg/kg, Oral, ONCE PRN For 1 Doses, infusion
reaction
hydrocortisone sodium succinate injection -
NOTE: Maximum Dose = 100 mg [800189]
1 mg/kg, Intravenous, ONCE PRN For 1 Doses,
infusion reaction
Administer over 3 minutes.
Page 2 of 2
Printed by WILLIAMS, HEATHER R [HRS0] at 8/1/2017 11:56:41 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org