1. Introduction
Intravenous Immune Globulin (IVIG) is an expensive blood derived product. IVIG is a product made from large pools of human plasma by a combination of fractionation, precipitation, filtration and/or chromatography. The indications for IVIG are constantly evolving due to clinical practices and research. IVIG is contraindicated in recipients who are:
|
Hypersensitive to the active substance or in the formulation of the IVIG product. |
|
Known to have had a previous history of a severe systemic or anaphylactic response to IVIG. |
|
Known to have anti-IgA antibodies with selective IgA deficiencies. |
2. Procedure of administration
● Pre-Infusion Preparation
|
Validate IVIG clinical indication and dose. |
|
Verify informed consent for transfusion has been obtained. |
|
Prepare the following before starting infusion. ● Peripheral or Central venous access. ● IV fluid (Normal Saline / Balanced Salt Solution: 1000 ml) ● Inj Paracetamol 1 gm. ● Inj Pheniramine (Avil) 25 mg. ● Inj Hydrocortisone 100 mg. ● Inj Adrenaline 1mg/ml, 100 mcg/ml, 10 mcg/ml solutions. |
|
Prior to first IVIG infusion ● Record allergies, medications, and baseline height and weight. ● Review history for previous IVIG treatment; if previously received IVIG, any history of adverse reactions to IVIG or to other blood components (history of anaphylaxis, anti-IgA antibodies). ● As per prescriber, baseline blood work: ABO blood group Haemoglobin Kidney function tests, Liver function tests ● Assess patient for TACO (Transfusion Associated Circulatory Overload) risk factors. |
|
Administer the following medication as premedication (start 30 minutes prior to IVIG infusion) ● Inj Paracetamol 1 gm IV stat over 30 mins. ● Inj Ranitidine 50 mg IV stat. ● Inj Pheniramine maleate (Avil) 25 mg IV stat. ● Hydration - IV stat bolus of 500 mL 0.9% Normal Saline prior to infusion. |
● During Infusion:
|
Doctor must be readily available during IVIG treatment. |
|
Visual inspection: bottle seal intact, product appears as clear or slightly opalescent solution that is colourless to pale yellow in colour. |
|
DO NOT infuse different IVIG brands during a single treatment setting. |
|
Do not mix with any other medications/ do not add any medications to IVIG. |
|
Do not dilute IVIG. |
|
Do not shake the IVIG. |
|
Use aseptic technique when handling IVIG. |
|
Administer with standard IV tubing. |
|
For added patient safety, administration using a standard infusion pump is recommended to set the infusion rate precisely. |
|
Infusion Rate: Refer to Table 1. |
Table: 1
|
First Infusion |
Subsequent infusions (Patients who have tolerated the first infusion with no adverse effects.) |
|
30 mL/hr for 30 minutes. 60 mL/hr for 30 minutes. 90 mL/hr for 30 minutes. 120 mL/hr for 30 minutes. 150 mL/hr for 30 minutes* 180 mL/hr till the total dose is infused * Consider remaining at 150 mL/hr rates if the patient is unwell or has a low body mass or where there is a large loading dose prescribed. |
60 mL/hr for 15 minutes 120 mL/hr for 15 minutes 180 mL/hr for 15 minutes 240 mL/hr till the total dose is infused Consider maximum rates of between 150 – 180 mL/hr in patients who have experienced mild to moderate systemic effects with a previous infusion. |
● Patient assessment and vital signs, at minimum
|
Within 30 minutes prior to the start of the infusion. |
|
15 minutes after of start of the infusion. |
|
After each rate increase, then hourly until the infusion is completed. |
|
On completion of the infusion. |
|
For inpatients, 1 hour following completion of the infusion. |
|
For outpatients, prior to discharge. |
|
If clinically indicated, or when a reaction is suspected. |
● Watch for adverse reaction: Refer to Table 2.
Table: 2
|
Mild Reactions |
|
|
● Itching. ● Muscle aches. ● Flushing. ● Mild headache ● Shivering. ● Light headedness/dizziness. ● Nausea. ● Anxiety. |
● Inform the doctor. ● These reactions generally do not require the infusion to be stopped. ● The rate should be slowed to its minimum. ● Oral analgesia and antihistamines may be given as prescribed. ● If symptoms subside the infusion rate may be gradually increased. |
|
Moderate reactions |
|
|
● Itchy, raised rash. ● Severe headache. ● Worsening or reoccurrence of mild reaction. |
● STOP the infusion. ● Inform the doctor. ● Oral or intravenous anti-histamine and Hydrocortisone be given as prescribed for such situations. ● The patient should be closely observed for the worsening of symptoms. ● The infusion may be recommenced slowly and cautiously if symptoms are relieved. |
|
Severe Reactions |
|
|
● Chest pain or pressure in the chest. ● Tightness of the throat. ● Severe dizziness or fainting. ● Bronchospasm/wheeze. ● Collapse. ● Moderate symptoms reoccurring or becoming worse. |
● STOP the infusion. ● Inform the doctor. ● Give adrenaline as per anaphylaxis protocol. ● Also consider fluid, steroid, antihistamine. ● Supportive care per prescriber’s discretion: oxygen, respiratory support, vasopressors. ● Re-assess indication for IVIG. |
● Post-Infusion:
|
Document the following details in the nursing notes ● IVIG brand. ● Dose. ● Lot numbers. ● Date and infusion start time and stop time. ● Volume infused. ● Patient assessments and vital signs. ● Signature with designation. |
|
Discard empty IVIG bottles and tubing in biohazardous waste. |
Further Readings:
1. Katz, U., Achiron, A., Sherer, Y., & Shoenfeld, Y. (2007). Safety of intravenous immunoglobulin (IVIG) therapy. Autoimmunity reviews, 6(4), 257-259.
2. Reid, B., Van Allen, D., LaGrange, C. A., & Boissonneault, N. (2006). Protocol recommendations for administration of intravenous immunoglobulin in Canada. Journal of Infusion Nursing, 29(3), 158-164.
