IV Immunoglobulin (IVIg): Use in the ED

Background

IVIg is a concentrated solution of immune-supporting antibodies, given as an infusion. It is a blood product and must be managed as such.

IVIg is not routinely given in the ED - the usual setting is Wards 1A, 3A or 3D.

Departmental Position

In the ED, IVIg is only given for life-threatening indications, as outlined in table below
It should only be given if agreed by the CNM, and administered in Resus or Majors
Medical and nursing staff should seek support if unfamiliar with prescribing or administering IVIg

Indications

Indications where IVIg treatment must not be delayed
Specialty	Indication
Haematology	Severe thrombocytopaenia in ITP with platelets <10 Severe refractory AIHA with Hb <7
Rheumatology	Myositis (particularly with dysphagia) Haemophagocytic lymphohistiocytosis (HLH)
Neurology	Severe Guillain-Barré syndrome Relapse of CIDP Myasthenia Gravis crisis - give within 12 hours of admission

Contraindications

Patient is acutely unwell with untreated infection - wait until infection is controlled and the patient is improving clinically

Prescriber Protocol

Verbal consent, documented in the notes - indication, possible side-effects, and blood component/haemovigilance discussed
Pre-treatment bloods: FBC, U&E, creatinine must be back before treatment; LFTs and HepB/C/HIV serology also taken
Prescribe on Form 15B (Intravenous Immunoglobulin Prescription and Administration Record)

Caution

Kiovig® and Flebogamma® are not interchangeable
Contact Pharmacy to confirm stock, dose rounding, and the patient's IVIg brand history

Dose

Dose is calculated using an adjusted body weight for overweight or obese adults, not actual weight:

Dosing weight = IBW + [0.4 × (Actual weight − IBW)] (if actual weight is less than IBW, use actual weight)
IBW (Devine formula, using cm):
- Male: 50 + 0.91 × (height cm − 152.4)
- Female: 45.5 + 0.91 × (height cm − 152.4)

Round the dose down to the nearest whole vial to minimise waste - never use part vials in adults. If the dose is split over several days, the daily amount may vary.

Infusion rate
Stage	Rate
Start (first 30 min)	0.5 ml/kg/hr
Then, every 30 min as tolerated	increase by 0.5 ml/kg/hr
Maximum	6 ml/kg/hr (rarely >4 ml/kg/hr for inpatients)

The Alberta Health Services IVIg calculator can be used to assist with calculations

Two nurses must independently double-check the dose and preparation before it is connected.

Monitoring

Observations (temp, pulse, sats, BP) at the start, at every rate change, and at the end - document on the INEWS chart
Ensure adequate hydration before starting, and monitor urine output and creatinine throughout
Watch for signs and symptoms of thrombosis
First infusion, a switched product, or a long gap since the last dose: monitor throughout and for 1 hour after. All other patients: observe for at least 20 minutes after

Adverse Reaction

Stop the infusion immediately
Contact a member of the medical team
Please report any suspected adverse reactions

IV Immunoglobulin (IVIg)