IVIG titration rates

[LJ85, ADN, BSN, CNA, LPN]

So I work for two home infusion companies and they both have different policies on how to titrate IVIG.

Company A says they titrate IVIG as follows: 15ml @ 30ml/h x 30 min, 30ml @ 60ml/h x 30 min, 45ml @ 90ml/h x 30 min and the remainder at 100-120/h Unless pharmacy states a specific rate

Company B says they do:

5ml @ 20ml/h x 15 min, 10ml @ 40ml/h x 15 min, 15 ml @ 60ml/h x 15 min, 20 ml @ 80ml/h x 15 min and remainder strictly at 100ml/h unless pharmacy specifically states a higher rate.

The websites for the actual manufacturers state much higher rates and it’s not usual procedure for pts to infuse this quickly and fast rates tend to cause symptoms like headaches and flu like symptoms in pts.

Every time I go in to a new case that had a nurse prior to me the pumps are set differently so I am just wondering if there is a standard way? The pharmacist I spoke with once said they don’t recommend more than 10mg/h but I’m wondering more about the titration as IVIG is a blood product.

[scribblz, BSN, CNA, LPN]

I think the titration is specific to each patient based on what they've tolerated in the past. I have one client who did not tolerate her infusion with her previous home infusion nurse, and her physician got rid of her pump all together. Now I give her Privigen 4gm/450ml via gravity...6gtts/min x30 mins, 12gtts/min x 1 hr then 20gtts/min for the reminder. It takes approximately 8hrs! And I have to give her Benadryl before and half way through, also tons of water or she developed the headaches and flu like malaise.

I appreciate your post as I'm fairly new to home infusion nursing, and it's nice to hear about other nurses' experiences. Outpatient nursing is so much more isolating than inpatient!

[CritterLover, BSN, RN]

My approach:

If the agency or pharmacy has a set way to do it, I follow that titration protocol unless the patient doesn't tolerate it -- then I slow it down to what the patient tolerates.

If the agency and pharmacy both leave it up to the RN, I do what the patient tells me works for them. Obviously they don't want adverse reactions but they also don't want you in their house all day. If they are new, I follow whatever protocol they tolerated for their first infusion, and gradually (over many months) up the titration rate to see what they tolerate.

If the patient wants it faster than agency policy allows, I still follow agency policy and let the patient know why. They can plead their case with the agency or ask for a different nurse. I'm OK if I get "fired" from a case because I refuse to break agency policy.

I worked for a pharmacy whose IVIG titration policy was sooooo slow that we often did two day visits for an amount that I've infused (easily) in one day for patients at another agency. It was crazy. But, they didn't have many reactions either.

I'm a rule-follower for good or bad. If others don't follow the agency rules, I don't make an issue of it unless it is putting the patient's safety in jeopardy. I figure that my supervisor can read and comprehend nurses notes, and if my coworkers aren't following policy as far as titration protocol, it will be noticed. If it isn't noticed I'm OK with that. If at some point I am asked why a coworker can see more patients than can in the same time frame, I will point the supervisor to my notes and ask them how I should move faster.