Intravenous Iron Orders - HUMCMD.net

AUTOMATIC
STOP ORDERS
Requires renewal every 24
hours:
• Oral Anticoagulants
• Albumin
• Large Volume IV Solutions
Requires renewal every 5
days:
• Injectable Anticoagulants(sc)
• Controlled Substances
• Cortisone Products
UNACCEPTABLE
ABBREVIATIONS
DO
NOT
USE
SAFE PRESCRIBING
Always write the order as follows
1.0 MG - Express as whole number only – 1 mg
.5 MG - Always use zero before decimal – 0.5 mg
U - Always write out the word – “unit”
MSO4 - Always write out the word – “morphine”
MgSO4 - Always write out the words – “magnesium sulfate”
IU - Always write out the words – “international unit”
QD - Always write out the word – “daily”
QOD - Always write out the words – “every other day”
AFFIX PATIENT INFO LABEL HERE
Patient Name ________________________ MR# ___________
ALLERGIES:
Date
of
Order
Hour
of
Order
Nurse’s Signature
PHYSICIAN MUST ENTER DATE, HOUR, AND SIGN EACH SET OF ORDERS.
INTRAVENOUS IRON ORDER FOR ADULT PATIENTS
(IRON DEXTRAN and FERRIC GLUCONATE-FERRLECIT)
1. Baseline Hgb, Hct, Fe, TIBC, transferrin saturation, and ferritin must be available
prior to ordering IV iron
2. Use pediatric tubes for all blood draws.
3. PRE-MEDICATIONS (only if needed )- include name, dosages, route and frequency:
___________________________________________________________________
___________________________________________________________________
4. IV IRON ORDERS (see back page for dosing information)
♣ PATIENT’S HGB= _________g/dL HGB GOAL = _________g/dL
♣ WEIGHT (use IBW unless actual weight is less) = ______kg (see back of order)
♣ ESTIMATED IV IRON REQUIREMENT = __________mg (see back of order for
estimation of iron requirement). Choose ONE of the following iron products:
A. IRON DEXTRAN IV:
Test dose Iron Dextran: 25mg IV in 50mL NS over 15 minutes X 1
If adverse reactions do not occur after one hour, initiate dose below.
Total dose Iron Dextran (recommend maximum 1000mg per day - see back of order)♦:
Day #1: Give _______ mg Iron Dextran IV in 250mL NS over _____hrs (4-6hrs)
Day #2: Give ________mg Iron Dextran IV in 250mL NS over _____hrs (4-6hrs)
Other or maintenance dose ___________________________________
Have the following medications available prior to infusing Iron Dextran:
Epinephrine 1:1000 (1mg/1mL) injectable
Diphenhydramine 50mg injectable
Hydrocortisone 100mg injectable
Vital signs: baseline, then q 15 minutes X 1 h, then q 1 h during each infusion
B. FERRIC GLUCONATE IV (FERRLECIT):
IV infusion 125mg in 100mL NS over 1 hour (recommend maximum 125mg per day)
once daily X ____ doses OR _____________________________________________
IV push 125mg (10mL) undiluted over 10 minutes per dialysis session / patient visit X
_____________doses (dialysis patients only)
Vital signs: baseline, q 30 minutes during first infusion, then per unit policy
Ferric Gluconate infusion must be used immediately after mixed by pharmacy
RN to please call pharmacy prior to giving each infusion dose.
Do NOT mix or infuse IV Iron with any other medications
5. OTHER ORDERS:
___________________________________________________________________
___________________________________________________________________
Physician Signature: ____________________________________________________
PLEASE DO NOT RETURN CHARTS WITH NEW ORDERS TO RACK-FLAG CHART
HACKENSACK UNIVERSITY MEDICAL CENTER
PHYSICIANS ORDERS AND TREATMENTS Page 1 of 1
Intravenous Iron Order Medical Record HUMC NS#5031599 Rev.7/24/06

ESTIMATION OF IV IRON REQUIREMENT IN ADULT PATIENTS - Iron Dextran or Ferric Gluconate (Ferrlecit)
DIRECTION:
1. Use TABLE 1 to obtain IBW (use actual weight if it is less than IBW).
2. Choose your Hemoglobin goal and use TABLE 2 to find the estimated dose of IV IRON (iron dextran or ferric gluconate (Ferrlecit)) in MG based on the
patient’s current Hemoglobin.
TABLE 1: IDEAL BODY WEIGHT (IBW) IN KG - Round weight down to the nearest 5kg
HEIGHT 5ft 1 5ft 2 5ft 3 5ft 4 5ft 5 5ft 6 5ft 7 5ft 8 5ft 9 5ft 10 5ft 11 6ft 6ft 1 6ft 2 6ft 3 6ft 4 6ft 5 6ft 6 6ft 7 6ft 8 6ft 9
MALE 52kg 55kg 57kg 59kg 62kg 64kg 66kg 68kg 71kg 73kg 75kg 78kg 80kg 82kg 85kg 87kg 89kg 91kg 94kg 96kg 98kg
FEMALE 48kg 50kg 52kg 55kg 57kg 59kg 62kg 64kg 66kg 69kg 71kg 73kg 75kg 78kg 80kg 82kg 85kg 87kg 89kg 92kg 94kg
• IBW in kg (male)= 50kg + 2.3kg/inch over 60 inches
• IBW in kg (female)= 45.5kg + 2.3kg/inch over 60 inches (These equations are use to calculated IBW in TABLE 1 above)
TABLE 2: HEMOGLOBIN GOALS - Round dose to the nearest 50 or 100mg
HEMOGLOBIN GOAL = 12 g/dL WEIGHT WEIGHT HEMOGLOBIN GOAL = 13 g/dL HEMOGLOBIN GOAL = 14.8 g/dL
WEIGHT MG of IV IRON based on patient Hgb MG of IV IRON based on patient Hgb MG of IV IRON based on patient Hgb
(kg) 6g/dL 7g/dL 8g/dL 9g/dL 10g/dL (kg) 6g/dL 7g/dL 8g/dL 9g/dL 10g/dL (kg) 6g/dL 7g/dL 8g/dL 9g/dL 10g/dL
40 1320 1100 880 660 440 40 1422 1218 1015 812 609 40 1570 1391 1213 1035 856
45 1485 1238 990 743 495 45 1599 1371 1142 914 685 45 1766 1565 1365 1164 963
50 1650 1375 1100 825 550 50 1777 1523 1269 1015 762 50 1962
55 1815 1513 1210 908 605 55 1955 1675 1396 1117 838 55 2158
60 1980 1650 1320 990 660 60 2132 1828 1523 1218 914 60 2355
65 2145 1788 1430 1073 715 65 2310 1980 1650 1320 990 65 2551
70 2310 1925 1540 1155 770 70 2488 2132 1777 1422 1066 70 2747
75 2475 2063 1650 1238 825 75 2665 2285 1904 1523 1142 75 2943
80 2640 2200 1760 1320 880 80 2843 2437 2031 1625 1218 80 3139
85 2805 2338 1870 1403 935 85 3021 2589 2158 1726 1295 85 3336
90 2970 2475 1980 1485 990 90 3198 2742 2285 1828 1371 90 3532
1739 1516 1293 1070
1913 1668 1423 1177
2087 1819 1552 1284
2261 1971 1681 1391
2435 2123 1811 1498
2609 2274 1940 1605
2783 2426 2069 1712
2957 2578 2199 1819
3131 2729 2328 1926
MG of Iron = 0.66 X IBW in kg X [ 100 − (Observed Hgb X 100) ] (This equation is used to estimate the dosages in TABLE 2 above.
Desired Hgb Use this equation if your Hgb goal is different from the above)
FERRIC GLUCONATE (FERRLECIT):
‣ Recommend no more than 125mg per day at 125mg/h per manufacturer and HUMC guidelines.
IRON DEXTRAN:
‣ Recommend no more than 1000mg per day per HUMC guidelines.
‣ Doses higher than 1000mg per day can be prescribed at the discretion of the prescribing physician with staff hematology consultation.
‣ Suggested infusion time is 4-6 hours (shorter infusion time may be appropriate at the discretion of the prescriber and should not be faster than 500mg/h)
JBui\071506
Intravenous Iron Order Medical Record HUMC NS#5031599 Rev.7/24/06