Intravenous Immunoglobulin (IVIG)

Treatment to be determined by primary team and subspecialty consultants (e.g., infectious diseases/rheumatology). Consults
These discussions will be expedited in the setting of critical illness
Monitor Clinical Response
- Resolution of fever, other clinical features and improving markers of inflammation
Lack of clinical response: Further recommendations per Rheumatology and DIRT
- Ongoing Laboratory Monitoring

Discuss Risks of Transfusion

Occasional risks include: fever and allergic reactions due to the formation of antibodies
Less common risks include: infections with viruses such as hepatitis, and fluid overload
Risk of contracting infectious diseases from IVIG is extremely rare, IVIG is considered to be one of the safest blood products
Written consent is no longer required for blood derived therapeutics such as IVIG

Dose	2 gram/kg Gamunex (Gammagard is acceptable in the setting of shortage) IVIG should be dosed based on IBW for patients meeting the following criteria: Patients age 2-19 years with actual body weight > IBW by 20% Adults > 19 years with BMI > 30 kg/m2
Rate Considerations	Rate of infusion should be low at the beginning and increased gradually based on patient’s tolerance (osmolality and sugar content of preparation affect tolerability) Monitor for symptoms of fluid overload (Respiratory distress, heart failure) Consider continuing low rated and possible diuretic use for patients with evidence of significant myocardial dysfunction. Administration of Large Volume IV Medications > 60 ml that Require Rate Titration Job Aid
Pretreatment Considerations	Administer antihistamines and acetaminophen prior to IVIG. Depending on length of treatment, consider additional doses.
Reactions	Reactions may be due to the active component (IgG) or “impurity of commercial preparations” (stabilizing agents). Classified as immediate (during transfusion) or delayed (after infusion). Mild/Mod reactions Pause infusion and call FLOC. Consider slowing infusion rate. Flushing Chills Myalgia Mild fever ( > 1° C increase in temperature) Headache Hypertension Tachycardia Rash Nausea/vomiting/abdominal pain Severe reactions Stop infusion, discuss with Immunology Anaphylaxis Pathway Anaphylactoid reaction (IgA deficient patients or those with anti-IgA antibodies): hives, respiratory distress, hypotension, massive urticaria, wheezing Delayed reactions Hyperproteinemia Hyponatremia Noncardiogenic pulmonary edema (transfusion-related acute lung injury) Hemolytic anemia (due to passive transfer of anti-A and anti-B) Risk factors include patient blood group (A, B, or AB), a high cumulative dose of IVIG, and concomitant inflammation. Patients would be Coombs positive or have signs of hemolysis. Aseptic meningitis Thrombosis such as PE/stroke Renal dysfunction/acute renal failure
Post-infusion Considerations	IVIG will elevate ESR, so it should not be rechecked post-infusion. If patient requires 2 or more doses of IVIG, it is prudent to check for hemolytic anemia. Check hemolysis labs (CBC, retic, LDH, LFTs) 12-24 hours after repeat dose of IVIG. Consult Hematology for any patient with severe anemia or hemolytic anemia. Fever is typical within first 24 hours post completion of IVIG and should not prompt retreatment.
Special Considerations	Ig-A deficient patients or antibodies against IgA: Discuss with Immunology prior to administration. Risk of thrombosis: Risk factors: advanced age, prolonged immobilization, hypercoagulable conditions, h/o thrombosis, use of estrogens, indwelling central line, hyperviscosity, cardiovascular risk factors Administer at minimum dose and infusion rate, ensure adequate hydration, monitor for signs/symptoms of thrombosis and assess blood viscosity in patients at risk of hyperviscosity Avoid live vaccines (e.g. MMR, varicella)
Related Procedure/Policy/Job Aids	Blood-Derived Product From Pharmacy Procedure Administration of Intravenous Immune Globulin (IVIG) Job Aid Formulary: IVIG

Transfusion. 2015 Jul: Suppl 2:S90-4. Intravenous immunoglobulin-related hemolysis in patients treated for Kawasaki disease. Luban NL, Wong EC, Henrich Lobo R, Pary P, Duke S
Asia Pac Allergy. 2013;3:249-256. Adverse events of intravenous immunoglobulin infusion: a ten-year retrospective study. Palabrica Frances Rose R, Kwong Shirley L., and Padua, Florecita R.
Clin Exp Immunol. 1994; 97 (Suppl 1): 79-83. Side-effects of intravenous immune globulins. Duhem C, Dicato A, and Ries F.

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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