BEAUMONT HOSPITAL DEPARTMENT OF NEPHROLOGY RENAL BIOPSY

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2 BEAUMONT HOSPITAL DEPARTMENT OF NEPHROLOGY GUIDELINES ON ADMINISTRATION OF INTRAVENOUS IRON SUCROSE (VENOFER) AS A BOLUS DOSE IN THE RENAL OUTPATIENT SETTING Date Developed: August- October 2007 RENAL BIOPSY Developed By; SEE UNDER PRODUCTION/CONSULTATION TEAM Approved By: Date of Approval: September 23 rd 2007 Review Date; 1st February 2008 Date Effective from: 1 st November 2007 Document No. 01 Supersedes Documents; New document PRODUCTION AND CONSULTATION TEAM 2

3 Petrina Donnelly Louise Kelly Renal Clinical Practice Support Nurse CNM 1 Renal Day Care Renal Policy Committee Sharon Dwyer Neal Morgan Ashling Courtney Peter Conlon Louise McSkane Niamh Carroll Renal Divisional Nurse Manager Consultant Nephrologist Consultant Nephrologist Consultant Nephrologist CNM1 Ambulatory Care Nurse CNM 1 Hamilton Ward Johanna McWilliams Martin Ferguson CNM 2 Peritoneal Dialysis Department Renal Pharmacist TABLE OF CONTENTS 1.0 Aims / Purpose of Policy. 3

4 1.0 Aims / Purpose of Policy. 2.0 Scope of Policy 3.0 Definitions 4.0 Responsibilities 5.0 Procedure 5.1 Protocol for administrating of intravenous iron sucrose (venofer) 5.2 Special Warning and Precautions for use 6.0 Distribution 7.0 Filing 8.0 Overview 9.0 Superseded Documents 1.0 Aim and Purpose of Policy The aim of this document is to provide up to date guidelines for nurses and medical practitioners administering Intravenous iron sucrose (Venofer) to patients as a bolus dose. 4

5 2.0 Scope of Policy This policy refers to all registered nursing staff and medical staff working in the renal unit at Beaumont Hospital. This policy will initially be piloted in the Renal Day Care Ward on Hamilton. It will be reviewed in 3months time and may be incorporated to other areas within the renal unit. 3.0 Definitions Venofer is a sterile, dark brown, non transparent aqueous solution of Iron intended to be used only for intravenous injection or as a concentrate only for solution for infusion which contains the active ingredient iron as a solution of iron sucrose [ iron (III)- Hydroxide sucrose complex]. The solution also contains sodium hydroxide and water for injection. Venofer is supplied in glass ampoules which contain 5ml of solution = 100mgs of iron. Measuring Iron Status Target Hb >11g/dl: (KDOQI 2006) Patients should be in iron balance and have sufficient iron to maintain a haemoglobin level of 11g/dl Iron deficiency anaemia; diagnosed when serum ferritin <100 ug/l aim for ug/l upper limit 800ug/l Functional iron deficiency defined by; Serum ferritin >100Ug/l and either %HRC > 5% Nice Guidelines (2006) 4.0 Responsibility Each practitioner is responsible and accountable for their actions. They must acknowledge any limitations of competence and refuse in such cases to accept delegated functions. The practitioner administering bolus dosing of Intravenous Iron Sucrose must read and understand this guideline prior to taking on this role. 5.0 Procedure RENAL UNIT 5

6 INTRAVENOUS IRON SUCROSE (VENOFER) PRESCRIPTION AND INFUSION RECORD FORM Affix Addressograph label here Patient Name Date Of Birth History/Patient Number Prescription Instructions This prescription is for the use of IV Iron Sucrose only, used specifically for the Renal Department within Beaumont Hospital The prescription must be completed by a doctor with signature, date and bleep number. The patients allergies should be noted by the doctor The Doctor must tick the relevant box to indicate the amount of doses to be administered. This prescription will last for a full course of IV Iron Sucrose (200mgs x 5 doses) or a Maintenance course up to 5 doses Oral Iron should not be taken while IV Iron is being administered it should be recommenced five days after the completion of IV Iron sucrose The patient must have first dose of IV Iron Sucrose given by a doctor if they not received this drug within Beaumont Hospital before. Patient Allergies Oral Iron Yes No Last course of IV Iron Epo Treatment Yes No Drug/Dose Corrective Course Maintenance Course How many 200mg doses of iron sucrose required Frequency Prescribed By Dr (Print Name) Bleep Signature; Date; Affix Addressograph label here Patient Name Date Of Birth History/Patient Number 6

7 Date Drug Dose Route Dose Number Iron sucrose Iron sucrose Iron sucrose Iron sucrose Iron sucrose 200mg 1 of 5 200mgs 2 of 5 200mgs 3 of 5 200mgs IV Bolus By 4 of 5 slow IV injection 200mgs Over 10 5 of 5 minutes S/N Print Name 2nd Signature Print Name Blood Results Pre Iron Treatment Post Iron Treatment bloods Hypochromic % (obtained two weeks post completed course) TSATS B12 Folate Affix Addressograph label here 7

8 Patient Name Date Of Birth History/Patient Number Record of Vital Signs 1 st Dose Date Vital Signs interval Time Blood Pressure Butterfly Site Checked By Baseline Completion Infusion Reaction Yes No Incident Form completed Yes No 2 nd Dose Date Vital Signs interval Time Blood Pressure Butterfly Site Checked By Baseline Completion Infusion Reaction Yes No Incident Form completed Yes No 8

9 3rd Dose Date Vital Signs interval Time Blood Pressure Butterfly Site Checked By Baseline Completion Infusion Reaction Yes No Incident Form completed Yes No 4th Dose Date Time Butterfly Site Vital Signs interval Baseline Blood Pressure Checked By Completion Infusion Reaction Yes No Incident Form completed Yes No 5th Dose Date Vital Signs interval Time Blood Pressure Butterfly Site Checked By Baseline Completion 9

10 Infusion Reaction Yes No Incident Form completed Yes No Further Appointments for IV Iron Sucrose administration Date Time Location 10

11 5.1 PROTOCOL FOR ADMINISTRATION OF INTRAVENOUS IRON SUCROSE (VENOFER) Equipment Required Solutions Required Completed Patient IV Iron Sucrose Prescription IV tray with sharps bin 1x sterile alcohol wipe 1 x 10 ml syringe 1 x 21 gage butterfly Non sterile Gloves 1 x tourniquet 1 x blue needle Mepore tape to secure butterfly Gauze Labeled blood bottles if required Appropriate size syringe for obtaining blood samples if required 200mg IV Iron Sucrose Vial (Venofer) Procedure Check completed prescription for IV Iron Sucrose Check Patient identity against medical chart details and patient confirmation Check appropriate drugs with second person (registered nurse, doctor, roistered student nurse) for drug, dose and expiry date Check patient allergies Check patients blood pressure pre administration Apply gloves Apply tourniquet and select site Cleanse site with alcohol swab avoid if possible future fistula sites- allow to dry Draw up IV Iron Sucrose dose as prescribed in a 10 ml syringe Check blood labels if ordered Insert butterfly needle and allow to bleed out to ensure correct position prime the line with blood taking special care that blood does not flow out. Attach appropriate syringe for blood samples (if required) and take samples Secure butterfly needle with mepore tape ensuring both sides are folded back Kink the butterfly line at the end and remove blood syringe and place on sharps tray Attach the 10ml syringe with Iron Sucrose and administer as below. 11

12 BEFORE ADMINISTRATING THE FIRST DOSE TO A NEW PATIENT A TEST DOSE OF VENOFER MUST BE GIVEN BY A DOCTOR. DRUG DETAIL Test Dose (undiluted) IV rate 20mgs/min. Bolus Dose INSTRUCTION Test Dose only given on 1 st administration. 20 mgs (1ml) Iron sucrose slow push 1-2 minutes if no reaction after 15 minutes continue, If a reaction occurs contact the medical team immediately. Give remaining 180 mgs (9mls) Iron sucrose over 10 minutes Subsequent Dosing 200 mgs Iron sucrose (10mls) over 10 minutes Follow Up Post treatment bloods should be obtained two weeks after treatment completion Reassess Total dose of 1000mgs/1grm is maximum dose treatment Do not flush the line post administration Remove the butterfly needle and discard according to sharps policy Apply gauze to site and ensure bleeding has stopped Ensure the arm is not bent post removal of butterfly needle Assess the site for any signs of inflammation or pain and document same Check patients blood pressure post administration Document the administration of IV Iron Sucrose on prescription and any adverse events Arrange next appointment if required for further treatment 5.2 Special Warnings and Precautions for use. Parentally administered iron preparations can cause severe allergic or anaphylactoid reactions, which may be potentially fatal. Anaphylactic Shock pack must always be available when administering iron treatment. Intravenous Chlorpheniramine and Hydrocortisone should be available for immediate use in the event of a severe drug reaction these can be located in the emergency drug trays at ward level. Adverse Reaction Serious Allergic Reaction Treatment In the event of a serious allergic or anaphylactoid reaction, administration of iron sucrose must be stopped, intramuscular adrenaline should be administered immediately and other supportive measures initiated in line with the established cardio-pulmonary resuscitation procedures of Beaumont hospital. 12

13 Adverse Reaction Mild Allergic Reaction Hypotensive Effects Undesirable Effects Treatment Mild allergic reactions should be managed by stopping the administration of Iv Iron Sucrose And administering antihistamines. Hypotensive episodes may occur if the injection is administered too rapidly. Administration should be slowed down. Taste perversion fever and shivering. Injection site reaction nausea. 6.0 Distribution The Divisional Nurse Manager will circulate a copy of this policy to the relevant areas. The clinical nurse manager in each area is responsible to ensure all nursing staff access and read this guideline. Consultants are responsible to ensure all their medical team have access and read this guideline. 7.0 Filing The policy will be available on the hospital intranet and a hard copy kept in the Divisional Nurse Manager office. Also a paper copy will be available in each area in the renal policy/guideline folder located at the nurses stations and in the Renal day care Ward. 8.0 Review This policy is to be piloted in the Renal Day Care Ward on Hamilton it will be reviewed in three months time. It may be rolled out throughout the unit after this period. 9.0 Superseded Document This is a new policy so it does not supersede any other document. 13

14 Reference List European Best Practice Guidelines for the management of anaemia in patients with Chronic renal failure, Nephrology Dialysis Transplantation. Vol 19 May 2004 Suppl 2 KDOQI (2006) Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease. American Journal of Kidney Disease Vol 47,Suppl 3 Nice Guidelines (2006) Anemia Management in Chronic Kidney Disease 14