关于我院丙种球蛋白滴注前后应用生理盐水冲管的建议
传染性单核细胞增多症护理研究进展李虹
传染性单核细胞增多症护理研究进展李虹发布时间：2023-06-15T01:37:33.374Z 来源：《中国医学人文》(学术版)2023年6月6期作者：李虹[导读] 传染性单核细胞增多症是临床较常见的综合征之一，多发生于儿童，临床多表现为发热、咽峡炎、淋巴结肿大等，不仅影响患儿及家属身心健康，而且还威胁患儿生命安全。
当前，无特效治疗方法，临床往往采用对症治疗，除此之外，还应加强护理干预，从而改善预后。
本文现对传染性单核细胞增多症的护理进行综述，以望对后期的相关工作提供参考借鉴。
四川大学华西第二医院小儿心血管科四川成都 610041摘要：传染性单核细胞增多症是临床较常见的综合征之一，多发生于儿童，临床多表现为发热、咽峡炎、淋巴结肿大等，不仅影响患儿及家属身心健康，而且还威胁患儿生命安全。
当前，无特效治疗方法，临床往往采用对症治疗，除此之外，还应加强护理干预，从而改善预后。
本文现对传染性单核细胞增多症的护理进行综述，以望对后期的相关工作提供参考借鉴。
关键词：传染性单核细胞增多症；护理；进展传染性单核细胞增多症(infectious mononucleosis，IM)是由EB病毒感染所引起的单核-巨噬细胞系统急性增生性传染病，由于其发病群体多为小儿，加上临床表现的多样性，多数患儿有较好的预后，但不排除引发其他严重并发症。
经口接触是此病的主要传播途径，如共用餐具、亲吻等[1-2]，除了对症治疗外，还应结合相应护理。
本文将其护理措施综述如下：1、心理护理传染性单核细胞增多症患儿多表现持续不退的高热、咽峡炎所致的疼痛，加上小儿耐受力较弱，容易哭闹，无疑增加了患儿家属的恐惧及焦虑情绪[3]。
因此，作为护理人员，对于年龄较大的患儿，可进行详细解释，并耐心安慰及鼓励。
同时采用和善及关切的态度与患儿家属进行交流，加强医患之间的沟通，从而提高治疗依从性。
也可向患儿家属列举治疗成功的病例，鼓励患者配合临床治疗，树立治疗自信心。
关于我院丙种球蛋白滴注前后应用生理盐水冲管的建议
关于我院丙种球蛋白应用前后使用生理盐水冲管的建议我院丙种球蛋白(冻干/静注人免疫球蛋白)主要在皮肤病区、老年病区及风湿病区应用为主，近月来丙种球蛋白临床消耗量呈现一定的增长趋势,为杜绝临床不合理应用,临床药师展开了初步的调查,暂未发现临床滥用的现象，但值得引起临床高度重视的是95%丙球在用药前后均使用0.9%氯化钠注射液进行冲管,部分科室医生在应用时未交待或未明确交待滴注速度。
冻干/静注人免疫球蛋白（PH4）说明书用法用量及注意事项明确标示：如有需要，可以用5%葡萄糖注射液稀释本品，即不建议临床应用生理盐水及电解质溶液进行稀释或冲管。
另有文献《Safety and Adverse Events Profiles of Intravenous Gammaglobulin Products Used for Immunomodulation ：A Single-Center Experience》com from the American Society of Nephrology 1: 844–852, 2006报道丙球的不良反应跟其所含氯化钠、糖分、PH、渗透压不同而不同，可出现急性心肌梗死、急性肾功能衰竭等，研究表明含氯化钠的丙球可能导致急性心肌梗死。
据皮肤病区医生反应曾有多例应用丙球冲击治疗患者出现“类心衰样”表现的现象出现，故综上所述不建议临床应用生理盐水冲管，建议改用5%葡萄糖注射液冲管,糖尿病人可适当加用胰岛素控制血糖。
关于滴速问题，皮肤病区医生大都交待明确，其他病区有交待为“慢滴”，甚至不交代滴速的现象。
根据药品说明书推荐建议前15min 不超过20d/分,之后可逐渐加快滴速,但不宜超过60d/分。
滴注速度过快,瞬间血液粘稠度升高,胶体渗透压升高,更容易出现不良反应事件,故建议临床医生开具医嘱时一定要交待清楚滴注速度。
药学部临床药学室2013.10.11。
两种护理方式在丙种球蛋白冲击治疗川崎病患儿护理应用的效果观察
两种护理方式在丙种球蛋白冲击治疗川崎病患儿护理应用的效果观察目的探讨丙种球蛋白冲击治疗川崎病患儿中两种护理方法及其临床意义。
方法将我院2015年1月～2017年1月22例川崎病患儿作为研究对象，均分为两组，予以丙种球蛋白冲击治疗。
对照组采取常规护理模式，观察组实施综合护理及延续护理干预。
观察两组生活质量、实验室检查指标以及不良事件发生情况。
结果观察组出院时、出院15、30d生活质量高于对照组，出院15、30d C反应蛋白、血小板计数、白细胞计数各项指标数据均优于对照组，未出现不良事件，与对照组相比差异较大（P＜0.05）。
结论在丙种球蛋白冲击治疗川崎病中，综合护理及延续护理干預可在不同时期发挥作用。
[Abstract] Objective To investigate the two nursing methods of children with Kawasaki disease treated by gamma globulin challenge and its clinical significance. Methods 22 cases of children with Kawasaki disease cured in our hospital from January 2015 to January 2017 were selected as the object of study. They were divided into two groups，and all of them were treated with gamma globulin shock treatment. Patients in control group were treated with routine nursing mode，and patients in observation group were treated with comprehensive nursing and extended nursing intervention. The quality of life，the laboratory examination index and the occurrence of adverse events were observed. Results At the time of discharge，15 days and 30 days later，the quality of life of the observation group was higher than that of the control group. After 15 days and 30 days of discharge，the data of C-reactive protein，platelet count and white blood cell count of the observation group were better than those of the control group. There were no adverse events in the observation group，which were different from the control group（P＜0.05）. Conclusion In combination with gamma globulin in the treatment of Kawasaki disease，comprehensive care and extended care interventions can play a role in different periods[Key words] Kawasaki disease；Gamma globulin；Impact therapy；Two kinds of care；Application effect川崎病属于结缔组织病，其病理改变以全身小血管变态反应为主，患儿通常会出现皮肤肿胀、皮疹、发热等症状，对动静脉、毛细血管等多个系统均会累及，冠状动脉损伤是最为严重的危害因素[1-2]，可导致动脉瘤及动脉扩张，是儿童发生后天性心脏病原因中较为主要的一种，临床证实[3]，予以丙种球蛋白治疗可获得较佳治疗效果，能够有效改善冠状动脉受累情况，其作用机制尚无统一定论，可能与抑制免疫复合物反应，从而避免冠状动脉受损，起到降温效果有关，同时予以有效的护理干预对于预后效果具有改善作用，可保证患儿生活质量，常规护理干预无法取得理想效果。
关于我院丙种球蛋白滴注前后应用生理盐水冲管的建议
个人收集整理仅供参考学习关于我院丙种球蛋白应用前后使用生理盐水冲管的建议我院丙种球蛋白(冻干/静注人免疫球蛋白)主要在皮肤病区、老年病区及风湿病区应用为主，近月来丙种球蛋白临床消耗量呈现一定的增长趋势,为杜绝临床不合理应用,临床药师展开了初步的调查,暂未发现临床滥用的现象，但值得引起临床高度重视的是95%丙球在用药前后均使用0.9%氯化钠注射液进行冲管,部分科室医生在应用时未交待或未明确交待滴注速度。
冻干/静注人免疫球蛋白（PH4）说明书用法用量及注意事项明确标示：如有需要，可以用5%葡萄糖注射液稀释本品，即不建议临床应用生理盐水及电解质溶液进行稀释或冲管。
另有文献《Safety and Adverse Events Profiles ofIntravenousGammaglobulin Products Used forImmunomodulation ：A Single-Center Experience》com from the American Society of Nephrology 1: 844–852, 2006报道丙球的不良反应跟其所含氯化钠、糖分、PH、渗透压不同而不同，可出现急性心肌梗死、急性肾功能衰竭等，研究表明含氯化钠的丙球可能导致急性心肌梗死。
据皮肤病区医生反应曾有多例应用丙球冲击治疗患者出现“类心衰样”表现的现象出现，故综上所述不建议临床应用生理盐水冲管，建议改用5%葡萄糖注射液冲管,糖尿病人可适当加用胰岛素控制血糖。
关于滴速问题，皮肤病区医生大都交待明确，其他病区有交待为“慢滴”，甚至不交代滴速的现象。
根据药品说明书推荐建议前15min 不超过20d/分,之后可逐渐加快滴速,但不宜超过60d/分。
滴注速度过快,瞬间血液粘稠度升高,胶体渗透压升高,更容易出现不良反应事件,故建议临床医生开具医嘱时一定要交待清楚滴注速度。
药学部临床药学室2013.10.111 / 1。
丙种球蛋白联合阿司匹林治疗小儿川崎病的观察及护理
3.5口腔皮肤护理护理患儿口腔、咽粘膜出现弥漫性充血，每日做好口腔护理，保持口腔清洁。注意操作时动作轻柔，避免发生出血和疼痛，用软毛牙刷刷牙，指导患儿餐前、餐后漱口，对口唇皲裂者涂石蜡油或无色唇膏；对于眼部分泌物多，眼球干涩者，每天用生理盐水冲洗双眼保持眼部的清洁，预防感染。
丙种球蛋白联合阿司匹林治疗小儿川崎病的观察及护理
摘要】目的：探讨丙种球蛋白联合阿司匹林治疗小儿川崎病的疗效，提高川崎病患儿的治疗效果。方法：回顾分析74例患儿应用丙种球蛋白联合阿司匹林治疗小儿川崎病的护理过程，结果74例川崎病患儿未发生并发症，全部治愈出院。结论：丙种球蛋白联合阿司匹林治疗小儿川崎病，通过全面细致的护理，可以缩短病程，提高川崎病患儿的疗效，减少并发症的发生。
1.2方法所有患儿在确诊后根据具体病情给予抗感染、纠正水、电解质、酸碱平衡等对症支持治疗，在此基础上加用[1]静脉用丙种球蛋白，采用2g/kg/d×1天疗法，结合临床症状，采用相应的治疗措施。[2]阿司匹林有抗炎、抗凝的作用。早期与丙种球蛋白联合可控制急性炎症过程，减少冠状动脉病变，用法：每日30-50mg/kg,口服，退热后每日3-5mg/kg,持续用药至症状消失，血沉正常，共用1-3个月。
1.3疗效观察本组经大量丙种球蛋白治疗后体温2-3天体温全部恢复正常，3天后皮肤粘膜损害逐步恢复正常，生化指标恢复正常，复查彩超多普勒心动图冠状动脉无扩张。
2.结果本组患儿经1个疗程丙种球蛋白和阿司匹林的联合治疗，平均住院15天，本组患儿全部治愈出院。
磁共振增强后推注生理盐水冲洗注射部位的方法初探
磁共振增强后推注生理盐水冲洗注射部位的方法初探田彬;任莲花;左灵芝【摘要】@@ 近年来,磁共振成像(MRI)技术发展迅速,在临床各系统疾病的应用范围也日益广泛,其增强检查范围也不断扩大.增强MRI可提高正常组织与病变组织的对比度,其高空间分辨率提高了MRI诊断敏感性和特异性[1].但在临床应用过程中,由于各种原因会发生注射部位不同程度的不良反应.有文献报道,推注生理盐水可提高注射部位耐受性,减少不良反应[2].但与增强剂剂量、推注速度与冲管剂量、冲管方法有无相关性未做深入探讨.我科对2 200例使用增强造影剂的病人在冲管剂量和冲管方法方面进行观察.现报告如下.【期刊名称】《护理研究》【年(卷),期】2011(025)023【总页数】2页(P2115-2116)【作者】田彬;任莲花;左灵芝【作者单位】830001,新疆维吾尔自治区人民医院;830001,新疆维吾尔自治区第一济困医院;830001,新疆维吾尔自治区人民医院【正文语种】中文【中图分类】R472近年来,磁共振成像(MRI)技术发展迅速,在临床各系统疾病的应用范围也日益广泛,其增强检查范围也不断扩大。
增强MRI可提高正常组织与病变组织的对比度,其高空间分辨率提高了MRI诊断敏感性和特异性[1]。
但在临床应用过程中,由于各种原因会发生注射部位不同程度的不良反应。
有文献报道,推注生理盐水可提高注射部位耐受性,减少不良反应[2]。
但与增强剂剂量、推注速度与冲管剂量、冲管方法有无相关性未做深入探讨。
我科对2 200例使用增强造影剂的病人在冲管剂量和冲管方法方面进行观察。
现报告如下。
1 资料和方法1.1 临床资料选择2010年4月—2011年1月在我科行MRI增强扫描的病人2 200例,分为A组、B组。
A组均为颅外原单磁共振血管成像(M RA)病人共1 600例,其中男960例,女640例;年龄36岁～83岁,平均 45.3岁;采用 8 NV头颈联合线圈行T ricks多期动态扫描,时间20 s～35 s。
关于静脉滴注丙种球蛋白治疗新生儿ABO_溶血疗效评价及护理
关于静脉滴注丙种球蛋白治疗新生儿ABO溶血疗效评价及护理金云（宿迁市妇产医院，江苏 宿迁 223800）【摘要】目的：探讨静脉滴注丙种球蛋白在新生儿ABO溶血病中的治疗效果及护理。
方法：选择2020年4月至2022年1月新生儿ABO溶血病患者96例为对象，所有患儿均给予静脉滴注丙种球蛋白治疗，随机数字表法分为两组各48例。
对照组采用常规护理，观察组联合护理干预，两组均完成2周干预，比较两组血清总胆红素水平、TbiL、Hb水平、治疗费用、住院时间、1周后进奶量、黄疸出现、消退时间、空腹血糖（FPG）、降钙素原（PCT）、超敏C反应蛋白（hs-CRP）水平、不良反应发生率、新生儿依从性及家属满意度。
结果：两组干预2周后TbiL、Rtc及Hb水平得到改善；观察组TbiL、Rtc水平低于对照组（P＜0.05）；Hb水平高于对照组（P＜0.05）；观察组治疗费用、住院时间、黄疸消退时间短于对照组（P＜0.05）；1周后进奶量高于对照组（P＜0.05）；两组干预2周后生化指标得到改善；观察组FPG、PCT及hs-CRP水平低于对照组（P＜0.05）；两组干预过程中发热、呕吐、拒奶、贫血及感染发生率无统计差异（P＞0.05）；观察组干预2周后遵医治疗、遵医查体、尿布更换依从性和家属干预方法、服务态度、护患沟通满意度高于对照组（P＜0.05）。
结论：护理干预用于新生儿ABO溶血病静脉滴注丙种球蛋白治疗中，有助于降低血清总胆红素水平，能降低降低PCT、hs-CRP及生化指标，缩短症状消失时间，可降低不良反应发生率，获得较高的新生儿依从性和家属满意度，值得推广应用。
【关键词】护理干预；新生儿ABO溶血病；静脉滴注；丙种球蛋白；治疗效果【中图分类号】R473.72 【文献标识码】A 【文章编号】2096-5249（2023）01-00103-04新生儿ABO溶血病是由于母子ABO血型不合引起的新生儿溶血，多见于母亲血型为O型，婴儿为A型或B型。
小儿川崎病怎样护理？
小儿川崎病怎样护理？川崎病又名黏膜皮肤淋巴结综合征，在儿科疾病属于临床常见症，其发病率会随着时间的延长而不断提高。
由于该疾病是以年龄未超过5岁的小儿为发病群体，其症状能严重影响小儿机体健康。
由于发病后小儿常因不适而出现哭闹情绪，为能缓解小儿病情，及早开展合理有效的护理干预非常重要。
现就对小儿川崎病如何护理做介绍如下。
小儿川崎病病因对于川崎病，虽然目前临床尚不明确疾病发生原因，但流行病学资料显示，其病症的发生和支原体感染和葡萄球菌、丙酸杆菌和链球菌等因素相关，但均未得到证实。
流行病学调查发现，曾有家庭发病情况，临床上许多表现均与急性感染相似，说明存在病原体。
发病人群以男性小儿居多，发病率最高的国家当属日本；由于至今未将直接将引发病症发生的病原体找出，所以无法完全确立感染这一说法。
链球菌在所有病原菌中最受关注，然而直至现在也未从患儿体内将链球菌分离出来。
小儿川崎病临床表现一般情况下，川崎病发作最初表现是高热，体温不低于38℃，热程时间不低于5天，通常是1至2周，有的患儿退热一两天后又出现体温增高情况，热程最长时间能够达到3至4周，虽然退热药的应用能短期能使患儿体温下降，但针对热程时间较长的患儿，用药疗效不佳。
发热数日后掌跖面痛且有红肿情况，躯干部有斑丘疹，且大小不一，无特殊形态。
针对此情况，如果不加以控制，斑丘疹则会向患者四肢和面部发展，不痒，无结痂与疱疹。
两侧眼结膜在发热数日后有充血情况出现，球结膜尤重，只有部分患儿会出现化脓性结膜炎情况；用裂隙灯能将前红膜睫状体炎查出。
唇面会出现皸裂、干燥及红肿等情况，甚至会发生出血情况；舌常呈杨梅舌，虽然口腔黏膜有充血情况，但未有溃疡情况出现。
小儿川崎病护理干预（1）发热针对性护理：通常患川崎病的小儿多伴有发热症状，持续性发热是其主要表现，应遵照医嘱应用退热药物降温治疗，包括安乃近、布洛芬等，同时开展物理降温等方法，能对高热病的发展及发生起到预防作用。
（2）皮肤粘膜护理：应结合患者具体情况，对口腔护理方案予以制定。
抗NMDA受体脑炎病人的护理
抗NMDA受体脑炎病人的护理抗ＮＭＤＡ受体脑炎是一种自身免疫性脑炎，在２００７年于此类病人体内发现了抗Ｎ－甲基－Ｄ－天冬氨酸受体（Ｎ－ｍｅｔｈｙｌ－Ｄ－ａｓｐａｒｔａｔｅｒｅｃｅｐｔｏｒ-ＮＭＤＡ）抗体，并提出了抗ＮＭＤＡ受体脑炎的诊断，具体病因及发病机制尚不明确。
ＮＭＤＡ受体是一种分布于海马、前额皮质离子型谷氨酸受体，属于突触后膜的阳离子通道，与学习、记忆和精神行为密切相关。
其临床表现包括精神异常、意识障碍、异常运动和自主神经功能紊乱、癫痫发作等。
其中疾病早期出现中枢性通气功能障碍为其突出的临床特征，脑脊液抗ＮＭＤＡ抗体阳性可确诊［1］。
抗ＮＭＤＡ受体脑炎可见于任何年龄段，以年轻女性多见（约９１％），约５９％的病人伴有肿瘤，多为成熟型卵巢畸胎瘤［2］。
该病病人治疗过程长、病死率及病残率高，护理难度及强度均很大。
１、病例介绍【例1】病人均为年轻男性，年龄１５岁～２２岁，既往体健。
左侧肢体麻木２０余天，发作性抽搐１０ｄ，言行紊乱１ｄ入住我院精神科，入院前２０ｄ病人出现头痛，左侧肢体每次麻木数秒后缓解，病人及家属未引起重视，１０ｄ前病人突然倒地，呼之不应伴肢体抽动，以癫痫在外院治疗５ｄ后出现精神症状遂入我院。
头颅增强ＭＲＩ、胸部Ｘ线片、心电图及脑电图未见异常，腹部ＣＴ未见异常，２次血培养、脑脊液培养均未见异常，住院期间出现发热，经神经内科、感染科会诊考虑脑炎后转入我科继续治疗，予阿昔洛韦抗病毒、德巴金抗癫痫、补充Ｂ族维生素、营养支持等治疗。
入院２周后，血清及脑脊液标本送至北京协和医院检测后提示：血清抗ＮＭＤＡＲ抗体和脑脊液抗ＮＭＤＡＲ抗体呈阳性，考虑为抗Ｎ－甲基－Ｄ天门冬氨酸受体脑炎，予人免疫球蛋白１７．５ｇ静脉输注５ｄ后，病人情况好转能简单对话，自行下地行走，但夜间较兴奋，表现为阵发性亢奋，经我院精神科会诊后考虑为器质性精神障碍，加用抗精神症状药物，病情稳定后出院。
【例2】病人为年轻男性，年龄２２岁，既往体健。
丙种球蛋白静脉滴注治疗重症肺炎的效果分析
丙种球蛋白静脉滴注治疗重症肺炎的效果分析[摘要] 目的探讨丙种球蛋白静脉滴注治疗重症肺炎的效果。
方法选择2011年8月～2015年1月在我院诊治的成年人重症肺炎150例，根据随机数字表法分为治疗组与对照组，各75例，对照组给予头孢曲松钠+米力农治疗，在此基础上治疗组加用丙种球蛋白静脉滴注治疗，1周后观察两组预后情况。
结果治疗组的治疗总有效率为94.7%，对照组为86.7%，治疗组的总有效率明显高于对照组（P0.05），具有可比性。
1.2 治疗方法对照组：给予常规基础治疗，选择头孢曲松钠（丽珠集团丽珠制药厂，国药准字H10910004）1.0 g加入生理盐水100 ml，静脉滴注，1次/d；给予负荷量米力农（安徽万邦医药科技有限公司，国药准字H10970052）50 μg/kg，5 min 缓慢静脉滴注以后0.5 μg/（kg・min）维持2 h，1次/d。
治疗组：在对照组治疗的基础上给予静脉滴注丙种球蛋白（武汉生物制品研究所，国药准字S2*******），1 g/kg，给药浓度为2.5%，滴速为（5～6） ml/（kg・min），8～10 h 内滴完，1次/d。
两组治疗1周后观察预后情况。
1.3 观察指标显效：治疗后临床症状消失、实验室指标完全改善；有效：治疗后临床症状基本消失、实验室指标明显改善；无效：治疗后无达到上述标准。
观察比较两组住院时间、体温恢复正常时间与咳嗽消失时间。
1.4 统计学方法采用SPSS 13.00统计软件对数据进行分析和处理，计量资料以x±s表示，采用t检验，计数资料用百分率（%）表示，采用χ2检验，以P<0.05为差异有统计学意义。
2 结果2.1 两组患者综合疗效的比较治疗组总有效率为94.7%，对照组为86.7%，治疗组的总有效率明显高于对照组，差异有统计学意义（P<0.05）（表1）。
2.2 两组患者住院时间、体温恢复正常时间、咳嗽消失时间的比较治疗组的住院时间、体温恢复正常时间与咳嗽消失时间均明显短于对照组，差异有统计学意义（P<0.05）（表2）。
婴儿重度自身免疫性溶血性贫血8例临床护理
及稳定期护理要 点， 并有针对性地进行护理 干预 。结果 ： 本组 患儿心功 能不全 纠正 ， 黄疸 消退 ， 体温 下降至正 常 ， 神食 精 欲好转 ， 大小便 正常 ， 色素逐 渐上 升 ， 血 症状 明显 好转 出院。结论 ： 针对 不同病程有预 见性及 时正确地采 取护理 措施 ， 是
神食欲好转 ， 大小便 正 常 ， 色素 逐渐 上升 ， 状 明显好 转 出 血 症
院。 ２ 护 理
２ １ 急危期病情观察与护理 ．
２ １ １ 迅 速纠正心 功 能不全及 脑 缺氧 ．．
入 院时患 儿 由 于重
未 出现局部外渗 及静 脉炎 ， 出现 腹泻 症状 时及 时做 好肛 周皮 肤护理 ， 用温水清洗 屁股 ， 干净 软纱 布蘸 干 水分 ， 润烧 伤 膏 湿 涂抹肛周皮肤 ， 防止皮肤破溃 ， 减轻患儿痛苦 。
慢滴速或暂停输注 。应用 氨曲南 及 阿奇 霉素静 脉滴注 联合抗 感染治疗 。用药期 间监测 有 无不 良反 应发 生 ， 恶心 、 如 呕吐 、 食欲低下 、 腹痛 、 泻等 变化 ， 腹 应用 甲氧氯普 胺 注射 液静 脉滴 注 防治 胃肠道反应 。选择粗 直的外周静 脉作 为留置针 穿刺部 位 ， 液过程中加强 巡视 ， 输 随时 观察 液体 有无 外渗 。经 护理 ，
２ １４ 家 长心 理 疏 导 ．． 患儿人院 时病情危 重 ， 家 长下病危 给
度贫血 出现心功 能不 全 征象 ， 率 １０￣／ ｎ 伴烦 躁 不安 ， 心 ８ ｍｉ，
１ 临 床 资 料
输液速度 ， 采用 微泵输 液 ， ２ ｌｈ速度 均匀 泵入 。详 细 准 以 ０ｍ／ 确记录输液量 、 药量 、 进食量 、 大小便 等 出入 量 ， 达到 出入量平
静脉输液的配制
生理盐水与葡萄糖作为溶媒的运用区别一、用糖水还是用盐水要根据病人的具体情况而定。
1、根据病人的原发病及其并发症而定：（1）如果病人有高血压、冠心病及心功能不好，应减少盐水的摄入，以减轻心脏负担。
（2）如果病人有糖尿病但心肾功能尚可，可以用盐水，用糖水时可加胰岛素兑调。
（3）如病人肾功能不好，要减少钠水的摄入，减轻钠水储溜。
2、根据病人的化验结果：（1）如电解质结果。
如有低钠血症，则给予盐水，反之用糖水。
（2）根据心肌酶等评测心功能来决定盐糖的选择。
3、配液：有的药物溶于糖或盐其效能会好点，这要根据药物说明书选择糖盐。
4、如病人休克，应先给于盐水补充血容量，再给于糖水补充能量。
5、盐水主要用于电解质的调节，而糖水主要作为能量，选用时要首先想到这点。
总之，选择时要慎重，尤其是呼吸科，老年病人多，不同程度地存在心功能不好或糖尿病，在选盐时要谨慎，选糖时考虑是否加用胰岛素。
二：溶媒的选择主要从抗生素的稳定性方面考虑。
1、溶媒的选择主要要从抗生素的稳定性方面考虑。
在制剂时，葡萄糖在生产过程中需加入盐酸，成品溶液pH值多为3.5~5.5左右，而生理盐水稍高，pH值一般为6.5～7.5。
β—内酰胺类在近中性溶液中较为稳定，酸性或碱性溶液均易使β—内酰胺环开环，失去抗菌活性，应用时最好用注射用水或等渗氯化钠注射液溶解青霉素类。
溶于葡萄糖液中可有一定程度的分解。
青霉素类在碱性溶液中分解极快。
因此，严禁将碱性药液（碳酸氢钠、氨茶碱等）与其配伍。
合成类抗生素如甲硝唑、奎诺酮类等由于其分子结构的特定性，在5%的葡萄糖溶液中比生理盐水形态更稳定，特别是培氟沙星，应该用糖水配，培氟沙星不能见氯离子，否则会形成沉淀。
2、溶媒使用的量一般以说明书规定的最低量控制。
对于半衰期短的药物，如青霉素，我在儿科临床中就有看到溶于500ml糖溶液的，输了2个多小时，前面的药物都代谢了，还没输完，根本达不到有效药物浓度。
现在大多是使用100ml辅液+抗生素，为什么不用250ml？其实这是个习惯问题了，没有绝对要求的。
丙种球蛋白合理使用及注意事项、儿童预防接种影响、使用争议、使用前后冲管及IVIG不良反应处置
丙种球蛋白的合理使用及注意事项、儿童预防接种影响、使用争议、使用前后冲管及IVIG不良反应处置血液制品丙种球蛋白里静注人免疫球蛋白用于治疗原发性和继发性免疫缺陷相关疾病。
丙种球蛋白合理使用及注意事项1、FDA 批准的丙球在疾病中应用（1）原发性体液免疫缺陷：X 连锁无丙种球蛋白血症。
IVIG治疗XLA总原则是早用比晚用效果好；较大剂量比小剂量好。
IVIG治疗开始较晚，感染所致器质性损害将是不可逆，剂量为400-600mg/kg，每 3-4周1次，血清IgG维持5g/L以上，感染明显减少。
（2）多灶型运动神经病：初始可给予 0.4 g/kg/d，共 5 d，观察肢体无力变化，根据具体情况个体化间断使用不同剂量IVIG维持治疗，免疫球蛋白皮下注射（13-51g/w）治疗更方便，疗效与静脉用药相似。
（3）B细胞慢性淋巴细胞白血病：反复感染且IgG＜5g/L患者需静脉注射丙种球蛋白IVIG至IgG＞5 g/L以提高机体非特异性免疫。
（4）免疫性血小板减少症：重症ITP患儿可选用静脉输注免疫球蛋白IVIG，1g/kg，连用2-3d。
（5）川崎病：明确川崎病应尽早开始治疗，大剂量IVIG，2g/kg，静脉输注时间控制在10-12h，大体重患儿可采用每天1 g/kg剂量，连用2d。
（6）慢性炎症性脱髓鞘性多发性神经病：明确诊断后使用剂量200-400mg/kg/次，连用3-5d。
丙球使用1.新生儿Rh溶血病和ABO溶血病新生儿母婴血型不符合常导致高胆红素血症产生，继而引起核黄疸等严重并发症。
母婴血型不合溶血病新生儿使用IVIG可封闭网状内皮系统的Fc受体，减少吞噬细胞对致敏红细胞的破坏。
适应症：母婴血型不合溶血病新生儿，加强光疗后血清或血浆胆红素仍然继续上升或在换血疗法阈值 2-3 mg/dL（34-51 umol/L）之内则给予IVIG。
用法用量：0.5-1.0g/kg/d，于2-4小时内静脉持续滴注，必要时可12h后重复使用1剂从而减少换血。
精制丙种球蛋白治疗重症手足口病36例的疗效及护理对策
天 疾病 ； 无药 物 过敏 史 。 临床 表 现 为手 足 红斑 疱 疹 ， 口腔 黏膜 溃 疡 ， 以 及不 同程 度 的精 神差 、 嗜睡 、 寒战、 高热 、 惊厥 、 呕吐 、 肢体抖动、 呼 吸 急促 、 血 压 不稳 等 重 症 表 现 ； 另 有 ４例脊 髓 膜 炎 患 儿 ， 表 现为 一 侧 肢体 肌 力下 降不 能站 立 ， 不能 竖 颈 。 入 院后为 １ ０例患 儿 采集 了咽 拭 子送 湖 州市 疾病 控制 中心检 测 ， 结果 与 一般 情况 比较 见表 １ 。
近 几年 来 我 国有 数个 城市 和 地 区 出现 手足 口病 疫情 的蔓 延 Ｉ ，
其主要病原为 Ｃ ｏ ｘ Ａ １ ６和 Ｅ Ｖ ７ １ 。 相 比之 下 ， Ｅ Ｖ ７ １ 感 染 的患 者 病 情
相对 较 重 ， 会 引发 较 严 重 的 中枢 神 经 症状 如脑 膜 炎 、 脑炎 、 脑 干 脑
儿 ３ ６例 ， 疗 效 良好 。 现报道如下。
１ 资 料 与 方 法
根 据 医 嘱监 测 血压 、 呼吸 、 心率 、 心律等生命体征 ， 若 患 儿 出现 烦 躁、 呕吐 、 肢体抽搐 、 血氧饱和度下降等情况 时， 及 时 向值 班 医 生
报告 ， 根 据 医 嘱 及 时 进 行相 应 处 置 。
表 ｌ 患 儿 临床 资 料 的 详 细 情 况
３ ６例患 儿 全部 治 愈 出院 ， 未 出现 输 液反 应 或过 敏 反应 ； 也 未 见
院内感 染或 交叉 感染 发 生 ； 治 愈Ｈ ｌ ， ｌ ＇ ￣ ｑ 最短 ６ ｄ ， 最长 １ ５ ｄ ， 平均 ９ ｄ 。
３ 讨 论
炎、 急性 、 迟 缓 性 瘫 痪 等 。 少数病 情严重患儿进展迅 速 ， 可 在 短 时间内出现呼吸衰竭 、 肺 水 肿 及 肺 出血 ， 死亡率可高达 ７ ％ ， 台 湾１ ９ ９ ８至 ２ ０ ０ ０ 年 爆 发两 次 手 足 口病 流行 ， 死亡 ７ ８例 Ｉ 。
静脉丙种球蛋白早期治疗预防极低体重儿感染31例临床观察
静脉丙种球蛋白早期治疗预防极低体重儿感染31例临床观察【关键词】静脉丙种球蛋白；极低体重儿；早期治疗；预防；感染极低体重儿是指出生体重在1000g-1499g之间的早产儿`[1]。
因体液免疫、细胞免疫均不成熟，来自母体的抗体缺乏，皮肤屏障功能差，对感染的抵抗力极弱，容易合并感染并使感染扩散，尤其胎膜早破在极低出生体重儿中更易引起肺炎及败血症，临床难以诊治，死亡率高。
随着围生医学技术的迅速发展，近年来极低出生体重儿存活率逐渐提高，极低体出生重儿无论先天性免疫还是获得性免疫均存在明显缺陷，是易于被病原微生物侵害的主要原因。
近年新生儿重症监护室感染仍是造成极低体重儿病死率的主要原因，成为新生儿医生面临最棘手的问题，目前免疫疗法及免疫预防已成为治疗新生儿感染的重要手段。
现将我科新生儿重症监护室2008年元月至2012年元月收治的极低体重儿59例，其中31例应用静脉丙种球蛋白早期治疗，预防极低体重儿感染临床疗效观察报告如下。
1 资料与方法1.1 一般资料 59例极低出生体重儿随机分成二组。
观察组31例中，男18例，女13例；胎龄29-32周，体重1000g-1499g，母亲患有妊高症3例，出生有窒息史2例。
对照组28例，男15例，女13例；胎龄29-32周，体重1000g-1499g，母亲患有妊高症2例，出生有窒息史1例。
两组极低体重儿母亲妊娠后期均无感染及胎膜早破病史，均于出生后30分钟至2小时转住新生儿重症监护室。
1.2 治疗方法对照组采用常规治疗方法（监护生命体征、暖箱保暖、营养、支持治疗，必要时吸氧及应用肺成熟药物或使用抗生素）进行治疗，观察组在常规治疗基础上，均于出生后24小时静脉滴注静脉丙种球蛋白，按400-500mg/（kg*d），用5%葡萄糖注射液稀释2-3倍，控制滴速，输注前后用生理盐水冲管，一天一次静脉滴注，疗程3-5天。
1.3 疗效判定标准显效：住院期间无感染发生，增奶顺利，平均住院日2-3周达出院标准；有效：住院期间无感染发生，但增奶缓慢，伴有呼吸暂停发生，经对症处理好转，平均住院3-4周达出院标准；无效：住院期间发生感染，放弃治疗出院。
手足口病合并病毒性脑炎应用丙种球蛋白的护理体会
手足口病合并病毒性脑炎应用丙种球蛋白的护理体会目的总结手足口病合并病毒性脑炎应用丙种球蛋白的护理方法。
方法对手足口病合并病毒性脑炎应用丙种球蛋白的患儿采取正确的护理措施，包括消毒隔离、发热护理、皮肤护理、饮食护理、用药护理、健康教育等。
结果患儿全部治愈，无后遗症。
结论抗病毒、降低颅内压、静脉使用丙种球蛋白配合正确的护理，可提高手足口病合并病毒性脑炎患儿的救治效果，减少并发症及后遗症。
标签：手足口病；病毒性脑炎；丙种球蛋白；护理手足口病是由多种肠道病毒引起的常见传染病。
主要由柯萨奇A16和EV71两种病毒感染引起[1]。
症状表现为手、足、口腔等部位的斑丘疹、疱疹[2]，对于绝大多数患儿而言，预后良好，少数患儿发病非常急促，且進展较快，很易发展为重症，甚至危重症而死亡[3]。
我科2013年6月～2014年6月共收治手足口病合并病毒性脑炎应用丙种球蛋白58例，经过精心治疗，细心护理，全部治愈出院。
现将护理体会报告如下：1临床资料本组病例58例，男37例，女21例，年龄8个月～7岁；住院天数7～19d。
临床表现发热、高血糖、精神差、呕吐、嗜睡、惊颤、烦躁等症状。
实验室检查：WBC升高47例；脑脊液检查：细胞数升高39例；体格检查：有阳性体征41例。
经抗炎、抗病毒、降低颅内压、营养脑细胞及静脉使用丙种球蛋白等对症治疗，效果满意。
患儿均治愈或好转出院，随访3个月，无1例发生后遗症。
2护理2.1密切观察病情变化EV71具有嗜神经性，病毒在早期即可侵犯中枢神经系统，护士要严密观察患儿的精神状态、瞳孔、头痛头晕、恶心呕吐、肌张力等。
一旦发现患儿精神改变、恶心呕吐、肢体抖动等异常，立即报告医生及时处置。
血糖居高不下与患儿的预后不良相关[4]，定期监测血糖，将血糖控制在8mmol/L 以内。
生命体征是患儿病情的最基础体现。
高热是手足口病进展的危险因素之一，心率快、血压高是最常见的重症表现[5]。
应根据病情轻重，定期监测生命体征。
;丙种球蛋白静脉滴注佐治小儿疗效重症肺炎的临床观察与分析
丙种球蛋白静脉滴注佐治小儿疗效重症肺炎的临床观察与分析[摘要]目的：研究探讨丙种球蛋白滴注佐治小儿重症肺炎的临床效果。
方法：选取2013年8月~12月早我院儿科接受治疗的50例患有重症肺炎的婴幼儿，将所有患儿进行随机分组分为对照组和观察组，每组均25例，给对照组患儿给予抗生素进行对症治疗，给观察组患儿在给予抗生素对症治疗的基础之上，加用丙种球蛋白滴注，然后记录两组患儿治疗情况，比较两组患儿的临床症状、生命体征、胸片等恢复情况。
结果：小儿重症肺炎的主要临床表现是呼吸困难，而且病情比较重，容易发生变化，使用丙种球蛋白之后患儿的临床症状得到改善，病态体征消失明显，治疗效果明显好于对照组（P<0.05）。
结论：小儿重症肺炎在得到及时治疗的基础上，要是加用丙种球蛋白静脉滴注，能够有效治疗疾病，有助于身体健康的恢复，而且还会提高治疗效果，在临床上值得推广和应用。
[关键词]丙种球蛋白；重症肺炎；临床效果小儿重症肺炎属于临床上婴幼儿常见的疾病，因为婴幼儿的自身免疫力比较低，年龄小，因此很容易患上肺炎，病情也很容易加重。
小儿重症肺炎起病比较急，病情比较重，因此是临床上导致小儿死亡的原因之一。
目前临床上使用抗生素进行重症肺炎治疗的同时还加用了丙种球蛋白佐治重症肺炎，取得了十分明显的效果，对临床经验进行总结后，现将具体结果报告如下：1、临床资料及方法1.1一般资料选取2013年8月~12月早我院儿科接受治疗的50例患有重症肺炎的婴幼儿，将所有患儿进行随机分组分为对照组和观察组，每组均25例，其中，对照组的30例患儿，男性有20 例，女性有10 例，年龄最小为6个月，年龄最大为6岁，平均年龄为（3±0.5）岁；观察组的30例患儿当中，男性有22例，女性有8例，年龄最小的有8个月，年龄最大的为7岁，平均年龄为（4±0.6）岁。
其中，入选的患儿中有先天性心脏病的有1例，所有患儿的患病时间均未超过 4 天，且在入院之前没有疫苗接种史。
丙种球蛋白应用的安全性单中心研究
Safety and Adverse Events Profiles of Intravenous Gammaglobulin Products Used for Immunomodulation:A Single-Center ExperienceAshley A.Vo,*Vinh Cam,*Mieko Toyoda,†Dechu P.Puliyanda,*Marina Lukovsky,*Suphamai Bunnapradist,*Alice Peng,*Kai Yang,‡and Stanley C.Jordan*†*Comprehensive Transplant Center,†Transplant Immunology Laboratory,and‡Department of Medical Genetics, Cedars-Sinai Medical Center,David Geffen School of Medicine at University of California Los Angeles,Los Angeles, CaliforniaIntravenous Ig(IVIg)products are used in various medical conditions.Differences in excipients account for most adverse events(AE).Reports of complications including acute myocardial infarction(AMI)and acute renal failure(ARF)have emerged.Herein is described one institution’s experience with IVIg-related complications.This study is a retrospective analysis of infusion-related AE that are associated with various IVIg products.Infusion-related AE were monitored during and after the administration of three IVIg products:Gamimune-N10%(n؍76),Polygam(n؍105),and Carimune(n؍98).AE segregated to specific IVIg products.No patients who received Gamimune-N experienced AMI or ARF.Five(4.7%)patients (P<0.01)in the Polygam group experienced AMI.Eight(8.2%)patients(P<0.0001)in the Carimune group developed ARF. IVIg was safe to give on hemodialysis.IVIg products differ in osmolality,pH,and sugar and sodium content;this results in specific AE.Polygam resulted in no ARF but an increase in AMI.Carimune products at9%concentration resulted in an increase in ARF.Gamimune-N10%and other IVIg products were frequently associated with headaches.Administration of IVIg to patients who are on hemodialysis seems to be safe and effective.Clin J Am Soc Nephrol1:844–852,2006.doi:10.2215/CJN.01701105I ntravenous Ig(IVIg)products initially were developed fortreatment of immune deficiency disorders.The immuno-modulatory effects of IVIg rapidly led to a broader usage of IVIg in autoimmune and inflammatory disorders,usually at much higher doses(1).More recently,IVIg has been used in kidney transplantation for decreasing panel reactive antibodies in highly sensitized patients(2)and for the treatment of anti-body-mediated rejection(AMR)(3–5).Although many consider that all IVIg products are similar,it now is clear that they differ greatly in regard to excipient compounds and related adverse effects(6).Proper product selection for each patient is critical because the adverse effect profiles of each formulation differ on the basis of the excipient.Certain patients,such as those with diabetes or those who are at risk for renal failure and/or heart disease,may not tolerate particular IVIg formulations.Product features that affect tolerability include volume load,infusion rates,osmolality,pH,and sodium or sugar content.Specific adverse effects seem to correlate with product excipient(su-crose/sodium)and osmolality.Therefore,there is a need to define better the relationship among various IVIg preparations, patient risk factors,and specific adverse effects.Twenty-nine cases of thrombotic complications with the use of IVIg have been reported and include acute myocardial in-farction(AMI),cerebral infarction,pulmonary embolism(PE), deep venous thrombosis(DVT),hepatic veno-occlusive disease, and spinal cord ischemia(7–12).No correlation yet has been made between particular IVIg products and thrombotic com-plications.Many papers suggest that the thrombosis was in-cited specifically from the gammaglobulin incipient,contami-nants such as activated factor XI,or a high rate of drug infusion (13,14).There have been attempts to delineate the mechanism of IVIg-induced thrombosis(7,15–18),but no clear cause has been established.Another known complication of IVIg is acute renal failure (ARF)(19).Previous reports seem to suggest that sucrose-based products are commonly associated with ARF(19–22). Here,we report on the adverse effect profiles of three prod-ucts that were used at Cedars-Sinai Medical Center between 1997and2004.This study represents a nonrandomized,retro-spective study of patients who received those IVIg products during that period.Specific product use was based on phar-macy purchasing practices.Furthermore,no protocols for pre-medication before IVIg infusion to reduce adverse effects have been established.Here,we discuss procedures that were devel-oped at our center to attempt to decrease adverse events(AE) that are related to IVIg infusion.Received November10,2005.Accepted March12,2006.Published online ahead of print.Publication date available at .Address correspondence to:Dr.Ashley A.Vo,Center for Kidney Diseases&Transplantation,Cedars-Sinai Medical Center,8635W.3rd Street,Suite590W,Los Angeles,CA90048.Phone:310-423-2967;Fax:310-423-6369;E-mail:ashley.vo@Copyright©2006by the American Society of Nephrology ISSN:1555-9041/104-0844Materials and MethodsPatients and AEAfter approval was obtained from the Institutional Review Board, 279patients who received IVIg at Cedars-Sinai Medical Center between 1997and2004were identified for retrospective analysis.Seventy-six patients received Gamimune-N10%(Bayer Biologicals,West Haven, CT;October1997to June2000);105patients received Polygam(Baxter Inc.,Los Angeles,CA;April2000to February2002),and98patients received Carimune(ZLB Biologicals,Berne,Switzerland;March2002to September2004).A retrospective analysis of significant AE that were associated with various IVIg products was performed.Premedication protocols and product selection paradigms were developed from the data and applied to minimize serious AE.Postimplementation moni-toring of AE then was recorded.Any documentation of AMI,ARF,hypotension,or death within72h of administration was considered related to IVIg infusion.In addition, reports of other common adverse effects of headaches,flushing,pruri-tus,or rash were noted.To determine whether there was causality,we calculated an Adverse Drug Reaction score on the basis of10questions that were developed by Naranjo et al.(23)by two independent review-ers.A score of9of13or higher was considered highly probable, whereas5to8was moderate and1to4was unlikely.Once an AE was identified and found to be specific to a particular IVIg formulation with probable causality,product selection paradigms and premedication protocols were developed and applied to minimize AE.After these changes were made in2002,postimplementation mon-itoring for AE was reported.Three primary areas of risk for IVIg infusions were identified.These were cardiovascular disease,renal disease,and propensity for hyper-coagulation.Risk factors for AMI were based on National Cholesterol Education Program(NCEP)III guidelines(24)and included age(Ͼ50 for men,Ͼ60for women),history of AMI,hypertension,hypercholes-terolemia,diabetes,obesity,or previous evidence of peripheral vascu-lar disease(e.g.,stroke,atherosclerotic aortoiliac disease).Risk factors for ARF included(1)a history of diabetes,(2)history of cardiovascular disease and congestive heart failure,(3)history of elevated serum creatinine(Ͼ2.0mg/dl),and(4)advanced age(Ͼ70yr).Statistical AnalysesStatistical analysis was performed using the2test.AE in each IVIg group were analyzed and compared.Differences were considered sig-nificant at the0.05level.ResultsProduct Composition and Relations to AEGamimune-N10%,Carimune,and Polygam were the three IVIg products that were used at Cedars-Sinai Medical Center during the study period.Product selection was based on phar-macy purchasing practices.Table1identifies the most common IVIg products that were commercially available in the United States during the study period and their constituent makeup. Gamimune-N-10%excipient(Glycine)had the least amount of sodium chloride,had no sucrose,and is isosmolar(274 mOsm/L at10%).Carimune is a lyophilized powder that can be reconstituted in sterile water or normal saline.It contains 1.67g sucrose/g IVIg and at12%in saline has an osmolality of 1074mOsm/L and when reconstituted in sterile water has an osmolality of768mOsm/L.Polygam10%also is lyophilized and can be reconstituted in sterile water or normal saline.If reconstituted in NS,Polygam10%has an osmolality of1250 mOsm/L.In fact,at10%,the osmolality is identical to a2% saline infusion.The indications for use of IVIg in the279patients were hypogammaglobulinemia,idiopathic thrombocytic purpura, treatment of acute AMR,polyneuropathy,hematologic malig-nancy,and desensitization of highly HLA-sensitized patients who were awaiting solid-organ transplantation.Ages of recip-ients were4mo to92yr,and there was equal gender distribu-tion among groups.Approximately half of the patients in each group had risk factors for heart disease.Dosages received were between0.5and2g/kg(Table2).All IVIg products were infused at rates recommended by the manufacturer.For Gamimune-N10%the start infusion rate was0.01to0.02ml/kgTable1.Product characteristicsPreparation/ Concentrations Available Manufacturer Osmolality Sucrose Content(g/g protein)Sodium Content(mEq/L at5%concentration)Gamimune-N10% N/5%,10%Bayer309mOsm/kg solvent(water)for5%solution;274mOsm/kgsolvent(water)for10%solution0TraceGammagard/5%,10%Hyland Division ofBaxter Healthcare 636mOsm/kg solvent(water)for5%solution;1250mOsm/kgsolvent(water)for10%solution0147Polygam/5%,10%Hyland Division ofBaxter Healthcare 590mOsm/kg solvent(water)for5%solution;1179mOsm/kgsolvent(water)for10%solution0147Carimune3%,6%, 9%,12%ZLB CentralLaboratory3%,192mOsm/kg;6%,384mOsm/kg;9%,576mOsm/kg;12%,768mOsm/kg solvent(water)1.67 1.3Clin J Am Soc Nephrol1:844–852,2006Safety and Adverse Events of IVIg for Immunomodulation845per min for30min.If no adverse reactions occurred,then the rate was increased gradually to a maximum of0.08ml/kg per min.For Carimune,the start infusion rate was30ml/h for30 min,then60ml/h for30min,and was increased as tolerated by 30ml/h every15min to a maximum rate of120ml/h.For Polygam,the start infusion rate was0.5ml/kg per h and was increased slowly to a maximum rate of4ml/kg per h if well tolerated in patients with thrombotic risk factors such as coro-nary artery disease,hypertension and cerebrovascular disease, and diabetes.Significant AE(AMI and ARF)were noted only in the Po-lygam(PϽ0.01)and Carimune(PϽ0.0001)groups,respec-tively.Headache was the only notable adverse effect of Gamimune-N10%infusion(52%)but also occurred in other products.In our experience,headaches were self-limited and did not require additional investigation(computed tomogra-phy or magnetic resonance imaging)and usually respond to acetaminophen.Patient demographics are shown in Table2. The distribution of AE and significant AE is shown in Table3. IVIg and AMIFive cases of AMI were noted in patients who received IVIg. The ages ranged from34to72yr(Table4).All five patients had risk factors for cardiac disease.The number of IVIg treatments that were received before the event ranged from one to eight. Each patient developed symptoms during or shortly(3to5h) after IVIg infusion,which included shortness of breath and chest pain.The diagnosis of AMI was confirmed by electrocar-diogram and/or troponin elevations.In four cases,AMI pro-longed hospitalization.In the fifth case,the diagnosis of AMI resulted in the hospitalization after the patient received IVIg as an outpatient infusion.All patients recovered without signifi-cant long-term effects.Because AMI occurred only with Po-lygam,these were reported to the manufacturer and the Food and Drug Administration MedWatch.This resulted in a“Dear Doctor Letter”regarding the risk for thrombotic events that were associated with Polygam(25).Polygam’s excipient is a sodium chloride solution with an approximate osmolality of1250mOsm/L at10%.Analysis using the Naranjo algorithm yielded a moderate probability of causality.The risk for development of thrombotic events with Polygam also was statistically significantly different when com-pared with the other IVIg products(PϽ0.01).We hypothesized that the salt-based high-viscosity vehicle of this product likely was responsible for initiation of the thrombotic event seenTable2.DemographicsCarimune (nϭ98)Gamimune-N(nϭ76)Polygam(nϭ105)Gender(%)male484151female525949Indications(%)desensitization776637autoimmune212655immune deficiency288Age range2to84yr15to75yr4mo to92yr Cardiovascular risk factors a(%)565040Dose(g/kg;averageϮSD) 1.1Ϯ0.47 2.0 1.25Ϯ0.63a Coronary heart disease and coronary heart disease risk equivalents as defined by National Cholesterol Education Program (NCEP)III.Table3.AE and SAE aCarimune (nϭ98)Gamimune-N(nϭ76)Polygam(nϭ105)%AE or SAE nϭ8(SAE)N/A nϭ5(SAE) Gender3male/5female N/A2male/3female Age range(yr)39to7915to7534to77 Type of AE/SAEthrombotic005(4.7%);PϽ0.01 ARF8(8.2%);PϽ0.00100other(headache)49(50%)39(52%)52(50%)Doses2g/kgϭ7patients1g/kgϭ1patient 2g/kg2g/kgϭ4patients1g/kgϭ1patienta AE,adverse events;ARF,acute renal failure;SAE,significant adverse events.846Clinical Journal of the American Society of Nephrology Clin J Am Soc Nephrol1:844–852,2006T a b l e 4.M y o c a r d i a l i n f a r c t i o n i n p a t i e n t s w h o r e c e i v e d P o l y g a m aP a t i e n t A g e /G e n d e rC o m o r b i d i t i e sI n d i c a t i o n f o r I V I g T o t a l N o .o f I V I g D o s e s D o s e o f I V I gR a t e o f I V I g I n f u s i o n b T i m e C o r r e l a t i o n b e t w e e n I V I g I n f u s i o n a n d O n s e t o f S y m p t o m s54/m a l e A I D S ,n o n -H o d g k i n ’sl y m p h o m a ,a o r t i c s t e n o s i sI T P2(i n p a t i e n t )D a y 1ϭ70g (1g /k g ;1400m l o f 5%)D a y 2ϭ70g (700m l o f10%)o v e r 12h ,1.7m l /k g p e r h o v e r 6h ,1.7m l /k g p e r h D a y 2:5h i n t o I V I g i n f u s i o nd e v e l o p e d S O B ,n o N /V ,C P .E C G c h a n g e s ,e l e v a t e dt r o p o n i n s ,t r a n s f e r r e d t oI C U .D i s c h a r g e h o m e 10dl a t e r49/f e m a l e P a u c i i m m u n eg l o m e r u l o n e p h r i t i s ,E S R D ,S /p k i d n e y t r a n s p l a n t ,h y p e r c h o l e s t e r o l e m i aS /p k i d n e y t r a n s p l a n t w i t hi n c r e a s i n g S C r 1(i n p a t i e n t )140g (2g /k g ;1400m l o f 10%)o v e r 5h ,3.9m l /k g p e r h A t t h e e n d o f i n f u s i o n ,p a t i e n t d e v e l o p e d C Pr a d i a t i n g t o l e f t a r m ,N /V ,S O B .S T e l e v a t i o n s ,e l e v a t e d t r o p o n i n .T r a n s f e r r e d t o I C U .D i s c h a r g e d h o m e 6d l a t e r34/f e m a l e S L E ,E S R D S /p k i d n e yt r a n s p l a n tT o r e d u c e P R A8(e v e r y m o n t h i n t h e o u t p a t i e n t p r o c e d u r e c e n t e r )100g (2g /k g ;1000m l o f 10%)o v e r 6h ,3.4m l /k g p e r h 5h a f t e r s t a r t o f i n f u s i o n ,d e v e l o p e d C P ,r a d i a t i n g t ot h e j a w ,S O B .E l e v a t e dt r o p o n i n s .D i s c h a r g e dh o m e 4d l a t e r77/f e m a l e C A D ,C H F ,M V R ,p a c e m a k e rp l a c e m e n t 1m o a g o ,d i a be t e s ,h y p e r t e n s i o nI T P 2.5(i n p a t i e n t )D a y 1ϭ66g (1g /k g ;660m l o f 10%)D a y 2ϭ63g (1g /k g ;630m l o f 10%)D a y 3ϭ31g (0.5g /k g ;310m l o f 10%)o v e r 6h ,1.7m l /k g p e r ho v e r 6h ,0.8m l /k g p e r hD a y 2:3h a f t e r s t a r t o fi n f u s i o n d e v e l o p e ds u b s t e r n a l c h e s t p a i n ,d i a p h o re s i s ,n o S O B ,N /V .E C G c h a n g e s ,e l e v a t e dt r o p o n i n s .D a y 3:N oc o m p l i c a t i o n s .U nde r w e n ts c h e d u l e d M V R n e x t d a y69/m a l e B r o n c h i e c t a s i s ,r e c u r r e n tr e s p i r a t o r y i n f e c t i o n s ,H /od e c r e a s e d I g G l e v e l s w i t hn o r m a l a n t i g e n r e s p o n s eT o m a i n t a i n a n t i b a c t e r i a l /v i r a l a n t i b o d y t i t e r s t op r e v e n t r e c u r r e n ti n f e c t i o n s1(i n p a t i e n t )70g (1g /k g ;700m l o f 10%)o v e r 6h ,1.7m l /k g p e r h E l e v a t e d t r o p o n i n ,u n d e r w e n t e m e r g e n ts t e n t i n gaC AD ,c o r o n a r y a r t e r y d i s e a s e ;C H F ,c o n g e s t i v e h e a r t f a i l u r e ;C P ,c h e s t p a i n ;E C G ,e l e c t r o c a r d i o g r a m ;H /o ,h i s t o r y o f ;I C U ,i n t e n s i v e c a r e u n i t ;I T P ,i d i o p a t h i c t h r o m b o c y t o p e n i c p u r p u r a ;I V I g ,i n t r a v e n o u s I g ;M V R ,m i t r a l v a l v e r e p a i r ;N /V ,n a u s e a a n d v o m i t i n g ;P R A ,p a n e l r e a c t i v e a n t i b o d i e s ;S C r ,s e r u m c r e a t i n i n e ;S L E ,s y s t e m i c l u p u s e r y t h e m a t o s u s ;S O B ,s h o r t n e s s o f b r e a t h .b P o l y g a m S /D 5%s o l u t i o n s h o u l d b e i n f u s e d a t a n i n i t i a l r a t e o f 0.5m l /k g p e r h .I f t h i s r a t e c a u s e s t h e p a t i e n t n o d i s t r e s s ,t h e n t h e r a t e m a y b e i n c r e a s e d g r a d u a l l y u p t o 4m l /k g p e r h .T h e 10%s o l u t i o n c a n b e s t a r t e d a t 0.5m l /k g p e r h u p t o a m a x i m u m o f 8m l /k g p e r h .Clin J Am Soc Nephrol 1:844–852,2006Safety and Adverse Events of IVIg for Immunomodulation847(AMI).Therefore,steps were taken to change the standard default IVIg formulation to one of a non–sodium-based lower osmolality solution(530mOsm/L;Carimune9%)or309 mOsm/L(Gamimune-N10%).In addition,premedication with aspirin as well as an option to hydrate patients was suggested. Because these changes were implemented and after approxi-mately250IVIg doses,no further cases of AMI have been reported.IVIg and ARFAfter the change from routine use of Polygam to that of either Carimune or Gamimune-N10%,eight cases of ARF were seen. ARF occurred only in patients who received the sucrose-con-taining IVIg(Carimune;PϽ0.0001;see Tables2and3).A Naranjo algorithm analysis also yielded a moderate probability of causality(score6).All eight patients had identifiable risk factors for ARF.Five of the eight patients had a history of chronic kidney disease or had received a kidney transplant,and the other three had diabetes,congestive heart failure,or recent IV contrast dye administration.Six of eight patients had signif-icant renal dysfunction with doubling of serum creatinine after IVIg administration,with six requiring hemodialysis.However, recovery of renal function occurred in all patients within2mo.A renal allograft biopsy was done in one patient who had marked delayed graft function and received IVIg before kidney transplantation for a positive cross-match.Results were notable for acute tubular necrosis and marked vacuolization of proxi-mal tubular cells that were attributed to IVIg/sucrose.Table5 shows the characteristics of patients who developed ARF after sucrose-containing IVIg infusions.Figure1shows an electron micrograph demonstrating vacuolization in renal tubules in a patient with osmotic nephropathy after sucrose-containing IVIg infusion.After noting the relationship between ARF and previous kidney dysfunction in patients who received Carimune,all patients who receive IVIg now are required to have a preinfu-sion baseline serum creatinine and screening for risk factors for renal disease.Subsequently,avoidance of sucrose-based prod-ucts in patients who are at risk by specifically selecting non–sucrose-containing isosmolar products has resulted in no addi-tional cases of ARF.IVIg Infusions in ESRD Patients on Hemodialysis Administering IVIg is challenging in patients who are unable to tolerate high volumes or solute loads,such as those with congestive heart failure and ESRD.This is particularly impor-tant for prekidney transplant recipients,who usually are dial-ysis dependent and prone to volume overload.Like any other blood product,we infused IVIg(Gamimune-N10%)during hemodialysis and compared this with placebo(albumin0.1%) as part of the NIH IG02study(26).More than300infusions of IVIg were given to50patients and compared with an equiva-lent number of placebo infusions to52patients.Analysis showed that IVIg was well tolerated with a low incidence of volume overload,pruritus,and rash.The number of minor (7.7%in IVIg versus7.5%in albumin)and significant(0.3%IVIg versus2.8%albumin)AE were comparable to or less than that of placebo.DiscussionThe use of IVIg products for the treatment of autoimmune and inflammatory disorders has increased dramatically in the past decade.In addition,recent data suggest that IVIg products are useful in the treatment of highly HLA-sensitized patients who are awaiting transplantation and for the management of viral infections and AMR(26–28).The use of higher doses, concentrations,and rapid rates of infusion of IVIg products has resulted in higher rates of infusion-related complications that, at first,were not anticipated and were poorly understood.It now is very clear that IVIg products vary considerably in their composition and that these differences have clinical im-plications(29).All contain IgG molecules(90to99%)but differ considerably in excipient.IVIg products differ in osmolality, pH,and sugar and sodium content,and this is postulated to result in product-specific adverse effects(6).The use of Po-lygam,which contains high concentrations of sodium at10%, was associated with five cases of AMI.MI is a known compli-cation of IVIg infusion(10,14).Our findings suggest that this may be due to the excipient(sodium chloride)and not incipient as evidenced by the lack of events with sucrose-based and isosmolar products.In addition,these events did not occur when Polygam was administered to patients who were on hemodialysis,suggesting that reductions in sodium content and/or heparinization was protective.Furthermore,it seems that viscosity of the diluent may be a factor that increases the risk for thrombosis as Polygam10%had a much higher osmo-lality than Carimune9%or Gamimune-N10%.Previous re-ports have shown that IVIg increases blood viscosity(30),and it is possible that it contributes to the thrombogenic nature of sodium-based IVIg formulations.Other possible explanations for the prothrombotic effects of IVIg suggest that there might be an effect on platelet aggregation.However,Vassilev et al.(31) showed that IVIg actually contains antibodies that are inhibi-tory to inducers of platelet aggregation.Data from Abe et al.(32)also support an antithrombotic effect of IVIg in Kawasaki disease.The antiplatelet agent aspirin may decrease the risk for myo-cardial events during IVIg infusion.Whether Ig causes in-creased platelet aggregation in vivo is unknown but seems unlikely on the basis of published data.This is consistent with previous experiments in which IVIg did not cause an increase in platelet ADP release and actually can reduce aggregation that is seen with other agents(7,11).However,unless there is a contraindication,we would recommend that patients who are at higher risk for thrombosis or MI receive aspirin and hydra-tion(250ml of0.9normal saline over30min)before IVIg infusion.There are no data to support any particular premed-ication regimen.However,our experience supports the pre-IVIg infusion use of Benadryl25to50mg orally or intrave-nously,Tylenol650mg orally,or aspirin325mg orally and Solu-Medrol40mg intravenously30min before the infusion to reduce infusion-related adverse effects.Selection of products with lower osmolality or reduction in osmolality of sodium-848Clinical Journal of the American Society of Nephrology Clin J Am Soc Nephrol1:844–852,2006T a b l e 5.I V I g a n d r e n a l f a i l u r e aP a t i e n t A g e /G e n d e rC o m o r b i d i t i e sI n d i c a t i o n f o r I V I gT o t a l N o .o f I V I g D o s e s D o s e o f I V I g R a t e o f I V I g I n f u s i o n T i m e C o r r e l a t i o n b e t w e e n I V I g I n f u s i o n a n d O n s e t o f S y m p t o m s40/f e m a l e S /p l i v i n g -u n r e l a t e d k i d n e y t r a n s p l a n tw i t h r e n a l i n s u f f i c i e n c y (b a s e l i n ec r e a t i n i n e 1.9)S /p k i d n e y t r a n s p l a n t ϫ1m o w i t hp o s i t i v e c r o s s -m a t c h 2140g o v e r 8h ,2.5m l /k g p e r h D a y 2:F o l l o w -u p a t r e n a l t r a n s p l a n tc l i n i c r e v e a l ed t h a t c re a t i n i n e w a se l e v a t e df r o m b a s e l i n e o f 1.9t o 2.3.P a t i e n t u n d e r w e n t b i o p s y ,w h i c hs h o w e d e a r l y c a l c i n e u r i n t o x i c i t y .R e n a l f u n c t i o n r e c o v e r e d a f t e r 4d .72/m a l e S /p c a d a v e r i c k i d n e y t r a n s p l a n t w i t hr e n a l d y s f u n c t i o n (b a s e l i n e c r e a t i n i n e3.4).P e r i p h e r a l v a s c u l a r d i s e a s eI T P 170g o v e r 6h ,1.2m l /k g p e r h D a y 2:C r e a t i n i n e i n c r e a s e d f r o mb a s e l i n e o f 3.4t o 7.2.P a t i e n t r e q u i r e dh e m o d i a l y s i s .R e n a l f u n c t i o n s l o w l yr e c o v e r e d t o b e t t e r t h a n b a s e l i n e a f t e r5w k ,a n d p a t i e n t w a s t a k e n o f fd i a l y s i s .54/f e m a l e C o n g e s t i v e h e a r t f a i l u r e w i t h r e n a li n s u f f i c i e n c y ,r e c e n t c o n t r a s t d y ea d m i n i s t r a t i o n ,g o u tP o s i t i v e Q u i c k S c r e e n P R A a n d c r o s s -m a t c h b e f o r e h e a r t t r a n s p l a n t 270g o v e r 8h ,1.2m l /k g p e r h D a y 2:C r e a t i n i n e i n c r e a s e d a f t e r s e c o n dd o se of I V Ig f r o m 1.3t o 1.9w i t ha n u r i a .P a t i e n t r e q u i r e d h e m o d i a l y s i sa n d h i g h -d o s e d i u r e t i c .P a t i e n tr e q u i r e d d i a l y s i s f o r 1w k b u tr e c o v e r e d c o m p l e t e l y .79/m a l e D i a b e t e s w i t h C K D ,b a s e l i n e c r e a t i n i n e1.5t o2.2.H e a r t f a i l u r e ,g o u t ,a n dn e p h r o l i t h i a s i s .A t r i a l f i b r i l l a t i o nI T P 170g 1.2m l /k g p e r h D a y 2:C r e a t i n i n e i n c r e a s e d f r o m 1.3t o7.0.P a t i e n t b e c a m e o v e r t l y u r e m i c a n dr e q u i r e d d i a l y s i s f o r 7d .R e n a lf u n c t i o n r e c o v e r e d a n d c r e a t i n i n e w a sb ac k t o b a s e l i n e b y 10d a f te r I V I gi n f u s i o n .70/f e m a l e S /p c a d a v e r i c k i d n e y t r a n s p l a n tP o s i t i v e c r o s s -m a t c h b e f o r e k i d n e yt r a n s p l a n t .G i v e n r i g h t b e f o r et r a n s p l a n t170g o v e r 4h ,2.5m l /k g p e r h D a y 1:D e l a y e d g r a f t f u n c t i o ni m m e d i a t e l y a f t e r k i d n e y t r a n s p l a n t .P a t i e n t r e q u i r e d h e m o d i a l y s i s f o r 1w k b u t r e c o v e r e d c o m p l e t e l y .B i o p s ys h o w e d p r o x i m a l t u b u l a r c e l lv a c u o l i z a t i o n s u g g e s t i v e o f I V I g -i n d u c e d A T N .39/f e m a l e C K D s e c o n d a r y t o c a r d i o m y o p a t h y w i t hb a s e l i n ec r e a t i n i n e 1.6.R e c e n t h i s t o r yo f p r e r e n a l a z o t e m i a f r o m d i u r e t i c u s ef o r m a n ag e m e n t o f C H FP o s i t i v e Q u i c k S c r e e n P R A 175g 1.2m l /k g p e r h D a y 2:C r e a t i n i n e i n c r e a s e d f r o m 1.6t o2.2b y d a y3.P a t i e n t b e c a m e o v e r t l yu r e m i c a n d r e q u i r e d d i a l y s i s f o r 7d .R e n a l f u n c t i o n r e c o v e r e d a n dc r e a t i n i n e w a s b a c k t o b a s e l i n e b y 10d a f te r I V I g i nf u s i o n .Clin J Am Soc Nephrol 1:844–852,2006Safety and Adverse Events of IVIg for Immunomodulation849。