This is an example only.

1. Diagnosis: __________________________________________________ _ Date of Surgery: ______________
2. Please provide the most recent lab results for the following: Pt. Weight: __________ lb / kg

Hgb ________ Hct ________ Total Iron _________ Ferritin ________ B12 _________

3. Erythropoietin:
 Preferred dose regime for weekly administration 3 weeks prior to surgery
Procrit 40,000 units subcutaneous on approximately pre-op days 21, 14 and 7 (one week apart).
 Other: (Must be an FDA approved dosing schedule)
__________________________________________________ ____________________________

4. Draw H/H prior to day 14 and day 7 injection. If Hct  36, inform physician prior to injection.

Iron Supplementation:
Note: Erythropoietin-induced RBC synthesis puts a major strain on the iron storage pool. Patients with borderline iron stores may benefit from regular iron replacement during EPO therapy. The usual elemental iron requirement in patients being treated with epoetin alfa increases to 150-200 mg of elemental iron per day. For supplemental iron, consider Niferex 50 mg or Ferrous Sulfate 325 mg one TID. Consideration should also be given to folic acid and Vitamin C.

 Patient on oral supplement of iron per MD.
 IV Iron Dextran is the preferred single loading dose regime for patient with no known allergy or contra-indication to Iron Dextran use:
 For pt with history of inflammatory joint disease: Premedicate with 125 mg Methylprednisolone IVP x 1
a. Test dose: Iron Dextran 25 mg IV in 50 ml normal saline over 15 minutes. Monitor the patient for 1 hour for signs of an allergic reaction or anaphylaxis. (Monitor HR, RR, BP, Temp)
b. If patient tolerates test dose, start Iron Dextran 975 mg IV in 500 ml NS at a rate of 6mg/minute.
c. Discontinue oral iron supplementation
 IV Ferric Gluconate for patient with documented hypersensitivity to Iron Dextran:
a. Ferric Gluconate 125 mg IV in 100 ml NS over minimum of 1 hour for ____ doses given at least 4 days apart.
b. Discontinue oral supplementation.

5. For Severe Reactions (e.g. bronchospasm, loss of airway, fainting, severe flushing) notify physician and:
a. Stop Infusion
b. Call a code
c. Oxygen support
d. Epinephrine 0.5 ml of a 1:1000 solution IVP x 1
e. Benadryl 50 mg IVP x 1
f. Methylprednisolone 125 mg IVP x 1

6. For Minor Reactions (e.g. nausea, itching, joint pain, rash) notify physician and:
a. Stop infusion
b. Benadryl 50 mg IVP x 1
c. Pepcid 20 mg IVP x 1

7. Give 650 mg Acetaminophen po q 4-6 hrs prn flu-like symptoms or pain post infusion.

_______________________________
Physician Signature

__________________
Mr. Jan B. Wade
Blood Management Consultant
Enhance Outcomes - Control Cost
For Information Call - 360 296-1807
Email