Hospital Approved Consent Form Required

SAMPLE THERAPEUTIC PLASMAPHERESIS ORDERS

When ordering therapeutic plasmapheresis, please consider the following orders: *Items italicized and with an * are standard orders. 1) PROCEDURE TARGET:
Plasma to be Processed: *[ ] 1 Plasma Volume [ ] 1.5 PlasmaVolume [ ] Other:

2) FREQUENCY OF PROCEDURE:
[ ] Every other day x [ ] Daily x [ ] Other:

3) REPLACEMENT FLUIDS:
5% Albumin __________ ml or __________% and Normal Saline __________% Fresh Frozen plasma / Cryo-Reduced plasma: # of units __________ or __________ ml Other: ____________________ # of units _______________ or _______________ ml

4) ANTICOAGULATION of the blood in the machine is necessary for the procedure:

*ACD-A [ ] Other:

5) MEDICATIONS COMMONLY ORDERED:

Pre-Treatment Medications: (commonly used with FFP replacement) Diphenhydramine _______ mg [ ] IV push [ ] PO Acetaminophen _______ mg; PO [ ] Other: During treatment: CA Gluconate to prevent citrate reaction symptoms ________ grams/ ________ ml normal saline IV piggyback during treatment ________ mg/250ml of 5% albumin

PRN:
[ ] Solu-Medrol / Solu Cortef __________ mg IV push [ ] May repeat x __________, PRN [ ] CA Gluconate 10%: __________ grams/ __________ ml normal saline for citrate reaction symptoms [ ] Other:

6) CENTRAL VENOUS CATHETER Common orders for care of central venous catheters
*Flush each lumen of catheter with normal saline followed by Heparin ________ ml and normal saline to equal the internal volume of each lumen Flush each lumen with normal saline followed by ACD-A volume equal to the internal volume of each lumen [ ] Other:

7) LABORATORY ORDERS:
[ ] CBC [ ] Fibrinogen [ ] Complete metabolic panel [ ] Basic Metabolic Panel [ ] PT/INR PTT [ ] LDH [ ] Other

8) STANDING ORDERS Orders that are usually ordered with each treatment
*Notify MD for BP < 90/50 or > 180/100 mm Hg and for pulse rate < 50/min or >150 min *100-200 ml Normal Saline IV and/or 250 ml 5% albumin for hypotension (BP systolic < 90 mm Hg) PRN *Use Blood Warmer *Normal Saline 2-3 liters to prime, rinseback and infuse during treatment