I would like to hear from any nurse providing infusion services to rheumatology patients about the types of VADs you most commonly see in these patients. I am thinking of those in an ambulatory infusion center coming in periodically for infusion os Remicade, Orencia, etc. Do you most commonly see short peripheral catheters used? What percent would have some other type of CVAD? Are you preparing these drugs in the clinic or are the drugs obtained from a pharmacy already mixed? What are the most common infusion reactions that you see? Any input would be greatly appreciated. Thanks, Lynn
I work in a small clinic infusion center for Kaiser. We see alot of Remicade pts. They usually come in every 6-8 weeks with various doses according to wt and need. We always place peripheral IV's for this use. We don't give it if they have any infections or wounds or comprimised immune problems. This is because the Remicade lowers the body's immune response to fight infection. We give them pre meds usually Tylenol and Benadryl, rarely Solumedrol 30 " prior to dose. A filter is needed. The dose is titrated over about 2 hours and then we observe pts for 30 minutes post dose. I rarely see reactions to this medicine but they do occur. I see pts with SOB, chest tightness or pain sometimes. We stop the medicine and often they will go on to the Orencia etc. The side effects can be 'flu like' but I just don't remember hearing any of my pts complain of that. Not like the Reclast which really seems to give pt's problems for a day or two post dose with fever and aches etc. We give the Remicade for RA and Crohns's and rarely, skin diorders of the immune type. Our pt's swear by this med. We have an older pt now we have seen since young childhood. He came in to see us first in a wheel chair and not soon after, has lived a normal life. We obtain a TB test prior to initiation of the treatment and monitor labs esp. ALT . Pts have regular visits to the Rheumatologist every 3 months minumum . The MD is on hand across the hall for any problems we might see. Usually just call if reactions mentioned above. I have only seen maybe two allergic reactions over the years.
As far as Orencia. Again use the peripheral IV's but it goes in over 30-60 minutes with pre meds sometimes used. Seems easier on the body but does not seem to work as well.
Hope this helps. Alison
I have given quite a bit of Remicade as well. We usually premedicated with tylenol and claratin, and the patient was encouraged to take them at home. I also taught the patients to come well hydrated. I was taught by a rep once that the mild reactions can be limited by hydration. When we saw a mild reaction ("I feel kind of strange" ) usually slowing the infusion and giving some fluid would help. We would do IV benadryl or solu-medrol for those with a more significant reaction.
Most of the time I used 24G SaftiIntimas (I really like the butterfly shape - the patients say it is much more comfortable than the round needles). I have had a couple of patients with ports - those were mostly the GI patients who were also being hospitalized with complications of the disease. I saw a friend of my mother's the other day that is getting Remicade for RA at another center. She said that the only vein left was on the side of her right wrist and they were thinking of doing a port if necessary when that vein wouldn't work anymore. (Did some teaching about problems associated with that vein, and the idea that an alternative like a port might be overdue.) A number of the docs here in mid to northern NH still consider a port the last resort and something that should be temporary.
Our pharmacy prepares all the meds under the appropriate hood.
There was a presentation given by a Remicade rep a few years ago with a speaker that was a nurse giving Remicade in NY City. I don't remember who she was. At that time they were doing every 6 mo. TB testing on the innercity patients. She had also developed protocols for treating mild, moderate and severe reactions, and how to pretreat for the next dose.
Gail
Gail McCarter, BSN,CRNI
Franklin, NH
I work at a hospital based free standing ambulatory infusion center. We have have 950 patient visits in a month. 30% of the patients are what we consider as infusion patients. The other 70% are hematology/oncology patients. Of the infusion patients we do have large population of Remicade patients. So far the most commonly treated diagnosis being RA followed by crohns. We have not had any MS patients even thought there is an indication for MS. We also have RA patients that move from Remicade to Orencia.
The majority of the time the RA patient premedicates themselves before treatment. Some do receive IV Benadry before their treatment. The Crohns patients are premedicated with solumedrol most of the time, seems to be the GI doctors preferred premed.
I do not have any RA or crohns patients with central venous access. We practice the smallest catheter for the therapy. This means a 24g or 22g. The RA patients are usually every 8 weeks, so 6 PIV sites a year. Can be 6 weeks dosing eventually. If they have to move to 4 weeks then and the dose is max'd out and they have lost of function the doctor will move to another agent.
Reactions if seen with Remicade are typically the deer in the head lights look, flushed face, maybe chest pressure with back pain. We do al lot of teaching before first doses let the patients be aware of what a sensitivity could feel like and that we can handle the reactions quickly if needed. We usually can rechallenge the patient after stopping the infusion treating with IV bendadry, IV hydrocortisone and starting at a slower rate then 2 hours. If it is a worse reaction we don't rechallenge at that time and the doctor may change the premeds for the next infusion or stop the medication.
We are fortunate to have our own infusion pharmacist that prepares our IV medications.