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11 Administration rates and tolerance of intravenous immunoglobulin (IVIG) in patients with X-linked agammaglobulinemia (XLA)
S6
Abstracts
J ALLERGY CLIN IMMUNOL JANUARY 2000
11 Administration
Rates and Tolerance of Intravenous Immunoglobulin (IVIG) in Patients with X-linked Agsmma&obulinemia (XLA) D Se&& L Wft’iams Duke University Medical Center PURPOSE: We analyzed IVIG infusion records to determine how frequently actual rates of infusion exceeded the manufacturers’ maximum recommended rates and whether there were adverse reactions with these rapid infusions. METHOD: A retrospective chart analysis of 7 of 14 patients with XLA was performed. Alternately seen patients were selected for analysis. Age range of the patients was 3.0 to 14.25 years. Eightyseven (87) infusions during the year interval 7/l/98 to 6/30/99 were reviewed. We tabulated the ordered rates and timing, the actual rates and timing recorded by nursing personnel, the time required to complete the infusion, and the occurrence of any reaction. We calculated the ordered infusion time from the volume given and the rates ordered. We calculated the mean infusion rate from the volume administered and the actual time required. RESULTS: Data was available for 85 infusions. Gamimune-N 10% was administered 84 times and Venoglobulin-S was administered once, all without pre-medication. All infusions were via peripheral venous access with gravity dripped administration sets. The mean dose infused was 405 mg/kg (standard deviation 115). In 3 I (36%) of the infusions the maximum recorded infusion rate exceeded the manufacturer’s recommended maximum of 0.08 ml/kg&n. In 37 (44%) infusions, the recorded infusion time was less than the infusion time calculated from the orders (which had been based on manufacturer’s recommended rates). In 10 of these 37 infusions, the mean infusion rate was 1.5 times above the mean infusion rate that would have resulted from perfect adherence to the ordered rates and times. For these 37 infusions, the mean calculated time of infusion was 69 minutes with a standard deviation of 12. Mean real time of infusion was 53 minutes with a standard deviation of 14. No reactions were noted in the infusions that were faster than ordered. CONCLUSIONS: Rate fluctuations apparently occurred as a result of changes in patient position in patients who did not have an IV pump or controller. Such variations in rate are probably common in sites that administer IVIG; however, for patients with XLA, rates of administration moderately higher than the manufacturer’s recommendations appear to be well tolerated without the use of premedication. Other patient groups may have a different tolerance for increased rates.
12
Expected
and Actual Pain of Allergy Skin Tests S Flynn, Deborah Li Mayo Clinic PURPOSE: To compare the expected and experienced pain associated with allergy prick skin testing. METHODS: We conducted a structured interview of 100 patients undergoing aeroallergen prick skin tests. We asked “How painful or uncomfortable do you expect the allergy skin test to be?’ Participants rated the expected level of discomfort from 0- 10. After skin testing to 1658 aeroallergens, we then asked the participants to rate the actual level of discomfon, again from 0-lO.The expected and experienced ratings of discomfort werecompared using a two-tailed l-sample sign test. RESULTS:There were 85 participants with usable responses and 82 participants who gave both expected and actual ratings. The median expected pain rating was 3 and the median actual pain rating was 2. The actual pain rating was less than the expected rating for 50 participants (61%); was greater than the expected rating for 9 (11%); and equal to the expected rating for 23 (28%). There were significantly more participants who experienced less discomfort than expected compared with those who experienced more discomfort than expected (pcO.01). There were 19 participants who rated the actual pain 3 or more points less than expected, compared with none who rated the actual discomfort 3 or more points greater than expected. CONCLUSION: Patients undergoing allergy prick skin testing experience significantly less discomfort than expected. Clinicians can
Andrist,
James
reassure patients may think.
that the allergy
skin tests are less painful
than they
13
Effectiveness of Pediatric Asthma Management in an Army Hospital Kjell Ebena, Rhonda Schwanres US Army MEDDAC, Wuetzburg. Germany The Assistant Secretary of Defense (Health Affairs) released a study on the Management of Asthma in the Military Health Care System in 1995. The study identified multiple areas for improvement and lead to the recommendation to implement the National Heart, Lting and Blood Institute (NHLBI) Guidelines for the Diagnosis and Management of Asthma. Asthma was one of the top 3 diagnoses for the Wuetzburg MEDDAC’s pediatric clinic from August 1997 to October 1998. During this time, the NHLBI Guidelines were implemented and Asthma Case Management initiated. An asthma database was created and Asthma education based on the NHLBI Guidelines was offered to key members of the asthma team (patients, families, school personnel, physicians, and hospital personnel). Monthly reports from pharmacy revealed those patients who overused albuterol. These patients were brought back into the system for re-evaluation. Twice a week the emergency room log was reviewed for asthma exacerbations. These patients were called to schedule a follow-up appointment. Since the implementation of the NHLBI Guidelines and Asthma Case Management, over a 1Cmonth period of time, pediatric unplanned physician visits for asthma decreased 113 and pediatric admissions for asthma decreased 2J3. Future plans include organizing an asthma clinic within the pediatric clinic. Procedures planned to manage these patients more effectively include: using a Pediatric Initial Asthma Assessment Questionnaire, follow-up asthma questionnaire, evaluating inhaler and peakflow techniques, reviewing peakflow diary, reviewing home management plan and using reminder cards to bring patients back in for routine follow-up. The goal of having no admissions for asthma and only planned physician visits can be obtained with the continuation of proactive asthma management and use of the NHLBI guidelines.
14
The Eagle’s Circle, a Wellness Program for Children With Asthma and/or Obesity J Sgritto*, K Kellyf. J Shiraf, D Skoner$. R Kaye* *Pfizer Inc tMedica1 College of Wisconsin tuniversity of Colorado School of Medicine BChildren’s Hospital of Pittsburgh Children with asthma tend to be less physically active than healthy children, in part due to fear that exercise will bring on an asthma attack. The subsequent sedentary lifestyle is considered a significant cause of weight problems and obesity among asthma patients. Sedentary life styles and obesity are of particular importance in the asthma population, because both are associated with the onset and severity of asthma symptoms. For those whose condition prevents participation in sports or other activities that are critical to peer acceptance and a sense of achievement. self-esteem may suffer significantly. Collectively, decreased physical activity, obesity, and psychosocial challenges may set the stage for a vicious cycle that can result in poor treatment outcomes and increased asthma severity. The Eagle’s Circle (TEC), a wellness and fitness program comprises 16 biweekly sessions of 1-hour duration consisting of 40 minutes of innovative exercise training followed by a 20 minute health education/peer discussion group. TEC was previously studied in three urban sites with twenty-eight children aged lo-15 years with asthma and/or obesity. Results of the pilot study suggested that TEC safely improved overall fitness and quality of life. The expanded study was conducted to evaluate and confirm the results of this program on a larger sample of children. One hundred and nineteen children aged lo-15 years with asthma and/or obesity from 14 sites participated in the study. The subjects were tested for aerobic fitness, 3-minute step test heart rate reduced from 143 to 135 bpm (p=
Abstracts
J ALLERGY CLIN IMMUNOL JANUARY 2000
11 Administration
Rates and Tolerance of Intravenous Immunoglobulin (IVIG) in Patients with X-linked Agsmma&obulinemia (XLA) D Se&& L Wft’iams Duke University Medical Center PURPOSE: We analyzed IVIG infusion records to determine how frequently actual rates of infusion exceeded the manufacturers’ maximum recommended rates and whether there were adverse reactions with these rapid infusions. METHOD: A retrospective chart analysis of 7 of 14 patients with XLA was performed. Alternately seen patients were selected for analysis. Age range of the patients was 3.0 to 14.25 years. Eightyseven (87) infusions during the year interval 7/l/98 to 6/30/99 were reviewed. We tabulated the ordered rates and timing, the actual rates and timing recorded by nursing personnel, the time required to complete the infusion, and the occurrence of any reaction. We calculated the ordered infusion time from the volume given and the rates ordered. We calculated the mean infusion rate from the volume administered and the actual time required. RESULTS: Data was available for 85 infusions. Gamimune-N 10% was administered 84 times and Venoglobulin-S was administered once, all without pre-medication. All infusions were via peripheral venous access with gravity dripped administration sets. The mean dose infused was 405 mg/kg (standard deviation 115). In 3 I (36%) of the infusions the maximum recorded infusion rate exceeded the manufacturer’s recommended maximum of 0.08 ml/kg&n. In 37 (44%) infusions, the recorded infusion time was less than the infusion time calculated from the orders (which had been based on manufacturer’s recommended rates). In 10 of these 37 infusions, the mean infusion rate was 1.5 times above the mean infusion rate that would have resulted from perfect adherence to the ordered rates and times. For these 37 infusions, the mean calculated time of infusion was 69 minutes with a standard deviation of 12. Mean real time of infusion was 53 minutes with a standard deviation of 14. No reactions were noted in the infusions that were faster than ordered. CONCLUSIONS: Rate fluctuations apparently occurred as a result of changes in patient position in patients who did not have an IV pump or controller. Such variations in rate are probably common in sites that administer IVIG; however, for patients with XLA, rates of administration moderately higher than the manufacturer’s recommendations appear to be well tolerated without the use of premedication. Other patient groups may have a different tolerance for increased rates.
12
Expected
and Actual Pain of Allergy Skin Tests S Flynn, Deborah Li Mayo Clinic PURPOSE: To compare the expected and experienced pain associated with allergy prick skin testing. METHODS: We conducted a structured interview of 100 patients undergoing aeroallergen prick skin tests. We asked “How painful or uncomfortable do you expect the allergy skin test to be?’ Participants rated the expected level of discomfort from 0- 10. After skin testing to 1658 aeroallergens, we then asked the participants to rate the actual level of discomfon, again from 0-lO.The expected and experienced ratings of discomfort werecompared using a two-tailed l-sample sign test. RESULTS:There were 85 participants with usable responses and 82 participants who gave both expected and actual ratings. The median expected pain rating was 3 and the median actual pain rating was 2. The actual pain rating was less than the expected rating for 50 participants (61%); was greater than the expected rating for 9 (11%); and equal to the expected rating for 23 (28%). There were significantly more participants who experienced less discomfort than expected compared with those who experienced more discomfort than expected (pcO.01). There were 19 participants who rated the actual pain 3 or more points less than expected, compared with none who rated the actual discomfort 3 or more points greater than expected. CONCLUSION: Patients undergoing allergy prick skin testing experience significantly less discomfort than expected. Clinicians can
Andrist,
James
reassure patients may think.
that the allergy
skin tests are less painful
than they
13
Effectiveness of Pediatric Asthma Management in an Army Hospital Kjell Ebena, Rhonda Schwanres US Army MEDDAC, Wuetzburg. Germany The Assistant Secretary of Defense (Health Affairs) released a study on the Management of Asthma in the Military Health Care System in 1995. The study identified multiple areas for improvement and lead to the recommendation to implement the National Heart, Lting and Blood Institute (NHLBI) Guidelines for the Diagnosis and Management of Asthma. Asthma was one of the top 3 diagnoses for the Wuetzburg MEDDAC’s pediatric clinic from August 1997 to October 1998. During this time, the NHLBI Guidelines were implemented and Asthma Case Management initiated. An asthma database was created and Asthma education based on the NHLBI Guidelines was offered to key members of the asthma team (patients, families, school personnel, physicians, and hospital personnel). Monthly reports from pharmacy revealed those patients who overused albuterol. These patients were brought back into the system for re-evaluation. Twice a week the emergency room log was reviewed for asthma exacerbations. These patients were called to schedule a follow-up appointment. Since the implementation of the NHLBI Guidelines and Asthma Case Management, over a 1Cmonth period of time, pediatric unplanned physician visits for asthma decreased 113 and pediatric admissions for asthma decreased 2J3. Future plans include organizing an asthma clinic within the pediatric clinic. Procedures planned to manage these patients more effectively include: using a Pediatric Initial Asthma Assessment Questionnaire, follow-up asthma questionnaire, evaluating inhaler and peakflow techniques, reviewing peakflow diary, reviewing home management plan and using reminder cards to bring patients back in for routine follow-up. The goal of having no admissions for asthma and only planned physician visits can be obtained with the continuation of proactive asthma management and use of the NHLBI guidelines.
14
The Eagle’s Circle, a Wellness Program for Children With Asthma and/or Obesity J Sgritto*, K Kellyf. J Shiraf, D Skoner$. R Kaye* *Pfizer Inc tMedica1 College of Wisconsin tuniversity of Colorado School of Medicine BChildren’s Hospital of Pittsburgh Children with asthma tend to be less physically active than healthy children, in part due to fear that exercise will bring on an asthma attack. The subsequent sedentary lifestyle is considered a significant cause of weight problems and obesity among asthma patients. Sedentary life styles and obesity are of particular importance in the asthma population, because both are associated with the onset and severity of asthma symptoms. For those whose condition prevents participation in sports or other activities that are critical to peer acceptance and a sense of achievement. self-esteem may suffer significantly. Collectively, decreased physical activity, obesity, and psychosocial challenges may set the stage for a vicious cycle that can result in poor treatment outcomes and increased asthma severity. The Eagle’s Circle (TEC), a wellness and fitness program comprises 16 biweekly sessions of 1-hour duration consisting of 40 minutes of innovative exercise training followed by a 20 minute health education/peer discussion group. TEC was previously studied in three urban sites with twenty-eight children aged lo-15 years with asthma and/or obesity. Results of the pilot study suggested that TEC safely improved overall fitness and quality of life. The expanded study was conducted to evaluate and confirm the results of this program on a larger sample of children. One hundred and nineteen children aged lo-15 years with asthma and/or obesity from 14 sites participated in the study. The subjects were tested for aerobic fitness, 3-minute step test heart rate reduced from 143 to 135 bpm (p=