Infusion checklist (pdf, 22 KB)

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Paediatric Biologics Clerking Sheet
Assessment of patients fitness for Infliximab, Tocilizumab and Rituximab.
Date:
Patient’s Identification
Biologic therapy:
Infusion No:
Baseline Observations
Weight
Height
Latest Blood Results - Date:Hb
Plats
WCC
BP
Neut
Heart Rate
ALT
ESR
Resp Rate
CRP
Temp
Other
Take bloods prior to infusion from cannula for FBC, ESR, U&E’s, LFT’s & CRP. (If no chicken pox titre
result recorded on Biologics Pre-Infusion Checklist, please take blood for this also.) No need to wait for
results before giving infusion, unless concerns with patients fitness for infusion.
However please check results & record before patient is discharged.
Today bloods – Date: Hb
Plats
WCC
Neut
ALT
ESR
CRP
Other
Has child had any reactions to previous infusions? Yes □
No □
N/A □
If yes, explain:…………………………………………………………………………………………………………
Biologics Clerking Form. Eunice Kendall. Version 2. June 2012.
In the past 48 hours has child had:
Yes
No
Any infection including dental abscess
Been treated with antibiotics
Fever > 37.5*c
Cough or cold
Wheeze/shortness of breath
Chest pain
Vomiting
Diarrhoea
Dysuria or urinary symptoms (If symptoms dipstick urine)
Mouth ulcers
Females only. Have Periods started? Yes □ No □
If yes, ask if any chance they may be pregnant. Yes □
No □
If patient unsure, please perform pregnancy test.
Withhold infusion & discuss further with the paediatric rheumatology team if:
 Temp >37.5
 Child is systemically unwell
 Any sign of infection
 Abnormal blood results (HB <9, Platelets <150, Neut <1.5 cells x 109/ l, ALT >120)
Clerking
Patient fit to receive infusion
Yes □ No □
If No – Please state reason & plan:
Paediatric Rheumatology team informed of decision not to give infusion Yes □ No □
Signature:
Position:
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………………………………………….
…………………………………………….
Name:
Date
………………………………………
…………………………………………
Contacts for Paediatric Rheumatology Team
Paediatric Rheumatology ANPs 01865 737341 [email protected]
Dr Bailey (Consultant Paediatric Rheumatologist) via Marta Vilanova 01865 738026
Dr David (Consultant Rheumatologist) ext 01865 738107
Out of hours – Contact can be made with on-call SpR for rheumatology via NOC switchboard 01865 741155
Biologics Clerking Form. Eunice Kendall. Version 2. June 2012.
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