FERINJECT (ferric carboxymaltose)

Ferinject infusion is used to treat iron deficiency anaemia where oral iron therapy is ineffective, not tolerated, or clinically inappropriate.

IV iron infusion is appropriate where oral iron therapy is not suitable, including where:

Oral iron treatment has been proven ineffective, or
Oral iron is not treatment has resulted in dose-limiting intolerance
Rapid correction of anaemia is required
Patient has symptomatic heart failure, chronic kidney disease stage 3 or more or active inflammatory bowel disease and a trial of oral iron is unlikely to be effective

First Name

Last Name

Date of Birth

Month

Day

Year

NHI

POAC Claim Number

Ferritin Level

PATIENT HISTORY

Is this the first time receiving infusion today?

Yes

Any form of infusion via an IV Line for medical and non medical treatments

Any Known drug allergies

Yes

Allergy is defined as having Hives,Swelling of Airways, Shock. If patient has any known drug allergies please write below:

Known drug allergies

Pregnancy Term (Days/Week)

Known Medical Conditions

Does the Patient take any regular medications?

If on medication check for interactions and safety. You can check this by going to www.nzf.org

If taking medications, what regular medications are they taking?

PATIENT VITALS/OBS

Blood Pressure

NORMAL LESS THAN 120 and LESS THAN 80

ELEVATED 120 – 129 and LESS THAN 80 HIGH BLOOD PRESSURE (HYPERTENSION) STAGE 130 – 139 or 80 – 89

Heart Rate

Oxygen Saturation

Patients Weight

Temperature

Fetal Heart Rate

Consent for Infusions

Procedure Intravenous infusion of Ferric carboxymaltose (Ferinject) over at least 15 minutes for Iron Deficiency Anaemia.

Anaphylaxis—a severe allergic reaction to the infused drug. Although this is uncommon, it’s important to recognize

the symptoms, which include difficulty breathing, swelling of the lips or mouth, and the formation of a rash.

Common expected side effects include nausea, vomiting, dizziness or light-headedness, and hot flushes. If you experience any of these symptoms, please inform us immediately so we can adjust

your infusion accordingly.

Prior to my infusion i have:

Had explained to me the purpose and procedure of Ferric carboxymaltose (Ferinject) by intravenous infusion. 
I confirm that I have had explained to me adverse effects.
Have been provided with, or informed where to find electronic version of the Ferinject Patient Information Leaflet

By signing this consent form, you have been advised of the adverse effects of the infusions, have been provided information regarding the infusion.

I consent to this infusion and have taken the time to review the procedure and its known adverse effects.

Signature

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Infusion Details

Infusion Start

Time

HoursMinutes

Administered Drug

1 Vial Ferinject 500mg/10mL

2 Vials Ferinject 500mg/10mL

INFUSION DETAILS

IV Cannulation Site

LEFT ARM/WRIST

RIGHT ARM/WRIST

Cannulation Anatomy

Cephalic Vein

Medial Cubital Vein

Basilic Vein

Dorsal Metacarpal Vein

IV Catheter Size

22G

24G

Number of Attempts in Cannulation

This should not exceed more than 2 times for the same clinician.

IV Saline Push to check correct cannulation prior to mixing the drug.

IV Site Sterile, Cleaned with Alcohol and Aseptic Sterile Technique used.

Post Infusion Monitoring Completed

Contra-indication ruled out

Aftercare explained to patient, to keep well hydrated, and look out for allergy symptoms such as airway swelling, rash formations

Recent blood test checked

Blood form given for follow up blood test in 2 weeks time

Infusion Completed Time

Time

HoursMinutes

Adverse Event Notes

Any adverse event please report to CARMS and contact oversight

Clinician

Clinician Signature

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