By Candy Finley, RN, IgCN and Joe DiStefano, RPh.

NuFACTOR Specialty Pharmacy programs pumps specifically to the patient orders. Always verify the patient's order with the pump program. Pumps are sent out in Variable Mode, which means the pump will titrate up on its own as it has been programmed. Remember to attach the vented spike adaptor to the spike of Curlin tubing. Per our policy, after spiking three vials, the nurse must use a new spike adaptor and Curlin tubing as they become dull and it is nearly impossible to separate them.

Set up your drug and then turn on the pump. After a quick self-testing is performed the Curlin pump display will read "System OK" followed by battery strength. Next press "Enter" to select Program mode. Select "Repeat Rx" by pressing the "Yes" key. Scroll down to select "Variable Mode" from the therapy selection menu. The pump will display the programmed titration ramp up. Upon completion of review you will be asked to Press Run to Start, No to Review program again, Options or Prime. Select "Prime" to prime the tubing using the pump and not by gravity as it's easy to damage the tubing spring mechanism which may cause the set to malfunction. You must hold the "Prime" key the entire time or it will stop before it is done. Once priming is complete, you are ready to start your infusion. At this point, if you select "Options" you can verify if the Down Occlusion is set on Low or High. If infusing IVIG the pump setting needs to be on Low; if infusing facilitated SCIG (HyQvia) the pump setting needs to be on High. Now you are ready to start your infusion. First flush your patient's catheter to verify it is still patent. After connecting the Curlin tubing to the patient, press "Run to Start" and the green light will flash the entire time during the infusion. If your patient wants to be disconnected from the pump briefly, press the "Pause" key. After 5 minutes the alarm will sound if you do not restart the infusion. Silence the alarm if your patient is not yet ready to resume. One you reconnect your patient to the pump, select "Yes" and "Run" to resume. If you get an alarm at any time during the infusion, read the display screen to properly identify the problem. If it reads "Upstream Occlusion" there is a problem between the vial and pump. Most likely causes are not using a vented spike adaptor or allowing the vial to completely empty. If the display reads "Downstream Occlusion", check to make sure tubing is not kinked and slider clamps on both Curlin tubing and/or patient IV access are not closed. If clamps are open and tubing not kinked, I recommend flushing the patient's IV access to check patency.

If your patient desires a faster infusion rate, you MUST contact NuFACTOR pharmacy. The pharmacist will review the manufacturer's package insert and patient risk factors to ensure an increased rate is appropriate and then obtain an order from the prescriber. Otherwise, rate increases are never allowed. If permission is granted, you must reprogram the pump. With your orders and titration sheet are instructions on how to properly reprogram the pump. Press "Yes" at each field to confirm every value or the new program will not be saved. Only arrow past a field when the pump needs to calculate a value. Two of three of the values must be provided. Note Time is the only value the pump will automatically calculate. After reviewing the new program you are ready to "Run" the new program. Note: always request pharmacy send a new titration sheet to the home as soon as possible. This is important to avoid confusion if a different nurse sees the patient.

If your patient experiences a mild adverse drug reaction (ADR), decrease the rate, generally by lowering the rate by half. I recommend switching the pump to a continuous rate mode. If the ADR continues or worsens, stopping the infusion may be required until ADR resolves and then restarting at a slower rate. Remember rate decreases are at the nurse discretion. This will enable you to titrate up slowly and monitor your patient closely for tolerability. In addition, if the pump malfunctions during an infusion, the infusion needs to be continued via gravity flow. Our expectation is that you calculate the rates for titration ramp up if you are not at your hourly maximum rate. Upon completion of the infusion contact pharmacy for a replacement pump.

NOTE: NuFACTOR Specialty Pharmacy expects all infusions to be completed via pump unless the prescriber specifically orders infusing via gravity. Also patients should never be provided with pump unlock codes. If a HYQVIA patient requires a dose change, we will issue a new pump. We expect the nurse to remain with the patient for the entire infusion unless otherwise ordered.