Venofer (Iron Sucrose) Infusion Order Template
For iron deficiency anemia treatment, administer Venofer 300 mg intravenously weekly for three consecutive weeks, with each dose infused over 1.5 to 2 hours in 100-250 mL of 0.9% normal saline.
Complete Order for Infusion Center
Patient Information Section
- Patient Name: _________________
- Date of Birth: _________________
- Medical Record Number: _________________
- Diagnosis: Iron Deficiency Anemia (ICD-10: D50.9 or specify)
- Ordering Physician: _________________
- Contact Number: _________________
Medication Order
Drug: Venofer (Iron Sucrose Injection)
Dose: 300 mg IV per infusion 1, 2
Frequency: Once weekly for 3 weeks (total of 3 infusions) 1, 3
Schedule:
- Week 1: Date ________
- Week 2: Date ________ (7 days after first dose)
- Week 3: Date ________ (7 days after second dose)
Administration Instructions
Preparation:
- Dilute 300 mg Venofer in 100-250 mL of 0.9% Sodium Chloride Injection USP 1, 3
- Do NOT use 5% Dextrose solution for dilution
- Inspect solution for particulate matter before administration
Infusion Rate:
- Administer over 1.5 to 2 hours 1
- Do NOT administer as IV push or bolus
Route: Intravenous infusion only
Pre-Infusion Requirements
Vital Signs:
- Obtain baseline vital signs before each infusion
- Monitor blood pressure for orthostatic changes 1
Laboratory Monitoring:
- Baseline: Complete blood count with hemoglobin, serum ferritin, transferrin saturation
- Follow-up labs: Repeat CBC 14-15 days after completion of third dose 1, 2
Safety Monitoring During Infusion
Observe patient for:
- Hypersensitivity reactions (hypotension, dyspnea, rash, pruritus)
- Injection site reactions or pain 1
- Monitor vital signs every 30 minutes during infusion
Emergency Equipment:
- Ensure availability of resuscitation equipment and medications for anaphylaxis management
Post-Infusion Instructions
- Monitor patient for 30 minutes after completion of each infusion
- Document any adverse reactions
- Patient may experience transient metallic taste during infusion
Expected Outcomes
- Anticipated hemoglobin increase: 2.7-3.2 g/dL after completion of 3-week course 1
- Clinical improvement in anemia symptoms expected within 2-3 weeks 2
Contraindications and Precautions
Do NOT administer if:
- Known hypersensitivity to Venofer or any component
- Evidence of iron overload
- Anemia not caused by iron deficiency
Contact Information
For questions or adverse events, contact:
- Ordering physician: _________________
- Phone: _________________
- After hours: _________________
Physician Signature
Physician Signature: _________________ Date: _________
Print Name: _________________
DEA/License Number: _________________