1. Immunology nursing in the Czech republic today
Teplá Ilona
Králíčková Pavlína
Institute of Allergy and Clinical Immunology University Hospital Hradec Kralove
Czech Republic
sources: foto oficial pages in the Internet

2. Introduction
sources : oficial pages in the Internet / foto learning centre of the University Hospital Hradec Kralove

3. The main points
Statistical survey of our patients in the Czech PID database
Practical aspects in the administration
Immunoglobulin supplementation therapy and comparison
IVIG x SCIG
Most frequent questions/difficulties with the administration
Conclusion
Discussion

4. Statistical survey of PID patients
/Czech republic/
Actual status • general descriptions of database / immunoglobulin therapy/ • comparison of status in particular centres /referential values/
Czech PID registry, export of data 09/2014

5. Statistical survey of PID patients
/Czech republic
number of patients
% of valid cases
Total evidence
684
88,6%
Actual monitored
664
88,7%
Centre
Number of patients
valid
FNUSA Brno - Ústav klin. imunolog. a alergolog.
156
98,0%
FN Motol - Ústav imunologie
151
92,4%
FNHK - ÚKIA 79
93,7%
VFN Praha - Ústav imunologie a mikrobiologie 59
100,0%
FN Plzeň - Ústav imunologie a alergologie 43
64,3%
ZÚ ÚnL - Odd. klin. imunologie a alergologie 35
97,0%
IKEM Praha - Klinická a transplantační medicína 29
86,2%
FN Olomouc - Odd. alergologie a klin. imunologie 21
Nemocnice České Budějovice - Imunologické oddělení 18
88,9%
Zlín - Plicní oddělení, KNTB a.s. 14
ZÚ Ostrava - Oddělení imunologie a alergologie
FN Brno - Pediatrická klinika 13
91,7%
FNHK - Klinika dětského lékařství 11
FNKV Praha - Odd.alergologie a klin. imunologie
90,9%
FN Olomouc a LF UP - Dětská klinika 3
66,7%
Tábor-Kasmed s.r.o., alerg., imunolog, neurolog.
FN Ostrava - Alergologie 2
50,0%
Krnov SSZ - interní oddělení

6. Statistical survey of PID patients
/Czech republic/
N=664
(Currently monitored)
Male (N=300)
Female (N=364)

7. Basic characteristics

8. Replacement therapy

9. Practical aspects in the administration
Optimal IgG doses and target trough levels are individual
(clinical symptoms, comorbidities, genetic factors)
The route of administration could be the result of discussion (patient X nurse X doctor)
Negative influence - financial conditions in hospital
- statement of insurance company
- economical tender of immunoglobulin
preparation

10. Practical aspects in the administration
IVIG therapy
Advantages - cheaper in the Czech Rep.
- administration ones/twice a month
- more often checking of clinical status and
laboratory results
Disadvantages - administration at outpatient department (traveling, day off work)
- higher risk of adverse events
- more often intolerance of administered preparation
- necessary good venous access

11. Practical aspects in the administration
SCIG therapy
Advantages - home therapy with independence
- comfort, flexibility
- less frequent visits at the doctor
- better tolerance of Ig preparations
- low side effect profile (no severe systemic)
- alternative for patients with poor venous access
- benefit in case of gastrointestinal losses, malnutrition
- flexibility of dosing and ease of administration

12. Practical aspects in the administration
SCIG therapy
Practical aspects in the administration
Disadvantages/limitations
- fear from the inject or the needle
- administrations 1-3 times a week
- intolerance (local skin reactions, scars, stretch marks)
- risk of lower compliance

13. SCIG therapy
It is important to doing difference between methods of subcutaneous administrations, preparations
Individual approach to each patient
Choose areas from recommended sites
for the administration /abdomen, outer/
inner thighs, hips, upper arms/
Specific role of trained nurses in
the education of patients
It depends on the constitution of the patient,
the thickness of the subcutis and type of needles

14. SCIG therapy Subcutaneous administration
method rapid push /patient can adjust the rate of the infusion according to his tolerance without using the infusion pump/
….Rapid push significantly higher infusion rate (60ml/h x 20ml/h)
….Patients with 10ml and less per one site prefer rapid push
by the infusion pump /there should keep recommended rate
of the infusion/
….Infusion pumps provide pharmaceutical firms
….Comparable efficacy and tolerability

15. Our own experience – centre Hradec Kralove, Czech Rep.
47 patients regularly on Ig substitution therapy
27/47 IVIG
20/47 SCIG
SCIG with pump since … 2007 to Oct 2014: 9 patients
(3 died, 1 switched to IVIG – medication intolerance)
Rapid push since …2012 to Oct 2014: 11 patients
(2 switched to IVIG – 1 case patient preference, one case unsatisfactory IgG level and patients reluctance to increase Ig doses)

16. Side effects – pump x rapid push
No serious systemic reaction
• including patient experienced moderate systemic reaction - IgA antibodies
• 1 case - intolerance of two different preparations (fatigue)
Local reactions:
Pump: infrequently haematoma
Rapid push:
→ 2/11 mild itching, erythema
→ 2/11 pain during administration (change of the injection site to the inner thigh)

17. Often problems with administration / by patients
and nurse´s view

18. a view on our daily centre /outpatient ward/

19. Practical experience
Giving enough practical information to the patient by a nurse-specialist
Explanation of the whole procedure (initiation of SCIG therapy)
or providing an instructional video
Demonstration of administration
Reassurance of the patient (patient in home therapy after regaining certainty in the administration)

20. Question 1:
There are enlarged pores, which are usually disappear for a day, the area is painful. Shall I continue with the application?
There is the skin apparently attenuated (stretch marks, etc.) …
You will try to change the site. We choose a different area from the recommended injection sites. Mainly it depends on the tolerance of the patient ..
We had same patient in our department with this problem and she solved it just changing of the injection site. She started to administer to the inner side of thigh and she was satisfy.

21. Practical experience
- possibility of the administration

22. Question/difficulties 2:
There are stretch marks around the abdomen and it is very limited the choice to other site.
outside stretch marks (scars)
it depends again on the constitution of the patient,
the thickness of the subcutis

23. Question 3: The injection site is after the infusion leakage or wet …
There was probably made too shallow the introducing of the needle. The needle was only a little bent or it was just a poor implementation. We have tested for example bending the needle to the angle of 90 degrees /method rapid push/, the introduction of the needle is deep enough to the preparation is well absorbed and well tolerated by the patient.
the bending of the needle to 90°degrees is recommended in the administration to the abdomen (special type of the needle) and there is stronger thickness of the subcutis

24. Practical experience
- possibilty of administration

25. Question 4:
The injection site is after administration indurated and painful and it has been disappear for a long time..…
The dose of the liquid is probably too large on the thickness of the subcutis. We will try to divide the dose into two or more administrations. New sites should be at lest 2 inches apart.
We should have been always consulted with the doctor.

26. Conclusion
Immunoglobulin supplementation therapy represents a corner stone in the treatment of patients with disturbance of specific antibody production. The correctly guided treatment leads to decrease of severe illnesses and improve the quality of life. I am glad that I can participate in it.
There were used information from the official websites www. hizentra.com and the Internet .

27. Discussion

28. Immunology nursing in the Czech republic today
Thank you for your attention.
sources : foto oficial pages in the Internet