Protocol Index	

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IP APLASTIC ANEMIA - ATG/CSA	

Types:      ONCOLOGY TREATMENT
Synonyms:  ATGAM, ANTITHYMOCYTE GLOBULIN

Cycle 1	Repeat 1 time	Cycle length: 14 days	Day 1	Perform every 1 day x1		Provider Communication
  	ONC PROVIDER COMMUNICATION 64	Interval: Once	Occurrences: --	Comments:	Verify Hep B panel status prior to cycle. Date *** of panel. Result positive/negative/pending/unknown:22867

The required components for the hepatitis B panel includes: Hepatitis B surface antigen (HBsAg), total hepatitis B core antibody (anti-HBc), and hepatitis B antibody (anti-HBs).
			Medications
  	antithymocyte globulin (atg) (horse) test dose (ATGAM) 0.005 mg/0.1 mL intradermal injection 0.005 mg	Dose: 0.005 mg	Route: intradermal	once for 1 dose	Start: S			Instructions:	Give test dose 0.1mL (0.005mg) intradermally before Antithymocyte globulin dose.			Nursing Orders
  	NURSING COMMUNICATION - DO NOT USE IN ORDER SETS	Interval: Once	Occurrences: --	Comments:	Wait for an hour after Atgam test dose and call MD for a positive skin reaction (a positive reaction consists of a GREATER THAN or EQUAL TO 3 mm in diameter larger than the saline control with the intradermal test).
			Pre-Medications
☑	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to Atgam		☑	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to Atgam			Pre-Medications
  	methylPREDNISolone sodium succinate (Solu-MEDROL) injection 1 mg/kg (Treatment Plan)	Dose: 1 mg/kg	Route: intravenous	once for 1 dose			Offset: 1 Hours	Instructions:	Administer 1 hour PRIOR to Atgam			Medications
  	antithymocyte globulin (atg) (horse) (ATGAM) 40 mg/kg in sodium chloride 0.9 % 500 mL IVPB	Dose: 40 mg/kg	Route: intravenous	once over 4 Hours for 1 dose			Offset: 2 Hours	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION	Medications	40 mg/kg	Main Ingredient	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	500 mL	Always	Yes			  	cycloSPORINE modified (NEORAL) capsule 6 mg/kg (Treatment Plan)	Dose: 6 mg/kg	Route: oral	2 times daily at 0600, 1800 (TIME CRITICAL)			Offset: 0 Hours			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S						Days 2,3	Perform every 1 day x2		Pre-Medications
☑	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to Atgam		☑	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to Atgam			Pre-Medications
  	methylPREDNISolone sodium succinate (Solu-MEDROL) injection 1 mg/kg (Treatment Plan)	Dose: 1 mg/kg	Route: intravenous	once for 1 dose				Instructions:	Administer 1 hour PRIOR to Atgam			Medications
  	antithymocyte globulin (atg) (horse) (ATGAM) 40 mg/kg in sodium chloride 0.9 % 500 mL IVPB	Dose: 40 mg/kg	Route: intravenous	once over 4 Hours for 1 dose			Offset: 1 Hours	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION	Medications	40 mg/kg	Main Ingredient	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	500 mL	Always	Yes					Day 4	Perform every 1 day x1		Labs
  	CYCLOSPORINE LEVEL, RANDOM	Interval: AM draw	Occurrences: --			Pre-Medications
☑	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to Atgam		☑	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to Atgam			Pre-Medications
  	methylPREDNISolone sodium succinate (Solu-MEDROL) injection 1 mg/kg (Treatment Plan)	Dose: 1 mg/kg	Route: intravenous	once for 1 dose				Instructions:	Administer 1 hour PRIOR to Atgam			Medications
  	antithymocyte globulin (atg) (horse) (ATGAM) 40 mg/kg in sodium chloride 0.9 % 500 mL IVPB	Dose: 40 mg/kg	Route: intravenous	once over 4 Hours for 1 dose			Offset: 1 Hours	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION	Medications	40 mg/kg	Main Ingredient	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	500 mL	Always	Yes					Day 5	Perform every 1 day x1		Medications
  	predniSONE (DELTASONE) tablet 40 mg	Dose: 40 mg	Route: oral	daily			Offset: 0 Hours