Protocol Index	

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IP CAGT ALLOGENEIC SCT IV BU-FLU-PTCY	

Types:      ONCOLOGY TREATMENT
Synonyms:  BU, FLU, CAM, BUSULFAN, FLUDARABINE, FLUDARA, BMT

Transplant	Repeat 1 time	Cycle length: 86 days	Day -6 through -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).
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Additional Orders
  	ONC NURSING COMMUNICATION 49	Interval: Until discontinued	Occurrences: --	Comments:	Do NOT administer Acetaminophen/Azoles for 48 hours after last busulfan dose.
			Pre-Medications
  	ondansetron (ZOFRAN) 16 mg, dexAMETHasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	every 24 hours over 10 Minutes for 4 doses	Start: S+1  7:30 AM			Instructions:	Administer 30 minutes prior to treatment on Day -5, -4, -3, -2.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S+1  7:30 AM			Instructions:	Administer 30 minutes prior to treatment on Day -5		  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S+5  7:30 AM			Instructions:	Administer on Day -1.			Antiemetics
  	promethazine (PHENERGAN) injection 25 mg	Dose: 25 mg	Route: intravenous	every 4 hours PRN	Start: S					Supportive Care
  	acyclovir (ZOVIRAX) 5 mg/kg (Ideal)	Dose: 5 mg/kg	Route: intravenous	every 8 hours for 3 doses	Start: S				  	levoFLOXacin (LEVAQUIN) tablet 500 mg	Dose: 500 mg	Route: oral	daily at 0600	Start: S				  	micafungin (MYCAMINE) IVPB (RESTRICTED) 100 mg	Dose: 100 mg	Route: intravenous	every 24 hours over 1 Hours for 11 doses	Start: S					Chemotherapy
  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	During IV Busulfan:
o INFUSE in the WHITE lumen on the TRIPLE lumen catheter. 
o LABEL the White lumen: Busulfan. 
o Prime tubing and filter with Normal Saline only. 
o Do NOT give any Acetaminophen (Tylenol) during Busulfan doses and for 48 hours following the last dose of Busulfan. 
o Record START and STOP time of EVERY Busulfan dose. 
o FLUSH tubing and filter with 20cc Normal Saline after each dose.
		  	busulfan (BUSULFEX) in sodium chloride 0.9% EVERY 6 HOUR chemo IVPB	Dose: --	Route: intravenous	every 6 hours over 2 Hours for 16 doses	Start: S+1  8:00 AM			Instructions:	Day -5, -4, -3, -2	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BUSULFAN 60 MG/10 ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes			  	fludarabine (FLUDARA) 30 mg/m2 in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 30 mg/m2	Route: intravenous	every 24 hours over 30 Minutes for 4 doses	Start: S+1 10:00 AM			Instructions:	Day -5, -4, -3, -2	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION	Medications	30 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	No	Yes				Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN						Pharmacokinetic Instructions
  	ONC NURSING COMMUNICATION 18	Interval: Until discontinued	Occurrences: --	Comments:	1.	Infuse Busulfan through the White lumen of the TRIPLE lumen catheter
2.	LABEL the White lumen: Busulfan
3.	NO other fluids are to be infusing during the Busulfan infusion or the Pharmacokinetics period (Doses #1 and #9)
4.	IVF may resume AFTER the last PK is drawn for dose #1 and #9
5.	Busulfan infusion must be complete including flush. When infusion is finished, Disconnect & REMOVE Busulfan bag/tubing PRIOR to starting blood draws. (Does not matter if the post level is drawn 5 min after the infusion ends)
6.	USE the same CLOCK / WATCH to document start and stop times, AND all blood draw times
7.	ALL blood samples for Pharmacokinetics to be drawn from the RED lumen of the triple lumen CVC
8.	FLUSH the RED lumen with 30 mL saline flush PRIOR to EVERY blood draw EXCEPT immediately after end of infusion
9.	Use a green top, heparinized tube for all PK samples
10.	After sample is collected, label and place in a plastic biohazard lab bag (NO pre-labeling of tubes)
11.	Put sample on wet ice and place in the medication room refrigerator or in the medication room in a closed basin for pick up / transport to TCH lab
12.	DO NOT KEEP MULTIPLE SAMPLE at bedside
			Seizure Prophylaxis
  	levETIRAcetam (KEPPRA) tablet	Dose: --	Route: oral	2 times daily for 13 doses	Start: S  9:00 PM					VOD Prophylaxis
  	ursodioL (ACTIGALL) capsule 300 mg	Dose: 300 mg	Route: oral	3 times daily						Day of Rest
  	ONC NURSING COMMUNICATION 48	Interval: Until discontinued	Occurrences: --	Comments:	Day -1.
				Day 0	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Antiemetics
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S					Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Premed for TRANSPLANT		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Premed for TRANSPLANT		  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once for 1 dose				Instructions:	Premed for TRANSPLANT			Transplant Orders
  	ONC NURSING COMMUNICATION 55	Interval: Once	Occurrences: --	Comments:	-Oxygen at bedside during transplantation
-Anaphylaxis precautions at bedside during transplant:
		  	meperidine (DEMEROL) injection (RESTRICTED) 12.5 mg	Dose: 12.5 mg	Route: intravenous	every 15 min PRN for 3 doses				Instructions:	Administer every 15 minutes x 3 doses PRN for each episode of rigors (if rigors persist, call MD).		  	epINEPHrine (ADRENALIN) injection 1 mg/mL 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	once PRN	Start: S	End: S+2			  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S	End: S+2			  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN							Day 1 through 8	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	every 24 hours for 5 doses	Start: S  8:00 AM			Instructions:	Administer on Days +1 through +5		  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S+2  8:00 AM			Instructions:	Administer 30 minutes prior to treatment on Day +3.		  	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	every 8 hours PRN	Start: S+5			Instructions:	Start Day +6			Nursing Orders
  	ECG 12-LEAD	Interval: Daily	Occurrences: --	Comments:	Starting Day +3. Must be reviewed by MD daily prior to each Cyclophosphamide dose.
			Labs
  	URINALYSIS, AUTOMATED WITH MICROSCOPY	Interval: Daily	Occurrences: --	Comments:	Start Day +3
			Chemotherapy
  	ONC NURSING COMMUNICATION 7	Interval: Until discontinued	Occurrences: --	Comments:	During CYCLOPHOSPHAMIDE:
o 12 lead EKG must be ordered and reviewed by physician prior to each dose. 
o Starting 4 hours PRIOR to cyclophosphamide, change IVF to Normal Saline at 125 mL/hr and continue for 24 hours after last dose of cyclophosphamide completes.  (MAX total volume infusion rate during chemotherapy = 350 mL/hr). 
o Instruct patient to void every 1-2 hours DAILY x 3 days.
			Hydration
  	sodium chloride 0.9 % infusion	Dose: 125 mL/hr	Route: intravenous	continuous	Start: S+2					Chemotherapy
  	mesna (MESNEX) 20 mg/kg in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 20 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S+2  8:30 AM			Instructions:	Give immediately prior to first cyclophosphamide infusion	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	20 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			  	cycloPHOSphamide (CYTOXAN) 50 mg/kg in dextrose 5% 500 mL chemo IVPB	Dose: 50 mg/kg	Route: intravenous	every 24 hours over 2 Hours for 2 doses	Start: S+2  9:00 AM			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	50 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes			  	mesna (MESNEX) 10 mg/kg in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 10 mg/kg	Route: intravenous	every 4 hours over 30 Minutes for 12 doses	Start: S+2  1:00 PM			Instructions:	Start 4 hours after loading dose of Mesna	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Additional Orders
  	furosemide (LASIX) injection 20 mg	Dose: 20 mg	Route: intravenous	every 24 hours for 2 doses	Start: S+2 11:00 AM			Instructions:	Give at completion of each dose of cyclophosphamide infusion on Day +3 and Day +4 .		  	furosemide (LASIX) injection 20 mg	Dose: 20 mg	Route: intravenous	every 24 hours for 2 doses	Start: S+2  5:00 PM			Instructions:	Give 6 hours AFTER completion of each dose of Cyclophosphamide infusion on Day +3 and Day +4			Supportive Care
  	posaconazole (NOXAFIL) tablet (RESTRICTED) 300 mg	Dose: 300 mg	Route: oral	every 24 hours	Start: S+4  9:00 AM			Instructions:	Start Day +5. 
Do NOT crush, split, or chew.  The delayed release tablet is NOT to interchange / substitute with oral posaconazole suspension.		  	filgrastim-sndz (ZARXIO) injection solution	Dose: --	Route: subcutaneous	daily at 1600	Start: S+6  4:00 PM			Instructions:	Start Day +7. 
Do not administer filgrastim-sndz within 24 hours before chemotherapy.			Acute Graft Versus Host Prophylaxis
  	tacrolimus (PROGRAF) IVPB 0.02 mg/kg (Ideal)	Dose: 0.02 mg/kg	Route: intravenous	every 24 hours over 24 Hours	Start: S			Instructions:	May cause QTc prolongation.  Use the lesser of IBW or actual body weight (ABW).		  	mycophenolate (CELLCEPT) 1,000 mg in dextrose 5% IVPB	Dose: 1,000 mg	Route: intravenous	Every 8 Hours (TIME CRITICAL)  over 2 Hours	Start: S+4			Instructions:	Start Day +5	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION	Medications	1,000 mg	Main Ingredient	No	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	167 mL	Always	Yes