Protocol Index	

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IP INTRATHECAL CHEMOTHERAPY	

Types:      ONCOLOGY TREATMENT
Synonyms:  MTX, METHOTREXATE, METHO, ARAC, ARA-C, CYTARABINE, CYT, IT, BMT, CAGT, HYDROCORTISONE, CYTOSAR, DEPOCYT, LIPOSOMAL, HERCEPTIN, TRASTUZUMAB, HYCAMTIN, TOPOTECAN

Cycle 1	Repeat 1 time	Cycle length: 30 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).
			Labs
☑	CSF CELL COUNT WITH DIFFERENTIAL	Interval: Once	Occurrences: --		☑	GLUCOSE LEVEL, CSF	Interval: Once	Occurrences: --		☑	PROTEIN, CSF	Interval: Once	Occurrences: --		☑	FLOW CYTOMETRY EVALUATION	Interval: Once	Occurrences: --		☑	CYTOLOGY (NON-GYNECOLOGICAL) REQUEST	Interval: Once	Occurrences: --			Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	Hold and NOTIFY provider for platelets less than 50,000.
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Pre-Medications
☐	ondansetron (ZOFRAN) tablet 24 mg	Dose: 24 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 10 mg	Dose: 10 mg	Route: oral	once for 1 dose	Start: S					Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	PRN	Start: S					Provider Ordering Guidelines
  	ONC PROVIDER COMMUNICATION 15	Interval: Once	Occurrences: --	Comments:	If IT chemotherapy is to be administered by IR (interventional radiology) then please place a "Lumbar Puncture by Radiology" order panel in Managed Orders.
			Intrathecal Injections
☑	methotrexate Preservative Free in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: --	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	6 mL	Yes	Yes			☐	cytarabine PF (CYSTOSAR) in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: --	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS
Handle with care	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	6 mL	Yes	Yes			☐	cytarabine PF (CYSTOSAR), methotrexate Preservative Free, hydrocortisone sodium succinate (Solu-CORTEF) in sodium chloride 0.9% 5 mL chemo INTRATHECAL injection	Dose: 5 mL	Route: intrathecal	once for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS - Handle with care	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	 	Yes	Yes	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	 	Yes	Yes	HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION	Medications	 	Yes	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	5 mL	Yes	Yes			☐	topotecan (HYCAMTIN) in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: --	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS
Handle with care	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	6 mL	Yes	Yes			☐	trastuzumab (HERCEPTIN) in sodium chloride 0.9% 6 mL INTRATHECAL injection (RESTRICTED)	Dose: --	Route: intrathecal	once for 1 dose	Start: S	End: S		Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION (RESTRICTED)	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	6 mL	Yes	Yes				Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN