Protocol Index	

If this file opens in Compatibility Mode using Microsoft Word, convert to the latest document format to avoid potential formatting issues.	

IP/OP BLINATUMOMAB MRD+ EVERY 42 DAYS	

Types:      ONCOLOGY TREATMENT
Synonyms:  

Cycle 1	Repeat 1 time	Cycle length: 42 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).
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Until discontinued	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains OR losses of greater than or equal to 10%.
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Once	Occurrences: --	Comments:	Hospitalization is recommended for the first 3 days of cycle 1, and the first 2 days of cycle 2. Close observation by a health care professional (or hospitalization) is recommended for initiation of all subsequent cycles or for therapy re-initiation (eg, if treatment is interrupted for >=4 hours).
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		  	MAGNESIUM LEVEL	Interval: Once	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	Notify the provider if there has been an interruption in the infusion GREATER than 4 hours. Premedicating would be required for re-initiation.
		  	ONC NURSING COMMUNICATION 5	Interval: Once	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist
		  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Check for blood return prior to start of Blinatumomab infusion.  Do not check for blood return during infusion.
			Pre-Medications
  	ondansetron (ZOFRAN) tablet 8 mg	Dose: 8 mg	Route: oral	once for 1 dose	Start: S				  	dexAMETHasone (DECADRON) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 60 minutes before Blinatumomab.			Chemotherapy
  	blinatumomab 28 mcg in sodium chloride (NON-PVC) 0.9 % 270 mL chemo IVPB	Dose: 28 mcg	Route: intravenous	once @ 10 mL/hr over 24 Hours for 1 dose			Offset: 1 Hours	Instructions:	Infusion rate of 10 mL/hour for a duration of 24 hours.  Total to be infused = 240 mL.
Use low protein-binding 0.2 micron in-line filter.  
Pharmacy to prime line with medication during preparation.
Do NOT flush the infusion line, especially when changing infusion bags; flushing when changing bags or at the completion of the infusion can result in an excess dosage.
There will be some solution left in the bag and/or IV tubing; dispose of unused solution in the IV bag and IV lines at the end of the infusion.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BLINATUMOMAB 35 MCG INTRAVENOUS KIT	Medications	28 mcg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	Base	270 mL	Yes	Yes				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		Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	Notify the provider if there has been an interruption in the infusion GREATER than 4 hours. Premedicating would be required for re-initiation.
		  	ONC NURSING COMMUNICATION 5	Interval: Once	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist
		  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Check for blood return prior to start of Blinatumomab infusion.  Do not check for blood return during infusion.
			Pre-Medications
  	ondansetron (ZOFRAN) tablet 8 mg	Dose: 8 mg	Route: oral	once for 1 dose	Start: S					Chemotherapy
  	blinatumomab 28 mcg in sodium chloride (NON-PVC) 0.9 % 270 mL chemo IVPB	Dose: 28 mcg	Route: intravenous	once @ 10 mL/hr over 24 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Infusion rate of 10 mL/hour for a duration of 24 hours.  Total to be infused = 240 mL.
Use low protein-binding 0.2 micron in-line filter.  
Pharmacy to prime line with medication during preparation.
Do NOT flush the infusion line, especially when changing infusion bags; flushing when changing bags or at the completion of the infusion can result in an excess dosage.
There will be some solution left in the bag and/or IV tubing; dispose of unused solution in the IV bag and IV lines at the end of the infusion.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BLINATUMOMAB 35 MCG INTRAVENOUS KIT	Medications	28 mcg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	Base	270 mL	Yes	Yes					Day 4	Perform every 1 day x1		Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	Notify the provider if there has been an interruption in the infusion GREATER than 4 hours. Premedicating would be required for re-initiation.
		  	ONC NURSING COMMUNICATION 5	Interval: Once	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist
		  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Check for blood return prior to start of Blinatumomab infusion.  Do not check for blood return during infusion.
			Pre-Medications
  	ondansetron (ZOFRAN) tablet 8 mg	Dose: 8 mg	Route: oral	once for 1 dose	Start: S					Chemotherapy
  	blinatumomab 28 mcg/day (BLINCYTO) 24-hour infusion - Ambulatory Pump	Dose: 28 mcg/day	Route: intravenous	continuous over 24 Hours			Offset: 30 Minutes	Instructions:	Administer as a continuous infusion using low protein-binding 0.2 micron in-line filter. 
Infusion rate of 10 mL/hour for a duration of 24 hours.  
Total to be infused = 240 mL.
Pharmacy to prime line with medication during preparation.
Do NOT flush the infusion line, especially when changing infusion bags; flushing when changing bags or at the completion of the infusion can result in an excess dosage.
There will be some solution left in the bag and/or IV tubing; dispose of unused solution in the IV bag and IV lines at the end of the infusion.
HAZARDOUS - Handle with care	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BLINATUMOMAB 35 MCG INTRAVENOUS SOLUTION	Medications	2.6 mL	Concentration Dosed Ingredient	Yes	IV SOLUTION STABILIZER FOR BLINATUMOMAB INTRAVENOUS SOLUTION	Additives	5.5 mL	Yes	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	270 mL	Yes	Yes					Day 5	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Notify the provider if there has been an interruption in the infusion GREATER than 4 hours. Premedicating would be required for re-initiation.
		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Check for blood return prior to start of Blinatumomab infusion.  Do not check for blood return during infusion.
			Chemotherapy
  	blinatumomab 84 mcg (BLINCYTO) 72-hour infusion - Ambulatory Pump	Dose: 28 mcg/day	Route: intravenous	continuous over 72 Hours	Start: S			Instructions:	Administer as a continuous infusion on days 1 to 3 via non-DEHP CADD pump.
Infusion rate of 1.8 mL/hour for a duration of 3 days. Total to be infused = 130 mL. 
There will be overfill remaining at time of pump exchange. 
DO NOT use low protein-binding 0.2 micron in-line filter. 
HAZARDOUS - Handle with care
Pharmacy to prime line with medication during preparation. 
Do NOT flush the infusion line, especially when changing infusion bags; flushing when changing bags or at the completion of the infusion can result in an excess dosage.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BLINATUMOMAB 35 MCG INTRAVENOUS SOLUTION	Medications	8.4 mL	Concentration Dosed Ingredient	Yes	IV SOLUTION STABILIZER FOR BLINATUMOMAB INTRAVENOUS SOLUTION	Additives	3.2 mL	Yes	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	105.4 mL	Yes	Yes	SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION	Additives	45 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S						Days 8,15,22	Perform every 7 days x3		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Outpatient Electrolyte Replacement Protocol
  	TREATMENT CONDITIONS 39	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Potassium level LESS than 3.5 mEq/L; 
3. Recent pre-infusion labs.   

Dosing is based on lab value.
o Serum potassium less than 3.0mEq/L, give 40mEq KCL IV or PO and contact MD/NP. 
o Serum potassium 3.0 to 3.2mEq/L, give 40mEq KCL IV or PO. 
o Serum potassium 3.3 to 3.4mEq/L, give 20mEq KCL IV or PO. 
o Serum potassium 3.5 mEq/L or greater, do not give potassium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
		  	TREATMENT CONDITIONS 40 	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Magnesium level LESS than 1.6 mg/dL; 
3. Recent pre-infusion labs. 

Dosing is based on lab value. 
o Serum Magnesium less than 1.0 mg/dL, give 2 gram magnesium sulfate IV and contact MD/NP. 
o Serum Magnesium 1.0 to 1.2 mg/dL, give 2 gram magnesium sulfate IV. 
o Serum Magnesium 1.3 to 1.5 mg/dL, give 1 gram magnesium sulfate IV. 
o Serum Magnesium 1.6 mg/dL or greater, do not give magnesium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Notify the provider if there has been an interruption in the infusion GREATER than 4 hours. Premedicating would be required for re-initiation.
		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Check for blood return prior to start of Blinatumomab infusion.  Do not check for blood return during infusion.
			Chemotherapy
  	blinatumomab 196 mcg (BLINCYTO) 7-day infusion 110 mL - Ambulatory Pump	Dose: 28 mcg/day	Route: intravenous	continuous over 168 Hours	Start: S			Instructions:	Administer as a continuous infusion on days 1 to 7 via non-DEHP CADD pump. 
Infusion rate of 0.6 mL/hour for a duration of 7 days. Total to be infused = 100 mL. 
There will be expected overfill at time of pump exchange.
DO NOT use low protein-binding 0.2 micron in-line filter.  
HAZARDOUS - Handle with care
Pharmacy to prime line with medication during preparation. 
Do NOT flush the infusion line, especially when changing infusion bags; flushing when changing bags or at the completion of the infusion can result in an excess dosage.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BLINATUMOMAB 35 MCG INTRAVENOUS SOLUTION	Medications	16.8 mL	Concentration Dosed Ingredient	Yes	IV SOLUTION STABILIZER FOR BLINATUMOMAB INTRAVENOUS SOLUTION	Additives	2.2 mL	Yes	Yes	SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION	Additives	90 mL	Yes	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	1 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S						Day 29	Perform every 1 day x1		Pump Disconnect Appointment Request
  	ONC PUMP DISCONNECT APPOINTMENT REQUEST	Interval: --	Occurrences: --			Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.			Discharge Nursing Orders
  	alteplase (CATHFLO) for NON Quinton and NON Hemodialysis Catheters 2 mg	Dose: 2 mg	Route: intra-catheter	once PRN	Start: S			Instructions:	HOLD and notify provider if Platelets LESS than 50.  Instill dose into occluded catheter. Do not force solution into
catheter. After a 30-minute dwell time, assess catheter function by attempting
to aspirate blood. If catheter is functional, aspirate 4 to 5 mL of blood in
patients greater than or equal to 10 kg to remove Cathflo Activase and
residual clots. Gently irrigate the catheter with NS. If catheter remains
nonfunctional, let Cathflo Activase dwell for another 90 minutes (total dwell
time: 120 minutes) and reassess function. If catheter function is not restored,
a second dose may be instilled					
Cycle 2	Repeat 1 time	Cycle length: 42 days	Day 1	Perform every 1 day x1		Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Until discontinued	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains OR losses of greater than or equal to 10%.
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Once	Occurrences: --	Comments:	Hospitalization is recommended for the first 3 days of cycle 1, and the first 2 days of cycle 2. Close observation by a health care professional (or hospitalization) is recommended for initiation of all subsequent cycles or for therapy re-initiation (eg, if treatment is interrupted for >=4 hours).
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		  	MAGNESIUM LEVEL	Interval: Once	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	Notify the provider if there has been an interruption in the infusion GREATER than 4 hours. Premedicating would be required for re-initiation.
		  	ONC NURSING COMMUNICATION 5	Interval: Once	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist
		  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Check for blood return prior to start of Blinatumomab infusion.  Do not check for blood return during infusion.
			Pre-Medications
  	ondansetron (ZOFRAN) tablet 8 mg	Dose: 8 mg	Route: oral	once for 1 dose	Start: S				  	dexAMETHasone (DECADRON) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 60 minutes before Blinatumomab.			Chemotherapy
  	blinatumomab 28 mcg in sodium chloride (NON-PVC) 0.9 % 270 mL chemo IVPB	Dose: 28 mcg	Route: intravenous	once @ 10 mL/hr over 24 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Infusion rate of 10 mL/hour for a duration of 24 hours.  Total to be infused = 240 mL.
Use low protein-binding 0.2 micron in-line filter.  
Pharmacy to prime line with medication during preparation.
Do NOT flush the infusion line, especially when changing infusion bags; flushing when changing bags or at the completion of the infusion can result in an excess dosage.
There will be some solution left in the bag and/or IV tubing; dispose of unused solution in the IV bag and IV lines at the end of the infusion.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BLINATUMOMAB 35 MCG INTRAVENOUS KIT	Medications	28 mcg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	Base	270 mL	Yes	Yes				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						Day 2	Perform every 1 day x1		Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	Notify the provider if there has been an interruption in the infusion GREATER than 4 hours. Premedicating would be required for re-initiation.
		  	ONC NURSING COMMUNICATION 5	Interval: Once	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist
		  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Check for blood return prior to start of Blinatumomab infusion.  Do not check for blood return during infusion.
			Pre-Medications
  	ondansetron (ZOFRAN) tablet 8 mg	Dose: 8 mg	Route: oral	once for 1 dose	Start: S					Chemotherapy
  	blinatumomab 28 mcg in sodium chloride (NON-PVC) 0.9 % 270 mL chemo IVPB	Dose: 28 mcg	Route: intravenous	once @ 10 mL/hr over 24 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Infusion rate of 10 mL/hour for a duration of 24 hours.  Total to be infused = 240 mL.
Use low protein-binding 0.2 micron in-line filter.  
Pharmacy to prime line with medication during preparation.
Do NOT flush the infusion line, especially when changing infusion bags; flushing when changing bags or at the completion of the infusion can result in an excess dosage.
There will be some solution left in the bag and/or IV tubing; dispose of unused solution in the IV bag and IV lines at the end of the infusion.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BLINATUMOMAB 35 MCG INTRAVENOUS KIT	Medications	28 mcg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	Base	270 mL	Yes	Yes					Day 3	Perform every 1 day x1		Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	Notify the provider if there has been an interruption in the infusion GREATER than 4 hours. Premedicating would be required for re-initiation.
		  	ONC NURSING COMMUNICATION 5	Interval: Once	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist
		  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Check for blood return prior to start of Blinatumomab infusion.  Do not check for blood return during infusion.
			Pre-Medications
  	ondansetron (ZOFRAN) tablet 8 mg	Dose: 8 mg	Route: oral	once for 1 dose	Start: S					Chemotherapy
  	blinatumomab 28 mcg/day (BLINCYTO) 24-hour infusion - Ambulatory Pump	Dose: 28 mcg/day	Route: intravenous	continuous over 24 Hours			Offset: 30 Minutes	Instructions:	Administer as a continuous infusion using low protein-binding 0.2 micron in-line filter. 
Infusion rate of 10 mL/hour for a duration of 24 hours.  
Total to be infused = 240 mL.
Pharmacy to prime line with medication during preparation.
Do NOT flush the infusion line, especially when changing infusion bags; flushing when changing bags or at the completion of the infusion can result in an excess dosage.
There will be some solution left in the bag and/or IV tubing; dispose of unused solution in the IV bag and IV lines at the end of the infusion.
HAZARDOUS - Handle with care	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BLINATUMOMAB 35 MCG INTRAVENOUS SOLUTION	Medications	2.6 mL	Concentration Dosed Ingredient	Yes	IV SOLUTION STABILIZER FOR BLINATUMOMAB INTRAVENOUS SOLUTION	Additives	5.5 mL	Yes	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	270 mL	Yes	Yes					Day 4	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Notify the provider if there has been an interruption in the infusion GREATER than 4 hours. Premedicating would be required for re-initiation.
		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Check for blood return prior to start of Blinatumomab infusion.  Do not check for blood return during infusion.
			Chemotherapy
  	blinatumomab 112 mcg (BLINCYTO) 96-hour infusion - Ambulatory Pump	Dose: 28 mcg/day	Route: intravenous	continuous over 96 Hours	Start: S			Instructions:	Administer as a continuous infusion on days 1 to 4 via non-DEHP CADD pump.
Infusion rate of 1.8 mL/hour for a duration of 4 days. Total to be infused = 173 mL. 
There will be overfill remaining at time of pump exchange. 
DO NOT use low protein-binding 0.2 micron in-line filter. 
HAZARDOUS - Handle with care
Pharmacy to prime line with medication during preparation. 
Do NOT flush the infusion line, especially when changing infusion bags; flushing when changing bags or at the completion of the infusion can result in an excess dosage.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BLINATUMOMAB 35 MCG INTRAVENOUS SOLUTION	Medications	10.4 mL	Concentration Dosed Ingredient	Yes	IV SOLUTION STABILIZER FOR BLINATUMOMAB INTRAVENOUS SOLUTION	Additives	4 mL	Yes	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	129.6 mL	Yes	Yes	SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION	Additives	56 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S						Days 8,15,22	Perform every 7 days x3		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Outpatient Electrolyte Replacement Protocol
  	TREATMENT CONDITIONS 39	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Potassium level LESS than 3.5 mEq/L; 
3. Recent pre-infusion labs.   

Dosing is based on lab value.
o Serum potassium less than 3.0mEq/L, give 40mEq KCL IV or PO and contact MD/NP. 
o Serum potassium 3.0 to 3.2mEq/L, give 40mEq KCL IV or PO. 
o Serum potassium 3.3 to 3.4mEq/L, give 20mEq KCL IV or PO. 
o Serum potassium 3.5 mEq/L or greater, do not give potassium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
		  	TREATMENT CONDITIONS 40 	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Magnesium level LESS than 1.6 mg/dL; 
3. Recent pre-infusion labs. 

Dosing is based on lab value. 
o Serum Magnesium less than 1.0 mg/dL, give 2 gram magnesium sulfate IV and contact MD/NP. 
o Serum Magnesium 1.0 to 1.2 mg/dL, give 2 gram magnesium sulfate IV. 
o Serum Magnesium 1.3 to 1.5 mg/dL, give 1 gram magnesium sulfate IV. 
o Serum Magnesium 1.6 mg/dL or greater, do not give magnesium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Notify the provider if there has been an interruption in the infusion GREATER than 4 hours. Premedicating would be required for re-initiation.
		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Check for blood return prior to start of Blinatumomab infusion.  Do not check for blood return during infusion.
			Chemotherapy
  	blinatumomab 196 mcg (BLINCYTO) 7-day infusion 110 mL - Ambulatory Pump	Dose: 28 mcg/day	Route: intravenous	continuous over 168 Hours	Start: S			Instructions:	Administer as a continuous infusion on days 1 to 7 via non-DEHP CADD pump. 
Infusion rate of 0.6 mL/hour for a duration of 7 days. Total to be infused = 100 mL. 
There will be expected overfill at time of pump exchange.
DO NOT use low protein-binding 0.2 micron in-line filter.  
HAZARDOUS - Handle with care
Pharmacy to prime line with medication during preparation. 
Do NOT flush the infusion line, especially when changing infusion bags; flushing when changing bags or at the completion of the infusion can result in an excess dosage.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BLINATUMOMAB 35 MCG INTRAVENOUS SOLUTION	Medications	16.8 mL	Concentration Dosed Ingredient	Yes	IV SOLUTION STABILIZER FOR BLINATUMOMAB INTRAVENOUS SOLUTION	Additives	2.2 mL	Yes	Yes	SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION	Additives	90 mL	Yes	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	1 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S						Day 29	Perform every 1 day x1		Pump Disconnect Appointment Request
  	ONC PUMP DISCONNECT APPOINTMENT REQUEST	Interval: --	Occurrences: --			Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.			Discharge Nursing Orders
  	alteplase (CATHFLO) for NON Quinton and NON Hemodialysis Catheters 2 mg	Dose: 2 mg	Route: intra-catheter	once PRN	Start: S			Instructions:	HOLD and notify provider if Platelets LESS than 50.  Instill dose into occluded catheter. Do not force solution into
catheter. After a 30-minute dwell time, assess catheter function by attempting
to aspirate blood. If catheter is functional, aspirate 4 to 5 mL of blood in
patients greater than or equal to 10 kg to remove Cathflo Activase and
residual clots. Gently irrigate the catheter with NS. If catheter remains
nonfunctional, let Cathflo Activase dwell for another 90 minutes (total dwell
time: 120 minutes) and reassess function. If catheter function is not restored,
a second dose may be instilled					
Cycles 3,4	Repeat 2 times	Cycle length: 42 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION 34	Interval: --	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains OR losses of greater than or equal to 10%.
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Notify the provider if there has been an interruption in the infusion GREATER than 4 hours. Premedicating would be required for re-initiation.
		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Check for blood return prior to start of Blinatumomab infusion.  Do not check for blood return during infusion.
			Pre-Medications
  	dexAMETHasone (DECADRON) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 60 minutes before chemo.			Chemotherapy
  	blinatumomab 196 mcg (BLINCYTO) 7-day infusion 110 mL - Ambulatory Pump	Dose: 28 mcg/day	Route: intravenous	continuous over 168 Hours	Start: S			Instructions:	Administer as a continuous infusion on days 1 to 7 via non-DEHP CADD pump. 
Infusion rate of 0.6 mL/hour for a duration of 7 days. Total to be infused = 100 mL. 
There will be expected overfill at time of pump exchange.
DO NOT use low protein-binding 0.2 micron in-line filter.  
HAZARDOUS - Handle with care
Pharmacy to prime line with medication during preparation. 
Do NOT flush the infusion line, especially when changing infusion bags; flushing when changing bags or at the completion of the infusion can result in an excess dosage.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BLINATUMOMAB 35 MCG INTRAVENOUS SOLUTION	Medications	16.8 mL	Concentration Dosed Ingredient	Yes	IV SOLUTION STABILIZER FOR BLINATUMOMAB INTRAVENOUS SOLUTION	Additives	2.2 mL	Yes	Yes	SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION	Additives	90 mL	Yes	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	1 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S						Days 8,15,22	Perform every 7 days x3		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Outpatient Electrolyte Replacement Protocol
  	TREATMENT CONDITIONS 39	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Potassium level LESS than 3.5 mEq/L; 
3. Recent pre-infusion labs.   

Dosing is based on lab value.
o Serum potassium less than 3.0mEq/L, give 40mEq KCL IV or PO and contact MD/NP. 
o Serum potassium 3.0 to 3.2mEq/L, give 40mEq KCL IV or PO. 
o Serum potassium 3.3 to 3.4mEq/L, give 20mEq KCL IV or PO. 
o Serum potassium 3.5 mEq/L or greater, do not give potassium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
		  	TREATMENT CONDITIONS 40 	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Magnesium level LESS than 1.6 mg/dL; 
3. Recent pre-infusion labs. 

Dosing is based on lab value. 
o Serum Magnesium less than 1.0 mg/dL, give 2 gram magnesium sulfate IV and contact MD/NP. 
o Serum Magnesium 1.0 to 1.2 mg/dL, give 2 gram magnesium sulfate IV. 
o Serum Magnesium 1.3 to 1.5 mg/dL, give 1 gram magnesium sulfate IV. 
o Serum Magnesium 1.6 mg/dL or greater, do not give magnesium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Notify the provider if there has been an interruption in the infusion GREATER than 4 hours. Premedicating would be required for re-initiation.
		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Monitor for neurotoxicity such as somnolence, confusion, hallucinations, blurred vision, and seizures. Notify the provider if any of these symptoms exist
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Check for blood return prior to start of Blinatumomab infusion.  Do not check for blood return during infusion.
			Chemotherapy
  	blinatumomab 196 mcg (BLINCYTO) 7-day infusion 110 mL - Ambulatory Pump	Dose: 28 mcg/day	Route: intravenous	continuous over 168 Hours	Start: S			Instructions:	Administer as a continuous infusion on days 1 to 7 via non-DEHP CADD pump. 
Infusion rate of 0.6 mL/hour for a duration of 7 days. Total to be infused = 100 mL. 
There will be expected overfill at time of pump exchange.
DO NOT use low protein-binding 0.2 micron in-line filter.  
HAZARDOUS - Handle with care
Pharmacy to prime line with medication during preparation. 
Do NOT flush the infusion line, especially when changing infusion bags; flushing when changing bags or at the completion of the infusion can result in an excess dosage.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BLINATUMOMAB 35 MCG INTRAVENOUS SOLUTION	Medications	16.8 mL	Concentration Dosed Ingredient	Yes	IV SOLUTION STABILIZER FOR BLINATUMOMAB INTRAVENOUS SOLUTION	Additives	2.2 mL	Yes	Yes	SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION	Additives	90 mL	Yes	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	1 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: --	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 4	Interval: --	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 83	Interval: --	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					  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S						Day 29	Perform every 1 day x1		Pump Disconnect Appointment Request
  	ONC PUMP DISCONNECT APPOINTMENT REQUEST	Interval: --	Occurrences: --			Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
			Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.			Discharge Nursing Orders
  	alteplase (CATHFLO) for NON Quinton and NON Hemodialysis Catheters 2 mg	Dose: 2 mg	Route: intra-catheter	once PRN	Start: S			Instructions:	HOLD and notify provider if Platelets LESS than 50.  Instill dose into occluded catheter. Do not force solution into
catheter. After a 30-minute dwell time, assess catheter function by attempting
to aspirate blood. If catheter is functional, aspirate 4 to 5 mL of blood in
patients greater than or equal to 10 kg to remove Cathflo Activase and
residual clots. Gently irrigate the catheter with NS. If catheter remains
nonfunctional, let Cathflo Activase dwell for another 90 minutes (total dwell
time: 120 minutes) and reassess function. If catheter function is not restored,
a second dose may be instilled