Protocol Index	

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IP/OP TEBENTAFUSP-TEBN	

Types:      ONCOLOGY TREATMENT
Synonyms:  KIMMTRAK, MELANOMA

Cycle 1	Repeat 1 time	Cycle length: 28 days	Day 1	Perform every 1 day x1		Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		  	MAGNESIUM LEVEL	Interval: Once	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS	Interval: Once	Occurrences: --	Comments:	Hold and notify physician if
o LFTs GREATER than 5x ULN; 
o Bilirubin GREATER than 3x ULN.
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Provider Communication
  	ONC PROVIDER COMMUNICATION 3	Interval: Once	Occurrences: --	Comments:	o Administer the first 3 tebentafusp-tebn infusions in an appropriate health care setting with immediate access to medications and resuscitative equipment to manage cytokine release syndrome;  
o If the patient did not experience GREATER than or EQUAL to grade 2 hypotension (requiring medical intervention) during or after the third infusion, may administer subsequent doses in an ambulatory care setting.
			Provider Communication
  	ONC PROVIDER COMMUNICATION 7	Interval: Once	Occurrences: --	Comments:	HLA-A*02:01 status should be determined prior to initiation of therapy.  HLA-A*02:01 status: Please Push F2:22332.
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	o For the first three infusions, monitor body temperature, heart rate, respiratory rate, blood pressure - Vitals collected at MINIMUM every 4 hours.  
o For the first three infusions, patients should be monitored at least 16 hours. 
o If the patient does not experience GREATER than or EQUAL to Grade 2 hypotension (requiring medical intervention) during or after the first three infusions, monitor patients for a MINIMUM of 30 minutes following each of these infusions in an ambulatory setting.
		  	ONC NURSING COMMUNICATION 5	Interval: Once	Occurrences: --	Comments:	o If the patient experienced grade GREATER than or EQUAL to 3 hypotension (requiring medical intervention) at C1D1, C1D8, or C1D15, must monitor vital signs every hour for a MINIMUM of 8 hours after dosing for any doses administered as an ambulatory through C3D1.
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	o Patients with break or delay in treatment for GREATER THAN 2 weeks AND with history of a grade GREATER than or EQUAL to 3 event of hypotension (requiring medical intervention) with Tebentafusp-tebn dosing during the first weeks of treatment, will require monitoring in an appropriate healthcare setting with vital signs performed at a minimum of every 4 hours and monitoring for at least 16 hours after dosing for all subsequent doses.
		  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	o HOLD tebentafusp-tebn and alert oncologist if drop in oxygen saturation LESS than 88% or systolic blood pressure LESS than 90 mmHg.
			Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.		  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemotherapy. 			Chemotherapy
  	tebentafusp-tebn (KIMMTRAK) 20 mcg in albumin human 5 % 0.5 mL, sodium chloride 0.9% 100 mL chem infusion	Dose: 20 mcg	Route: intravenous	once over 20 Minutes for 1 dose				Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TEBENTAFUSP-TEBN 100 MCG/0.5 ML INTRAVENOUS SOLUTION	Medications	20 mcg	Main Ingredient	Yes	ALBUMIN, HUMAN 5 % WRAPPER	Base	0.5 mL	Yes	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	100 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, 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 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	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					  	epINEPHrine (ADRENALIN) injection 1 mg/mL 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: Until discontinued	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.				Day 8	Perform every 1 day x1		Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		  	MAGNESIUM LEVEL	Interval: Once	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS	Interval: Once	Occurrences: --	Comments:	Hold and notify physician if
o LFTs GREATER than 5x ULN; 
o Bilirubin GREATER than 3x ULN.
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Provider Communication
  	ONC PROVIDER COMMUNICATION 3	Interval: Once	Occurrences: --	Comments:	o Administer the first 3 tebentafusp-tebn infusions in an appropriate health care setting with immediate access to medications and resuscitative equipment to manage cytokine release syndrome;  
o If the patient did not experience GREATER than or EQUAL to grade 2 hypotension (requiring medical intervention) during or after the third infusion, may administer subsequent doses in an ambulatory care setting.
			Provider Communication
  	ONC PROVIDER COMMUNICATION 7	Interval: Once	Occurrences: --	Comments:	HLA-A*02:01 status should be determined prior to initiation of therapy.  HLA-A*02:01 status: Please Push F2:22332.
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	o For the first three infusions, monitor body temperature, heart rate, respiratory rate, blood pressure - Vitals collected at MINIMUM every 4 hours.  
o For the first three infusions, patients should be monitored at least 16 hours. 
o If the patient does not experience GREATER than or EQUAL to Grade 2 hypotension (requiring medical intervention) during or after the first three infusions, monitor patients for a MINIMUM of 30 minutes following each of these infusions in an ambulatory setting.
		  	ONC NURSING COMMUNICATION 5	Interval: Once	Occurrences: --	Comments:	o If the patient experienced grade GREATER than or EQUAL to 3 hypotension (requiring medical intervention) at C1D1, C1D8, or C1D15, must monitor vital signs every hour for a MINIMUM of 8 hours after dosing for any doses administered as an ambulatory through C3D1.
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	o Patients with break or delay in treatment for GREATER THAN 2 weeks AND with history of a grade GREATER than or EQUAL to 3 event of hypotension (requiring medical intervention) with Tebentafusp-tebn dosing during the first weeks of treatment, will require monitoring in an appropriate healthcare setting with vital signs performed at a minimum of every 4 hours and monitoring for at least 16 hours after dosing for all subsequent doses.
		  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	o HOLD tebentafusp-tebn and alert oncologist if drop in oxygen saturation LESS than 88% or systolic blood pressure LESS than 90 mmHg.
			Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.		  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemotherapy. 			Chemotherapy
  	tebentafusp-tebn (KIMMTRAK) 30 mcg in albumin human 5 % 0.5 mL, sodium chloride 0.9% 100 mL chem infusion	Dose: 30 mcg	Route: intravenous	once over 20 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TEBENTAFUSP-TEBN 100 MCG/0.5 ML INTRAVENOUS SOLUTION	Medications	30 mcg	Main Ingredient	Yes	ALBUMIN, HUMAN 5 % WRAPPER	Base	0.5 mL	Yes	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	100 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, 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 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	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					  	epINEPHrine (ADRENALIN) injection 1 mg/mL 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: Until discontinued	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.				Day 15	Perform every 1 day x1		Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		  	MAGNESIUM LEVEL	Interval: Once	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS	Interval: Once	Occurrences: --	Comments:	Hold and notify physician if
o LFTs GREATER than 5x ULN; 
o Bilirubin GREATER than 3x ULN.
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Provider Communication
  	ONC PROVIDER COMMUNICATION 3	Interval: Once	Occurrences: --	Comments:	o Administer the first 3 tebentafusp-tebn infusions in an appropriate health care setting with immediate access to medications and resuscitative equipment to manage cytokine release syndrome;  
o If the patient did not experience GREATER than or EQUAL to grade 2 hypotension (requiring medical intervention) during or after the third infusion, may administer subsequent doses in an ambulatory care setting.
			Provider Communication
  	ONC PROVIDER COMMUNICATION 7	Interval: Once	Occurrences: --	Comments:	HLA-A*02:01 status should be determined prior to initiation of therapy.  HLA-A*02:01 status: Please Push F2:22332.
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	o For the first three infusions, monitor body temperature, heart rate, respiratory rate, blood pressure - Vitals collected at MINIMUM every 4 hours.  
o For the first three infusions, patients should be monitored at least 16 hours. 
o If the patient does not experience GREATER than or EQUAL to Grade 2 hypotension (requiring medical intervention) during or after the first three infusions, monitor patients for a MINIMUM of 30 minutes following each of these infusions in an ambulatory setting.
		  	ONC NURSING COMMUNICATION 5	Interval: Once	Occurrences: --	Comments:	o If the patient experienced grade GREATER than or EQUAL to 3 hypotension (requiring medical intervention) at C1D1, C1D8, or C1D15, must monitor vital signs every hour for a MINIMUM of 8 hours after dosing for any doses administered as an ambulatory through C3D1.
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	o Patients with break or delay in treatment for GREATER THAN 2 weeks AND with history of a grade GREATER than or EQUAL to 3 event of hypotension (requiring medical intervention) with Tebentafusp-tebn dosing during the first weeks of treatment, will require monitoring in an appropriate healthcare setting with vital signs performed at a minimum of every 4 hours and monitoring for at least 16 hours after dosing for all subsequent doses.
		  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	o HOLD tebentafusp-tebn and alert oncologist if drop in oxygen saturation LESS than 88% or systolic blood pressure LESS than 90 mmHg.
			Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.		  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemotherapy. 			Chemotherapy
  	tebentafusp-tebn (KIMMTRAK) 68 mcg in albumin human 5 % 0.5 mL, sodium chloride 0.9% 100 mL chem infusion	Dose: 68 mcg	Route: intravenous	once over 20 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TEBENTAFUSP-TEBN 100 MCG/0.5 ML INTRAVENOUS SOLUTION	Medications	68 mcg	Main Ingredient	Yes	ALBUMIN, HUMAN 5 % WRAPPER	Base	0.5 mL	Yes	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	100 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, 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 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	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					  	epINEPHrine (ADRENALIN) injection 1 mg/mL 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: Until discontinued	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.				Day 22	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
  	TREATMENT CONDITIONS	Interval: --	Occurrences: --	Comments:	Hold and notify physician if
o LFTs GREATER than 5x ULN; 
o Bilirubin GREATER than 3x ULN.
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Provider Communication
  	ONC PROVIDER COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	o Administer the first 3 tebentafusp-tebn infusions in an appropriate health care setting with immediate access to medications and resuscitative equipment to manage cytokine release syndrome.  
o If the patient did not experience GREATER than or EQUAL to grade 2 hypotension (requiring medical intervention) during or after the third infusion, may administer subsequent doses in an ambulatory care setting.
			Provider Communication
  	ONC PROVIDER COMMUNICATION 7	Interval: --	Occurrences: --	Comments:	HLA-A*02:01 status should be determined prior to initiation of therapy.  HLA-A*02:01 status: Please Push F2:22332.
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	o For the first three infusions, monitor body temperature, heart rate, respiratory rate, blood pressure - Vitals collected at MINIMUM every 4 hours. 
o For the first three infusions, patients should be monitored at least 16 hours. 
o If the patient does not experience GREATER than or EQUAL to Grade 2 hypotension (requiring medical intervention) during or after the first three infusions, monitor patients for a MINIMUM of 30 minutes following each of these infusions in an ambulatory setting.
		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	o If the patient experienced grade GREATER than or EQUAL to 3 hypotension (requiring medical intervention) at C1D1, C1D8, or C1D15, must monitor vital signs every hour for a MINIMUM of 8 hours after dosing for any doses administered as an ambulatory through C3D1.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	o Patients with break or delay in treatment for GREATER THAN 2 weeks AND with history of a grade GREATER than or EQUAL to 3 event of hypotension (requiring medical intervention) with Tebentafusp-tebn dosing during the first weeks of treatment, will require monitoring in an appropriate healthcare setting with vital signs performed at a minimum of every 4 hours and monitoring for at least 16 hours after dosing for all subsequent doses.
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	o HOLD tebentafusp-tebn and alert oncologist if drop in oxygen saturation LESS than 88% or systolic blood pressure LESS than 90 mmHg.
			Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.		  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemotherapy. 			Chemotherapy
  	tebentafusp-tebn (KIMMTRAK) 68 mcg in albumin human 5 % 0.5 mL, sodium chloride 0.9% 100 mL chem infusion	Dose: 68 mcg	Route: intravenous	once over 20 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TEBENTAFUSP-TEBN 100 MCG/0.5 ML INTRAVENOUS SOLUTION	Medications	68 mcg	Main Ingredient	Yes	ALBUMIN, HUMAN 5 % WRAPPER	Base	0.5 mL	Yes	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	100 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					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 2 to 4	Repeat 3 times	Cycle length: 28 days	Days 1,8,15,22	Perform every 7 days x4		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	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
  	TREATMENT CONDITIONS	Interval: --	Occurrences: --	Comments:	Hold and notify physician if
o LFTs GREATER than 5x ULN; 
o Bilirubin GREATER than 3x ULN.
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Provider Communication
  	ONC PROVIDER COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	o Administer the first 3 tebentafusp-tebn infusions in an appropriate health care setting with immediate access to medications and resuscitative equipment to manage cytokine release syndrome.  
o If the patient did not experience GREATER than or EQUAL to grade 2 hypotension (requiring medical intervention) during or after the third infusion, may administer subsequent doses in an ambulatory care setting.
			Provider Communication
  	ONC PROVIDER COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	o If a patient had a reaction(s) with a previous infusion, consider adding premedications as appropriate. 
o For moderate cytokine release syndrome that is persistent (lasting 2-3 hours) or recurrent cytokine release syndrome or severe (defined as temperature GREATER than or EQUAL to 38°C and hemodynamic instability or worsening hypoxia) cytokine release syndrome, administer corticosteroid premedication at least 30 minutes prior to next dose.
			Provider Communication
  	ONC PROVIDER COMMUNICATION 7	Interval: --	Occurrences: --	Comments:	HLA-A*02:01 status should be determined prior to initiation of therapy.  HLA-A*02:01 status: Please Push F2:22332.
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	o For the first three infusions, monitor body temperature, heart rate, respiratory rate, blood pressure - Vitals collected at MINIMUM every 4 hours. 
o For the first three infusions, patients should be monitored at least 16 hours. 
o If the patient does not experience GREATER than or EQUAL to Grade 2 hypotension (requiring medical intervention) during or after the first three infusions, monitor patients for a MINIMUM of 30 minutes following each of these infusions in an ambulatory setting.
		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	o If the patient experienced grade GREATER than or EQUAL to 3 hypotension (requiring medical intervention) at C1D1, C1D8, or C1D15, must monitor vital signs every hour for a MINIMUM of 8 hours after dosing for any doses administered as an ambulatory through C3D1.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	o Patients with break or delay in treatment for GREATER THAN 2 weeks AND with history of a grade GREATER than or EQUAL to 3 event of hypotension (requiring medical intervention) with Tebentafusp-tebn dosing during the first weeks of treatment, will require monitoring in an appropriate healthcare setting with vital signs performed at a minimum of every 4 hours and monitoring for at least 16 hours after dosing for all subsequent doses.
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	o HOLD tebentafusp-tebn and alert oncologist if drop in oxygen saturation LESS than 88% or systolic blood pressure LESS than 90 mmHg.
			Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.		  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemotherapy. 			Chemotherapy
  	tebentafusp-tebn (KIMMTRAK) 68 mcg in albumin human 5 % 0.5 mL, sodium chloride 0.9% 100 mL chem infusion	Dose: 68 mcg	Route: intravenous	once over 20 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TEBENTAFUSP-TEBN 100 MCG/0.5 ML INTRAVENOUS SOLUTION	Medications	68 mcg	Main Ingredient	Yes	ALBUMIN, HUMAN 5 % WRAPPER	Base	0.5 mL	Yes	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	100 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, 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 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	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					  	epINEPHrine (ADRENALIN) injection 1 mg/mL 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					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