Therapeutic Apheresis - Therapeutic Plasma Exchange		version 4/25/2025		

Procedures 	

	
	Interval	Defer Until	Duration	
	☐	Therapeutic plasma exchange	Once	S	1 treatment	
		Routine, Once Starting when released		
	☐	albumin 5% + calcium gluconate 4.6 mEq/L + potassium chloride 4 mEq/L plasmapheresis solution 1,000 mL	Once	S	1 treatment	
		1,000 mL, intravenous, at 999 mL/hr, Administer over: 1 Hours, every 30 min, Starting when released, for 3 doses
	For Plasmapheresis Only !!!
	Each liter contains 4.6 mEq of calcium gluconate and 4 mEq of potassium chloride. Do NOT administer with PHOSPHATE-containing products.		
	☐	Prepare fresh frozen plasma	Once	S	1 treatment	
		Routine, Blood		
	☐	Transfuse fresh frozen plasma	Once	S	1 treatment	
		Routine		
	☐	sodium chloride 0.9% infusion 1,000 mL	Once	S	1 treatment	
		1,000 mL, intravenous, once, Starting when released
	Priming solution		
	☐	anticoagulant citrate dextrose (ACD-A) solution 1,000 mL	Once	S	1 treatment	
		1,000 mL, extracorporeal, once, Starting when released
	Not for IV Use.  For Extracorpeal Use ONLY. Must be given with calcium infusion.		

Pre-Procedure 	

	
	Interval	Defer Until	Duration	
	☐	CBC hemogram	Once	S	1 treatment	
		STAT, Once Starting when released, Blood		
	☐	Comprehensive metabolic panel	Once	S	1 treatment	
		STAT, Once Starting when released, Blood		
	☐	Prothrombin time with INR	Once	S	1 treatment	
		STAT, Once Starting when released, Blood		
	☐	Partial thromboplastin time, activated	Once	S	1 treatment	
		STAT, Once Starting when released, Blood		
	☐	Fibrinogen	Once	S	1 treatment	
		STAT, Once Starting when released, Blood		
	☐	Ionized calcium	Once	S	1 treatment	
		STAT, Once Starting when released, Blood		
	☐	LDH	Once	S	1 treatment	
		STAT, Once Starting when released, Blood		
	☐	Hemoglobin electrophoresis	Once	S	1 treatment	
		STAT, Once Starting when released, Blood		
	☐	Miscellaneous referral test	Once	S	1 treatment	
		STAT, Once Starting when released, Blood
	ADAMTS-13 - Misc referral test		
	☐	lidocaine PF (XYLOCAINE) local injection 1%	Once	S	1 treatment	
		0.3 mL, intradermal, once PRN, local anesthetic, Starting when released, for 2 doses		
	☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Once	S	1 treatment	
		25 mg, intravenous, once, Starting when released		
	☐	methylPREDNISolone sodium succinate (Solu-MEDROL) injection 40 mg	Once	S	1 treatment	
		40 mg, intravenous, once, Starting when released		
	☐	ondansetron ODT (ZOFRAN-ODT) disintegrating tablet 4 mg	Once	S	1 treatment	
		4 mg, oral, once PRN, nausea, vomiting, Starting when released, Until Discontinued
	Give if patient is able to tolerate oral medication.
	May cause QTc prolongation.		
	☐	ondansetron (ZOFRAN) IV 4 mg	Once	S	1 treatment	
		4 mg, intravenous, once PRN, nausea, vomiting, Starting when released, Until Discontinued
	Give if patient is UNable to tolerate oral medication OR if a faster onset of action is required.
	May cause QTc prolongation.		
	☐	promethazine (PHENERGAN) 12.5 mg in sodium chloride 0.9% 20 mL syringe	Once	S	1 treatment	
		12.5 mg, intravenous, once PRN, nausea, vomiting, Starting when released, Until Discontinued
	Give if ondansetron (ZOFRAN) is ineffective and patient is UNable to tolerate oral or rectal medication OR if a faster onset of action is required.
	If active tasks are available for both ondansetron and promethazine, you may administer promethazine if ondansetron is ineffective.

	Dilute promethazine with preservative-free normal saline, 12.5 mg dose: dilute with 19.5 mL and 6.25 mg dose: dilute with 19.75 mL, to a total volume of 20 mL. 

	Administer over 20 minutes.

	Use only assigned diluent for reconstitution. Do NOT use saline flush for reconstitution or dilution. 

	Give through a large vein (avoid hand or wrist if possible). 

	STOP administration if pain, redness, or burning occurs.

	☐	promethazine (PHENERGAN) tablet 12.5 mg	Once	S	1 treatment	
		12.5 mg, oral, once PRN, nausea, vomiting, Starting when released, Until Discontinued
	Give if ondansetron (ZOFRAN) is ineffective and patient is able to tolerate oral medication.		
	☐	promethazine (PHENERGAN) suppository 12.5 mg	Once	S	1 treatment	
		12.5 mg, rectal, once PRN, nausea, vomiting, Starting when released, Until Discontinued
	Give if ondansetron (ZOFRAN) is ineffective and patient is UNable to tolerate oral medication.		
	☐	acetaminophen (TYLENOL) tablet 325 mg	Once	S	1 treatment	
		325 mg, oral, once PRN, fever, Starting when released, for 2 doses
	Maximum of 4 grams of acetaminophen per day from all sources. (Cirrhosis patients maximum: 2 grams per day from all sources).		
	☐	calcium gluconate injection	Once	S	1 treatment	
		0.5 g, intravenous, once, Starting when released
	Administer at 1.5 mL/minute (150 mg/minute) or less to avoid adverse effects.		
	☐	calcium gluconate injection	Once	S	1 treatment	
		1 g, intravenous, once, Starting when released
	Administer at 1.5 mL/minute (150 mg/minute) or less to avoid adverse effects.		
	☐	alteplase (CATHFLO) for NON Quinton and NON Hemodialysis Catheters 1 mg	Once	S	1 treatment	
		1 mg, intra-catheter, once, Starting when released
	1 mg dose of Cathflo is for NON Quinton and Hemodialysis Catheter Clearance
	Alteplase is to be instilled into the catheter then removed and NOT flushed into the patient.		

Intra-Procedure 	

	
	Interval	Defer Until	Duration	
	☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Once	S	1 treatment	
		25 mg, intravenous, once, Starting when released		
	☐	methylPREDNISolone sodium succinate (Solu-MEDROL) injection 40 mg	Once	S	1 treatment	
		40 mg, intravenous, once, Starting when released		
	☐	ondansetron ODT (ZOFRAN-ODT) disintegrating tablet 4 mg	Once	S	1 treatment	
		4 mg, oral, once PRN, nausea, vomiting, Starting when released, Until Discontinued
	Give if patient is able to tolerate oral medication.
	May cause QTc prolongation.		
	☐	ondansetron (ZOFRAN) IV 4 mg	Once	S	1 treatment	
		4 mg, intravenous, once PRN, nausea, vomiting, Starting when released, Until Discontinued
	Give if patient is UNable to tolerate oral medication OR if a faster onset of action is required.
	May cause QTc prolongation.		
	☐	promethazine (PHENERGAN) 12.5 mg in sodium chloride 0.9% 20 mL syringe	Once	S	1 treatment	
		12.5 mg, intravenous, once PRN, nausea, vomiting, Starting when released, Until Discontinued
	Give if ondansetron (ZOFRAN) is ineffective and patient is UNable to tolerate oral or rectal medication OR if a faster onset of action is required.
	If active tasks are available for both ondansetron and promethazine, you may administer promethazine if ondansetron is ineffective.

	Dilute promethazine with preservative-free normal saline, 12.5 mg dose: dilute with 19.5 mL and 6.25 mg dose: dilute with 19.75 mL, to a total volume of 20 mL. 

	Administer over 20 minutes.

	Use only assigned diluent for reconstitution. Do NOT use saline flush for reconstitution or dilution. 

	Give through a large vein (avoid hand or wrist if possible). 

	STOP administration if pain, redness, or burning occurs.

	☐	promethazine (PHENERGAN) tablet 12.5 mg	Once	S	1 treatment	
		12.5 mg, oral, once PRN, nausea, vomiting, Starting when released, Until Discontinued
	Give if ondansetron (ZOFRAN) is ineffective and patient is able to tolerate oral medication.		
	☐	promethazine (PHENERGAN) suppository 12.5 mg	Once	S	1 treatment	
		12.5 mg, rectal, once PRN, nausea, vomiting, Starting when released, Until Discontinued
	Give if ondansetron (ZOFRAN) is ineffective and patient is UNable to tolerate oral medication.		
	☐	acetaminophen (TYLENOL) tablet 325 mg	Once	S	1 treatment	
		325 mg, oral, once PRN, fever, Starting when released, for 2 doses
	Maximum of 4 grams of acetaminophen per day from all sources. (Cirrhosis patients maximum: 2 grams per day from all sources).		
	☐	calcium gluconate injection	Once	S	1 treatment	
		0.5 g, intravenous, once, Starting when released
	Administer at 1.5 mL/minute (150 mg/minute) or less to avoid adverse effects.		
	☐	calcium gluconate injection	Once	S	1 treatment	
		1 g, intravenous, once, Starting when released
	Administer at 1.5 mL/minute (150 mg/minute) or less to avoid adverse effects.		

Post-Procedure 	

	
	Interval	Defer Until	Duration	
	☐	CBC hemogram	Once	S	1 treatment	
		STAT, Once Starting when released, Blood		
	☐	Hemoglobin electrophoresis	Once	S	1 treatment	
		STAT, Once Starting when released, Blood		
	☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Once	S	1 treatment	
		25 mg, intravenous, once, Starting when released		
	☐	methylPREDNISolone sodium succinate (Solu-MEDROL) injection 40 mg	Once	S	1 treatment	
		40 mg, intravenous, once, Starting when released		
	☐	ondansetron ODT (ZOFRAN-ODT) disintegrating tablet 4 mg	Once	S	1 treatment	
		4 mg, oral, once PRN, nausea, vomiting, Starting when released, Until Discontinued
	Give if patient is able to tolerate oral medication.
	May cause QTc prolongation.		
	☐	ondansetron (ZOFRAN) IV 4 mg	Once	S	1 treatment	
		4 mg, intravenous, once PRN, nausea, vomiting, Starting when released, Until Discontinued
	Give if patient is UNable to tolerate oral medication OR if a faster onset of action is required.
	May cause QTc prolongation.		
	☐	promethazine (PHENERGAN) 12.5 mg in sodium chloride 0.9% 20 mL syringe	Once	S	1 treatment	
		12.5 mg, intravenous, once PRN, nausea, vomiting, Starting when released, Until Discontinued
	Give if ondansetron (ZOFRAN) is ineffective and patient is UNable to tolerate oral or rectal medication OR if a faster onset of action is required.
	If active tasks are available for both ondansetron and promethazine, you may administer promethazine if ondansetron is ineffective.

	Dilute promethazine with preservative-free normal saline, 12.5 mg dose: dilute with 19.5 mL and 6.25 mg dose: dilute with 19.75 mL, to a total volume of 20 mL. 

	Administer over 20 minutes.

	Use only assigned diluent for reconstitution. Do NOT use saline flush for reconstitution or dilution. 

	Give through a large vein (avoid hand or wrist if possible). 

	STOP administration if pain, redness, or burning occurs.

	☐	promethazine (PHENERGAN) suppository 12.5 mg	Once	S	1 treatment	
		12.5 mg, rectal, once PRN, nausea, vomiting, Starting when released, Until Discontinued
	Give if ondansetron (ZOFRAN) is ineffective and patient is UNable to tolerate oral medication.		
	☐	acetaminophen (TYLENOL) tablet 325 mg	Once	S	1 treatment	
		325 mg, oral, once PRN, fever, Starting when released, for 2 doses
	Maximum of 4 grams of acetaminophen per day from all sources. (Cirrhosis patients maximum: 2 grams per day from all sources).		
	☐	calcium gluconate injection	Once	S	1 treatment	
		0.5 g, intravenous, once, Starting when released
	Administer at 1.5 mL/minute (150 mg/minute) or less to avoid adverse effects.		
	☐	calcium gluconate injection	Once	S	1 treatment	
		1 g, intravenous, once, Starting when released
	Administer at 1.5 mL/minute (150 mg/minute) or less to avoid adverse effects.		
	☐	sodium chloride 0.9% flush 10 mL	Once	S	1 treatment	
		10 mL, intravenous, once PRN, line care, Starting when released, Until Discontinued		
	☐	HEParin, porcine injection 100 Units	Once	S	1 treatment	
		100 Units, intra-catheter, once PRN, line care, Starting when released, Until Discontinued		

PRN Medications 	

	
	Interval	Defer Until	Duration	
	☐	ondansetron (ZOFRAN) tablet 4 mg	PRN	S	Until discont'd	
		4 mg, oral, once, Starting when released
	May cause QTc prolongation.		
	☐	diphenhydrAMINE (BENADRYL) injection 25 mg	PRN	S	Until discont'd	
		25 mg, intravenous, once, Starting when released		
	☐	calcium gluconate injection	PRN	S	Until discont'd	
		1 g, intravenous, once, Starting when released
	Administer at 1.5 mL/minute (150 mg/minute) or less to avoid adverse effects.