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IP BLINATUMOMAB	

Types:      ONCOLOGY TREATMENT
Synonyms:  ALL, ACUTE , LYMPHO, LEUKEMIA, BLINCYTO, BLIN, BLINA, BLENA, BLINATUMOMAB

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 5	Interval: Once	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains/losses of greater than or equal to 10%.
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	LDH	Interval: Once	Occurrences: --		☐	URIC ACID LEVEL	Interval: Once	Occurrences: --			Nursing Orders
  	ONC DO NOT FLUSH INFUSION LINE	Interval: --	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
			Nursing Orders
  	ONC NURSING COMMUNICATION 108	Interval: Until discontinued	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				◯	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Pre-Medications
  	dexamethasone (DECADRON) IV 20 mg	Dose: 20 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	blinatumomab 9 mcg in sodium chloride (NON-PVC) 0.9 % 250 mL chemo IVPB	Dose: 9 mcg	Route: intravenous	once over 24 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Administer as a continuous infusion on days 1 to 7.
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	9 mcg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	Base	250 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 2,3,4,5,6,7	Perform every 1 day x6		Nursing Orders
  	ONC DO NOT FLUSH INFUSION LINE	Interval: --	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
			Pre-Medications
◉	ondansetron (ZOFRAN) tablet 8 mg	Dose: 8 mg	Route: oral	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	blinatumomab 9 mcg in sodium chloride (NON-PVC) 0.9 % 250 mL chemo IVPB	Dose: 9 mcg	Route: intravenous	once over 24 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Administer as a continuous infusion on days 1 to 7.
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	9 mcg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	Base	250 mL	Yes	Yes					Day 8	Perform every 1 day x1		Nursing Orders
  	ONC DO NOT FLUSH INFUSION LINE	Interval: --	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
			Pre-Medications
◉	ondansetron (ZOFRAN) tablet 8 mg	Dose: 8 mg	Route: oral	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Pre-Medications
  	dexamethasone (DECADRON) IV 20 mg	Dose: 20 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	blinatumomab 28 mcg in sodium chloride (NON-PVC) 0.9 % 250 mL chemo IVPB	Dose: 28 mcg	Route: intravenous	once over 24 Hours for 1 dose			Offset: 60 Minutes	Instructions:	Administer as a continuous infusion on days 8 to 28.
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	250 mL	Yes	Yes					Days 9,10,11,12,13,...,28	Perform every 1 day x20		Nursing Orders
  	ONC DO NOT FLUSH INFUSION LINE	Interval: --	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
			Pre-Medications
◉	ondansetron (ZOFRAN) tablet 8 mg	Dose: 8 mg	Route: oral	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	blinatumomab 28 mcg in sodium chloride (NON-PVC) 0.9 % 250 mL chemo IVPB	Dose: 28 mcg	Route: intravenous	once over 24 Hours for 1 dose			Offset: 60 Minutes	Instructions:	Administer as a continuous infusion on days 8 to 28.
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	250 mL	Yes	Yes						
Cycle 2-5	Repeat 1 time	Cycle length: 28 days	Day 1	Perform every 1 day x1		Provider Communication
  	ONC PROVIDER COMMUNICATION 5	Interval: Once	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains/losses of greater than or equal to 10%.
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	LDH	Interval: Once	Occurrences: --		☐	URIC ACID LEVEL	Interval: Once	Occurrences: --			Nursing Orders
  	ONC DO NOT FLUSH INFUSION LINE	Interval: --	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
			Nursing Orders
  	ONC NURSING COMMUNICATION 108	Interval: Until discontinued	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				◯	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Pre-Medications
  	dexamethasone (DECADRON) IV 20 mg	Dose: 20 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	blinatumomab 28 mcg in sodium chloride (NON-PVC) 0.9 % 250 mL chemo IVPB	Dose: 28 mcg	Route: intravenous	once over 24 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Administer as a continuous infusion on days 1 to 28.
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	250 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 2,3,4,5,6,...,28	Perform every 1 day x27		Nursing Orders
  	ONC DO NOT FLUSH INFUSION LINE	Interval: --	Occurrences: --	Comments:	DO NOT FLUSH INFUSION LINE, particularly when changing infusion bags or at completion of infusion; may result in overdose and complications.
			Pre-Medications
◉	ondansetron (ZOFRAN) tablet 8 mg	Dose: 8 mg	Route: oral	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	blinatumomab 28 mcg in sodium chloride (NON-PVC) 0.9 % 250 mL chemo IVPB	Dose: 28 mcg	Route: intravenous	once over 24 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Administer as a continuous infusion on days 1 to 28.
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	250 mL	Yes	Yes