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OP INTRATHECAL CHEMOTHERAPY	

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

Cycle 1	Repeat 1 time	Cycle length: 30 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION 64	Interval: --	Occurrences: --	Comments:	Verify Hep B panel status prior to cycle. Date *** of panel. Result positive/negative/pending/unknown:22867

The required components for the hepatitis B panel includes: Hepatitis B surface antigen (HBsAg), total hepatitis B core antibody (anti-HBc), and hepatitis B antibody (anti-HBs).
			Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Labs
☑	CSF CELL COUNT WITH DIFFERENTIAL	Interval: --	Occurrences: --		☑	GLUCOSE LEVEL, CSF	Interval: --	Occurrences: --		☑	PROTEIN, CSF	Interval: --	Occurrences: --		☑	FLOW CYTOMETRY EVALUATION	Interval: --	Occurrences: --		☑	CYTOLOGY (NON-GYNECOLOGICAL) REQUEST	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Hold and NOTIFY provider for platelets less than 50,000.
			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.
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Pre-Medications
☐	ondansetron (ZOFRAN) tablet 24 mg	Dose: 24 mg	Route: oral	once for 1 dose	Start: S				☐	dexamethasone (DECADRON) tablet 10 mg	Dose: 10 mg	Route: oral	once for 1 dose	Start: S					Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	PRN	Start: S					Provider Ordering Guidelines
  	ONC PROVIDER COMMUNICATION 15	Interval: --	Occurrences: --	Comments:	If IT (intrathecal) chemotherapy is to be administered by IR (interventional radiology) then please place a "Lumbar Puncture by Radiology" order panel under Meds & Orders.

IT chemotherapy administered in clinic does NOT need a Lumbar Puncture order.
			Intrathecal Injections
☑	methotrexate Preservative Free in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: --	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	6 mL	Yes	Yes			☐	cytarabine PF (CYSTOSAR) in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: --	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS
Handle with care	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	6 mL	Yes	Yes			☐	cytarabine PF (CYSTOSAR), methotrexate Preservative Free, hydrocortisone sodium succinate (Solu-CORTEF) in sodium chloride 0.9% 5 mL chemo INTRATHECAL injection	Dose: 5 mL	Route: intrathecal	once for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS - Handle with care	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	 	Yes	Yes	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	 	Yes	Yes	HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION	Medications	 	Yes	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	5 mL	Yes	Yes			☐	topotecan (HYCAMTIN) in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: --	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	HAZARDOUS
Handle with care	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	6 mL	Yes	Yes			☐	trastuzumab (HERCEPTIN) in sodium chloride 0.9% 6 mL INTRATHECAL injection (RESTRICTED)	Dose: --	Route: intrathecal	once for 1 dose	Start: S	End: S		Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION (RESTRICTED)	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	6 mL	Yes	Yes				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					Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN