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OP RESEARCH PRO00021286 KAMAT NRG-GY009 ARM 2	

Types:      Research Oncology Treatment
Synonyms:  PRO21286, 21286, GY009, LIPOSOMAL DOXORUBICIN, DOXOL, AVASTIN, BEVACIZUMAB, TECENTRIQ, ATEZOLIZUMAB

Pre-Treatment	Repeat 1 time	Cycle length: 28 days	Day -28 to 0	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Nursing Orders
  	ECG 12-LEAD	Interval: --	Occurrences: --			Labs
  	HEPATITIS B SURFACE ANTIGEN	Interval: --	Occurrences: --		  	HEPATITIS B CORE ANTIBODY TOTAL	Interval: --	Occurrences: --		  	HEPATITIS C ANTIBODY	Interval: --	Occurrences: --		  	PROTHROMBIN TIME WITH INR	Interval: --	Occurrences: --		  	PARTIAL THROMBOPLASTIN TIME (PTT)	Interval: --	Occurrences: --		  	CANCER ANTIGEN 125	Interval: --	Occurrences: --			Imaging
  	CT CHEST W WO CONTRAST ABDOMEN W WO CONTRAST PELVIS W CONTRAST	Interval: --	Occurrences: --		  	CT PELVIS WO CONTRAST	Interval: --	Occurrences: --			Imaging
  	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: --	Occurrences: --					
Cycle 1	Repeat 1 time	Cycle length: 28 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Flush
  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Administer ONLY for Liposomal Doxorubicin.		  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Do NOT administer with Liposomal Doxorubicin.			Nursing Orders
  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open for Liposomal Doxorubicin.		  	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.  Do NOT administer with Liposomal Doxorubicin.			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	Verify Ejection Fraction prior to Cycle 1.  Ejection Fraction: ***% on *** (date).

If patient has not had a recent MUGA or ECHO, order one via order entry. A baseline cardiac evaluation with a MUGA scan or an ECHO is recommended, especially in patients with risk factors for increased cardiac toxicity. Repeated MUGA or ECHO determinations of LVEF should be performed, particularly with higher, cumulative anthracycline doses.
			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
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	History and physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	RESEARCH - HEIGHT AND WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Concomitant medications
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	ECOG performance status
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Toxicity Assessment
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	Quality of Life Questionnaires
		  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --		  	T4	Interval: --	Occurrences: --		  	CANCER ANTIGEN 125	Interval: --	Occurrences: --		  	URINE PROTEIN/CREATININE RATIO, RANDOM	Interval: --	Occurrences: --			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --	Comments:	Only for females of childbearing potential
			Labs
  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --			Imaging
  	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 10	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1500, Platelets LESS than 75,000.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 18	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.2 mg/dL.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL .
			Pre-Medications
◉	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous		Start: S					Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	once PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	once PRN	Start: S					Antiemetics
◯	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: injection	once PRN	Start: S					Chemotherapy
  	DOXOrubicin liposomal (DOXIL) 40 mg/m2 in dextrose 5% 250 mL chemo IVPB	Dose: 40 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	DRUG IS AN IRRITANT.  Initial infusion infused at 1 mg/min, but no faster than 1 hour to prevent infusion related reactions.  Monitor vital signs 15 minutes, 30 minutes, and one hour into infusion, then hourly for remainder of initial infusion.  Stay with patient for the first 15 minutes of the initial infusion.  If patient tolerated initial infusion, subsequent infusions to be given over 1 hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION	Medications	40 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes				Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 180 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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				Day 15	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					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
  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 14	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.5x ULN.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL.
			Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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					
Cycle 2	Repeat 1 time	Cycle length: 28 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Flush
  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Administer ONLY for Liposomal Doxorubicin.		  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Do NOT administer with Liposomal Doxorubicin.			Nursing Orders
  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open for Liposomal Doxorubicin.		  	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.  Do NOT administer with Liposomal Doxorubicin.			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
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	History and physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	RESEARCH - HEIGHT AND WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Concomitant medications
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	ECOG performance status
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Toxicity Assessment
		  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --		  	T4	Interval: --	Occurrences: --		  	CANCER ANTIGEN 125	Interval: --	Occurrences: --			Labs
  	URINALYSIS, AUTOMATED WITH MICROSCOPY	Interval: --	Occurrences: --			Labs
☑	ONC NURSING COMMUNICATION 10	Interval: --	Occurrences: --	Comments:	o IF patient signs consent for optional blood draw. 
o Right click to add orders.
		☐	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --			Imaging
☑	ONC NURSING COMMUNICATION 11	Interval: --	Occurrences: --	Comments:	o ECHO or MUGA is necessary when the cumulative dose of PLD exceeds 550 mg/m2. Repeat echocardiogram or MUGA scan every other cycle or according to institutional standards. 
o Right click to add orders.
		☐	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 10	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1500, Platelets LESS than 75,000.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 18	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.2 mg/dL.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL .
			Pre-Medications
◉	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous		Start: S					Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	once PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	once PRN	Start: S					Antiemetics
◯	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: injection	once PRN	Start: S					Chemotherapy
  	DOXOrubicin liposomal (DOXIL) 40 mg/m2 in dextrose 5% 250 mL chemo IVPB	Dose: 40 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	DRUG IS AN IRRITANT.  Initial infusion infused at 1 mg/min, but no faster than 1 hour to prevent infusion related reactions.  Monitor vital signs 15 minutes, 30 minutes, and one hour into infusion, then hourly for remainder of initial infusion.  Stay with patient for the first 15 minutes of the initial infusion.  If patient tolerated initial infusion, subsequent infusions to be given over 1 hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION	Medications	40 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes				Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 180 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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				Day 15	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					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
  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 14	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.5x ULN.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL.
			Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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					
Cycle 3	Repeat 1 time	Cycle length: 28 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Flush
  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Administer ONLY for Liposomal Doxorubicin.		  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Do NOT administer with Liposomal Doxorubicin.			Nursing Orders
  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open for Liposomal Doxorubicin.		  	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.  Do NOT administer with Liposomal Doxorubicin.			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
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	History and physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	RESEARCH - HEIGHT AND WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Concomitant medications
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	ECOG performance status
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Toxicity Assessment
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	Quality of Life Questionnaires
		  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --		  	T4	Interval: --	Occurrences: --		  	CANCER ANTIGEN 125	Interval: --	Occurrences: --		  	URINE PROTEIN/CREATININE RATIO, RANDOM	Interval: --	Occurrences: --			Imaging
  	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: --	Occurrences: --			Imaging
  	CT CHEST W WO CONTRAST ABDOMEN W WO CONTRAST PELVIS W CONTRAST	Interval: --	Occurrences: --		  	CT PELVIS WO CONTRAST	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 10	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1500, Platelets LESS than 75,000.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 18	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.2 mg/dL.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL .
			Pre-Medications
◉	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous		Start: S					Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	once PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	once PRN	Start: S					Antiemetics
◯	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: injection	once PRN	Start: S					Chemotherapy
  	DOXOrubicin liposomal (DOXIL) 40 mg/m2 in dextrose 5% 250 mL chemo IVPB	Dose: 40 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	DRUG IS AN IRRITANT.  Initial infusion infused at 1 mg/min, but no faster than 1 hour to prevent infusion related reactions.  Monitor vital signs 15 minutes, 30 minutes, and one hour into infusion, then hourly for remainder of initial infusion.  Stay with patient for the first 15 minutes of the initial infusion.  If patient tolerated initial infusion, subsequent infusions to be given over 1 hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION	Medications	40 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes				Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 180 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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				Day 15	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					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
  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 14	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.5x ULN.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL.
			Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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					
Cycle 4	Repeat 1 time	Cycle length: 28 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Flush
  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Administer ONLY for Liposomal Doxorubicin.		  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Do NOT administer with Liposomal Doxorubicin.			Nursing Orders
  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open for Liposomal Doxorubicin.		  	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.  Do NOT administer with Liposomal Doxorubicin.			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
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	History and physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	RESEARCH - HEIGHT AND WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Concomitant medications
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	ECOG performance status
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Toxicity Assessment
		  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --		  	T4	Interval: --	Occurrences: --		  	CANCER ANTIGEN 125	Interval: --	Occurrences: --			Labs
  	URINALYSIS, AUTOMATED WITH MICROSCOPY	Interval: --	Occurrences: --			Imaging
☑	ONC NURSING COMMUNICATION 11	Interval: --	Occurrences: --	Comments:	o ECHO or MUGA is necessary when the cumulative dose of PLD exceeds 550 mg/m2. Repeat echocardiogram or MUGA scan every other cycle or according to institutional standards. 
o Right click to add orders.
		☐	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 10	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1500, Platelets LESS than 75,000.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 18	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.2 mg/dL.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL .
			Pre-Medications
◉	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous		Start: S					Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	once PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	once PRN	Start: S					Antiemetics
◯	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: injection	once PRN	Start: S					Chemotherapy
  	DOXOrubicin liposomal (DOXIL) 40 mg/m2 in dextrose 5% 250 mL chemo IVPB	Dose: 40 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	DRUG IS AN IRRITANT.  Initial infusion infused at 1 mg/min, but no faster than 1 hour to prevent infusion related reactions.  Monitor vital signs 15 minutes, 30 minutes, and one hour into infusion, then hourly for remainder of initial infusion.  Stay with patient for the first 15 minutes of the initial infusion.  If patient tolerated initial infusion, subsequent infusions to be given over 1 hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION	Medications	40 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes				Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 180 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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				Day 15	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					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
  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 14	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.5x ULN.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL.
			Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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					
Cycle 5	Repeat 1 time	Cycle length: 28 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Flush
  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Administer ONLY for Liposomal Doxorubicin.		  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Do NOT administer with Liposomal Doxorubicin.			Nursing Orders
  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open for Liposomal Doxorubicin.		  	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.  Do NOT administer with Liposomal Doxorubicin.			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
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	History and physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	RESEARCH - HEIGHT AND WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Concomitant medications
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	ECOG performance status
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Toxicity Assessment
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	Quality of Life Questionnaires
		  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --		  	T4	Interval: --	Occurrences: --		  	CANCER ANTIGEN 125	Interval: --	Occurrences: --		  	URINE PROTEIN/CREATININE RATIO, RANDOM	Interval: --	Occurrences: --			Imaging
  	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: --	Occurrences: --			Imaging
  	CT CHEST W WO CONTRAST ABDOMEN W WO CONTRAST PELVIS W CONTRAST	Interval: --	Occurrences: --		  	CT PELVIS WO CONTRAST	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 10	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1500, Platelets LESS than 75,000.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 18	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.2 mg/dL.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL .
			Pre-Medications
◉	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous		Start: S					Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	once PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	once PRN	Start: S					Antiemetics
◯	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: injection	once PRN	Start: S					Chemotherapy
  	DOXOrubicin liposomal (DOXIL) 40 mg/m2 in dextrose 5% 250 mL chemo IVPB	Dose: 40 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	DRUG IS AN IRRITANT.  Initial infusion infused at 1 mg/min, but no faster than 1 hour to prevent infusion related reactions.  Monitor vital signs 15 minutes, 30 minutes, and one hour into infusion, then hourly for remainder of initial infusion.  Stay with patient for the first 15 minutes of the initial infusion.  If patient tolerated initial infusion, subsequent infusions to be given over 1 hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION	Medications	40 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes				Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 180 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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				Day 15	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					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
  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 14	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.5x ULN.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL.
			Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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					
Cycle 6	Repeat 1 time	Cycle length: 28 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Flush
  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Administer ONLY for Liposomal Doxorubicin.		  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Do NOT administer with Liposomal Doxorubicin.			Nursing Orders
  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open for Liposomal Doxorubicin.		  	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.  Do NOT administer with Liposomal Doxorubicin.			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
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	History and physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	RESEARCH - HEIGHT AND WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Concomitant medications
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	ECOG performance status
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Toxicity Assessment
		  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --		  	T4	Interval: --	Occurrences: --		  	CANCER ANTIGEN 125	Interval: --	Occurrences: --			Labs
  	URINALYSIS, AUTOMATED WITH MICROSCOPY	Interval: --	Occurrences: --			Imaging
☑	ONC NURSING COMMUNICATION 11	Interval: --	Occurrences: --	Comments:	o ECHO or MUGA is necessary when the cumulative dose of PLD exceeds 550 mg/m2. Repeat echocardiogram or MUGA scan every other cycle or according to institutional standards. 
o Right click to add orders.
		☐	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 10	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1500, Platelets LESS than 75,000.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 18	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.2 mg/dL.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL .
			Pre-Medications
◉	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous		Start: S					Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	once PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	once PRN	Start: S					Antiemetics
◯	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: injection	once PRN	Start: S					Chemotherapy
  	DOXOrubicin liposomal (DOXIL) 40 mg/m2 in dextrose 5% 250 mL chemo IVPB	Dose: 40 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	DRUG IS AN IRRITANT.  Initial infusion infused at 1 mg/min, but no faster than 1 hour to prevent infusion related reactions.  Monitor vital signs 15 minutes, 30 minutes, and one hour into infusion, then hourly for remainder of initial infusion.  Stay with patient for the first 15 minutes of the initial infusion.  If patient tolerated initial infusion, subsequent infusions to be given over 1 hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION	Medications	40 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes				Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 180 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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				Day 15	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					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
  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 14	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.5x ULN.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL.
			Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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					
Cycle 7	Repeat 1 time	Cycle length: 28 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Flush
  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Administer ONLY for Liposomal Doxorubicin.		  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Do NOT administer with Liposomal Doxorubicin.			Nursing Orders
  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open for Liposomal Doxorubicin.		  	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.  Do NOT administer with Liposomal Doxorubicin.			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
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	History and physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	RESEARCH - HEIGHT AND WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Concomitant medications
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	ECOG performance status
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Toxicity Assessment
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	Quality of Life Questionnaires
		  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --		  	T4	Interval: --	Occurrences: --		  	CANCER ANTIGEN 125	Interval: --	Occurrences: --		  	URINE PROTEIN/CREATININE RATIO, RANDOM	Interval: --	Occurrences: --			Imaging
  	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: --	Occurrences: --			Imaging
  	CT CHEST W WO CONTRAST ABDOMEN W WO CONTRAST PELVIS W CONTRAST	Interval: --	Occurrences: --		  	CT PELVIS WO CONTRAST	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 10	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1500, Platelets LESS than 75,000.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 18	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.2 mg/dL.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL .
			Pre-Medications
◉	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous		Start: S					Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	once PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	once PRN	Start: S					Antiemetics
◯	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: injection	once PRN	Start: S					Chemotherapy
  	DOXOrubicin liposomal (DOXIL) 40 mg/m2 in dextrose 5% 250 mL chemo IVPB	Dose: 40 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	DRUG IS AN IRRITANT.  Initial infusion infused at 1 mg/min, but no faster than 1 hour to prevent infusion related reactions.  Monitor vital signs 15 minutes, 30 minutes, and one hour into infusion, then hourly for remainder of initial infusion.  Stay with patient for the first 15 minutes of the initial infusion.  If patient tolerated initial infusion, subsequent infusions to be given over 1 hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION	Medications	40 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes				Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 180 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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				Day 15	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					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
  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 14	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.5x ULN.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL.
			Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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					
Cycle 8	Repeat 1 time	Cycle length: 28 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Flush
  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Administer ONLY for Liposomal Doxorubicin.		  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Do NOT administer with Liposomal Doxorubicin.			Nursing Orders
  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open for Liposomal Doxorubicin.		  	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.  Do NOT administer with Liposomal Doxorubicin.			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
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	History and physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	RESEARCH - HEIGHT AND WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Concomitant medications
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	ECOG performance status
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Toxicity Assessment
		  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --		  	T4	Interval: --	Occurrences: --		  	CANCER ANTIGEN 125	Interval: --	Occurrences: --			Labs
  	URINALYSIS, AUTOMATED WITH MICROSCOPY	Interval: --	Occurrences: --			Imaging
☑	ONC NURSING COMMUNICATION 11	Interval: --	Occurrences: --	Comments:	o ECHO or MUGA is necessary when the cumulative dose of PLD exceeds 550 mg/m2. Repeat echocardiogram or MUGA scan every other cycle or according to institutional standards. 
o Right click to add orders.
		☐	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 10	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1500, Platelets LESS than 75,000.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 18	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.2 mg/dL.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL .
			Pre-Medications
◉	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous		Start: S					Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	once PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	once PRN	Start: S					Antiemetics
◯	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: injection	once PRN	Start: S					Chemotherapy
  	DOXOrubicin liposomal (DOXIL) 40 mg/m2 in dextrose 5% 250 mL chemo IVPB	Dose: 40 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	DRUG IS AN IRRITANT.  Initial infusion infused at 1 mg/min, but no faster than 1 hour to prevent infusion related reactions.  Monitor vital signs 15 minutes, 30 minutes, and one hour into infusion, then hourly for remainder of initial infusion.  Stay with patient for the first 15 minutes of the initial infusion.  If patient tolerated initial infusion, subsequent infusions to be given over 1 hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION	Medications	40 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes				Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 180 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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				Day 15	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					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
  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 14	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.5x ULN.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL.
			Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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					
Cycle 9	Repeat 1 time	Cycle length: 28 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Flush
  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Administer ONLY for Liposomal Doxorubicin.		  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Do NOT administer with Liposomal Doxorubicin.			Nursing Orders
  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open for Liposomal Doxorubicin.		  	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.  Do NOT administer with Liposomal Doxorubicin.			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
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	History and physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	RESEARCH - HEIGHT AND WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Concomitant medications
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	ECOG performance status
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Toxicity Assessment
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	Quality of Life Questionnaires
		  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --		  	T4	Interval: --	Occurrences: --		  	CANCER ANTIGEN 125	Interval: --	Occurrences: --		  	URINE PROTEIN/CREATININE RATIO, RANDOM	Interval: --	Occurrences: --			Imaging
  	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: --	Occurrences: --			Imaging
  	CT CHEST W WO CONTRAST ABDOMEN W WO CONTRAST PELVIS W CONTRAST	Interval: --	Occurrences: --		  	CT PELVIS WO CONTRAST	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 10	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1500, Platelets LESS than 75,000.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 18	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.2 mg/dL.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL .
			Pre-Medications
◉	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous		Start: S					Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	once PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	once PRN	Start: S					Antiemetics
◯	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: injection	once PRN	Start: S					Chemotherapy
  	DOXOrubicin liposomal (DOXIL) 40 mg/m2 in dextrose 5% 250 mL chemo IVPB	Dose: 40 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	DRUG IS AN IRRITANT.  Initial infusion infused at 1 mg/min, but no faster than 1 hour to prevent infusion related reactions.  Monitor vital signs 15 minutes, 30 minutes, and one hour into infusion, then hourly for remainder of initial infusion.  Stay with patient for the first 15 minutes of the initial infusion.  If patient tolerated initial infusion, subsequent infusions to be given over 1 hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION	Medications	40 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes				Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 180 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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				Day 15	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					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
  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 14	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.5x ULN.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL.
			Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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					
Cycle 10	Repeat 1 time	Cycle length: 28 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Flush
  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Administer ONLY for Liposomal Doxorubicin.		  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Do NOT administer with Liposomal Doxorubicin.			Nursing Orders
  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open for Liposomal Doxorubicin.		  	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.  Do NOT administer with Liposomal Doxorubicin.			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
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	History and physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	RESEARCH - HEIGHT AND WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Concomitant medications
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	ECOG performance status
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Toxicity Assessment
		  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --		  	T4	Interval: --	Occurrences: --		  	CANCER ANTIGEN 125	Interval: --	Occurrences: --			Labs
  	URINALYSIS, AUTOMATED WITH MICROSCOPY	Interval: --	Occurrences: --			Imaging
☑	ONC NURSING COMMUNICATION 11	Interval: --	Occurrences: --	Comments:	o ECHO or MUGA is necessary when the cumulative dose of PLD exceeds 550 mg/m2. Repeat echocardiogram or MUGA scan every other cycle or according to institutional standards. 
o Right click to add orders.
		☐	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 10	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1500, Platelets LESS than 75,000.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 18	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.2 mg/dL.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL .
			Pre-Medications
◉	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous		Start: S					Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	once PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	once PRN	Start: S					Antiemetics
◯	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: injection	once PRN	Start: S					Chemotherapy
  	DOXOrubicin liposomal (DOXIL) 40 mg/m2 in dextrose 5% 250 mL chemo IVPB	Dose: 40 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	DRUG IS AN IRRITANT.  Initial infusion infused at 1 mg/min, but no faster than 1 hour to prevent infusion related reactions.  Monitor vital signs 15 minutes, 30 minutes, and one hour into infusion, then hourly for remainder of initial infusion.  Stay with patient for the first 15 minutes of the initial infusion.  If patient tolerated initial infusion, subsequent infusions to be given over 1 hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION	Medications	40 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes				Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 180 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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				Day 15	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					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
  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 14	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.5x ULN.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL.
			Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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					
Cycle 11	Repeat 1 time	Cycle length: 28 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Flush
  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Administer ONLY for Liposomal Doxorubicin.		  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Do NOT administer with Liposomal Doxorubicin.			Nursing Orders
  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open for Liposomal Doxorubicin.		  	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.  Do NOT administer with Liposomal Doxorubicin.			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
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	History and physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	RESEARCH - HEIGHT AND WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Concomitant medications
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	ECOG performance status
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Toxicity Assessment
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	Quality of Life Questionnaires
		  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --		  	T4	Interval: --	Occurrences: --		  	CANCER ANTIGEN 125	Interval: --	Occurrences: --		  	URINE PROTEIN/CREATININE RATIO, RANDOM	Interval: --	Occurrences: --			Imaging
  	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: --	Occurrences: --			Imaging
  	CT CHEST W WO CONTRAST ABDOMEN W WO CONTRAST PELVIS W CONTRAST	Interval: --	Occurrences: --		  	CT PELVIS WO CONTRAST	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 10	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1500, Platelets LESS than 75,000.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 18	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.2 mg/dL.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL .
			Pre-Medications
◉	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous		Start: S					Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	once PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	once PRN	Start: S					Antiemetics
◯	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: injection	once PRN	Start: S					Chemotherapy
  	DOXOrubicin liposomal (DOXIL) 40 mg/m2 in dextrose 5% 250 mL chemo IVPB	Dose: 40 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	DRUG IS AN IRRITANT.  Initial infusion infused at 1 mg/min, but no faster than 1 hour to prevent infusion related reactions.  Monitor vital signs 15 minutes, 30 minutes, and one hour into infusion, then hourly for remainder of initial infusion.  Stay with patient for the first 15 minutes of the initial infusion.  If patient tolerated initial infusion, subsequent infusions to be given over 1 hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION	Medications	40 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes				Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 180 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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				Day 15	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					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
  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 14	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.5x ULN.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL.
			Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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					
Cycle 12	Repeat 1 time	Cycle length: 28 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Flush
  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Administer ONLY for Liposomal Doxorubicin.		  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Do NOT administer with Liposomal Doxorubicin.			Nursing Orders
  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open for Liposomal Doxorubicin.		  	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.  Do NOT administer with Liposomal Doxorubicin.			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
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	History and physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	RESEARCH - HEIGHT AND WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Concomitant medications
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	ECOG performance status
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Toxicity Assessment
		  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --		  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --		  	T3, FREE	Interval: --	Occurrences: --		  	T4	Interval: --	Occurrences: --		  	CANCER ANTIGEN 125	Interval: --	Occurrences: --			Labs
  	URINALYSIS, AUTOMATED WITH MICROSCOPY	Interval: --	Occurrences: --			Imaging
☑	ONC NURSING COMMUNICATION 11	Interval: --	Occurrences: --	Comments:	o ECHO or MUGA is necessary when the cumulative dose of PLD exceeds 550 mg/m2. Repeat echocardiogram or MUGA scan every other cycle or according to institutional standards. 
o Right click to add orders.
		☐	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 10	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1500, Platelets LESS than 75,000.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 18	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.2 mg/dL.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL .
			Pre-Medications
◉	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S				◯	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous		Start: S					Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	once PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	once PRN	Start: S					Antiemetics
◯	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: injection	once PRN	Start: S					Chemotherapy
  	DOXOrubicin liposomal (DOXIL) 40 mg/m2 in dextrose 5% 250 mL chemo IVPB	Dose: 40 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	DRUG IS AN IRRITANT.  Initial infusion infused at 1 mg/min, but no faster than 1 hour to prevent infusion related reactions.  Monitor vital signs 15 minutes, 30 minutes, and one hour into infusion, then hourly for remainder of initial infusion.  Stay with patient for the first 15 minutes of the initial infusion.  If patient tolerated initial infusion, subsequent infusions to be given over 1 hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION	Medications	40 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes				Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 180 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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				Day 15	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					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
  	ONC NURSING COMMUNICATION 100	Interval: --	Occurrences: --	Comments:	On days where more than one study drug is to be administered, the order of administration should be as follows:

1. PLD
2. Bevacizumab
3. Atezolizumab
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 16	Interval: --	Occurrences: --	Comments:	Do NOT administer within 28 days of surgery/procedure and until the surgical wound is fully healed or within 14 days of port placement.
		  	TREATMENT CONDITIONS 15	Interval: --	Occurrences: --	Comments:	HOLD bevacizumab (Avastin) and notify provider for SBP GREATER than 160 mmHg or DBP GREATER than 100 mmHg.
		  	TREATMENT CONDITIONS 17	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if PROTEIN 2+ is detected in UA.
		  	TREATMENT CONDITIONS 3	Interval: --	Occurrences: --	Comments:	IF Urinary protein GREATER than or EQUAL to 3.5 g/24 hrs, hold bevacizumab.
		  	TREATMENT CONDITIONS 14	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if T-Bilirubin is GREATER than 1.5x ULN.
		  	TREATMENT CONDITIONS 12	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if AST or ALT GREATER than 3x ULN.
		  	TREATMENT CONDITIONS 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if  SCr greater than 1.5 x baseline or SCr increase of GREATER or Equal to 0.3 mg/dL.
			Provider Communication
☑	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	o Preparative antihistamine use is allowed (e.g., diphenhydramine 25 mg IV) prior to FIRST dose (and subsequent doses if hypersensitivity reaction is seen with a previous dose). 
o Right click to add order.
			Pre-Medications
☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S					Chemotherapy
  	INV-bevacizumab (GY009/Pro00021286/Kamat) 10 mg/kg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Hazardous drug. Infuse intravenously: 1st dose over minimum of 90 minutes; if no infusion reaction, infuse 2nd dose over 60 minutes; if no reactions after 2nd dose, infuse subsequent doses over 30 minutes.  If infusion-related reactions occur, all subsequent infusions should be administered over the shortest period that was well tolerated. Stability: if not used immediately, store at 2-8 C for maximum 24 hours. 
New Drug - Limited by Federal (USA) Law to Investigational use. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-BEVACIZUMAB 25 MG/ML INJECTION (GY009/PRO00021286/KAMAT)	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Chemotherapy
  	INV-Atezolizumab/placebo (GY009/Pro00021286/Kamat) 800 mg in sodium chloride 0.9% 250 mL IVPB	Dose: 800 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	Infuse using 0.22 micron inline filter; 1st dose over 60 (+/- 15) minutes; if no infusion reaction, subsequent infusions over 30 (+/- 10) minutes. If there is any reaction, infuse over 60 minutes. Stability: if not used immediately, store at 2-25 C for maximum 8 hours. 
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLN (GY009/PRO00021286/KAMAT)	Medications	800 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	236.67 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