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RESEARCH / HILL CTL H-43761 CRIMSON-NE	

Types:      Research Oncology Treatment
Synonyms:  

Cy/Flu Lymphodepletion	Repeat 1 time	Cycle length: 8 days	Consent and Labwork	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --	Comments:	Please schedule a lab draw and MD visit with Dr. Hill.
			Nursing Orders
  	MEASURE WEIGHT	Interval: --	Occurrences: --		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	PULSE OXIMETRY	Interval: --	Occurrences: --		  	OK TO USE	Interval: --	Occurrences: --		  	ACCESS PORTACATH	Interval: --	Occurrences: --			Labs
  	COVID-19 QUALITATIVE RT-PCR	Interval: --	Occurrences: --		  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --	Comments:	For childbearing females only.
		  	LDH	Interval: --	Occurrences: --		  	TB NK CELLS	Interval: --	Occurrences: --		  	HUMAN HERPESVIRUS 6, QUANTITATIVE PCR	Interval: --	Occurrences: --		  	BK VIRUS BY PCR	Interval: --	Occurrences: --		  	ADENOVIRUS BY PCR	Interval: --	Occurrences: --		  	CYTOMEGALOVIRUS, QUANTITATIVE PCR	Interval: --	Occurrences: --		  	EPSTEIN BARR VIRUS (EBV) BY PCR	Interval: --	Occurrences: --		  	TOXOPLASMA GONDII ANTIBODY, IGG	Interval: --	Occurrences: --		  	TOXOPLASMA IGM AB	Interval: --	Occurrences: --		  	CYTOMEGALOVIRUS AB, IGG	Interval: --	Occurrences: --		  	CYTOMEGALOVIRUS AB, IGM	Interval: --	Occurrences: --		  	ZZEPSTEIN-BARR VIRUS ANTIBODY TEST	Interval: --	Occurrences: --		  	TYPE AND SCREEN	Interval: --	Occurrences: --			Labs
  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Research Coordinator:  Please schedule required studies.
				Day -5	Perform every 1 day x1		Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 2	Interval: --	Occurrences: --	Comments:	STAT Please schedule for Cyclophosphamide + Fludarabine infusions.
			Nursing Orders
  	MEASURE WEIGHT	Interval: --	Occurrences: --		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	PULSE OXIMETRY	Interval: --	Occurrences: --		  	OK TO USE	Interval: --	Occurrences: --		  	ACCESS PORTACATH	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	See separate Cyclophosphamide and Fludarabine orders.
				Day -4	Perform every 1 day x1		Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 2	Interval: --	Occurrences: --	Comments:	STAT Please schedule for Cyclophosphamide + Fludarabine infusions.
			Nursing Orders
  	MEASURE WEIGHT	Interval: --	Occurrences: --		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	PULSE OXIMETRY	Interval: --	Occurrences: --		  	OK TO USE	Interval: --	Occurrences: --		  	ACCESS PORTACATH	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	See separate Cyclophosphamide and Fludarabine orders.
				Day -3	Perform every 1 day x1		Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 2	Interval: --	Occurrences: --	Comments:	STAT Please schedule for Cyclophosphamide + Fludarabine infusions.
			Nursing Orders
  	MEASURE WEIGHT	Interval: --	Occurrences: --		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	PULSE OXIMETRY	Interval: --	Occurrences: --		  	OK TO USE	Interval: --	Occurrences: --		  	ACCESS PORTACATH	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	See separate Cyclophosphamide and Fludarabine orders.
				Day 0 (OUTpatient)	Perform every 1 day x1		Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 3	Interval: --	Occurrences: --	Comments:	Please schedule CTL infusion.
			Nursing Orders
  	MEASURE WEIGHT	Interval: --	Occurrences: --		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --	Comments:	Vitals (include breath sounds) Pre-Infusion, During Infusion, and Post-Infusion.

Following Post Infusion: Monitor Every 30 minutes x2, Then Every 1 hour x2.

(Total monitoring period Post Infusion is 3 hours.)
		  	PULSE OXIMETRY CONTINUOUS	Interval: --	Occurrences: --	Comments:	Continuous Pulse Oximetry for Oxygen Saturation levels GREATER THAN 90% Before, During and, at least, 30 minutes Post-Infusion.
		  	INSERT PERIPHERAL IV OR ACCESS PORTACATH	Interval: --	Occurrences: --	Comments:	Start peripheral IV, if no central line.  Use 3-way stopcock and tubing.
		  	SUPPLIES/KIT TO BEDSIDE	Interval: --	Occurrences: --	Comments:	Must be at bedside prior to infusion:  Oxygen and suction set up, normal saline flushes, sterile gloves, red caps, and syringes with needles (1mL and 3mL).
		  	ASSESS	Interval: --	Occurrences: --	Comments:	Patient for immediate reactions:  1) Allergic reactions (anaphylaxis); 2) Decreased oxygenation (due to migration of lymphocytes to lungs).
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	EPSTEIN BARR VIRUS (EBV) BY PCR	Interval: --	Occurrences: --		  	CYTOMEGALOVIRUS, QUANTITATIVE PCR	Interval: --	Occurrences: --		  	ADENOVIRUS BY PCR	Interval: --	Occurrences: --		  	HUMAN HERPESVIRUS 6, QUANTITATIVE PCR	Interval: --	Occurrences: --		  	BK VIRUS BY PCR	Interval: --	Occurrences: --		  	LDH	Interval: --	Occurrences: --			Labs
  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --			Outpatient Electrolyte Replacement Protocol
  	TREATMENT CONDITIONS 39	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Potassium level LESS than 3.5 mEq/L; 
3. Recent pre-infusion labs.   

Dosing is based on lab value.
o Serum potassium less than 3.0mEq/L, give 40mEq KCL IV or PO and contact MD/NP. 
o Serum potassium 3.0 to 3.2mEq/L, give 40mEq KCL IV or PO. 
o Serum potassium 3.3 to 3.4mEq/L, give 20mEq KCL IV or PO. 
o Serum potassium 3.5 mEq/L or greater, do not give potassium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
		  	TREATMENT CONDITIONS 40 	Interval: --	Occurrences: --	Comments:	The protocol applies only if the following is met. 
1. SCr LESS than 1.5; 
2. Magnesium level LESS than 1.6 mg/dL; 
3. Recent pre-infusion labs. 

Dosing is based on lab value. 
o Serum Magnesium less than 1.0 mg/dL, give 2 gram magnesium sulfate IV and contact MD/NP. 
o Serum Magnesium 1.0 to 1.2 mg/dL, give 2 gram magnesium sulfate IV. 
o Serum Magnesium 1.3 to 1.5 mg/dL, give 1 gram magnesium sulfate IV. 
o Serum Magnesium 1.6 mg/dL or greater, do not give magnesium replacement. 

If patient meets criteria, order THERAPY PLAN called "Outpatient Electrolyte Replacement". 
Sign electrolyte replacement order as Per protocol: cosign required.
			Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose			Offset: 0 Minutes	Instructions:	Give 30 minutes prior to product administration.		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose			Offset: 0 Minutes	Instructions:	Give 30 minutes prior to product administration.			Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Cells to be administered by physician (generally by syringe injection with 0.9% Normal Saline flush).

Verify cell dose and patient information on Component Infusion Form.  Record infusion start and stop time on form and place in patient's medical record.

Clinic nurse to remain at bedside during the entire infusion.

Ensure informed consent is obtained.
			Emergency Medications
  	TRANSFUSION REACTION EVALUATION	Interval: --	Occurrences: --	Comments:	Anaphylactic precautions:  Keep medications at the bedside to administer per physician's orders.
		  	diphenhydrAMINE (BENADRYL) injection 50 mg	Dose: 50 mg	Route: intravenous	once PRN	Start: S			Instructions:	Keep at bedside to administer per physician's orders.		  	hydrocortisone sodium succinate (Solu-CORTEF) injection 250 mg	Dose: 250 mg	Route: intravenous	once PRN	Start: S			Instructions:	Keep at bedside to administer per physician's orders.		  	EPINEPHrine (ADRENALIN) 1 mg/mL injection FOR IM/SQ USE 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	once PRN	Start: S			Instructions:	Keep at bedside to administer per physician's orders.			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
☑	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			Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.