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RESEARCH PRO00030861 / ZHANG / NRG-LU005 ARM 2	

Types:      Research Oncology Treatment
Synonyms:  NRG, LU005, 23051, PRO23051, PRO30861, 30861

Screening	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Pathologic proof of SCLC
		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	ECOG status
		  	CHECK TEMPERATURE	Interval: --	Occurrences: --	Comments:	Body temperature
		  	PULSE CHECKS	Interval: --	Occurrences: --		  	PULSE OXIMETRY	Interval: --	Occurrences: --		  	MEASURE BLOOD PRESSURE	Interval: --	Occurrences: --		  	RESEARCH - HEIGHT AND WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Questionnaires (to be performed by research staff)
			Nursing Orders
  	SPIROMETRY PRE AND POST WITH BRONCHILATOR	Interval: --	Occurrences: --		  	BODY PLETHYSMOGRAPHIC LUNG VOLUMES	Interval: --	Occurrences: --		  	DIFFUSION CAPACITY	Interval: --	Occurrences: --			Imaging
  	PET CT SKULL BASE TO MID THIGH	Interval: --	Occurrences: --	Comments:	For staging
		  	CT CHEST W CONTRAST ABDOMEN W CONTRAST	Interval: --	Occurrences: --		  	MRI BRAIN W CONTRAST	Interval: --	Occurrences: --		  	CT HEAD W CONTRAST	Interval: --	Occurrences: --			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --					
Cycles 1 to 3	Repeat 3 times	Cycle length: 21 days	Day 1	Perform every 1 day x1		Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 11	Interval: --	Occurrences: --			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.			Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	ECOG status
		  	CHECK TEMPERATURE	Interval: --	Occurrences: --	Comments:	Body temperature
		  	PULSE CHECKS	Interval: --	Occurrences: --		  	PULSE OXIMETRY	Interval: --	Occurrences: --		  	MEASURE BLOOD PRESSURE	Interval: --	Occurrences: --		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --			Imaging
  	ONC NURSING COMMUNICATION 12	Interval: --	Occurrences: --	Comments:	Radiation starts concurrent with chemo and atezolizumab after randomization
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	Thoracic RT 45 Gy every other day OR 66 Gy daily
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --	Comments:	If abnormal, T3 and T4 to be collected
		☐	T3	Interval: --	Occurrences: --	Comments:	To be collected if TSH is abnormal
		☐	T4	Interval: --	Occurrences: --	Comments:	To be collected if TSH is abnormal
			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
☑	palonosetron (ALOXI) injection 0.25 mg	Dose: 0.25 mg	Route: intravenous	once for 1 dose	Start: S				☑	dexAMETHasone (DECADRON) IV 12 mg	Dose: 12 mg	Route: intravenous	once for 1 dose	Start: S				☑	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S				☐	netupitant-palonosetron (AKYNZEO) 300-0.5 mg per capsule 1 capsule	Dose: 1 capsule	Route: oral	once for 1 dose	Start: S	End: S  5:30 PM		Instructions:	Administer approximately 1 hour prior to chemotherapy.		☐	ondansetron (ZOFRAN), dexAMETHasone (DECADRON) in sodium chloride 0.9% 50 mL IVPB	Dose: --	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	 	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes				Pre-Hydration
  	sodium chloride 0.9% infusion 1,000 mL	Dose: 1,000 mL	Route: intravenous	once @ 500 mL/hr for 1 dose	Start: S			Instructions:	Prior to Cisplatin			Chemotherapy
  	CISplatin (PLATINOL) 60 mg/m2 in sodium chloride 0.9% 500 mL chemo IVPB	Dose: 60 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 2 Hours	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION	Medications	60 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes				Chemotherapy
  	etoposide (TOPOSAR) 120 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 120 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 3 Hours	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	120 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Chemotherapy
  	INV-atezolizumab (LU005/Pro00023051/Zhang) 1,200 mg in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 1,200 mg	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 4 Hours	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. Handle as chemo drug. Stability: if not used immediately, store at 2-25 C for maximum 8 hours.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOL (LU005/PRO00030861/ZHANG)	Medications	1,200 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	230 mL	Yes	Yes				Chemotherapy
☐	ONC NURSING COMMUNICATION 10	Interval: --	Occurrences: --	Comments:	If cisplatin not used then carboplatin can be administered
		☐	ondansetron (ZOFRAN) 16 mg, dexAMETHasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes				Pre-Medications
☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy		☐	netupitant-palonosetron (AKYNZEO) 300-0.5 mg per capsule 1 capsule	Dose: 1 capsule	Route: oral	once for 1 dose	Start: S	End: S  5:30 PM		Instructions:	Administer approximately 1 hour prior to chemotherapy.			Chemotherapy
☐	CARBOplatin (PARAplatin) in sodium chloride 0.9% 250 mL chemo IVPB	AUC: 5 Use AUC	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Hours	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes			☐	etoposide (TOPOSAR) 100 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 100 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 60 Minutes	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	100 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 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					Post-Hydration
◯	sodium chloride 0.9% infusion 1,000 mL	Dose: 1,000 mL	Route: intravenous	once @ 500 mL/hr for 1 dose			Offset: 4 Hours	Instructions:	Following chemotherapy with Cisplatin			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.				Days 2,3	Perform every 1 day x2		Appointment Requests
  	ONC INFUSION APPOINTMENT REQUEST 4	Interval: --	Occurrences: --			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.			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.
			Imaging
  	ONC NURSING COMMUNICATION 12	Interval: --	Occurrences: --	Comments:	Radiation starts concurrent with chemo and atezolizumab after randomization
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	Thoracic RT 45 Gy every other day OR 66 Gy daily
			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	once for 1 dose	Start: S					Chemotherapy
◉	etoposide (TOPOSAR) 120 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 120 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	120 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes			◯	etoposide (TOPOSAR) 100 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 100 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	100 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 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.				Days 8,15	Perform every 7 days x2		Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	ECOG status
		  	PULSE CHECKS	Interval: --	Occurrences: --		  	PULSE OXIMETRY	Interval: --	Occurrences: --		  	MEASURE BLOOD PRESSURE	Interval: --	Occurrences: --		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Questionnaires (to be performed by research staff)
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --					
Cycles 4 to 17	Repeat 14 times	Cycle length: 21 days	Day 1	Perform every 1 day x1		Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	ECOG status
		  	PULSE CHECKS	Interval: --	Occurrences: --		  	PULSE OXIMETRY	Interval: --	Occurrences: --		  	MEASURE BLOOD PRESSURE	Interval: --	Occurrences: --		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 11	Interval: --	Occurrences: --	Comments:	Consolidative Immunotherapy (every 3 weeks)
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --	Comments:	If abnormal, T3 and T4 to be collected
		☐	T3	Interval: --	Occurrences: --	Comments:	To be collected if TSH is abnormal
		☐	T4	Interval: --	Occurrences: --	Comments:	To be collected if TSH is abnormal
					
End of Trial	Repeat 1 time	Cycle length: 90 days	Day 1	Perform every 1 day x1		Imaging
  	CT CHEST W CONTRAST	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Questionnaires (to be performed by research staff)
			Labs
  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --					
Long Term Follow Up Every 3 Mo for 2 Years	Repeat 7 times	Cycle length: 90 days	Day 1	Perform every 1 day x1		Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	ECOG status
		  	PULSE CHECKS	Interval: --	Occurrences: --		  	PULSE OXIMETRY	Interval: --	Occurrences: --		  	MEASURE BLOOD PRESSURE	Interval: --	Occurrences: --		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Questionnaires (to be performed by research staff)
			Imaging
  	CT CHEST W CONTRAST ABDOMEN W CONTRAST	Interval: --	Occurrences: --		  	MRI BRAIN W WO CONTRAST	Interval: --	Occurrences: --	Comments:	(if PCI not given)
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --	Comments:	If abnormal, T3 and T4 to be collected
		☐	T3	Interval: --	Occurrences: --	Comments:	To be collected if TSH is abnormal
		☐	T4	Interval: --	Occurrences: --	Comments:	To be collected if TSH is abnormal
		☑	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --					
Long Term Follow Up Every 3 Mo for 2 Years	Repeat 1 time	Cycle length: 180 days	Day 1	Perform every 1 day x1		Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	ECOG status
		  	PULSE CHECKS	Interval: --	Occurrences: --		  	PULSE OXIMETRY	Interval: --	Occurrences: --		  	MEASURE BLOOD PRESSURE	Interval: --	Occurrences: --		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Questionnaires (to be performed by research staff)
			Imaging
  	CT CHEST W CONTRAST ABDOMEN W CONTRAST	Interval: --	Occurrences: --		  	MRI BRAIN W WO CONTRAST	Interval: --	Occurrences: --	Comments:	(if PCI not given)
			Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --	Comments:	If abnormal, T3 and T4 to be collected
		☐	T3	Interval: --	Occurrences: --	Comments:	To be collected if TSH is abnormal
		☐	T4	Interval: --	Occurrences: --	Comments:	To be collected if TSH is abnormal
		☑	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --					
Long Term Follow Up Every 6 Mo for 1 Year	Repeat 1 time	Cycle length: 180 days	Day 1	Perform every 1 day x1		Nursing Orders
  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	ECOG status
		  	PULSE CHECKS	Interval: --	Occurrences: --		  	PULSE OXIMETRY	Interval: --	Occurrences: --		  	MEASURE BLOOD PRESSURE	Interval: --	Occurrences: --		  	RESEARCH - MEASURE WEIGHT	Interval: --	Occurrences: --			Imaging
☑	CT CHEST W CONTRAST ABDOMEN W CONTRAST	Interval: --	Occurrences: --		☐	MRI BRAIN W WO CONTRAST	Interval: --	Occurrences: --	Comments:	If clinically indicated
			Labs
☐	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --	Comments:	If clinically indicated
		☐	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --	Comments:	If clinically indicated