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IP CODOX A	

Types:      ONCOLOGY TREATMENT
Synonyms:  CYTOX, NON-HOD, LYMP, MTX, NEOSTA, ADRIA, ONCOV, A, CODOX

Cycle 1	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	LDH	Interval: Once	Occurrences: --		☐	URIC ACID LEVEL	Interval: Once	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION 5	Interval: Once	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains/losses of greater than or equal to 10%.
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Once	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.

			Provider Communication
  	ONC PROVIDER COMMUNICATION 64	Interval: Once	Occurrences: --	Comments:	Verify Hep B panel status prior to cycle. Date *** of panel. Result positive/negative/pending/unknown:22867

The required components for the hepatitis B panel includes: Hepatitis B surface antigen (HBsAg), total hepatitis B core antibody (anti-HBc), and hepatitis B antibody (anti-HBs).
			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: Once	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1000; Platelets LESS than 100,000.
			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.			Hydration
  	sodium chloride 0.9 % infusion	Dose: 125 mL/hr	Route: intravenous	continuous				Instructions:	Infuse at 125 mL//hr.
Continue for 24 hours after cyclophosphamide is completed.			Pre-Medications
☑	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			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S	End: S 11:30 AM			☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	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					Chemotherapy
  	vinCRIStine (ONCOVIN) 1.4 mg/m2 in sodium chloride 0.9 % 50 mL chemo IVPB	Dose: 1.4 mg/m2	Route: intravenous	once over 10 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	DRUG IS A VESICANT.  FATAL IF GIVEN INTRATHECALLY.  Maximum dose = 2 mg.	Rule-Based Template: RULE ONCBCN VINCRISTINE 1.4 MG/M2	  Conditions:	  Modifications:	  BSA < 1.43 m2	  Set dose to 1.4 mg/m2	  BSA >= 1.43 m2	  Set dose to 2 mg	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	1.4 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	50 mL	Yes	Yes				Chemotherapy
  	DOXOrubicin (ADRIAmycin) 50 mg/m2 in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 45 Minutes	Instructions:	Protect from light; VESICANT	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	No	Yes				Chemotherapy
  	cyclophosphamide (CYTOXAN) 800 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 800 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 1.75 Hours	Instructions:	Rapid infusion may result in dizziness, nasal/sinus congestion, and/or nasal burning.  

For doses 1000 mg - 1500 mg, infuse over at least 1 hour.   
For doses 500 mg - 1 gm, infuse over at least 45 minutes.   
For doses < 500 mg, infuse over at least 30 minutes.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM/50 ML INTRAVENOUS POWDER FOR SOLUTION (RECONSTITUTED VIAL)	Medications	800 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes				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.				Day 2	Perform every 1 day x1		Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	LDH	Interval: Once	Occurrences: --		☐	URIC ACID LEVEL	Interval: Once	Occurrences: --			Hydration
  	sodium chloride 0.9 % infusion	Dose: 125 mL/hr	Route: intravenous	continuous				Instructions:	Infuse at 125 mL//hr.
Continue for 24 hours after cyclophosphamide is completed.			Pre-Medications
☑	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			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S	End: S 11:30 AM			☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	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					Chemotherapy
  	cyclophosphamide (CYTOXAN) 800 mg/m2 in dextrose 5% 500 mL chemo IVPB	Dose: 800 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Rapid infusion may result in dizziness, nasal/sinus congestion, and/or nasal burning.  

For doses 1000 mg - 1500 mg, infuse over at least 1 hour.   
For doses 500 mg - 1 gm, infuse over at least 45 minutes.   
For doses < 500 mg, infuse over at least 30 minutes.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM/50 ML INTRAVENOUS POWDER FOR SOLUTION (RECONSTITUTED VIAL)	Medications	800 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes					Day 10	Perform every 1 day x1		Labs
☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	LDH	Interval: Once	Occurrences: --		☐	URIC ACID LEVEL	Interval: Once	Occurrences: --			Labs
  	PH, URINALYSIS	Interval: Conditional Frequency	Occurrences: --	Comments:	Draw prior to starting methotrexate and PRN until pH GREATER than 7.  Then draw urine pH every 8 hours until MTX is LESS than 0.05
			Nursing Orders
  	ONC NURSING COMMUNICATION 64	Interval: Until discontinued	Occurrences: --	Comments:	Draw methotrexate level 24 hours, 48 hours and 72 hours AFTER COMPLETION of Methotrexate infusion and send STAT. Continue to obtain Methotrexate level every 24 hours until methotrexate level is less than 0.05.

Check stat urine pH prior to starting methotrexate and then every 8 hours. If urine ph is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, call provider.

The syringe that the blood is sent to lab in needs to be COVERED (brown bag/paper towel) going to the lab.
			Pre-Hydration
  	sodium bicarbonate 150 mEq in dextrose 5% 1,000 mL infusion	Dose: 150 mL/hr	Route: intravenous	continuous	Start: S			Instructions:	Run until methotrexate level is LESS than 0.05 micromol/L.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	850 mL	Yes	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	150 mEq	Yes	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Pre-Medications
☑	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			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S	End: S 11:30 AM			☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	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					Chemotherapy
  	vinCRIStine (ONCOVIN) 1.4 mg/m2 in sodium chloride 0.9 % 50 mL chemo IVPB	Dose: 1.4 mg/m2	Route: intravenous	once over 10 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	DRUG IS A VESICANT.  FATAL IF GIVEN INTRATHECALLY.  Maximum dose = 2 mg.	Rule-Based Template: RULE ONCBCN VINCRISTINE 1.4 MG/M2	  Conditions:	  Modifications:	  BSA < 1.43 m2	  Set dose to 1.4 mg/m2	  BSA >= 1.43 m2	  Set dose to 2 mg	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	1.4 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	50 mL	Yes	Yes				Chemotherapy
  	methotrexate PF 300 mg/m2 in sodium chloride 0.9% 500 mL chemo IVPB	Dose: 300 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 45 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	300 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes				Chemotherapy
  	methotrexate PF 2,700 mg/m2 in sodium chloride 0.9% 1,000 mL chemo IVPB	Dose: 2,700 mg/m2	Route: intravenous	once over 23 Hours for 1 dose			Offset: 1.75 Hours	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	2,700 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	Yes	Yes				Supportive Care
  	sodium bicarbonate 1 mEq/mL (8.4 %) injection 50 mEq	Dose: 50 mEq	Route: intravenous	every 8 hours PRN	Start: S			Instructions:	Check urine pH prior to start of methotrexate and then every shift. 
  
If urine pH is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour.
If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour.
If still LESS than 7, call Physician.

Continue until methotrexate levels are LESS than 0.05 or patient is discharged.				Day 11	Perform every 1 day x1		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 64	Interval: Until discontinued	Occurrences: --	Comments:	Draw methotrexate level 24 hours, 48 hours and 72 hours AFTER COMPLETION of Methotrexate infusion and send STAT. Continue to obtain Methotrexate level every 24 hours until methotrexate level is less than 0.05.

Check stat urine pH prior to starting methotrexate and then every 8 hours. If urine ph is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, call provider.

The syringe that the blood is sent to lab in needs to be COVERED (brown bag/paper towel) going to the lab.
			Labs
☑	METHOTREXATE LEVEL	Interval: Once	Occurrences: --		☑	PH, URINALYSIS	Interval: Conditional Frequency	Occurrences: --	Comments:	Draw prior to starting methotrexate and PRN until pH GREATER than 7.  Then draw urine pH every day until MTX is LESS than 0.05.
			Chemotherapy
  	leucovorin IV 50 mg	Dose: 50 mg	Route: intravenous	every 6 hours over 30 Minutes				Instructions:	Begin 24 hours AFTER COMPLETION of methotrexate infusion.

Continue every 6 hours until levels are LESS than 0.05 micromol/L.