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IP CYCLOPHOSPHAMIDE / FLUDARABINE / LIFILEUCEL / HIGH DOSE IL-2	

Types:      ONCOLOGY TREATMENT
Synonyms:  LAGRE B CELL, DIFFUSE, CYTOXAN, MESNEX, FLUDARA, ALDESLEUKIN, AMTAGVI)

Cycle 1	Repeat 1 time	Cycle length: 10 days	Day 1	Perform every 1 day x1		Supportive Care
  	pentamidine (PENTAM) 4 mg/kg in dextrose 5% 250 mL IVPB	Dose: 4 mg/kg	Route: intravenous	once over 60 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	PENTAMIDINE 300 MG/3 ML SOLUTION FOR INJECTION (RECONSTITUTED VIAL)	Medications	4 mg/kg	Main Ingredient	No	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	250 mL	Always	Yes			  	levoFLOXacin (LEVAQUIN) tablet 500 mg	Dose: 500 mg	Route: oral	daily at 0600	Start: S				  	valACYclovir (VALTREX) tablet 500 mg	Dose: 500 mg	Route: oral	2 times daily	Start: S				  	fluconazole (DIFLUCAN) tablet 400 mg	Dose: 400 mg	Route: oral	daily	Start: S					Nursing Orders
  	ECG 12-LEAD	Interval: Once	Occurrences: --	Comments:	EKG must be reviewed by MD daily prior to each Cyclophosphamide dose.
			Imaging
  	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: 1 time imaging	Occurrences: --			Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☑	LDH	Interval: Once	Occurrences: --		☑	URIC ACID LEVEL	Interval: Once	Occurrences: --	Comments:	.
			Labs
  	URINALYSIS, AUTOMATED WITH MICROSCOPY	Interval: Once	Occurrences: --			Labs
  	BILIRUBIN DIRECT	Interval: Once	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: Once	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 10	Interval: Once	Occurrences: --	Comments:	Nursing may enter hcg lab order if the patient is of child-bearing age.
			Treatment Conditions
  	TREATMENT CONDITIONS	Interval: Until discontinued	Occurrences: --	Comments:	HOLD and notify physician if:
- Platelets LESS than 50,000;
- CrCL LESS than 60 mL/min; 
- T. Bili GREATER than 2 mg/dL
- AST/ALT GREATER than 4x ULN.
			Nursing Orders
  	VITAL SIGNS - T/P/R/BP	Interval: Every 4 hours	Occurrences: --	Comments:	To be performed every 4 hours OR AS DIRECTED BY PHYSICIAN.
			Nursing Orders
  	STRICT INTAKE AND OUTPUT	Interval: Every 12 hours	Occurrences: --			Nursing Orders
  	MEASURE WEIGHT	Interval: Every 12 hours	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Until discontinued	Occurrences: --	Comments:	- Confirm no steroids or NSAIDS have been administered. 
- Confirm ECHO has been performed, EF GREATER than 45% required. 
- Confirm patient has central line access.
			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).
			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	Start: S	End: S+3		Instructions:	Start 4 hours before Cytoxan and continuing for 24 hours after the last dose of Cytoxan.			Pre-Medications
  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 3.5 Hours			Pre-Medications
  	palonosetron (ALOXI) injection 0.25 mg	Dose: 0.25 mg	Route: intravenous	once for 1 dose			Offset: 3.5 Hours			Pre-Medications
  	OLANZapine (ZYPREXA) tablet 10 mg	Dose: 10 mg	Route: oral	once for 1 dose			Offset: 3.5 Hours			Antiemetics
  	prochlorperazine (COMPAZINE) injection 10 mg	Dose: 10 mg	Route: intravenous	every 6 hours PRN	Start: S					Nursing Orders
  	ONC NURSING COMMUNICATION 35	Interval: Once	Occurrences: --	Comments:	During CYCLOPHOSPHAMIDE: 
1. 12 lead EKG must be ordered and reviewed by physician prior to each dose. 
2. Starting 4 hours PRIOR to cyclophosphamide, administer Normal Saline at 125 mL/hr and continue for 24 hours after last dose of cyclophosphamide completes.  (MAX total volume infusion rate during chemotherapy = 350 mL/hr). 
3. Instruct patient to void every 1-2 hours DAILY x 3 days.
			Chemotherapy
  	mesna (MESNEX) 12 mg/kg in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 12 mg/kg	Route: intravenous	once over 15 Minutes for 1 dose			Offset: 4 Hours	Instructions:	Administer BEFORE Mesna+Cyclophosphamide infusion.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION THERAPY PLAN	Medications	12 mg/kg	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			  	ONC PROVIDER COMMUNICATION 3	Interval: Once	Occurrences: --	Comments:	if patients body weight is LESS than 120% ideal then use ideal weight but if GREATER than 120% ideal use adjusted body weight using the 25% correction factor
		  	cycloPHOSphamide (CYTOXAN) 60 mg/kg in sodium chloride 0.9% 500 mL chemo IVPB	Dose: 60 mg/kg	Route: intravenous	once over 2 Hours for 1 dose			Offset: 4.5 Hours	Instructions:	If GREATER than 120% ideal body weight, then dose based on 25% adjusted body weight. 
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM/50 ML INTRAVENOUS POWDER FOR SOLUTION (RECONSTITUTED VIAL)	Medications	60 mg/kg	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			  	mesna (MESNEX) 48 mg/kg in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 48 mg/kg	Route: intravenous	once over 24 Hours for 1 dose			Offset: 4.5 Hours	Instructions:	80% of the Cytoxan dose. Start at the same time as Cytoxan.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION THERAPY PLAN	Medications	48 mg/kg	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				Supportive Care
  	furosemide (LASIX) injection 20 mg	Dose: 20 mg	Route: intravenous	once for 1 dose			Offset: 9.5 Hours		  	furosemide (LASIX) injection 20 mg	Dose: 20 mg	Route: intravenous	once for 1 dose			Offset: 15.5 Hours			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	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 83	Interval: Until discontinued	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 4	Interval: Until discontinued	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	Start: S				  	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.				Day 2	Perform every 1 day x1		Nursing Orders
  	ECG 12-LEAD	Interval: Once	Occurrences: --	Comments:	EKG must be reviewed by MD daily prior to each Cyclophosphamide dose.
			Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☑	LDH	Interval: Once	Occurrences: --		☑	URIC ACID LEVEL	Interval: Once	Occurrences: --	Comments:	.
			Labs
  	URINALYSIS, AUTOMATED WITH MICROSCOPY	Interval: Once	Occurrences: --			Labs
  	BILIRUBIN DIRECT	Interval: Once	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: Once	Occurrences: --			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.			Pre-Medications
  	OLANZapine (ZYPREXA) tablet 10 mg	Dose: 10 mg	Route: oral	once for 1 dose			Offset: 30 Minutes			Nursing Orders
  	ONC NURSING COMMUNICATION 35	Interval: Once	Occurrences: --	Comments:	During CYCLOPHOSPHAMIDE: 
1. 12 lead EKG must be ordered and reviewed by physician prior to each dose. 
2. Starting 4 hours PRIOR to cyclophosphamide, administer Normal Saline at 125 mL/hr and continue for 24 hours after last dose of cyclophosphamide completes.  (MAX total volume infusion rate during chemotherapy = 350 mL/hr). 
3. Instruct patient to void every 1-2 hours DAILY x 3 days.
			Chemotherapy
  	mesna (MESNEX) 12 mg/kg in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 12 mg/kg	Route: intravenous	once over 15 Minutes for 1 dose			Offset: 1 Hours	Instructions:	Administer BEFORE Mesna+Cyclophosphamide infusion.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION THERAPY PLAN	Medications	12 mg/kg	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			  	ONC PROVIDER COMMUNICATION 3	Interval: Once	Occurrences: --	Comments:	if patients body weight is LESS than 120% ideal then use ideal weight but if GREATER than 120% ideal use adjusted body weight using the 25% correction factor
		  	cycloPHOSphamide (CYTOXAN) 60 mg/kg in sodium chloride 0.9% 500 mL chemo IVPB	Dose: 60 mg/kg	Route: intravenous	once over 2 Hours for 1 dose			Offset: 1.5 Hours	Instructions:	If GREATER than 120% ideal body weight, then dose based on 25% adjusted body weight. 
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM/50 ML INTRAVENOUS POWDER FOR SOLUTION (RECONSTITUTED VIAL)	Medications	60 mg/kg	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			  	mesna (MESNEX) 48 mg/kg in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 48 mg/kg	Route: intravenous	once over 24 Hours for 1 dose			Offset: 1.5 Hours	Instructions:	80% of the Cytoxan dose. Start at the same time as Cytoxan.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION THERAPY PLAN	Medications	48 mg/kg	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				Supportive Care
  	furosemide (LASIX) injection 20 mg	Dose: 20 mg	Route: intravenous	once for 1 dose			Offset: 3.5 Hours		  	furosemide (LASIX) injection 20 mg	Dose: 20 mg	Route: intravenous	once for 1 dose			Offset: 9.5 Hours				Day 3	Perform every 1 day x1		Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☑	LDH	Interval: Once	Occurrences: --		☑	URIC ACID LEVEL	Interval: Once	Occurrences: --	Comments:	.
			Labs
  	URINALYSIS, AUTOMATED WITH MICROSCOPY	Interval: Once	Occurrences: --			Labs
  	BILIRUBIN DIRECT	Interval: Once	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: Once	Occurrences: --			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.			Pre-Medications
  	OLANZapine (ZYPREXA) tablet 10 mg	Dose: 10 mg	Route: oral	once for 1 dose			Offset: 30 Minutes			Provider Communication
  	ONC PROVIDER COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	In patients with impaired renal function, fludarabine dose should be reduced (20 mg/m2 in patients with CrCl 50-79 mL/min and 15 mg/m2 in patients with CrCl 40-49 mL/min)
			Chemotherapy
  	fludarabine (FLUDARA) 25 mg/m2 in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 25 mg/m2	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION	Medications	25 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					Day 4	Perform every 1 day x1		Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☑	LDH	Interval: Once	Occurrences: --		☑	URIC ACID LEVEL	Interval: Once	Occurrences: --	Comments:	.
			Labs
  	BILIRUBIN DIRECT	Interval: Once	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: Once	Occurrences: --			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.			Pre-Medications
  	OLANZapine (ZYPREXA) tablet 10 mg	Dose: 10 mg	Route: oral	once for 1 dose			Offset: 30 Minutes			Pre-Medications
  	palonosetron (ALOXI) injection 0.25 mg	Dose: 0.25 mg	Route: intravenous	once for 1 dose			Offset: 30 Minutes			Provider Communication
  	ONC PROVIDER COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	In patients with impaired renal function, fludarabine dose should be reduced (20 mg/m2 in patients with CrCl 50-79 mL/min and 15 mg/m2 in patients with CrCl 40-49 mL/min)
			Chemotherapy
  	fludarabine (FLUDARA) 25 mg/m2 in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 25 mg/m2	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION	Medications	25 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					Day 5	Perform every 1 day x1		Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☑	LDH	Interval: Once	Occurrences: --		☑	URIC ACID LEVEL	Interval: Once	Occurrences: --	Comments:	.
			Labs
  	BILIRUBIN DIRECT	Interval: Once	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: Once	Occurrences: --			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.			Pre-Medications
  	OLANZapine (ZYPREXA) tablet 10 mg	Dose: 10 mg	Route: oral	once for 1 dose			Offset: 30 Minutes			Provider Communication
  	ONC PROVIDER COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	In patients with impaired renal function, fludarabine dose should be reduced (20 mg/m2 in patients with CrCl 50-79 mL/min and 15 mg/m2 in patients with CrCl 40-49 mL/min)
			Chemotherapy
  	fludarabine (FLUDARA) 25 mg/m2 in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 25 mg/m2	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION	Medications	25 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					Days 6,7	Perform every 1 day x2		Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☑	LDH	Interval: Once	Occurrences: --		☑	URIC ACID LEVEL	Interval: Once	Occurrences: --	Comments:	.
			Labs
  	BILIRUBIN DIRECT	Interval: Once	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: Once	Occurrences: --			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.			Provider Communication
  	ONC PROVIDER COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	In patients with impaired renal function, fludarabine dose should be reduced (20 mg/m2 in patients with CrCl 50-79 mL/min and 15 mg/m2 in patients with CrCl 40-49 mL/min)
			Chemotherapy
  	fludarabine (FLUDARA) 25 mg/m2 in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 25 mg/m2	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 30 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION	Medications	25 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					Day 8	Perform every 1 day x1		Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☑	LDH	Interval: Once	Occurrences: --		☑	URIC ACID LEVEL	Interval: Once	Occurrences: --	Comments:	.
			Labs
  	BILIRUBIN DIRECT	Interval: Once	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: Once	Occurrences: --			Labs
  	FERRITIN LEVEL	Interval: Once	Occurrences: --			Labs
  	C-REACTIVE PROTEIN	Interval: Once	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 63	Interval: Once	Occurrences: --	Comments:	Amtagvi is to be administered AT LEAST 24 hours after the last dose of fludarabine
		  	ONC NURSING COMMUNICATION 72	Interval: Until discontinued	Occurrences: --	Comments:	Initiate telemetry monitoring once AMTAGVI begins and continue for 24 hours after the last dose of IL-2
			Nursing Orders
  	ONC NURSING COMMUNICATION 64	Interval: Once	Occurrences: --	Comments:	Confirm no doses of steroids have been administered
			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.			Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Premed for AMTAGVI infusion		  	diphenhydrAMINE (BENADRYL) injection 12.5 mg	Dose: 12.5 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Premed for AMTAGVI infusion			Nursing Orders
  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	Ensure antihypertensives are discontinued at least 24 hours prior to IL2 administration.
			Chemotherapy
  	lifileucel (AMTAGVI) infusion (RESTRICTED) 1 bag(s)	Dose: 1 bag(s)	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	o Do NOT use a leukocyte depleting filter with AMTAGVI. 
o Wait to thaw the next bag until the previous bag has been safely and completely administered. 
o Prime the tubing with normal saline prior to infusion. 
o Initiate the infusion. Infuse the entire contents of each bag as soon as possible but within 3 hours of thawing. 
o Administer AMTAGVI at an infusion rate of approximately 1 mL per minute for the initial 5 minutes; thereafter 5 mL to 10 mL per minute.
o After the last bag is infused, rinse the tubing with normal saline at the same infusion rate to ensure all product is delivered. 
o Ensure that all bags prescribed are infused. 
o Actual number of bags to be administered may differ from the order. Please adjust the number on the MAR.			Supportive Care
  	filgrastim-sndz (ZARXIO) injection solution	Dose: --	Route: subcutaneous	every 24 hours			Offset: 27 Hours	Instructions:	o To start 24 hours AFTER COMPLETION of AMTAGVI. 
o RN may change the start time of filgrastim to be 24 hours after the completion of AMTAGVI. 
o Continue daily until ANC is GREATER than 1000 cells/uL for 3 consecutive days	Rule-Based Template: RULE ONCBCN NEUPOGEN WEIGHT BASED	  Conditions:	  Modifications:	  Weight > 78 kg	  Set dose to 480 mcg	  Weight <= 78 kg	  Set dose to 300 mcg			Other
  	ONC NURSING COMMUNICATION 55	Interval: Once	Occurrences: --	Comments:	-Oxygen at bedside during infusion and until discharged. 
-Anaphylaxis precautions at bedside during infusion and until discharged.
		  	ONC NURSING COMMUNICATION 65	Interval: Until discontinued	Occurrences: --	Comments:	- Obtain baseline vital signs (T, P, R, BP, Oxygen saturation +/- breath sounds) 
- Vital signs every 15 minutes during infusion (T, P, R, BP) 
- Vital signs (T, P, R, BP, +/- breath sounds) at completion of infusion, then at 30 minutes post & 60 minutes post infusion
		  	VITAL SIGNS - T/P/R/BP	Interval: Once	Occurrences: --	Comments:	Baseline. With Oxygen saturation +/- breath sounds.
		  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	Occurrences: --	Comments:	Every 15 minutes during infusion.
		  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	Occurrences: --	Comments:	At completion of infusion, at 30 minutes post & 60 minutes post infusion, then hourly for 3 hours. +/- breath sounds.
		  	PULSE OXIMETRY	Interval: Continuous	Occurrences: --	Comments:	Continuous pulse oximetry monitoring during infusion and for 30 minutes post infusion
		  	ONC NURSING COMMUNICATION 66	Interval: Once	Occurrences: --	Comments:	RECORD administration of all bags in EPIC
			Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	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 83	Interval: Until discontinued	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 4	Interval: Until discontinued	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	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Hypersensitivity
  	meperidine (DEMEROL) injection 12.5 mg	Dose: 12.5 mg	Route: intravenous	every 15 min PRN for 3 doses	Start: S				  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	every 6 hours PRN	Start: S						Day 9 & 10	Perform every 1 day x1		Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☑	LDH	Interval: Once	Occurrences: --		☑	URIC ACID LEVEL	Interval: Once	Occurrences: --	Comments:	.
			Labs
  	BILIRUBIN DIRECT	Interval: Once	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: Once	Occurrences: --			Labs
  	THYROID STIMULATING HORMONE	Interval: Once	Occurrences: --		  	T3	Interval: Once	Occurrences: --		  	T4, FREE	Interval: Once	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 60	Interval: Until discontinued	Occurrences: --	Comments:	Please ensure patient has an active order for Zarxio. Zarxio should start 24 hours after the completion of Amtagvi.
			Nursing Orders
  	ONC NURSING COMMUNICATION 67	Interval: Once	Occurrences: --	Comments:	HOLD and notify provider if:
- Platelets LESS than 50,000; 
- Creatinine MORE than 2.5 mg/dL; 
- HCO3 LESS than 18 mEq/dL; 
- O2 saturation LESS than 90%; 
- Urine output LESS than 160 mL per 8 hours;
- Diarrhea MORE than 1000 mL per 8 hours or more than 5 episodes; 
- HR GREATER than 120 beats/min; 
- Weight gain GREATER than 15%;
- Total bilirubin GREATER than 7 mg/dL.
		  	ONC NURSING COMMUNICATION 68	Interval: Once	Occurrences: --	Comments:	Monitor blood pressure, heart rate, respiratory rate, pulse oximetry before each dose and every 4 hours
		  	ONC NURSING COMMUNICATION 71	Interval: Once	Occurrences: --	Comments:	Urine output should be assessed prior to each dose; the goal should be to maintain a urine output of at least 0.5 mL/ kg/hour. Contact provider before administering IL- 2 if the urine output falls below 4 mL/kg over a period of 8 hours.
		  	ONC NURSING COMMUNICATION 69	Interval: Once	Occurrences: --	Comments:	Diuretics should be avoided for at least 24 hours after the last dose of IL-2.
		  	ONC NURSING COMMUNICATION 70	Interval: Once	Occurrences: --	Comments:	Perform neurological assessment every 8 hours and notify provider for worsening mental status.
		  	ONC NURSING COMMUNICATION 62	Interval: Once	Occurrences: --	Comments:	o Contact provider prior to each dose. 
o Contact pharmacy prior to each dose.
			Line Flush
  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Nursing Orders
  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S					Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	every 4 hours for 18 doses	Start: S			Instructions:	Start 30 minutes prior to IL-2 and continue every 4 hours through the end of treatment.		  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	2 times daily for 6 doses	Start: S				  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S				  	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	every 8 hours for 8 doses	Start: S			Instructions:	Start 30 minutes prior to IL-2 and continue for 12 hours after the last dose of IL-2.		  	naproxen (NAPROSYN) tablet 250 mg	Dose: 250 mg	Route: oral	every 8 hours for 8 doses	Start: S			Instructions:	Start 30 minutes prior to IL-2 and continue for 12 hours after the last dose of IL-2. 
OMIT if CrCl LESS than 60 mL/min. Stop if SCr GREATER than 2mg/dL, decreased UOP, or platelets LESS than 50000 x10ˆ9/L. 
		  	prochlorperazine (COMPAZINE) injection 10 mg	Dose: 10 mg	Route: intravenous	every 6 hours PRN	Start: S			Instructions:	Start at the initial onset of nausea/vomiting.			Nursing Orders
  	ONC NURSING COMMUNICATION 52	Interval: Until discontinued	Occurrences: --	Comments:	Please request each dose of Interleukin-2 by pharmacy once approved by the Hematology/Oncology team
			Chemotherapy
  	aldesleukin (PROLEUKIN) 0.6 Million Units/kg in dextrose 5% 50 mL chemo IVPB	Dose: 0.6 Million Units/kg	Route: intravenous	every 8 hours over 15 Minutes for 6 doses	Start: S			Instructions:	Pharmacy: Please confirm each dose is indicated with the RN prior to dispensing/preparation. 
Flush line with D5W pre and post IL-2. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ALDESLEUKIN 22 MILLION UNIT/1.22 ML INTRAVENOUS SOLUTION (RECONSTITUTED VIAL)	Medications	0.6 Million Units/kg	Main Ingredient	Yes	ALBUMIN, HUMAN 5 % WRAPPER	Medications	 	No	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes				Discharge Nursing Orders
  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Supportive Care
  	white petrolatum ointment/jelly ointment	Dose: --	Route: Topical	PRN	Start: S			Instructions:	Specify Site: Skin. 
Apply as needed for dry skin. 
Steroids are CONTRAINDICATED with this regimen.		  	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	every 8 hours PRN	Start: S				  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	every 6 hours PRN	Start: S				  	meperidine (DEMEROL) injection 25 mg	Dose: 25 mg	Route: intravenous	every 4 hours PRN	Start: S			Instructions:	Max 100 mg in 1 hour. 
May repeat dose within 30 mins as needed for rigors. 
		  	loperamide (IMODIUM) capsule 2 mg	Dose: 2 mg	Route: oral	PRN	Start: S			Instructions:	Do NOT exceed 16mg per 24 hours		  	benadryl/lidocaine/maalox+simethicone (MAGIC MOUTHWASH) 1:1:1 suspension 10 mL	Dose: 10 mL	Route: --	every 6 hours PRN	Start: S			Instructions:	Swish and spit. 
SHAKE WELL BEFORE USE. 

		  	sodium chloride 0.9 % bolus 250 mL	Dose: 250 mL	Route: intravenous	once PRN over 30 Minutes	Start: S			Instructions:	May repeat twice within 24 hours.  If SBP remains below 90 mmHg after 3rd bolus contact MD to initiate vasopressors