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IP HIGH DOSE METHOTREXATE / LEUCOVORIN (DAY 2)	

Types:      ONCOLOGY TREATMENT
Synonyms:  MTX, METHOTREXATE, LEUCO, LEUCOVORIN, HIGH DOSE, PRIMARY, LYMPHOMA

Cycle 1	Repeat 1 time	Cycle length: 14 days	Day 1	Perform every 1 day x1		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).
			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%.
			Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☐	BASIC METABOLIC PANEL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	LDH	Interval: Once	Occurrences: --		☐	URIC ACID LEVEL	Interval: Once	Occurrences: --		☐	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: 1 time imaging	Occurrences: --		☑	METHOTREXATE LEVEL	Interval: Timed	Occurrences: --	Comments:	Timed draw frequency based on MTX dose. Verify with MD for draw frequency.
			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 Methotrexate is LESS than 0.05.
			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: Once	Occurrences: --	Comments:	HOLD and notify provider if ANC LESS than 1000; Platelets LESS than 100,000.
			Nursing Orders
  	ONC NURSING COMMUNICATION 35	Interval: Once	Occurrences: --	Comments:	1) NO carbonated beverages or fruit juices
2) Obtain weight and height on date of admission. Obtain weight every 8 hours
3) Strict I&O's every 8 hours
4) Check urine output every 4 hours
5) Check urine pH every shift with Nitrazine paper
			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.			Pre-Hydration
◯	sodium acetate 100 mEq in dextrose 5% 1,000 mL infusion	Dose: 125 mL/hr	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	950 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	100 mEq	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	100 mEq	Yes	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			◉	sodium bicarbonate 100 mEq in dextrose 5% 1,000 mL infusion	Dose: 125 mL/hr	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	900 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	100 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					Medications
☐	furosemide (LASIX) injection 5 mg	Dose: 5 mg	Route: intravenous	once for 1 dose	Start: S	End: S  8:00 PM		Instructions:	Give if daily weight is GREATER THAN 0.5 kg above admission weight		☐	furosemide (LASIX) injection 10 mg	Dose: 10 mg	Route: intravenous	once for 1 dose	Start: S	End: S  8:00 PM		Instructions:	Give if daily weight is GREATER THAN 1.0 kg above admission weight		☐	furosemide (LASIX) injection 15 mg	Dose: 15 mg	Route: intravenous	once for 1 dose	Start: S	End: S  8:00 PM		Instructions:	Give if daily weight is GREATER THAN 1.5 kg above admission weight			Nursing Orders
☑	ONC NURSING COMMUNICATION 33	Interval: Until discontinued	Occurrences: --	Comments:	Call MD if urine pH less than 7.0 with each void
			Medications
☐	sodium bicarbonate tablet 3,250 mg	Dose: 3,250 mg	Route: oral	every 4 hours while awake	Start: S			Instructions:	Give until Methotrexate level is LESS THAN or EQUAL to 0.09 mmol			Chemotherapy
  	methotrexate PF in sodium chloride 0.9 % 500 mL chemo IVPB	Dose: --	Route: intravenous	once over 4 Hours for 1 dose			Offset: 4 Hours	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	 	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				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	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		Labs
  	BASIC METABOLIC PANEL	Interval: Once	Occurrences: --			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
			Nursing Orders
  	ONC NURSING COMMUNICATION 35	Interval: Once	Occurrences: --	Comments:	1) NO carbonated beverages or fruit juices
2) Obtain weight and height on date of admission. Obtain weight every 8 hours
3) Strict I&O's every 8 hours
4) Check urine output every 4 hours
5) Check urine pH every shift with Nitrazine paper
			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.			Medications
☐	furosemide (LASIX) injection 5 mg	Dose: 5 mg	Route: intravenous	once for 1 dose	Start: S	End: S  8:00 PM		Instructions:	Give if daily weight is GREATER THAN 0.5 kg above admission weight		☐	furosemide (LASIX) injection 10 mg	Dose: 10 mg	Route: intravenous	once for 1 dose	Start: S	End: S  8:00 PM		Instructions:	Give if daily weight is GREATER THAN 1.0 kg above admission weight		☐	furosemide (LASIX) injection 15 mg	Dose: 15 mg	Route: intravenous	once for 1 dose	Start: S	End: S  8:00 PM		Instructions:	Give if daily weight is GREATER THAN 1.5 kg above admission weight			Nursing Orders
☑	ONC NURSING COMMUNICATION 33	Interval: Until discontinued	Occurrences: --	Comments:	Call MD if urine pH less than 7.0 with each void
			Medications
☐	sodium bicarbonate tablet 3,250 mg	Dose: 3,250 mg	Route: oral	every 4 hours while awake	Start: S			Instructions:	Give until Methotrexate level is LESS THAN or EQUAL to 0.09 mmol			Chemotherapy
  	leucovorin 25 mg in sodium chloride 0.9 % 100 mL chemo IVPB	Dose: 25 mg	Route: intravenous	continuous over 2 Hours			Offset: 0 Hours	Instructions:	-Begin initial infusion EXACTLY 24 hours after START of Methotrexate infusion

-Continue until MTX level is LESS THAN or EQUAL to 0.05 umol/L	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	LEUCOVORIN CALCIUM 350 MG/17.5 ML SOLUTION FOR INJECTION (RECONSTITUTED VIAL)	Medications	25 mg	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	98.75 mL	Yes	Yes			  	ONC NURSING COMMUNICATION 34	Interval: Until discontinued	Occurrences: --	Comments:	Check MTX levels DAILY beginning EXACTLY 24 hours AFTER completion of MTX infusion until MTX level is LESS THAN 0.05 umol/L