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NOGAPENDEKIN ALFA INBAKICEPT-PMLN (ANKTIVA) /BCG (BACILLUS CALMETTE-GUERIN)-MAINTENANCE	

Types:      ONCOLOGY TREATMENT
Synonyms:  MUSCLE, INVASIVE BLADDER, BCG

Cycle 1	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 7 days x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --			Labs
☑	HCG QUALITATIVE, SERUM SCREEN	Interval: --	Occurrences: --		☑	HCG QUALITATIVE, URINE SCREEN	Interval: --	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	1.	Insert Foley catheter into the bladder under sterile condition.
2.	Connect 60 mL syringe containing the medicine to the Foley catheter.
3.	Instill the medicine gently into the bladder over 2 minutes.
			Nursing Orders
  	ONC NURSING COMMUNICATION	Interval: --	Occurrences: --	Comments:	1.	Instruct patient to retain medicine in the bladder for 2 hours and then void
2.	During the 2 hours, reposition the patient from left side to the right side and also lie upon the back and the abdomen every 15 minutes to maximize bladder surface exposure to the medicine
3.	Monitor for signs and symptoms of urinary tract infection, bladder spasm, hematuria, dysuria, urinary frequency, fever, malaise and myalgia.
			Chemotherapy
  	Nogapendekin alfa inbakicept-pmln 400 mcg in 50 mL of BCG suspension with 0.9% sodium chloride (RESTRICTED)	Dose: --	Route: instillation	once for 1 dose	Start: S			Instructions:	BCG diluted in 50 mL normal saline
1. Draw 1 mL of sterile, preservative free saline (0.9% ND injection USP) from a 50 mL vial of sterile saline at 4C -25 C into a small syringe and add to 1 Ml of BCG to resuspend
2. Gently swirl the vial until a homogeneous suspension is obtained, avoid forceful agitation
3. Dilute the cloudy BCG suspension in the same 50 mL sterile, preservative free saline vial to a final volume of 50 mL

ANKTIVA ADMIXED IN 50 ML SALINE WITH BCG
1.	Draw 0.4 mL into a small syringe and using aseptic technique add it to the 50 mL saline volume containing the BCG. Gently mix the suspension. Using a 60 mL syringe withdraw the Anktiva and BCG mixture to a final volume of 50 mL
2.	Use immediately, if not, store refrigerated at 2C to 8C and use within 2 hours
3.	Do not use if visible particle; mixture must be clear to slightly opalescent 
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BCG LIVE 50 MG/ML INTRAVESICAL SUSPENSION (RECONSTITUTED VIAL)	Medications	50 mg	Always	No	NOGAPENDEKIN ALFA INBAKICEPT-PMLN 400 MCG/0.4 ML INTRAVESICAL SOLUTION	Medications	400 mcg	Always	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 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.
		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once PRN	Start: S				  	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	Interval: --	Occurrences: --	Comments:	After instillation was completed and the patient has voided the bladder, remove the Foley catheter prior to discharge.