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OP/IP EP-EMA	

Types:      ONCOLOGY TREATMENT
Synonyms:  EPEMA, EP-EMA, EMA-EP, GESTATIONAL, TROPHO, ETOPOSIDE, METHOTREXATE, ACTINOMYCIN, DACTINOMYCIN, MTX, FROMM

Cycle 1	Repeat 1 time	Cycle length: 14 days	Day 1 (Outpatient)	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Provider Communication
  	ONC PROVIDER COMMUNICATION 64	Interval: --	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).
			Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			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.
			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if 
o ANC LESS than 1000; 
o Platelets LESS than 100,000.
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Pre-Hydration
  	sodium chloride 0.9 % infusion 1,000 mL	Dose: 1,000 mL	Route: intravenous	once @ 999 mL/hr over 1 Hours for 1 dose	Start: S					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				Breakthrough Anti-Emetics
☐	diphenhydrAMINE (BENADRYL) tablet 12.5-25 mg	Dose: 12.5-25 mg	Route: oral	every 4 hours PRN	Start: S				☐	diphenhydrAMINE (BENADRYL) injection 12-25 mg	Dose: 12-25 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	promethazine (PHENERGAN) tablet 12.5-25 mg	Dose: 12.5-25 mg	Route: oral	every 4 hours PRN	Start: S				☐	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	promethazine (PHENERGAN) IVPB	Dose: 25 mg	Route: intravenous	every 4 hours PRN over 30 Minutes	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	PROMETHAZINE 25 MG/ML INJECTION SOLUTION	Medications	25 mg	Main Ingredient	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Always	Yes			☐	LORAZepam (ATIVAN) tablet 0.5-1 mg	Dose: 0.5-1 mg	Route: oral	every 4 hours PRN	Start: S				☐	LORAZepam (ATIVAN) injection 0.5-1 mg	Dose: 0.5-1 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	haloperidoL (HALDOL) tablet 0.5-1 mg	Dose: 0.5-1 mg	Route: oral	every 4 hours PRN	Start: S				☐	haloperidol lactate (HALDOL) injection 0.5-1 mg	Dose: 0.5-1 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	metoclopramide (REGLAN) tablet 10 mg	Dose: 10 mg	Route: oral	every 4 hours PRN	Start: S				☐	metoclopramide (REGLAN) injection 10 mg	Dose: 10 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	dexAMETHasone (DECADRON) tablet 10 mg	Dose: 10 mg	Route: oral	every 12 hours PRN	Start: S				☐	dexAMETHasone (DECADRON) IV 10 mg	Dose: 10 mg	Route: intravenous	every 12 hours PRN						Chemotherapy
  	etoposide (TOPOSAR) 150 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 150 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 1 Hours	Instructions:	Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	150 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes			  	CISplatin (PLATINOL) 75 mg/m2 in sodium chloride 0.9% 500 mL chemo IVPB	Dose: 75 mg/m2	Route: intravenous	once over 6 Hours for 1 dose			Offset: 2 Hours	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION	Medications	75 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	 	No	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					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.			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.			Discharge Nursing Orders
  	alteplase (CATHFLO) for NON Quinton and NON Hemodialysis Catheters 2 mg	Dose: 2 mg	Route: intra-catheter	once PRN	Start: S			Instructions:	HOLD and notify provider if Platelets LESS than 50.  Instill dose into occluded catheter. Do not force solution into
catheter. After a 30-minute dwell time, assess catheter function by attempting
to aspirate blood. If catheter is functional, aspirate 4 to 5 mL of blood in
patients greater than or equal to 10 kg to remove Cathflo Activase and
residual clots. Gently irrigate the catheter with NS. If catheter remains
nonfunctional, let Cathflo Activase dwell for another 90 minutes (total dwell
time: 120 minutes) and reassess function. If catheter function is not restored,
a second dose may be instilled				Days 8 (Inpatient)	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: --			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: Until discontinued	Occurrences: --	Comments:	HOLD and notify provider if 
o ANC LESS than 1000; 
o 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.			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
☑	etoposide (TOPOSAR) 100 mg/m2 in sodium chloride (NON-PVC) 0.9 % 250 mL chemo IVPB	Dose: 100 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Administer using 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	250 mL	Yes	Yes			☑	DACTINomycin (COSMEGEN) 500 mcg in sodium chloride 0.9% 50 mL chemo IVPB	Dose: 500 mcg	Route: intravenous	once over 10 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	VESICANT - AVOID EXTRAVASATION	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DACTINOMYCIN 0.5 MG/ML INTRAVENOUS SOLUTION (RECONSTITUTED VIAL)	Medications	500 mcg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	49 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			☐	DACTINomycin (COSMEGEN) chemo injection 500 mcg	Dose: 500 mcg	Route: intravenous	once for 1 dose			Offset: 90 Minutes		☑	methotrexate Preservative Free 300 mg/m2 in sodium chloride 0.9% 1,000 mL chemo IVPB	Dose: 300 mg/m2	Route: intravenous	once over 12 Hours for 1 dose			Offset: 120 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	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	Yes	Yes			☑	leucovorin tablet 15 mg	Dose: 15 mg	Route: oral	every 12 hours for 4 doses			Offset: 26 Hours	Instructions:	Administer every 12 hours for 4 doses starting 24 hours after the start of methotrexate.		☐	leucovorin 15 mg in sodium chloride 0.9% 100 mL IVPB	Dose: 15 mg	Route: intravenous	every 12 hours over 30 Minutes for 4 doses			Offset: 26 Hours	Instructions:	Administer every 12 hours for 4 doses starting 24 hours after the start of methotrexate.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	LEUCOVORIN CALCIUM 350 MG/17.5 ML SOLUTION FOR INJECTION (RECONSTITUTED VIAL)	Medications	15 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	99.25 mL	Yes	Yes			☑	allopurinoL (ZYLOPRIM) tablet 100 mg	Dose: 100 mg	Route: oral	3 times daily for 9 doses	Start: S					Breakthrough Anti-Emetics
☐	diphenhydrAMINE (BENADRYL) tablet 12.5-25 mg	Dose: 12.5-25 mg	Route: oral	every 4 hours PRN	Start: S				☐	diphenhydrAMINE (BENADRYL) injection 12-25 mg	Dose: 12-25 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	promethazine (PHENERGAN) tablet 12.5-25 mg	Dose: 12.5-25 mg	Route: oral	every 4 hours PRN	Start: S				☐	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	promethazine (PHENERGAN) IVPB	Dose: 25 mg	Route: intravenous	every 4 hours PRN over 30 Minutes	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	PROMETHAZINE 25 MG/ML INJECTION SOLUTION	Medications	25 mg	Main Ingredient	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Always	Yes			☐	LORAZepam (ATIVAN) tablet 0.5-1 mg	Dose: 0.5-1 mg	Route: oral	every 4 hours PRN	Start: S				☐	LORAZepam (ATIVAN) injection 0.5-1 mg	Dose: 0.5-1 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	haloperidoL (HALDOL) tablet 0.5-1 mg	Dose: 0.5-1 mg	Route: oral	every 4 hours PRN	Start: S				☐	haloperidol lactate (HALDOL) injection 0.5-1 mg	Dose: 0.5-1 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	metoclopramide (REGLAN) tablet 10 mg	Dose: 10 mg	Route: oral	every 4 hours PRN	Start: S				☐	metoclopramide (REGLAN) injection 10 mg	Dose: 10 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	dexAMETHasone (DECADRON) tablet 10 mg	Dose: 10 mg	Route: oral	every 12 hours PRN	Start: S				☐	dexAMETHasone (DECADRON) IV 10 mg	Dose: 10 mg	Route: intravenous	every 12 hours PRN						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.					
Cycle 2	Repeat 1 time	Cycle length: 14 days	Day 1 (Outpatient)	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: --	Occurrences: --			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.
			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if 
o ANC LESS than 1000; 
o Platelets LESS than 100,000.
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Pre-Hydration
  	sodium chloride 0.9 % infusion 1,000 mL	Dose: 1,000 mL	Route: intravenous	once @ 999 mL/hr over 1 Hours for 1 dose	Start: S					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				Breakthrough Anti-Emetics
☐	diphenhydrAMINE (BENADRYL) tablet 12.5-25 mg	Dose: 12.5-25 mg	Route: oral	every 4 hours PRN	Start: S				☐	diphenhydrAMINE (BENADRYL) injection 12-25 mg	Dose: 12-25 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	promethazine (PHENERGAN) tablet 12.5-25 mg	Dose: 12.5-25 mg	Route: oral	every 4 hours PRN	Start: S				☐	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	promethazine (PHENERGAN) IVPB	Dose: 25 mg	Route: intravenous	every 4 hours PRN over 30 Minutes	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	PROMETHAZINE 25 MG/ML INJECTION SOLUTION	Medications	25 mg	Main Ingredient	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Always	Yes			☐	LORAZepam (ATIVAN) tablet 0.5-1 mg	Dose: 0.5-1 mg	Route: oral	every 4 hours PRN	Start: S				☐	LORAZepam (ATIVAN) injection 0.5-1 mg	Dose: 0.5-1 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	haloperidoL (HALDOL) tablet 0.5-1 mg	Dose: 0.5-1 mg	Route: oral	every 4 hours PRN	Start: S				☐	haloperidol lactate (HALDOL) injection 0.5-1 mg	Dose: 0.5-1 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	metoclopramide (REGLAN) tablet 10 mg	Dose: 10 mg	Route: oral	every 4 hours PRN	Start: S				☐	metoclopramide (REGLAN) injection 10 mg	Dose: 10 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	dexAMETHasone (DECADRON) tablet 10 mg	Dose: 10 mg	Route: oral	every 12 hours PRN	Start: S				☐	dexAMETHasone (DECADRON) IV 10 mg	Dose: 10 mg	Route: intravenous	every 12 hours PRN						Chemotherapy
  	etoposide (TOPOSAR) 150 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 150 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 1 Hours	Instructions:	Administer using non-PVC tubing set.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	150 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes			  	CISplatin (PLATINOL) 75 mg/m2 in sodium chloride 0.9% 500 mL chemo IVPB	Dose: 75 mg/m2	Route: intravenous	once over 6 Hours for 1 dose			Offset: 2 Hours	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION	Medications	75 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	 	No	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					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.			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.			Discharge Nursing Orders
  	alteplase (CATHFLO) for NON Quinton and NON Hemodialysis Catheters 2 mg	Dose: 2 mg	Route: intra-catheter	once PRN	Start: S			Instructions:	HOLD and notify provider if Platelets LESS than 50.  Instill dose into occluded catheter. Do not force solution into
catheter. After a 30-minute dwell time, assess catheter function by attempting
to aspirate blood. If catheter is functional, aspirate 4 to 5 mL of blood in
patients greater than or equal to 10 kg to remove Cathflo Activase and
residual clots. Gently irrigate the catheter with NS. If catheter remains
nonfunctional, let Cathflo Activase dwell for another 90 minutes (total dwell
time: 120 minutes) and reassess function. If catheter function is not restored,
a second dose may be instilled				Days 8 (Inpatient)	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: --			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: Until discontinued	Occurrences: --	Comments:	HOLD and notify provider if 
o ANC LESS than 1000; 
o 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.			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
☑	etoposide (TOPOSAR) 100 mg/m2 in sodium chloride (NON-PVC) 0.9 % 250 mL chemo IVPB	Dose: 100 mg/m2	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Administer using 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	250 mL	Yes	Yes			☑	DACTINomycin (COSMEGEN) 500 mcg in sodium chloride 0.9% 50 mL chemo IVPB	Dose: 500 mcg	Route: intravenous	once over 10 Minutes for 1 dose			Offset: 90 Minutes	Instructions:	VESICANT - AVOID EXTRAVASATION	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DACTINOMYCIN 0.5 MG/ML INTRAVENOUS SOLUTION (RECONSTITUTED VIAL)	Medications	500 mcg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	49 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			☐	DACTINomycin (COSMEGEN) chemo injection 500 mcg	Dose: 500 mcg	Route: intravenous	once for 1 dose			Offset: 90 Minutes		☑	methotrexate Preservative Free 300 mg/m2 in sodium chloride 0.9% 1,000 mL chemo IVPB	Dose: 300 mg/m2	Route: intravenous	once over 12 Hours for 1 dose			Offset: 120 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	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	Yes	Yes			☑	leucovorin tablet 15 mg	Dose: 15 mg	Route: oral	every 12 hours for 4 doses			Offset: 26 Hours	Instructions:	Administer every 12 hours for 4 doses starting 24 hours after the start of methotrexate.		☐	leucovorin 15 mg in sodium chloride 0.9% 100 mL IVPB	Dose: 15 mg	Route: intravenous	every 12 hours over 30 Minutes for 4 doses			Offset: 26 Hours	Instructions:	Administer every 12 hours for 4 doses starting 24 hours after the start of methotrexate.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	LEUCOVORIN CALCIUM 350 MG/17.5 ML SOLUTION FOR INJECTION (RECONSTITUTED VIAL)	Medications	15 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	99.25 mL	Yes	Yes			☑	allopurinoL (ZYLOPRIM) tablet 100 mg	Dose: 100 mg	Route: oral	3 times daily for 9 doses	Start: S					Breakthrough Anti-Emetics
☐	diphenhydrAMINE (BENADRYL) tablet 12.5-25 mg	Dose: 12.5-25 mg	Route: oral	every 4 hours PRN	Start: S				☐	diphenhydrAMINE (BENADRYL) injection 12-25 mg	Dose: 12-25 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	promethazine (PHENERGAN) tablet 12.5-25 mg	Dose: 12.5-25 mg	Route: oral	every 4 hours PRN	Start: S				☐	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	promethazine (PHENERGAN) IVPB	Dose: 25 mg	Route: intravenous	every 4 hours PRN over 30 Minutes	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	PROMETHAZINE 25 MG/ML INJECTION SOLUTION	Medications	25 mg	Main Ingredient	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Always	Yes			☐	LORAZepam (ATIVAN) tablet 0.5-1 mg	Dose: 0.5-1 mg	Route: oral	every 4 hours PRN	Start: S				☐	LORAZepam (ATIVAN) injection 0.5-1 mg	Dose: 0.5-1 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	haloperidoL (HALDOL) tablet 0.5-1 mg	Dose: 0.5-1 mg	Route: oral	every 4 hours PRN	Start: S				☐	haloperidol lactate (HALDOL) injection 0.5-1 mg	Dose: 0.5-1 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	metoclopramide (REGLAN) tablet 10 mg	Dose: 10 mg	Route: oral	every 4 hours PRN	Start: S				☐	metoclopramide (REGLAN) injection 10 mg	Dose: 10 mg	Route: intravenous	every 4 hours PRN	Start: S				☐	dexAMETHasone (DECADRON) tablet 10 mg	Dose: 10 mg	Route: oral	every 12 hours PRN	Start: S				☐	dexAMETHasone (DECADRON) IV 10 mg	Dose: 10 mg	Route: intravenous	every 12 hours PRN						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.