BACLOFEN (LIORESAL) INTRATHECAL INJECTION TRIAL		version 11/17/2023		

Appointment Requests 	

	
	Interval	Defer Until	Duration	
	☑	Referral to IV Infusion Room	Once	S	1 treatment	
		Status: Future, Expected: S, Expires: S+365, Clinic Performed
	Urgency of Scheduling: Routine		

Pre Intrathecal Injection Orders 	

	
	Interval	Defer Until	Duration	
	☐	NPO after midnight	Once	S	1 treatment	
		Except sips with meds.		
	☐	Routine vital signs, neuro checks, O2 sats, and I&O's	Once	S	1 treatment	
		No details available for preview		
	☐	Insert Peripheral IV or Access Portacath	Once	S	1 treatment	
		No details available for preview		
	☐	Nursing communication: Maintain IV access	Once	S	1 treatment	
		No details available for preview		
	☐	Please have patient/family sign consent for Intrathecal Trial	Once	S	1 treatment	
		Procedure: Intrathecal baclofen injection trial		
	☐	Lumbar puncture tray to bedside	Once	S	1 treatment	
		Normal, Normal		
	☐	Nursing communication: please have the following items available for intrathecal injection:	Once	S	1 treatment	
		Iodine swabs,
	(2) 3 cc sterile syringes,
	7 1/2 and 6 1/2 sterile gloves,
	4x4 gauze,
	Bandaid		
	☐	Consult to PT eval and treat	Once	S	1 treatment	
		Normal
	Special Instructions: Please evaluate patient prior to baclofen injection and post injection.		
	☐	sodium chloride 0.9% flush 10 mL	Once	S	1 treatment	
		10 mL, intravenous, PRN, line care, Starting when released, for 10 doses		

Intrathecal Injections 	

	
	Interval	Defer Until	Duration	
	☐	baclofen (LIORESAL) 50 mcg/mL injection 50 mcg	Once	S	1 treatment	
		50 mcg, intrathecal, once, Starting when released
	For intrathecal use ONLY.		

Nursing Orders 	

	
	Interval	Defer Until	Duration	
	☐	Discontinue IV	Once	S	1 treatment	
		Until discontinued Starting when released Until Specified		
	☐	HEParin, porcine injection 500 Units	Once	S	1 treatment	
		500 Units, intra-catheter, once, Starting when released
	ONLY IF PATIENT HAS PORTACATH: Flush portacath before removing needle from portacath.		

Post Intrathecal Injection Orders 	

	
	Interval	Defer Until	Duration	
	☐	Nursing communication	Once	S	1 treatment	
		Continue all active admission orders including pulse ox.
	Flat in bed until ***.
	Regular diet after ***.
	Pt to take home medications.
	Discharge patient home after last PT visit.		
	☐	acetaminophen (TYLENOL) tablet 650 mg	Once	S	1 treatment	
		650 mg, oral, every 4 hours PRN, mild pain (score 1-3), Starting when released, Until Discontinued
	Maximum of 4 grams of acetaminophen per day from all sources. (Cirrhosis patients maximum: 2 grams per day from all sources).		
	☐	diphenhydrAMINE (BENADRYL) tablet 25 mg	Once	S	1 treatment	
		25 mg, oral, every 6 hours PRN, itching, Starting when released, Until Discontinued		
	☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Once	S	1 treatment	
		25 mg, intravenous, every 6 hours PRN, itching, Starting when released, Until Discontinued		
	☐	ondansetron (ZOFRAN) IV 4 mg	Once	S	1 treatment	
		4 mg, intravenous, every 4 hours PRN, nausea, vomiting, Starting when released, Until Discontinued
	May cause QTc prolongation.		
	☐	promethazine (PHENERGAN) tablet 25 mg	Once	S	1 treatment	
		25 mg, oral, every 6 hours PRN, nausea, vomiting, Starting when released, Until Discontinued		
	☐	promethazine (PHENERGAN) injection 25 mg	Once	S	1 treatment	
		25 mg, intravenous, every 6 hours PRN, nausea, vomiting, Starting when released, Until Discontinued		
	☐	sodium chloride 0.9% infusion 250 mL	Once	S	1 treatment	
		250 mL, intravenous, at 30 mL/hr, once, Starting when released
	TKO during recovery