CAGT- DONOR LEUKOCYTE INFUSION (DLI)		version 12/3/2021		

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		
	☑	Nursing communication	Every visit	S	Until discont'd	
		Please continue to schedule subsequent infusion appointments manually as appropriate.		

Provider Communication 	

	
	Interval	Defer Until	Duration	
	☐	Please place procedure, imaging, and referral orders using your preference list. These orders must be placed outside of the therapy plan to be scheduled.	Every 1 day	S	Until discont'd	
		No details available for preview		

Nursing Orders 	

	
	Interval	Defer Until	Duration	
	☐	Insert Peripheral IV or Access Portacath	Every visit	S	Until discont'd	
		No details available for preview		
	☐	sodium chloride 0.9% flush 10 mL	Every visit	S	Until discont'd	
		10 mL, intravenous, PRN, line care, Starting when released, for 10 doses		
	☐	sodium chloride 0.9% infusion 250 mL	Every visit	S	Until discont'd	
		250 mL, intravenous, at 30 mL/hr, PRN, Flush bag, Starting when released, Until Discontinued		

Labs 	

	
	Interval	Defer Until	Duration	
	☐	CBC with platelet and differential	Every visit	S	Until discont'd	
		STAT, Normal, Clinic Collect, HMH DEPARTMENT OF PATHOLOGY AND GENOMIC MEDICINE		
	☐	Comprehensive metabolic panel	Every visit	S	Until discont'd	
		STAT, Normal, Clinic Collect, HMH DEPARTMENT OF PATHOLOGY AND GENOMIC MEDICINE		
	☐	HLA Typing- Collect Specimens	Every visit	S	Until discont'd	
		Collect specimen and complete paper form. 
	Charge to (select one): { :11558515}
	
	Potential (circle one): { :11558516}
	
	Recipient HLA Laboratory Tests:
	{ :11558517}
	
	Donor HLA Laboratory Tests:
	{ :11558519}		

Nursing Pre-Procedure 	

	
	Interval	Defer Until	Duration	
	☐	Start IV at least 20 gauge	Every visit	S	Until discont'd	
		No details available for preview		
	☐	Large bore tubbing w/ no inline filter	Every visit	S	Until discont'd	
		No details available for preview		
	☐	Place a 3-way stop kock	Every visit	S	Until discont'd	
		No details available for preview		
	☐	Call BMT Provider	Every visit	S	Until discont'd	
		No details available for preview		
	☐	Have oxygen & suction set-up on standby during cell infusion	Every visit	S	Until discont'd	
		No details available for preview		
	☐	Monitor Vital Signs	Every visit	S	Until discont'd	
		No details available for preview		
	☐	Continuous Cardiac monitoring	Every visit	S	Until discont'd	
		No details available for preview		

Pre-Medications 	

	
	Interval	Defer Until	Duration	
	☐	diphenhydrAMINE (BENADRYL) injection 25 mg	Every visit	S	Until discont'd	
		25 mg, intravenous, once, Starting when released		
	☐	acetaminophen (TYLENOL) tablet 650 mg	Every visit	S	Until discont'd	
		650 mg, oral, once, Starting when released
	Maximum of 4 grams of acetaminophen per day from all sources. (Cirrhosis patients maximum: 2 grams per day from all sources).		
	☐	sodium chloride 0.9% infusion 500 mL	Every visit	S	Until discont'd	
		500 mL, intravenous, Starting when released		

Provider Intra-Procedure 	

	
	Interval	Defer Until	Duration	
	☐	Donor Leukocyte Infusion (DLI)	Every visit	S	Until discont'd	
		Clinic Performed, Normal		

Nursing Transfusion Orders 	

	
	Interval	Defer Until	Duration	
	☐	Infuse Donor Leukocytes	Every visit	S	Until discont'd	
		No details available for preview		

Nursing Post-Procedure 	

	
	Interval	Defer Until	Duration	
	☐	Vitals every 15 minutes until discharge	Every visit	S	Until discont'd	
		No details available for preview		
	☐	Discharge per guidelines 1 hour	Every visit	S	Until discont'd	
		No details available for preview		
	☐	Accompanied by adult at discharge	Every visit	S	Until discont'd	
		No details available for preview		

Emergency Medications 	

	
	Interval	Defer Until	Duration	
	☐	sodium chloride 0.9% infusion 500 mL	PRN	S	Until discont'd	
		500 mL, intravenous, once PRN, Starting when released, Until Discontinued		
	☐	epINEPHrine (ADRENALIN) injection 1 mg/mL 0.5 mg	PRN	S	Until discont'd	
		0.5 mg, subcutaneous, once PRN, infusion reaction, Starting when released, Until Discontinued		
	☐	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	PRN	S	Until discont'd	
		100 mg, intravenous, once PRN, infusion reaction, Starting when released, Until Discontinued		
	☐	diphenhydrAMINE (BENADRYL) injection 25 mg	PRN	S	Until discont'd	
		25 mg, intravenous, once PRN, Infusion reaction, Starting when released, Until Discontinued		

Discharge Nursing Orders 	

	
	Interval	Defer Until	Duration	
	☐	Discontinue IV	Every visit	S	Until discont'd	
		No details available for preview