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IP CAGT ALLOGENEIC SCT IV BU-CY-CAM	

Types:      ONCOLOGY TREATMENT
Synonyms:  BU, CY, CAM, BUSULFAN, CYTOXAN, CYCLOPHOSPHAMIDE, CAMPATH, ALEMTUZUMAB, ALMETUZUMAB, BMT, CAGT, ALLOGENEIC, SCT

Transplant	Repeat 1 time	Cycle length: 91 days	Days -8 through -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).
			Labs
☑	ECG 12-LEAD	Interval: Daily	Occurrences: --	Comments:	Starting Day -3.  Must be reviewed by MD daily prior to cyclophosphamide doses.
		☑	URINALYSIS, AUTOMATED WITH MICROSCOPY	Interval: Daily	Occurrences: --	Comments:	Day -3.
		☑	PHENYTOIN LEVEL	Interval: Daily	Occurrences: --	Comments:	Daily through Day -2
		☑	PHENYTOIN LEVEL	Interval: Daily	Occurrences: --	Comments:	Daily through Day -2
		☐	FREE PHENYTOIN LEVEL	Interval: Daily	Occurrences: --	Comments:	Daily through Day -2
		☐	FREE PHENYTOIN LEVEL	Interval: Daily	Occurrences: --	Comments:	Daily through Day -2
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Additional Orders
  	ONC NURSING COMMUNICATION 49	Interval: Until discontinued	Occurrences: --	Comments:	Do NOT administer Acetaminophen/Azoles for 48 hours after last busulfan dose.
			Pre-Medications
  	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	every 24 hours over 10 Minutes	Start: S+1			Instructions:	Administer 30 minutes prior to treatment on Day -7, -6, -5, -4, -3, -2, -1.	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			  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S+1					Antiemetics
  	promethazine (PHENERGAN) injection 25 mg	Dose: 25 mg	Route: intravenous	every 4 hours PRN	Start: S					Supportive Care
  	acyclovir (ZOVIRAX) 5 mg/kg (Ideal)	Dose: 5 mg/kg	Route: intravenous	every 8 hours	Start: S				  	levoFLOXacin (LEVAQUIN) tablet 500 mg	Dose: 500 mg	Route: oral	daily at 0600 (TIME CRITICAL)	Start: S				  	fluconazole (DIFLUCAN) tablet 200 mg	Dose: 200 mg	Route: oral	daily	Start: S+8			Instructions:	Start Day 0			Hydration
  	sodium chloride 0.9 % infusion	Dose: 125 mL/hr	Route: intravenous	continuous	Start: S+5					Chemotherapy
  	ONC NURSING COMMUNICATION 57	Interval: Until discontinued	Occurrences: --	Comments:	During IV Busulfan:
-INFUSE in the WHITE lumen on the TRIPLE lumen catheter
-LABEL the White lumen: Busulfan
-Prime tubing and filter with Normal Saline only
-Do NOT give any Acetaminophen (Tylenol) during Busulfan doses and for 48 hours following the last dose of Busulfan
-Record START and STOP time of EVERY Busulfan dose
-FLUSH tubing and filter with 20cc Normal Saline after each dose
		  	busulfan (BUSULFEX) in sodium chloride 0.9% EVERY 6 HOUR chemo IVPB	Dose: --	Route: intravenous	every 6 hours over 2 Hours for 16 doses	Start: S+1  8:00 AM			Instructions:	Day -7, -6, -5, -4.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	BUSULFAN 60 MG/10 ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes			  	ONC NURSING COMMUNICATION 17	Interval: Until discontinued	Occurrences: --	Comments:	-Monitor VS (temperature, pulse, respirations, and blood pressure) every 15 minutes during Alemtuzumab infusion and for 1 hour following completion
-Continuous oxygen saturation monitoring during Alemtuzumab infusion and for 1 hour following completion. Keep oxygen at bedside through Day 0
-STOP INFUSION and CONTACT MD if any of the following occur: shortness of breath, wheezing, chills, severe myalgia, hypotension, rash, or chest pain
		  	alemtuzumab (CAMPATH) 10 mg in sodium chloride 0.9% 100 mL IVPB	Dose: 10 mg	Route: intravenous	every 24 hours over 2 Hours for 3 doses	Start: S+2			Instructions:	Day -6, -5, -4.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ALEMTUZUMAB 30 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	100 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	100 mL	No	Yes			  	ONC NURSING COMMUNICATION 7	Interval: Until discontinued	Occurrences: --	Comments:	During CYCLOPHOSPHAMIDE:
-12 lead EKG must be ordered and reviewed by physician prior to each dose.
-Starting 4 hours PRIOR to cyclophosphamide, change IVF to Normal Saline at 125 mL/hr and continue for 24 hours after last dose of cyclophosphamide completes.  (MAX total volume infusion rate during chemotherapy = 350 mL/hr).
-Instruct patient to void every 1-2 hours DAILY x 3 days.
		  	mesna (MESNEX) 20 mg/kg in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 20 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S+5			Instructions:	Day -3.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	20 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			  	cycloPHOSphamide (CYTOXAN) 60 mg/kg in dextrose 5% 500 mL chemo IVPB	Dose: 60 mg/kg	Route: intravenous	every 24 hours over 2 Hours for 2 doses	Start: S+5			Instructions:	Day -3, -2.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM/50 ML INTRAVENOUS POWDER FOR SOLUTION (RECONSTITUTED VIAL)	Medications	60 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes			  	mesna (MESNEX) 10 mg/kg in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 10 mg/kg	Route: intravenous	every 4 hours over 30 Minutes for 12 doses	Start: S+5			Instructions:	Day -3, -2.

Start 4 hours after loading dose of Mesna	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Additional Orders
  	furosemide (LASIX) injection 20 mg	Dose: 20 mg	Route: intravenous	every 24 hours for 2 doses	Start: S+5			Instructions:	-Give at completion of each dose of cyclophosphamide infusion on Day -3 and Day -2.		  	furosemide (LASIX) injection 20 mg	Dose: 20 mg	Route: intravenous	every 24 hours for 2 doses	Start: S+5			Instructions:	-Give 6 hours AFTER completion of each dose of cyclophosphamide infusion on Day -3 and Day -2.		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	every 24 hours	Start: S+2			Instructions:	PREMED for ALEMTUZUMAB		  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	every 24 hours	Start: S+2			Instructions:	PREMED for ALEMTUZUMAB		  	meperidine (DEMEROL) injection (RESTRICTED) 12.5 mg	Dose: 12.5 mg	Route: intravenous	every 15 min PRN for 3 doses	Start: S+2					Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN						Pharmacokinetic Instructions
  	ONC NURSING COMMUNICATION 18	Interval: Until discontinued	Occurrences: --	Comments:	1. Infuse Busulfan through the WHITE lumen of the TRIPLE lumen Catheter. 
2. LABEL the White lumen: Busulfan.
3. NO other fluids are to be infusing during the Busulfan infusion or the Pharmacokinetics period (Doses #1 and #9).
4. IVF may resume AFTER the last PK is drawn for doses #1 and #9. 
5. Busulfan infusion must be complete including flush. When infusion is finished, Disconnect & REMOVE Busulfan bag/tubing PRIOR to starting blood draws. (Does not matter if the post level is drawn 5 min after the infusion ends). 
6. USE the same CLOCK / WATCH to document start and stop times, AND all blood draw times. 
7. ALL blood samples for Pharmacokinetics to be drawn from the RED lumen of the triple lumen CVC. 
8. FLUSH the RED lumen with 30 mL saline flush PRIOR to EVERY blood draw EXCEPT immediately after end of infusion. 
9. Use a green top, heparinized tube for all PK samples. 
10. After sample is collected, label and place in a plastic biohazard lab bag (NO pre-labeling of tubes). 
11. Put sample on wet ice and place in the medication room refrigerator or in the medication room in a closed basin for pick up / transport to TCH lab. 
12. DO NOT KEEP MULTIPLE SAMPLES at bedside.
			Seizure Prophylaxis
  	phenytoin (DILANTIN) ER capsule 2.5 mg/kg	Dose: 2.5 mg/kg	Route: oral	2 times daily	Start: S			Instructions:	Hold enteral nutrition at least 1 hour before and 2 hours after dose. Monitor drug levels.			VOD Prophylaxis
  	ursodiol (ACTIGALL) capsule 300 mg	Dose: 300 mg	Route: oral	3 times daily	Start: S+1					Acute Graft Versus Host Prophylaxis
  	tacrolimus (PROGRAF) IVPB 0.02 mg/kg (Ideal)	Dose: 0.02 mg/kg	Route: intravenous	every 24 hours over 24 Hours	Start: S			Instructions:	May cause QTc prolongation.  Use the lesser of IBW or actual body weight (ABW).			Day of Rest
  	ONC NURSING COMMUNICATION 48	Interval: Until discontinued	Occurrences: --	Comments:	Day -1.
				Day 0	Perform every 1 day x1		Labs
  	URINALYSIS, AUTOMATED WITH MICROSCOPY	Interval: Once	Occurrences: --	Comments:	Day 0.
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Antiemetics
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S					Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Premed for TRANSPLANT		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Premed for TRANSPLANT		  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once for 1 dose				Instructions:	Premed for TRANSPLANT			Transplant Orders
  	ONC NURSING COMMUNICATION 55	Interval: Once	Occurrences: --	Comments:	-Oxygen at bedside during transplantation
-Anaphylaxis precautions at bedside during transplant:
		  	meperidine (DEMEROL) injection (RESTRICTED) 12.5 mg	Dose: 12.5 mg	Route: intravenous	every 15 min PRN for 3 doses				Instructions:	Administer every 15 minutes x 3 doses PRN for each episode of rigors (if rigors persist, call MD).		  	epINEPHrine (ADRENALIN) injection 1 mg/mL 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	once PRN	Start: S	End: S+2			  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S	End: S+2			  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN							Day 1	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Antiemetics
  	ondansetron ODT (ZOFRAN-ODT) disintegrating tablet 8 mg	Dose: 8 mg	Route: oral	every 8 hours PRN	Start: S+1			Instructions:	Start Day +2