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IP/OP EMA-CO	

Types:      ONCOLOGY TREATMENT
Synonyms:  EMACO, EM, EMA/CO, EMA-CO, GESTATIONAL, TROPHO, ETOPOSIDE, METH, ACTINOM, DACTINO, VINCRISTINE, CYCLOPH, CYTOX, GYN

Cycle 1	Repeat 1 time	Cycle length: 14 days	Day 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
☑	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 13	Interval: Until discontinued	Occurrences: --	Comments:	HOLD and notify provider if 
o ANC LESS than 1000; 
o Platelets LESS than 100,000; 
o Serum Creatinine GREATER than 1.5; 
o Total Bilirubin GREATER than 1.5.
			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				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.				Day 2	Perform every 1 day x1		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	Yes	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	Yes	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				☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once 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				Day 8 (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 13	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if 
o ANC LESS than 1000; 
o Platelets LESS than 100,000; 
o SCr GREATER than 1.5; 
o Total Bilirubin GREATER than 1.5.
			Line Care
  	INSERT PERIPHERAL IV OR ACCESS PORTACATH	Interval: --	Occurrences: --		  	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				☐	palonosetron (ALOXI) injection 0.25 mg	Dose: 250 mcg	Route: intravenous	once for 1 dose	Start: S	End: S  3:00 PM		Instructions:	For OUTPATIENT use only.		☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Chemotherapy
  	vinCRIStine (ONCOVIN) 1 mg/m2 in sodium chloride 0.9 % 50 mL chemo IVPB	Dose: 1 mg/m2	Route: intravenous	once over 15 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Max dose = 2 mg.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	1 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	50 mL	Yes	Yes			  	cyclophosphamide (CYTOXAN) 600 mg/m2 in sodium chloride 0.9 % 250 mL chemo IVPB	Dose: 600 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 45 Minutes	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM/50 ML INTRAVENOUS POWDER FOR SOLUTION (RECONSTITUTED VIAL)	Medications	600 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes				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