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OP MIRVETUXIMAB SORAVTANSINE-GYNX (EVERY 21 DAYS)	

Types:      ONCOLOGY TREATMENT
Synonyms:  ELAHERE

Take Home Medications	Repeat 1 time	Cycle length: 1 day	Day 1	Perform every 1 day x1		Take-Home Medications
  	carboxymethyl-gly-poly80-PF (Refresh Optive Advanced, PF,) 0.5-1-0.5 % dropperette	Dose: 1 drop	Route: Both Eyes	see admin instructions	Dispense: 120 each	Refills: 5	Start: S			Instructions:	Instill drops four times daily AND as needed for the duration of therapy and for 30 days after the last dose. May substitute with alternative preservative-free lubricating eye drops.		  	prednisoLONE acetate, PF, 1 %	Dose: 1 drop	Route: Both Eyes	see admin instructions	Dispense: 5 mL	Refills: 5	Start: S			Instructions:	Instill one drop in each eye 6 times daily starting the day prior to each infusion until day 4; then instill one drop in each eye 4 times daily for days 5-8 of each cycle					
Cycle 1	Repeat 1 time	Cycle length: 21 days	Day 1	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
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Labs
  	CANCER ANTIGEN 125	Interval: --	Occurrences: --			Line Care
  	INSERT PERIPHERAL IV OR ACCESS PORTACATH	Interval: --	Occurrences: --			Line Flush
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Do NOT administer with Mirvetuximab Soravtansine-gynx.			Nursing Orders
  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open for Mirvetuximab Soravtansine-gynx.		  	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.  Do NOT administer with Mirvetuximab Soravtansine-gynx.			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	Folate receptor-alpha status should be determined prior to initiation of therapy.  Folate receptor alpha is positive on *** (date).
		  	ONC PROVIDER COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	o Please ensure that the ophthalmic examination with visual acuity and slit lamp is complete prior to treatment initiation. 
o Recommendation is to have ophthalmic exam every other cycle for the first 8 cycles, and as clinically indicated. 
		  	ONC PROVIDER COMMUNICATION 3	Interval: --	Occurrences: --	Comments:	Please ensure to prescribe the following ophthalmic drops for the patient: Topical corticosteroids and topical lubricating eye drops.
		  	ONC PROVIDER COMMUNICATION 4	Interval: --	Occurrences: --	Comments:	Initial prescription (and all renewals) for any corticosteroid should be made only after ophthalmic examination with slit lamp. 
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Mirvetuximab Soravtansine-gynx infusion is only compatible with D5W. Do not flush line with NS.
		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Verify if patient had ophthalmic examination prior to starting Mirvetuximab; if not hold therapy and contact provider.
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Please verify patient brought the topical corticosteroid ophthalmic drops and the topical lubricating ophthalmic drops to the appointment, if not, hold therapy and contact MD.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	For topical corticosteroid ophthalmic drops, confirm with patient on the following: 
o Topical corticosteroid ophthalmic drops have been started the day prior to the infusion. 
o Patient continued with eye drops administration in each eye as prescribed (6 times daily starting the day prior to each infusion until day 4; then instill one drop in each eye 4 times daily for days 5-8) after each mirvetuximab soravtansine-gynx infusion. 
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	For topical lubricating ophthalmic drops, confirm with patient on the following:
o Patient continued to administer in each eye at least four times daily. Lubricating eye drops can be used more than four times daily and for 30 days after the last mirvetuximab soravtansine-gynx dose. Advise them to wait at least 10 minutes after ophthalmic topical steroid administration before instilling lubricating eye drops. 
		  	ONC NURSING COMMUNICATION 10	Interval: --	Occurrences: --	Comments:	Patients should avoid wearing contact lens (unless advised by their eye care provider) for the duration of mirvetuximab soravtansine-gynx treatment. 
			Nursing Orders
  	TREATMENT CONDITIONS 19	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if: 
o ANC LESS than 1000; 
o Platelets LESS than 100,000; 
o Total Bilirubin GREATER than 1.5 x ULN.
			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.
			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			Instructions:	Administer 30 minutes prior to chemotherapy.	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				Pre-Medications
  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer via slow push 30 minutes prior to chemotherapy		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.			Chemotherapy
  	mirvetuximab soravtansine-gynx (ELAHERE) 6 mg/kg in dextrose 5% 500 mL chemo IVPB	Dose: 6 mg/kg	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	1. Administer the first dose as an intravenous infusion at the rate of 1 mg/min. 
	o If well tolerated after 30 minutes at 1 mg/min, increase the infusion rate to 3 	mg/min. 
	o If well tolerated after 30 minutes at 3 mg/min, increase the infusion rate to 5 	mg/min. 
2. If no infusion-related reactions occur with the previous dose, subsequent infusions should be started at the maximally tolerated rate and may be increased up to a maximum infusion rate of 5 mg/min, as tolerated. 
Following the infusion, flush the intravenous line with 5% Dextrose Injection, USP to ensure delivery of the full dose. 
3. Administer using an 0.2 or 0.22 ìm polyethersulfone (PES) in-line filter. 
HAZARDOUS - Handle with care / Do Not Shake. 
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION	Medications	6 mg/kg	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	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					Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
		  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S				  	HEParin, porcine 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					
Cycles 2 to 6	Repeat 5 times	Cycle length: 21 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --		  	COMPREHENSIVE METABOLIC PANEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --			Labs
  	CANCER ANTIGEN 125	Interval: --	Occurrences: --			Line Care
  	INSERT PERIPHERAL IV OR ACCESS PORTACATH	Interval: --	Occurrences: --			Line Flush
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Do NOT administer with Mirvetuximab Soravtansine-gynx.			Nursing Orders
  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open for Mirvetuximab Soravtansine-gynx.		  	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.  Do NOT administer with Mirvetuximab Soravtansine-gynx.			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: --	Occurrences: --	Comments:	Folate receptor-alpha status should be determined prior to initiation of therapy.  Folate receptor alpha is positive on *** (date).
		  	ONC PROVIDER COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	o Please ensure that the ophthalmic examination with visual acuity and slit lamp is complete prior to treatment initiation. 
o Recommendation is to have ophthalmic exam every other cycle for the first 8 cycles, and as clinically indicated. 
		  	ONC PROVIDER COMMUNICATION 3	Interval: --	Occurrences: --	Comments:	Please ensure to prescribe the following ophthalmic drops for the patient: Topical corticosteroids and topical lubricating eye drops.
		  	ONC PROVIDER COMMUNICATION 4	Interval: --	Occurrences: --	Comments:	Initial prescription (and all renewals) for any corticosteroid should be made only after ophthalmic examination with slit lamp. 
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Mirvetuximab Soravtansine-gynx infusion is only compatible with D5W. Do not flush line with NS.
		  	ONC NURSING COMMUNICATION 5	Interval: --	Occurrences: --	Comments:	Verify if patient had ophthalmic examination prior to starting Mirvetuximab; if not hold therapy and contact provider.
		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Please verify patient brought the topical corticosteroid ophthalmic drops and the topical lubricating ophthalmic drops to the appointment, if not, hold therapy and contact MD.
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	For topical corticosteroid ophthalmic drops, confirm with patient on the following: 
o Topical corticosteroid ophthalmic drops have been started the day prior to the infusion. 
o Patient continued with eye drops administration in each eye as prescribed (6 times daily starting the day prior to each infusion until day 4; then instill one drop in each eye 4 times daily for days 5-8) after each mirvetuximab soravtansine-gynx infusion. 
		  	ONC NURSING COMMUNICATION 9	Interval: --	Occurrences: --	Comments:	For topical lubricating ophthalmic drops, confirm with patient on the following:
o Patient continued to administer in each eye at least four times daily. Lubricating eye drops can be used more than four times daily and for 30 days after the last mirvetuximab soravtansine-gynx dose. Advise them to wait at least 10 minutes after ophthalmic topical steroid administration before instilling lubricating eye drops. 
		  	ONC NURSING COMMUNICATION 10	Interval: --	Occurrences: --	Comments:	Patients should avoid wearing contact lens (unless advised by their eye care provider) for the duration of mirvetuximab soravtansine-gynx treatment. 
			Nursing Orders
  	TREATMENT CONDITIONS 19	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if: 
o ANC LESS than 1000; 
o Platelets LESS than 100,000; 
o Total Bilirubin GREATER than 1.5 x ULN.
			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.
			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			Instructions:	Administer 30 minutes prior to chemotherapy.	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				Pre-Medications
  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer via slow push 30 minutes prior to chemotherapy		  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.			Chemotherapy
  	mirvetuximab soravtansine-gynx (ELAHERE) 6 mg/kg in dextrose 5% 500 mL chemo IVPB	Dose: 6 mg/kg	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	1. Administer the first dose as an intravenous infusion at the rate of 1 mg/min. 
	o If well tolerated after 30 minutes at 1 mg/min, increase the infusion rate to 3 	mg/min. 
	o If well tolerated after 30 minutes at 3 mg/min, increase the infusion rate to 5 	mg/min. 
2. If no infusion-related reactions occur with the previous dose, subsequent infusions should be started at the maximally tolerated rate and may be increased up to a maximum infusion rate of 5 mg/min, as tolerated. 
Following the infusion, flush the intravenous line with 5% Dextrose Injection, USP to ensure delivery of the full dose. 
3. Administer using an 0.2 or 0.22 ìm polyethersulfone (PES) in-line filter. 
HAZARDOUS - Handle with care / Do Not Shake. 
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION	Medications	6 mg/kg	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	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					Discharge Nursing Orders
  	ONC NURSING COMMUNICATION 76	Interval: --	Occurrences: --	Comments:	Discontinue IV.
		  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S				  	HEParin, porcine 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