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OP TRASTUZUMAB LOADING AND MAINTENANCE DOSE (EVERY 21 DAYS)	

Types:      ONCOLOGY TREATMENT
Synonyms:  TRAS, TRASTUZUMAB, HERCEPTIN, HURCEPTIN, HER, HUR, BREAST, TRAZIMERA

Cycle 1 - Loading Dose	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	Interval: --	Occurrences: --	Comments:	Verify Ejection Fraction prior to Cycle 1.  Ejection Fraction: ***% on *** (date).

If patient has not had a recent MUGA or ECHO, order one via order entry. A baseline cardiac evaluation with a MUGA scan or an ECHO is recommended, especially in patients with risk factors for increased cardiac toxicity. Repeated MUGA or ECHO determinations of LVEF should be performed, particularly with higher, cumulative anthracycline doses.
			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
  	HEPATITIS B SURFACE ANTIGEN	Interval: --	Occurrences: --		  	HEPATITIS B CORE ANTIBODY TOTAL	Interval: --	Occurrences: --		  	HEPATITIS B SURFACE ANTIBODY	Interval: --	Occurrences: --			Nursing Orders
  	ONC NURSING COMMUNICATION 64	Interval: --	Occurrences: --	Comments:	Ensure Hepatitis B panel obtained if not collected prior to C1D1.  Do not hold therapy to wait for results.  

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).
			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
  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.		  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes prior to chemotherapy.			Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	once PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	once PRN	Start: S					Antiemetics
◯	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: injection	once PRN	Start: S					Chemotherapy
◯	trastuzumab-qyyp (TRAZIMERA) 8 mg/kg in sodium chloride 0.9% 250 mL chemo IVPB (RESTRICTED)	Dose: 8 mg/kg	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Administer only via intravenous infusion. Do NOT administer as an intravenous push or bolus. Do not mix with other drugs. Administer the first dose over 90 minutes, and subsequent doses over 30 to 90 minutes. Monitor patient for hypersensitivity reactions during and following administration. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TRASTUZUMAB-QYYP 420 MG/20 ML INTRAVENOUS SOLUTION (RECONSTITUTED VIAL)	Medications	8 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			◯	trastuzumab (HERCEPTIN) 8 mg/kg in sodium chloride 0.9% 250 mL chemo IVPB (RESTRICTED)	Dose: 8 mg/kg	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Administer only via intravenous infusion. Do NOT administer as an intravenous push or bolus. Do not mix with other drugs. Administer the first dose over 90 minutes, and subsequent doses over 30 to 90 minutes. Monitor patient for hypersensitivity reactions during and following administration. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TRASTUZUMAB 150 MG/7.15 ML INTRAVENOUS SOLUTION (RESTRICTED) (RECONSTITUTED VIAL)	Medications	8 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			◉	trastuzumab-dkst (OGIVRI) 8 mg/kg in sodium chloride 0.9% 250 mL chemo IVPB (RESTRICTED)	Dose: 8 mg/kg	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Administer only via intravenous infusion. Do NOT administer as an intravenous push or bolus. Do not mix with other drugs. Administer the first dose over 90 minutes, and subsequent doses over 30 to 90 minutes. Monitor patient for hypersensitivity reactions during and following administration. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TRASTUZUMAB-DKST 150 MG/7.15 ML INTRAVENOUS SOLUTION (RECONSTITUTED VIAL)	Medications	8 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			◯	trastuzumab-pkrb (HERZUMA) 8 mg/kg in sodium chloride 0.9% 250 mL chemo IVPB (RESTRICTED)	Dose: 8 mg/kg	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Administer only via intravenous infusion. Do NOT administer as an intravenous push or bolus. Do not mix with other drugs. Administer the first dose over 90 minutes, and subsequent doses over 30 to 90 minutes. Monitor patient for hypersensitivity reactions during and following administration. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TRASTUZUMAB-PKRB 150 MG/7.15 ML INTRAVENOUS SOLUTION (RECONSTITUTED VIAL)	Medications	8 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			◯	trastuzumab-dttb (ONTRUZANT) 8 mg/kg in sodium chloride 0.9% 250 mL chemo IVPB (RESTRICTED)	Dose: 8 mg/kg	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Administer only via intravenous infusion. Do NOT administer as an intravenous push or bolus. Do not mix with other drugs. Administer the first dose over 90 minutes, and subsequent doses over 30 to 90 minutes. Monitor patient for hypersensitivity reactions during and following administration. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TRASTUZUMAB-DTTB 150 MG/7.15 ML INTRAVENOUS SOLUTION (RECONSTITUTED VIAL)	Medications	8 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 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.
			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					
Cycles 2 to 4	Repeat 3 times	Cycle length: 21 days	Day 1	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			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.			Supportive Care
◯	LORAZepam (ATIVAN) injection 1 mg	Dose: 1 mg	Route: intravenous	once PRN	Start: S				◯	LORAZepam (ATIVAN) tablet 1 mg	Dose: 1 mg	Route: oral	once PRN	Start: S					Antiemetics
◯	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: injection	once PRN	Start: S					Chemotherapy
◯	trastuzumab-qyyp (TRAZIMERA) 6 mg/kg in sodium chloride 0.9% 250 mL chemo IVPB (RESTRICTED)	Dose: 6 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Administer only via intravenous infusion. Do NOT administer as an intravenous push or bolus. Do not mix with other drugs. Administer the first dose over 90 minutes, and subsequent doses over 30 to 90 minutes. Monitor patient for hypersensitivity reactions during and following administration. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TRASTUZUMAB-QYYP 420 MG/20 ML INTRAVENOUS SOLUTION (RECONSTITUTED VIAL)	Medications	6 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			◯	trastuzumab (HERCEPTIN) 6 mg/kg in sodium chloride 0.9% 250 mL chemo IVPB (RESTRICTED)	Dose: 6 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose				Instructions:	Administer only via intravenous infusion. Do NOT administer as an intravenous push or bolus. Do not mix with other drugs. Administer the first dose over 90 minutes, and subsequent doses over 30 to 90 minutes. Monitor patient for hypersensitivity reactions during and following administration. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TRASTUZUMAB 150 MG/7.15 ML INTRAVENOUS SOLUTION (RESTRICTED) (RECONSTITUTED VIAL)	Medications	6 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			◉	trastuzumab-dkst (OGIVRI) 6 mg/kg in sodium chloride 0.9% 250 mL chemo IVPB (RESTRICTED)	Dose: 6 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose				Instructions:	Administer only via intravenous infusion. Do NOT administer as an intravenous push or bolus. Do not mix with other drugs. Administer the first dose over 90 minutes, and subsequent doses over 30 to 90 minutes. Monitor patient for hypersensitivity reactions during and following administration. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TRASTUZUMAB-DKST 150 MG/7.15 ML INTRAVENOUS SOLUTION (RECONSTITUTED VIAL)	Medications	6 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			◯	trastuzumab-pkrb (HERZUMA) 6 mg/kg in sodium chloride 0.9% 250 mL chemo IVPB (RESTRICTED)	Dose: 6 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose				Instructions:	Administer only via intravenous infusion. Do NOT administer as an intravenous push or bolus. Do not mix with other drugs. Administer the first dose over 90 minutes, and subsequent doses over 30 to 90 minutes. Monitor patient for hypersensitivity reactions during and following administration. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TRASTUZUMAB-PKRB 150 MG/7.15 ML INTRAVENOUS SOLUTION (RECONSTITUTED VIAL)	Medications	6 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			◯	trastuzumab-dttb (ONTRUZANT) 6 mg/kg in sodium chloride 0.9% 250 mL chemo IVPB (RESTRICTED)	Dose: 6 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose				Instructions:	Administer only via intravenous infusion. Do NOT administer as an intravenous push or bolus. Do not mix with other drugs. Administer the first dose over 90 minutes, and subsequent doses over 30 to 90 minutes. Monitor patient for hypersensitivity reactions during and following administration. 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TRASTUZUMAB-DTTB 150 MG/7.15 ML INTRAVENOUS SOLUTION (RECONSTITUTED VIAL)	Medications	6 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 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.
			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