CYCLOPHOSPHAMIDE (CYTOXAN) INFUSION		version 5/22/2025		

Appointment Requests 	

	
	Interval	Defer Until	Duration	
	☑	Referral to IV Infusion Room Appointment requests for initial doses.	Day 1 of every 1 month	S	6 treatments	
		Status: Future, Expected: S, Expires: S+365, Clinic Performed
	Urgency of Scheduling: Routine
	Appointment requests for initial doses.		
	☑	Referral to IV Infusion Room Appointment requests for subsequent doses.	Day 1 of every 3 months	S+179	18 treatments	
		Status: Future, Expected: S, Expires: S+365, Clinic Performed
	Urgency of Scheduling: Routine
	Appointment requests for subsequent doses.		

Provider Communication 	

	
	Interval	Defer Until	Duration	
	☐	Provider communication	Every visit	S	 treatments	
		Please order oral mesna prescription for patient.		
	☐	mesna (MESNEX) 400 mg tablet	Once	S	1 treatment	
		oral, Starting S		

Labs 	

	
	Interval	Defer Until	Duration	
	☐	CBC with platelet and differential	Every visit	S	Until discont'd	
		Normal, Clinic Collect
	Prior to initiating Cytoxan, on Day 10 and as directed by the physician.		
	☐	Comprehensive metabolic panel	Every visit	S	Until discont'd	
		Normal, Clinic Collect
	Prior to initiating Cytoxan, on Day 10 and as directed by the physician.		
	☐	Urinalysis, automated with microscopy	Every visit	S	Until discont'd	
		Normal, Clinic Collect
	Every visit.		

Nursing Orders 	

	
	Interval	Defer Until	Duration	
	☐	Vital signs - T/P/R/BP Per Unit Protocol	Every visit	S	Until discont'd	
		Obtain vital signs every 30 minutes for first hour during hydration, then every 15 minutes during Cytoxan administration, then every 30 minutes for remainder of infusion.		
	☐	Advise patient to have a light meal prior to chemotherapy, force fluid for 24-48 hours post chemotherapy, and empty bladder every 2 hours.	Every visit	S	Until discont'd	
		No details available for preview		
	☐	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, Until Discontinued		
	☐	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		
	☐	Discontinue IV	Every visit	S	Until discont'd	
		No details available for preview		
	☐	Nursing communication	Every visit	S	 treatments	
		Verify that patient has oral mesna prescription at home and to take a dose 4 hours and 8 hours after cyclophosphamide. Otherwise, please contact MD to order,		

Hydration 	

	
	Interval	Defer Until	Duration	
	☐	sodium chloride 0.45 % infusion 500 mL	Every visit	S	 treatments	
		500 mL, intravenous, at 500 mL/hr, once, Starting when released
	Infuse before and after Cytoxan at max rate of 500 mL/hr for hydration.		
	☐	sodium chloride 0.9 % infusion	Every visit	S	 treatments	
		500 mL, intravenous, at 500 mL/hr, once, Starting when released
	Infuse before and after Cytoxan at max rate of 500 mL/hr for hydration.		

Pre-Medications 	

	
	Interval	Defer Until	Duration	
	☐	ondansetron (ZOFRAN) IV 8 mg	Every visit	S	Until discont'd	
		8 mg, intravenous, once, Starting when released
	Administer 30 minutes prior to start of Cytoxan infusion.
	May cause QTc prolongation.		
	☐	dexAMETHasone (DECADRON) IV 8 mg	Every visit	S	Until discont'd	
		8 mg, intravenous, once, Starting when released
	Administer 30 minutes prior to start of Cytoxan infusion.		
	☐	palonosetron (ALOXI) injection 0.25 mg	Every visit	S	Until discont'd	
		0.25 mg, intravenous, once, Starting when released
	Administer 30 minutes prior to start of Cytoxan infusion.		
	☐	methylPREDNISolone sodium succinate (Solu-MEDROL) injection	Every visit	S	Until discont'd	
		intravenous, once, Starting when released
	Administer 30 minutes prior to start of Cytoxan infusion.		

Medications 	

	
	Interval	Defer Until	Duration	
	☐	cycloPHOSphamide (CYTOXAN) in sodium chloride 0.9% 250 mL chemo IVPB	Day 1 of every 1 month	S	6 treatments	
		intravenous, Administer over: 60 Minutes, once, Starting 30 minutes after treatment start time
	Administer every month x 6 months.
	HAZARDOUS - Handle with care		
	☐	mesna (MESNEX) in sodium chloride 0.9% 100 mL chemo IVPB	Day 1 of every 1 month	S	6 treatments	
		intravenous, Administer over: 15 Minutes, once, Starting at treatment start time
	20% of cyclophosphamide dose. Administer 30 minutes prior to start of cytoxan infusion. 		
	☐	cycloPHOSphamide (CYTOXAN) in sodium chloride 0.9% 250 mL chemo IVPB	Day 1 of every 3 months	S+179	18 treatments	
		intravenous, Administer over: 60 Minutes, once, Starting 30 minutes after treatment start time
	Administer every 3 months x 18 months.
	HAZARDOUS - Handle with care		
	☐	mesna (MESNEX) in sodium chloride 0.9% 100 mL chemo IVPB	Day 1 of every 3 months	S+179	18 treatments	
		intravenous, Administer over: 15 Minutes, once, Starting at treatment start time
	20% of cyclophosphamide dose. Administer 30 minutes prior to start of cytoxan infusion		

Supportive Care 	

	
	Interval	Defer Until	Duration	
	☐	promethazine (PHENERGAN) injection 25-50 mg	PRN	S	Until discont'd	
		25-50 mg, injection, every 4 hours PRN, nausea, vomiting, Starting when released, Until Discontinued		
	☐	promethazine (PHENERGAN) tablet 25 mg	PRN	S	Until discont'd	
		25 mg, oral, every 4 hours PRN, nausea, vomiting, Starting when released, Until Discontinued		
	☐	ondansetron (ZOFRAN) tablet 8 mg	PRN	S	Until discont'd	
		8 mg, oral, every 8 hours PRN, Nausea prevention, Starting when released, for 2 doses
	Zofran 8 mg Q8H x 2 doses, then 8 mg Q12H x 24-48 hours.
	May cause QTc prolongation.		
	☐	ondansetron (ZOFRAN) tablet 8 mg	PRN	S	Until discont'd	
		8 mg, oral, every 12 hours PRN, Nausea prevention, Starting when released, for 48 hours
	Zofran 8 mg Q8H x 2 doses, then 8 mg Q12H x 24-48 hours.
	May cause QTc prolongation.		
	☐	metoclopramide (REGLAN) tablet 10 mg	PRN	S	Until discont'd	
		10 mg, oral, 3 times daily, Starting S As Scheduled, for 4 days		
	☐	dexAMETHasone (DECADRON) tablet 8 mg	PRN	S	Until discont'd	
		8 mg, oral, every morning, Starting S+1 As Scheduled, for 3 doses
	Administer on Day 2-4.		

Hypersensitivity 	

	
	Interval	Defer Until	Duration	
	☐	Nursing communication				
		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.		
	☐	Nursing communication				
		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.		
	☐	Nursing communication				
		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				
		650 mg, oral, once PRN, Increased temperature, Starting when released, Until Discontinued
	Maximum of 4 grams of acetaminophen per day from all sources. (Cirrhosis patients maximum: 2 grams per day from all sources).		
	☐	diphenhydrAMINE (BENADRYL) injection 25 mg				
		25 mg, intravenous, PRN, Allergic reaction, Starting when released, Until Discontinued		
	☐	cetirizine (ZyrTEC) tablet 10 mg				
		10 mg, oral, once PRN, allergic reaction, Starting when released, Until Discontinued		
	☐	famotidine (PEPCID) injection 20 mg				
		20 mg, intravenous, PRN, Allergic reaction, Starting when released, Until Discontinued
	Indication(s) for H2 Receptor Antagonist (H2RA) Therapy: Allergic Reaction		
	☐	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg				
		100 mg, intravenous, PRN, Allergic reaction, Until Discontinued		
	☐	dexAMETHasone (DECADRON) IV 4 mg				
		4 mg, intravenous, PRN, Allergic reaction, Until Discontinued		
	☐	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg				
		0.3 mg, subcutaneous, PRN, anaphylaxis, Starting when released, Until Discontinued