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IP CAGT ALLOGENEIC SCT FLU-MEL-PTCY	

Types:      ONCOLOGY TREATMENT
Synonyms:  FLU, FLUDARA, MELPHALAN, ALKERAN, SARCOLYSIN, CYCLOPHOSPHAMIDE, CYTOXAN, BMT, CAGT, ALLOGENEIC, SCT, FLUMELCAM, PTCY

Transplant	Repeat 1 time	Cycle length: 90 days	Day -6 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).
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Supportive Care
  	valACYclovir (VALTREX) tablet 500 mg	Dose: 500 mg	Route: oral	daily	Start: S				  	micafungin (MYCAMINE) 100 mg in sodium chloride 0.9% 100 mL IVPB	Dose: 100 mg	Route: intravenous	every 24 hours over 60 Minutes for 11 doses	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MICAFUNGIN 100 MG INTRAVENOUS SOLUTION (RESTRICTED)	Medications	100 mg	Main Ingredient	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	100 mL	Yes	Yes			  	levoFLOXacin (LEVAQUIN) tablet 500 mg	Dose: 500 mg	Route: oral	daily at 0600 for 56 doses	Start: S+9			Instructions:	Start on Day +3.		  	ursodiol (ACTIGALL) capsule 300 mg	Dose: 300 mg	Route: oral	3 times daily	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) tablet 8 mg	Dose: 8 mg	Route: oral	every 24 hours for 4 doses	Start: S			Instructions:	Day -6 through Day -3		  	OLANZapine (ZYPREXA) tablet 5 mg	Dose: 5 mg	Route: oral	daily for 4 doses	Start: S+4  8:00 AM			Instructions:	Day -2 through Day +1		  	ondansetron (ZOFRAN) 16 mg, dexAMETHasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S+4  8:00 AM			Instructions:	Administer 30 mins prior to treatment on Day -2.	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+4  8:00 AM			Instructions:	Administer 30 minutes prior to treatment on Day -2.			Antiemetics
  	prochlorperazine (COMPAZINE) injection 10 mg	Dose: 10 mg	Route: intravenous	every 6 hours PRN	Start: S			Instructions:	If giving IV push, administer over 2-3 minutes. Give as needed if patient cannot tolerate oral.			Nursing Orders
  	TRANSFUSION REACTION EVALUATION	Interval: Until discontinued	Occurrences: --	Comments:	Ice chips and / or popsicles to patient 30 minutes prior, during and for 30 minutes following Melphalan infusion.
		  	ONC NURSING COMMUNICATION 30	Interval: Once	Occurrences: --	Comments:	Administer Melphalan NO later than 10:00 am.
			Nursing Orders
  	TREATMENT CONDITIONS 24	Interval: --	Occurrences: --	Comments:	HOLD and notify provider if :
o CrCl LESS than 70 ml/min
			Chemotherapy
  	fludarabine (FLUDARA) 30 mg/m2 in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 30 mg/m2	Route: intravenous	every 24 hours over 30 Minutes for 4 doses			Offset: 30 Minutes	Instructions:	Day -6, -5, -4, -3	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION	Medications	30 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	No	Yes			  	melphalan HCL (ALKERAN) 140 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 140 mg/m2	Route: intravenous	once over 15 Minutes for 1 dose	Start: S+4  9:00 AM			Instructions:	Day -2.

Infuse within 60 minutes from vial reconstitution.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MELPHALAN HCL 50 MG/10 ML INTRAVENOUS POWDER FOR SOLUTION (RECONSTITUTED VIAL)	Medications	140 mg/m2	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: Until discontinued	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 83	Interval: Until discontinued	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 4	Interval: Until discontinued	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.
		  	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	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Day of Rest
  	ONC NURSING COMMUNICATION 48	Interval: Until discontinued	Occurrences: --	Comments:	Day of Rest: Day-1 mm/dd/yyyy
				Day 0	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S				  	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:
		  	morPHINE injection 2 mg	Dose: 2 mg	Route: intravenous	every 30 min PRN for 2 doses	Start: S			Instructions:	- Give morphine 2 mg IV X 1 PRN drug-induced rigors. If no relief in 30 minutes, may give another dose of morphine 2 mg IV X 1 PRN for drug-induced rigors.
If both oral and IV options are ordered for same pain level, administer IV if patient not able to take oral medications.		  	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							Days 1 through 8	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Labs
  	ECG 12-LEAD	Interval: Daily	Occurrences: --	Comments:	Starting Day +3. Must be reviewed by MD daily prior to each Cyclophosphamide dose.
		  	URINALYSIS, AUTOMATED WITH MICROSCOPY	Interval: Daily	Occurrences: --	Comments:	Start Day +3.
			Hydration
  	sodium chloride 0.9 % infusion	Dose: 125 mL/hr	Route: intravenous	continuous	Start: S+2  5:00 AM			Instructions:	Start 4 hours prior to cyclophosphamide. Continue for 24 hours post cyclophosphamide completion.			Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	every 24 hours for 5 doses	Start: S  8:00 AM			Instructions:	Instructions: Administer on Days +1 through +5		  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S+2  8:00 AM			Instructions:	Instructions: Administer 30 minutes prior to treatment on Day +3		  	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	every 8 hours PRN	Start: S+5			Instructions:	Instructions: Start Day +6			Nursing Orders
  	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.
			Chemotherapy
  	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+2  8:30 AM			Instructions:	Instructions: Give immediately prior to first cyclophosphamide infusion.	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) 50 mg/kg in dextrose 5% 500 mL chemo IVPB	Dose: 50 mg/kg	Route: intravenous	every 24 hours over 2 Hours for 2 doses	Start: S+2  9:00 AM			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM/50 ML INTRAVENOUS POWDER FOR SOLUTION (RECONSTITUTED VIAL)	Medications	50 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+2  1:00 PM			Instructions:	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+2 11:00 AM			Instructions:	-Give at completion of each dose of cyclophosphamide infusion on Day +3 and Day +4		  	furosemide (LASIX) injection 20 mg	Dose: 20 mg	Route: intravenous	every 24 hours for 2 doses	Start: S+2  5:00 PM			Instructions:	Give 6 hours AFTER completion of each dose of Cyclophosphamide infusion on Day +3 and Day +4			Supportive Care
  	posaconazole (NOXAFIL) tablet (RESTRICTED) 300 mg	Dose: 300 mg	Route: oral	every 24 hours	Start: S+4  8:00 AM			Instructions:	Do NOT crush, split, or chew.  The delayed release tablet is NOT to interchange / substitute with oral posaconazole suspension.
Instructions: Stat Day +5		  	tbo-filgrastim (GRANIX) injection solution	Dose: --	Route: subcutaneous	daily at 1600	Start: S+6			Instructions:	Do not administer tbo-filgrastim within 24 hours before chemotherapy.
START Day +7.	Rule-Based Template: RULE ONCBCN NEUPOGEN WEIGHT BASED	  Conditions:	  Modifications:	  Weight > 78 kg	  Set dose to 480 mcg	  Weight <= 78 kg	  Set dose to 300 mcg			Acute Graft Versus Host Prophylaxis
  	tacrolimus (PROGRAF) IVPB 0.015 mg/kg (Ideal)	Dose: 0.015 mg/kg	Route: intravenous	every 24 hours over 24 Hours	Start: S+4  4:00 PM			Instructions:	May cause QTc prolongation.  Use the lesser of IBW or actual body weight (ABW).
Start on D+5.		  	mycophenolate (CELLCEPT) 1,000 mg in dextrose 5% IVPB	Dose: 1,000 mg	Route: intravenous	Every 8 Hours (TIME CRITICAL)  over 2 Hours	Start: S+4  8:00 AM			Instructions:	Start Day +5	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MYCOPHENOLATE 500 MG/15 ML INTRAVENOUS SOLUTION (RECONSTITUTED VIAL)	Medications	1,000 mg	Main Ingredient	No	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	167 mL	Always	Yes