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IP CAGT AUTOLOGOUS SCT HIGH DOSE ETOPOSIDE / CARBOPLATIN (TICE PROTOCOL)	

Types:      ONCOLOGY TREATMENT
Synonyms:  PARAPLATIN, VP 16, TOPOSAR, STEM CELL TRANSPLANT, AUC

Transplant 1	Repeat 1 time	Cycle length: 21 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					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
  	dexamethasone (DECADRON) IV 10 mg	Dose: 10 mg	Route: intravenous	once for 1 dose	Start: S  9:00 PM			Instructions:	Administer on Day -6		  	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	every 24 hours over 10 Minutes	Start: S+1			Instructions:	Administer 30 minutes prior to treatment on Days -5, -4, -3, -2, -1.	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+1			Instructions:	Administer 30 minutes prior to treatment on Days -5.		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	every 24 hours for 3 doses	Start: S+1			Instructions:	Administer on Days -5, -4, -3 prior to Etoposide infusion.			Antiemetics
  	promethazine (PHENERGAN) injection 25 mg	Dose: 25 mg	Route: injection	every 4 hours PRN	Start: S					Supportive Care
  	fluconazole (DIFLUCAN) tablet 200 mg	Dose: 200 mg	Route: oral	daily	Start: S				  	acyclovir (ZOVIRAX) 800 mg	Dose: 800 mg	Route: oral	daily	Start: S				  	levoFLOXacin (LEVAQUIN) tablet 500 mg	Dose: 500 mg	Route: oral	daily at 0600	Start: S					Hydration
  	sodium chloride 0.9 % infusion	Dose: 125 mL/hr	Route: intravenous	continuous						Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Until discontinued	Occurrences: --	Comments:	Etoposide Administration Instructions:
1.  Administer Etoposide first before Carboplatin
2.  Use DEHP-free IV bag and low-sorbing administration set
3.  NO FILTER needed
4.  Tubing will be primed with Etoposide, please use appropriate precautions
5.  Etoposide should be infused into a separate lumen from all other fluids/medications
6.  Run IV fluid concurrently through a separate lumen
7.  DO NOT FLUSH bag when infusion complete.
     A.  Bag will contain overfill to account for tubing volume
8.  When the two hour infusion is complete, disconnect tubing from CVC and flush with NS as per normal protocol.
		  	ONC NURSING COMMUNICATION 5	Interval: Until discontinued	Occurrences: --	Comments:	ETOPOSIDE DOSING INFORMATION:
1.  Bag contains overfill to account for tubing volume (26mL) since flushing is not allowed
2.  Dose/Volume/Rate listed on label includes overfill volume 
3.  Patient dose = *** mg
4.  Volume to be infused in patient will be *** mL over 2 hours
5.  Actual infusion rate should be *** mL/hr
6.  Please set pump according to rate specified in step 5 and stop infusion after 2 hours.
		  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	Occurrences: --	Comments:	During Etoposide infusion:
-Every 15 minutes for 1 hour, THEN
-Hourly until completion, THEN 
-May return to routine VS at completion of infusion
-If SBP is less than 90 or greater than 160, call MD and slow infusion rate to HALF PREVIOUS RATE for completion of infusion.
			Chemotherapy
  	etoposide (TOPOSAR) UNDILUTED chemo IVPB 400 mg/m2 (Treatment Plan)	Dose: 400 mg/m2	Route: intravenous	every 24 hours over 2 Hours for 3 doses	Start: S+1			Instructions:	HAZARDOUS - Handle with care 
Bag contains overfill. 
DO NOT infuse per rate listed on label - ONLY use rate listed below. 
Patient dose = *** mg; 
INFUSION RATE = *** mL/hr x 2 hours; 
Only for use in a stem cell transplant protocol, DO NOT use outside of this setting. 
Administer on day -5, -4, -3.
During Etoposide infusion:
-Every 15 minutes for 1 hour, THEN
-Hourly until completion, THEN 
-May return to routine VS at completion of infusion
-If SBP is less than 90 or greater than 160, call MD and slow infusion rate to HALF PREVIOUS RATE for completion of infusion.			Chemotherapy
  	CARBOplatin (PARAplatin) in sodium chloride 0.9% 250 mL chemo IVPB	AUC: 7 Use AUC	Route: intravenous	every 24 hours over 30 Minutes for 3 doses	Start: S+1			Instructions:	Use minimum serum creatinine 0.7 mg/dL for Carboplatin AUC dosing. HOLD and notify provider if SCr increase by GREATER than or EQUAL to 0.5 mg/dL from baseline or SCr GREATER than 1.4.
Administer on day -5, -4, -3.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION	Medications	 	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				Day of Rest
  	ONC NURSING COMMUNICATION 6	Interval: Until discontinued	Occurrences: --	Comments:	Days of Rest - Day -2, -1
No chemotherapy scheduled on these days.
			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					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 0	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Antiemetics
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S					Pre-Medications
  	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:	If no relief in 30 minutes, may give another dose morphine 2 mg IV X 1 PRN for drug-induced rigors.		  	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							Day 1	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Antiemetics
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S					Antiemetics
  	ondansetron ODT (ZOFRAN-ODT) disintegrating tablet 8 mg	Dose: 8 mg	Route: oral	every 8 hours PRN	Start: S+1							
Transplant 2	Repeat 1 time	Cycle length: 21 days	Day -6 through -1	Perform every 1 day x1		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
  	dexamethasone (DECADRON) IV 10 mg	Dose: 10 mg	Route: intravenous	once for 1 dose	Start: S  9:00 PM			Instructions:	Administer on Day -6		  	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	every 24 hours over 10 Minutes	Start: S+1			Instructions:	Administer 30 minutes prior to treatment on Days -5, -4, -3, -2, -1.	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+1			Instructions:	Administer 30 minutes prior to treatment on Days -5.		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	every 24 hours for 3 doses	Start: S+1			Instructions:	Administer on Days -5, -4, -3 prior to Etoposide infusion.			Antiemetics
  	promethazine (PHENERGAN) injection 25 mg	Dose: 25 mg	Route: injection	every 4 hours PRN	Start: S					Supportive Care
  	fluconazole (DIFLUCAN) tablet 200 mg	Dose: 200 mg	Route: oral	daily	Start: S				  	acyclovir (ZOVIRAX) 800 mg	Dose: 800 mg	Route: oral	daily	Start: S				  	levoFLOXacin (LEVAQUIN) tablet 500 mg	Dose: 500 mg	Route: oral	daily at 0600	Start: S					Hydration
  	sodium chloride 0.9 % infusion	Dose: 125 mL/hr	Route: intravenous	continuous						Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Until discontinued	Occurrences: --	Comments:	Etoposide Administration Instructions:
1.  Administer Etoposide first before Carboplatin
2.  Use DEHP-free IV bag and low-sorbing administration set
3.  NO FILTER needed
4.  Tubing will be primed with Etoposide, please use appropriate precautions
5.  Etoposide should be infused into a separate lumen from all other fluids/medications
6.  Run IV fluid concurrently through a separate lumen
7.  DO NOT FLUSH bag when infusion complete.
     A.  Bag will contain overfill to account for tubing volume
8.  When the two hour infusion is complete, disconnect tubing from CVC and flush with NS as per normal protocol.
		  	ONC NURSING COMMUNICATION 5	Interval: Until discontinued	Occurrences: --	Comments:	ETOPOSIDE DOSING INFORMATION:
1.  Bag contains overfill to account for tubing volume (26mL) since flushing is not allowed
2.  Dose/Volume/Rate listed on label includes overfill volume 
3.  Patient dose = *** mg
4.  Volume to be infused in patient will be *** mL over 2 hours
5.  Actual infusion rate should be *** mL/hr
6.  Please set pump according to rate specified in step 5 and stop infusion after 2 hours.
		  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	Occurrences: --	Comments:	During Etoposide infusion:
-Every 15 minutes for 1 hour, THEN
-Hourly until completion, THEN 
-May return to routine VS at completion of infusion
-If SBP is less than 90 or greater than 160, call MD and slow infusion rate to HALF PREVIOUS RATE for completion of infusion.
			Chemotherapy
  	etoposide (TOPOSAR) UNDILUTED chemo IVPB 400 mg/m2 (Treatment Plan)	Dose: 400 mg/m2	Route: intravenous	every 24 hours over 2 Hours for 3 doses	Start: S+1			Instructions:	HAZARDOUS - Handle with care 
Bag contains overfill. 
DO NOT infuse per rate listed on label - ONLY use rate listed below. 
Patient dose = *** mg; 
INFUSION RATE = *** mL/hr x 2 hours; 
Only for use in a stem cell transplant protocol, DO NOT use outside of this setting. 
Administer on day -5, -4, -3.
During Etoposide infusion:
-Every 15 minutes for 1 hour, THEN
-Hourly until completion, THEN 
-May return to routine VS at completion of infusion
-If SBP is less than 90 or greater than 160, call MD and slow infusion rate to HALF PREVIOUS RATE for completion of infusion.			Chemotherapy
  	CARBOplatin (PARAplatin) in sodium chloride 0.9% 250 mL chemo IVPB	AUC: 7 Use AUC	Route: intravenous	every 24 hours over 30 Minutes for 3 doses	Start: S+1			Instructions:	Use minimum serum creatinine 0.7 mg/dL for Carboplatin AUC dosing. HOLD and notify provider if SCr increase by GREATER than or EQUAL to 0.5 mg/dL from baseline or SCr GREATER than 1.4.
Administer on day -5, -4, -3.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION	Medications	 	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				Day of Rest
  	ONC NURSING COMMUNICATION 6	Interval: Until discontinued	Occurrences: --	Comments:	Days of Rest - Day -2, -1
No chemotherapy scheduled on these days.
			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					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 0	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Antiemetics
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S					Pre-Medications
  	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:	If no relief in 30 minutes, may give another dose morphine 2 mg IV X 1 PRN for drug-induced rigors.		  	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							Day 1	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Antiemetics
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S					Antiemetics
  	ondansetron ODT (ZOFRAN-ODT) disintegrating tablet 8 mg	Dose: 8 mg	Route: oral	every 8 hours PRN	Start: S+1							
Transplant 3	Repeat 1 time	Cycle length: 21 days	Day -6 through -1	Perform every 1 day x1		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
  	dexamethasone (DECADRON) IV 10 mg	Dose: 10 mg	Route: intravenous	once for 1 dose	Start: S  9:00 PM			Instructions:	Administer on Day -6		  	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	every 24 hours over 10 Minutes	Start: S+1			Instructions:	Administer 30 minutes prior to treatment on Days -5, -4, -3, -2, -1.	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+1			Instructions:	Administer 30 minutes prior to treatment on Days -5.		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	every 24 hours for 3 doses	Start: S+1			Instructions:	Administer on Days -5, -4, -3 prior to Etoposide infusion.			Antiemetics
  	promethazine (PHENERGAN) injection 25 mg	Dose: 25 mg	Route: injection	every 4 hours PRN	Start: S					Supportive Care
  	fluconazole (DIFLUCAN) tablet 200 mg	Dose: 200 mg	Route: oral	daily	Start: S				  	acyclovir (ZOVIRAX) 800 mg	Dose: 800 mg	Route: oral	daily	Start: S				  	levoFLOXacin (LEVAQUIN) tablet 500 mg	Dose: 500 mg	Route: oral	daily at 0600	Start: S					Hydration
  	sodium chloride 0.9 % infusion	Dose: 125 mL/hr	Route: intravenous	continuous						Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Until discontinued	Occurrences: --	Comments:	Etoposide Administration Instructions:
1.  Administer Etoposide first before Carboplatin
2.  Use DEHP-free IV bag and low-sorbing administration set
3.  NO FILTER needed
4.  Tubing will be primed with Etoposide, please use appropriate precautions
5.  Etoposide should be infused into a separate lumen from all other fluids/medications
6.  Run IV fluid concurrently through a separate lumen
7.  DO NOT FLUSH bag when infusion complete.
     A.  Bag will contain overfill to account for tubing volume
8.  When the two hour infusion is complete, disconnect tubing from CVC and flush with NS as per normal protocol.
		  	ONC NURSING COMMUNICATION 5	Interval: Until discontinued	Occurrences: --	Comments:	ETOPOSIDE DOSING INFORMATION:
1.  Bag contains overfill to account for tubing volume (26mL) since flushing is not allowed
2.  Dose/Volume/Rate listed on label includes overfill volume 
3.  Patient dose = *** mg
4.  Volume to be infused in patient will be *** mL over 2 hours
5.  Actual infusion rate should be *** mL/hr
6.  Please set pump according to rate specified in step 5 and stop infusion after 2 hours.
		  	VITAL SIGNS - T/P/R/BP	Interval: Per unit protocol	Occurrences: --	Comments:	During Etoposide infusion:
-Every 15 minutes for 1 hour, THEN
-Hourly until completion, THEN 
-May return to routine VS at completion of infusion
-If SBP is less than 90 or greater than 160, call MD and slow infusion rate to HALF PREVIOUS RATE for completion of infusion.
			Chemotherapy
  	etoposide (TOPOSAR) UNDILUTED chemo IVPB 400 mg/m2 (Treatment Plan)	Dose: 400 mg/m2	Route: intravenous	every 24 hours over 2 Hours for 3 doses	Start: S+1			Instructions:	HAZARDOUS - Handle with care 
Bag contains overfill. 
DO NOT infuse per rate listed on label - ONLY use rate listed below. 
Patient dose = *** mg; 
INFUSION RATE = *** mL/hr x 2 hours; 
Only for use in a stem cell transplant protocol, DO NOT use outside of this setting. 
Administer on day -5, -4, -3.
During Etoposide infusion:
-Every 15 minutes for 1 hour, THEN
-Hourly until completion, THEN 
-May return to routine VS at completion of infusion
-If SBP is less than 90 or greater than 160, call MD and slow infusion rate to HALF PREVIOUS RATE for completion of infusion.			Chemotherapy
  	CARBOplatin (PARAplatin) in sodium chloride 0.9% 250 mL chemo IVPB	AUC: 7 Use AUC	Route: intravenous	every 24 hours over 30 Minutes for 3 doses	Start: S+1			Instructions:	Use minimum serum creatinine 0.7 mg/dL for Carboplatin AUC dosing. HOLD and notify provider if SCr increase by GREATER than or EQUAL to 0.5 mg/dL from baseline or SCr GREATER than 1.4.
Administer on day -5, -4, -3.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION	Medications	 	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				Day of Rest
  	ONC NURSING COMMUNICATION 6	Interval: Until discontinued	Occurrences: --	Comments:	Days of Rest - Day -2, -1
No chemotherapy scheduled on these days.
			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					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 0	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Antiemetics
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S					Pre-Medications
  	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:	If no relief in 30 minutes, may give another dose morphine 2 mg IV X 1 PRN for drug-induced rigors.		  	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							Day 1	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Antiemetics
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S					Antiemetics
  	ondansetron ODT (ZOFRAN-ODT) disintegrating tablet 8 mg	Dose: 8 mg	Route: oral	every 8 hours PRN	Start: S+1