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IP CAGT AUTOLOGOUS SCT IV BEAM	

Types:      ONCOLOGY TREATMENT
Synonyms:  BEAM, CARMUSTINE, BICNU, CYTARABINE, ARAC, VP16, ETOPOSIDE, MELPHALAN, ALKERAN, BMT, CAGT, AUTOLOGOUS, SCT

Transplant	Repeat 1 time	Cycle length: 90 days	Days -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).
			Nursing Orders
  	TREATMENT CONDITIONS 14	Interval: Once	Occurrences: --	Comments:	HOLD and notify provider if:
o CRCL LESS than 60 mL/min,
o Serum Creatinine GREATER than 1.5 mg/dL,
o Bilirubin GREATER than or EQUAL to 1.5 mg/dL,
o Any elevation in AST / ALT.
			Nursing Orders
☑	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.
		☑	ONC NURSING COMMUNICATION 47	Interval: Once	Occurrences: --	Comments:	Begin Melphalan infusion NO later than 10:00 am.
		☑	ONC NURSING COMMUNICATION 25	Interval: Once	Occurrences: --	Comments:	Provide ice chips and / or popsicles to patient 30 minutes prior, during and for 30 minutes following Melphalan infusion.
			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	2 times daily	Start: S				  	fluconazole (DIFLUCAN) tablet 200 mg	Dose: 200 mg	Route: oral	daily	Start: S				  	levoFLOXacin (LEVAQUIN) tablet 500 mg	Dose: 500 mg	Route: oral	daily at 0600 (TIME CRITICAL)	Start: S+9			Instructions:	Start Day +3		  	tbo-filgrastim (GRANIX) injection solution	Dose: --	Route: subcutaneous	daily at 1600	Start: S+13  4:00 PM			Instructions:	Start on Day +7. Do not administer tbo-filgrastim within 24 hours before chemotherapy.	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		  	prednisoLONE acetate (PRED FORTE) 1 % ophthalmic suspension 2 drop	Dose: 2 drop	Route: Both Eyes	4 times daily	Start: S+1			Instructions:	Days -5, -4, -3, -2, -1, 0.			Antiemetics
  	prochlorperazine (COMPAZINE) injection 10 mg	Dose: 10 mg	Route: intravenous	every 6 hours PRN	Start: S					Pre-Medications
  	OLANZapine (ZYPREXA) tablet 5 mg	Dose: 5 mg	Route: oral	daily for 9 doses	Start: S			Instructions:	Day -6 through Day +2.
Give 30 minutes prior to chemotherapy.		  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Day -6.
Give 30 minutes prior to chemotherapy.		  	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:	Day -6. 
Give 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	QS Base	40.8 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	50 mL	No	Yes			  	ondansetron (ZOFRAN) tablet 8 mg	Dose: 8 mg	Route: oral	every 24 hours for 4 doses	Start: S+1  8:30 AM			Instructions:	Give 30 minutes prior to chemotherapy on Day -5 through Day -2.		  	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+5  8:00 AM			Instructions:	Day -1.
Give 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	QS Base	40.8 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	50 mL	No	Yes			  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S+5  8:00 AM			Instructions:	Day -1.
Give 30 minutes prior to chemotherapy.			Chemotherapy
☑	carmustine (BiCNU) 300 mg/m2 in dextrose (NON-PVC) 5% 500 mL chemo IVPB	Dose: 300 mg/m2	Route: intravenous	once over 2 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Day -6

Protect from light	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CARMUSTINE 100 MG INTRAVENOUS POWDER FOR SOLUTION	Medications	300 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) IV SOLP (EXCEL; NON-PVC)	QS Base	500 mL	Yes	Yes			☑	cytarabine PF (CYSTOSAR) 200 mg/m2 in dextrose 5% 100 mL chemo IVPB	Dose: 200 mg/m2	Route: intravenous	every 12 hours over 30 Minutes for 8 doses	Start: S+1  9:00 AM			Instructions:	Day -5, -4, -3, -2	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION	Medications	200 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	No	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes			☑	etoposide (TOPOSAR) 200 mg/m2 in sodium chloride (NON-PVC) 0.9 % 1,000 mL chemo IVPB	Dose: 200 mg/m2	Route: intravenous	every 12 hours over 3 Hours for 8 doses	Start: S+1  9:30 AM			Instructions:	Day -5, -4, -3, -2.  Administer using non-PVC tubing set.
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.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	200 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	1,000 mL	Yes	Yes			☑	ONC PROVIDER COMMUNICATION 8	Interval: Until discontinued	Occurrences: --	Comments:	Remove ETOPOPHOS order - only utilize this order if patient has an intolerability to standard etoposide.
		☑	etoposide phosphate (ETOPOPHOS) 200 mg/m2 in sodium chloride 0.9% 500 mL chemo IVPB	Dose: 200 mg/m2	Route: intravenous	every 24 hours over 3.5 Hours for 4 doses	Start: S+1			Instructions:	Day -5, -4, -3, -2.  Administer in place of Etoposide.
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.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE PHOSPHATE 100 MG/5 ML INTRAVENOUS SOLUTION (RECONSTITUTED VIAL)	Medications	200 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	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+5  9:00 AM			Instructions:	Day -1.

Infuse within 60 minutes from vial reconstitution.

DO NOT begin infusion after 10AM.	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 0	Perform every 1 day x1		Pre-Medications
  	ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes			  	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		Antiemetics
  	ondansetron ODT (ZOFRAN-ODT) disintegrating tablet 8 mg	Dose: 8 mg	Route: oral	every 8 hours PRN