If this file opens in Compatibility Mode using Microsoft Word, convert to the latest document format to avoid potential formatting issues.	

IP OXALIPLATIN DESENSITIZATION	

Types:      ONCOLOGY TREATMENT
Synonyms:  OXALIPLATIN, DESENS, ELOXATIN

Cycle 1	Repeat 1 time	Cycle length: 1 day	Day 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
  	ONC PROVIDER COMMUNICATION 53	Interval: Until discontinued	Occurrences: --	Comments:	All OXALIplatin desensitization protocols will start at 9 am of the treatment day. Any OXALIplatin desensitization protocol ordered after 9am will start on the following day.
			Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☐	BASIC METABOLIC PANEL	Interval: Once	Occurrences: --		☐	PULMONARY FUNCTION TEST	Interval: Once	Occurrences: --		☐	URINALYSIS, AUTOMATED WITH MICROSCOPY	Interval: Once	Occurrences: --		☐	TYPE AND SCREEN	Interval: Once	Occurrences: --			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: Until discontinued	Occurrences: --	Comments:	HOLD and notify provider if 
o ANC LESS than 1000; 
o Platelets LESS than 100,000.
			Line Flush
  	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Administer ONLY for Oxaliplatin.			Nursing Orders
  	dextrose 5% infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open for Oxaliplatin.			Hydration
◯	custom IV infusion builder	Dose: --	Route: intravenous	continuous	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Provider Communication
  	ONC PROVIDER COMMUNICATION 52	Interval: Until discontinued	Occurrences: --	Comments:	Total OXALIplatin dose: ***

Please manually calculate and enter in Dose 1, 2, 3, 4, and 5.
			Pre-Medications
  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once for 1 dose	Start: S  9:00 AM			Instructions:	Administer 30 minutes prior to FIRST OXALIplatin dose on Day 1.			Provider Communication
  	ondansetron (ZOFRAN) 16 mg, dexAMETHasone (DECADRON) 20 mg in dextrose 5% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S  9:00 AM			Instructions:	Administer 30 minutes prior to FIRST OXALIplatin dose on Day 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	20 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	No	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes				Pre-Medications
  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S  9:00 AM			Instructions:	Administer 30 minutes prior to FIRST OXALIplatin dose on Day 1.			Chemotherapy
  	OXALIplatin (ELOXATIN) in dextrose 5% 100 mL chemo FOR DESENSITIZATION	Dose: --	Route: intravenous	once over 1 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Bag 1 = 1/10000 of the dose
Irritant, avoid extravasation. Flush line with D5W before and after oxaliplatin infusion.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	OXALIPLATIN 50 MG/10 ML IV SOLN FOR DESENSITIZATION	Medications	 	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes			  	OXALIplatin (ELOXATIN) in dextrose 5% 100 mL chemo IVPB	Dose: --	Route: intravenous	once over 1 Hours for 1 dose			Offset: 90 Minutes	Instructions:	Bag 2 = 1/1000 of the dose
Irritant, avoid extravasation. Flush line with D5W before and after oxaliplatin infusion.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes			  	OXALIplatin (ELOXATIN) in dextrose 5% 100 mL chemo IVPB	Dose: --	Route: intravenous	once over 1 Hours for 1 dose			Offset: 150 Minutes	Instructions:	Bag 3 = 1/100 of the dose 
Irritant, avoid extravasation. Flush line with D5W before and after oxaliplatin infusion.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes			  	OXALIplatin (ELOXATIN) in dextrose 5% 100 mL chemo IVPB	Dose: --	Route: intravenous	once over 1 Hours for 1 dose			Offset: 210 Minutes	Instructions:	Bag 4 = 1/10 of the dose
Irritant, avoid extravasation. Flush line with D5W before and after oxaliplatin infusion.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Nursing Orders
  	ONC CARBO DESENSITIZATION AFTER DOSE 3	Interval: Until discontinued	Occurrences: --	Comments:	After completion of dose 4 of OXALIplatin and if no hypersensitivity reactions noted, please call pharmacy for dose 5 to be delivered.
			Provider Communication
  	ondansetron (ZOFRAN) 8 mg in dextrose 5% 50 mL IVPB	Dose: 8 mg	Route: intravenous	once over 15 Minutes for 1 dose			Offset: 270 Minutes	Instructions:	Administer 30 minutes prior to LAST (Bag 5) OXALIplatin dose on Day 1.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	8 mg	Main Ingredient	No	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	No	Yes				Pre-Medications
  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose			Offset: 270 Minutes	Instructions:	Administer 30 minutes prior to LAST (Bag 5) OXALIplatin dose on Day 1.		  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once for 1 dose			Offset: 270 Minutes	Instructions:	Administer 30 minutes prior to LAST (Bag 5) OXALIplatin dose on Day 1.			Chemotherapy
  	OXALIplatin (ELOXATIN) in dextrose 5% 500 mL chemo IVPB	Dose: --	Route: intravenous	once over 4 Hours for 1 dose			Offset: 300 Minutes	Instructions:	Bag 5  = Total dose  minus the sum of the four previous bags.
Irritant, avoid extravasation. Flush line with D5W before and after oxaliplatin infusion.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 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					Discharge Nursing Orders
☑	dextrose 5% flush syringe 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S			Instructions:	Administer ONLY for Oxaliplatin.		☑	HEParin, porcine 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.