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CSC BMT INPT/OUTPT (CBV) Rituximab/Carmustine/Etoposide/Cyclophosphamide VER 10-25-17 (HL 4132)

CSC BMT INPT/OUTPT (CBV) Rituximab/Carmustine/Etoposide/Cyclophosphamide VER 10-25-17 (HL 4132) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, BMT


CSC BMT INPT/OUTPT (CBV) RITUXIMAB/CARMUSTINE/ETOPOSIDE/CYCLOPHOSPHAMIDE VER: 10-25-
17 –  Properties
Conditioning Regimen prior to BMT –  10/25/2017 through 11/1/2017 (8 days), Planned
OP Treatment Orders for Day -7, Conditioning Regimen prior to BMT –  Planned for 10/25/2017
Treatment Plan Information
Reference Information (1)
BMT (Autologous): Gutierrez-Delgado F, et al.  Bone Marrow Transplant 2001;28(5):455-61.
Reference Information (2)
NON-HODGKIN'S LYMPHOMA: Plosker GL, et al. Drugs 2003;63(8):803-43.
Reference Information (3)
BMT (Autologous): Stiff PJ, et al. J Clin Oncol 1998;16(1):48-55.
Treatment Plan Summary
DISEASE: Non-Hodgkin's Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day -7, carmustine 15 mg/kg IV Day -6,
etoposide 60 mg/kg IV Day -4, mesna 60 mg/kg IV Day -2 followed by mesna 500 mg IV every 6 hours for 6 doses and
cyclophosphamide 100 mg/kg IV  Day -2; CYCLE LENGTH: 8 days; COURSE: 1 cycle.
Dose Calculation Instructions
All chemotherapy for BMT conditioning regimens should be dosed based on the medication-specific weight in
Standard Operating Procedure (SOP) B4.400: Calculation of High Dose Chemotherapy Doses. Document can be
accessed from the Reference Link of the Navigator.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
HEPATITIS B CORE AB, TOTAL
Expected: S Approximate, Expires: S+365, Routine
HEPATITIS B SURFACE AG
Expected: S Approximate, Expires: S+365, Routine
HEPATITIS B SURFACE AB
Expected: S Approximate, Expires: S+122, Routine
Pre-Labs (delete all that do not apply)
HEPATITIS B DNA, ULTRA QUANT, PCR
Expected: S Approximate, Expires: S+122, Routine
Draw if Hepatitis B Core AB is positive.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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ZZtestonc,Andrew [2428787]
10/25/2017 4:36:00 PM Page 1 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if
greater than 6 months since last dose. For first and second dose patient should be treated in a location
to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion
complete. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension,
stop infusion and contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during
which the reaction occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
dextrose 5%- NaCl 0.9% with KCl 20 mEq/L infusion
Intravenous, CONTINUOUS Starting when released Until Discontinued
Day -7. Infuse at 2 L/m2/24h.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Day -7: Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Day -7: Administer prior to rituximab.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 650 mg in sodium chloride 0.9 % 500 mL bag
650 mg (rounded from 693.75 mg = 375 mg/m2 × 1.85 m2), Intravenous, ONCE, 1 dose Starting when released
Day -7: Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note
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ZZtestonc,Andrew [2428787]
10/25/2017 4:36:00 PM Page 2 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

on MAR for infusion rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain
or hypotension, contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during
which the reaction occurred.
IP Treatment Orders for Day -6 to Day 0, Conditioning Regimen prior to BMT –  Planned for
10/26/2017 through 11/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin's Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day -7, carmustine 15 mg/kg IV Day -6,
etoposide 60 mg/kg IV Day -4, mesna 60 mg/kg IV Day -2 followed by mesna 500 mg IV every 6 hours for 6 doses and
cyclophosphamide 100 mg/kg IV  Day -2; CYCLE LENGTH: 8 days; COURSE: 1 cycle.
Dose Calculation Instructions
All chemotherapy for BMT conditioning regimens should be dosed based on the medication-specific weight in
Standard Operating Procedure (SOP) B4.400: Calculation of High Dose Chemotherapy Doses. Document can be
accessed from the Reference Link of the Navigator.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify labs from BMT Admission Order Set with authorizing prescriber prior to releasing treatment medications and
document in a progress note.
Nursing Procedure, Assessment and Monitoring
Vital Signs
EVERY 1 HOUR Starting S+2 at 0000 for 4 occurrences
Day -4 during etoposide infusion, check BP and HR every hour. During etoposide infusion if BP falls below 100 mm Hg
or if baseline BP less than 100 mm Hg systolic but then decreases by 10%, STOP etoposide infusion and start Sodium
Chloride 0.9% at 250 mL/hr and notify BMT Team.
Measure Intake And Output
EVERY 4 HOURS Starting S+4 at 0000 Until Specified
Day -2: If urine output less than 400 mL over 4 hours, notify BMT team
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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ZZtestonc,Andrew [2428787]
10/25/2017 4:36:00 PM Page 3 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

dextrose 5%- NaCl 0.9% with KCl 20 mEq/L infusion
Intravenous, CONTINUOUS, For 6 days Starting when released until S+6
Day -6 through Day -1. Infuse at 2 L/m2/24h.
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L infusion
at 100 mL/hr, Intravenous, CONTINUOUS Starting S+6 at 0000 Until Discontinued
Day 0: Following completion of stem cell tranfusion.
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Day-6: administer prior to carmustine. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
lorazepam (ATIVAN) tab 1 mg
1 mg, Oral, ONCE, 1 dose Starting when released
Day -6: Administer 15 minutes prior to carmustine.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, 6 doses Starting when released
Day -6 through Day -1.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, 6 doses Starting when released, nausea/vomiting, If unable to tolerate PO
Day -6 through Day -1.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, EVERY 48 HOURS, 3 doses Starting when released
Day -6, Day -4, Day -2: Administer prior to chemotherapy.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 48 HOURS PRN, For 6 days Starting when released until S+6, nausea/vomiting, if PO not
tolerated
Day -6, Day -4, Day -2. Administer prior to chemotherapy.
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, EVERY 2 HOURS, 2 doses Starting S+2 at 0000, Administer over 1 Minutes
Day -4: Administer IV 15 minutes prior to the start of etoposide and 2 hours after the start of etoposide.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting S+4 at 0000
Day-2: administer prior to cyclophosphamide. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
Treatment Medications
carmustine (BiCNU) 973.667 mg in dextrose 5 % 250 mL non-PVC bag
973.667 mg (rounded from 973.5 mg = 15 mg/kg × 64.9 kg Adjusted weight), Intravenous, ONCE, 1 dose Starting when
released
Day -6: Administer with Non-PVC tubing.
etoposide (VEPESID) 3,894 mg in sodium chloride 0.9 % NSS bag
3,894 mg (60 mg/kg × 64.9 kg Adjusted weight), Intravenous, ONCE, 1 dose Starting S+2 at 0000
Day -4. Administer UNDILUTED in non-PVC tubing over 4 hours.
mesna (MESNEX) 3,690 mg in sodium chloride 0.9 % 250 mL bag
3,690 mg (60 mg/kg × 61.5 kg Ideal weight), Intravenous, ONCE, 1 dose Starting S+4 at 0000
Day -2: Administer IV immediately before cyclophosphamide.
mesna in sodium chloride 0.9% (MESNEX) 20 MG/ML injection 500 mg
500 mg, Intravenous, EVERY 6 HOURS, 6 doses Starting S+4 at 0000, Administer over 15 Minutes
Day -2: After cyclophosphamide administer IV push.
cyclophosphamide (CYTOXAN) 6,150 mg bag
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ZZtestonc,Andrew [2428787]
10/25/2017 4:36:00 PM Page 4 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

6,150 mg (100 mg/kg × 61.5 kg Ideal weight), Intravenous, ONCE, 1 dose Starting S+4 at 0000
Day -2: Administer  IV UNDILUTED over 2 hours.
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, EVERY 5 HOURS, 2 doses Starting S+4 at 0000
Day -2: Administer 1 hour and 6 hours after completion of cyclophosphamide to promote diuresis. IV push rate 10
mg/minute.
Conditional Orders
diphenhydramine (BENADRYL) cap RANGE 25-50 mg
25-50 mg, Oral, EVERY 4 HOURS PRN, For 1 day Starting S+4 at 0000 until S+5, infusion reaction, To treat reaction of
nasal burning or discomfort during cyclophosphamide infusion.
Day-2
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ZZtestonc,Andrew [2428787]
10/25/2017 4:36:00 PM Page 5 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org