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CSC BMT OUTPT Rituximab/Cyclophosphamide/Fludarabine Reduced Intensity VER 10-25-17 (HL 5412)

CSC BMT OUTPT Rituximab/Cyclophosphamide/Fludarabine Reduced Intensity VER 10-25-17 (HL 5412) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, BMT


CSC BMT OUTPT RITUXIMAB/CYCLOPHOSPHAMIDE/FLUDARABINE REDUCED INTENSITY VER: 10-25-
17 –  Properties
Cycle 1 –  10/26/2017 through 11/19/2017 (25 days), Planned
Conditioning Regimen prior to BMT, Treatment Orders for Day -13 , Cycle 1 –  Planned for
10/26/2017
Treatment Plan Information
Reference Information (1)
BMT (Allogeneic): Khouri I, et al. Blood 2001;98(13):3595-9.
Reference Information (2)
BMT (Allogeneic): Wondergem MJ, et al. Bone Marrow Transplantation 2014;49:513–518.
Reference Information (3)
BMT (Allogeneic): Khouri IF, et al. Blood 2008;111(12):5530-5536.
Reference Information (4)
BMT (Allogeneic): Escalon MP, et al. J Clin Oncol 2004; 22(12):2419-2423.
Treatment Plan Summary
DISEASE: Non-Hodgkins Lymphoma, Chronic Lymphocytic Leukemia, Hodgkin’s Disease; THERAPY: rituximab 375
mg/m2 IV Day -13, Day -6, Day +1 and Day +8, fludarabine 30 mg/m2 IV Day -6, -5 and -4, cyclophosphamide 750
mg/m2 IV Day -6, -5 and -4; GRAFT VS. HOST DISEASE PROPHYLAXIS: tacrolimus 0.06 mg/kg by mouth twice daily
beginning Day -3 and continuing through Day +90; methotrexate 15 mg/m2 IV on Day +1, methotrexate 10 mg/m2 IV
on Day +3, +6, +11; CYCLE LENGTH: 25 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
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ZZtestonc,Andrew [2428787]
10/26/2017 11:33:11 AM Page 1 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Expected: S Approximate, Expires: S+122, Routine
Draw if Hepatitis B Core AB is positive.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
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
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ZZtestonc,Andrew [2428787]
10/26/2017 11:33:11 AM Page 2 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
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. Administer rituximab prior to any chemotherapy. See Note 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.
Follow-Up
DAY -6 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for rituximab, fludarabine, and cyclophosphamide for 6 hours.
MULTIPLE DAY FOLLOW-UP (1)
Day -5 and Day -4: CHEMOTHERAPY ROOM APPOINTMENT for fludarabine and cyclophosphamide for 210 minutes.
Follow-Up
DAY 0 FOLLOW-UP - CHEMOTHERAPY ROOM APPOINTMENT/BMT HIGH RISK WITH ***:  peripheral blood stem cell
infusion for 120 minutes.
DAY 1 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT/BMT HIGH RISK WITH ***: rituximab and methotrexate for 240 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT/BMT HIGH RISK WITH ***: methotrexate.
DAY 6 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT/BMT HIGH RISK WITH ***: methotrexate.
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT/BMT HIGH RISK WITH ***: rituximab.
DAY 11 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT/BMT HIGH RISK WITH *** . methotrexate.
Conditioning Regimen prior to BMT, Treatment Orders for Day -6 , Cycle 1 –  Planned for 11/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkins Lymphoma, Chronic Lymphocytic Leukemia, Hodgkin’s Disease; THERAPY: rituximab 375
mg/m2 IV Day -13, Day -6, Day +1 and Day +8, fludarabine 30 mg/m2 IV Day -6, -5 and -4, cyclophosphamide 750
mg/m2 IV Day -6, -5 and -4; GRAFT VS. HOST DISEASE PROPHYLAXIS: tacrolimus 0.06 mg/kg by mouth twice daily
beginning Day -3 and continuing through Day +90; methotrexate 15 mg/m2 IV on Day +1, methotrexate 10 mg/m2 IV
on Day +3, +6, +11; CYCLE LENGTH: 25 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.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
10/26/2017 11:33:11 AM Page 3 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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.
Monitoring Parameters (2)
Verify the patient is voiding prior to leaving the clinic
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.
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water the day of and for two days after treatment.
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
sodium chloride 0.9% BOLUS
2,000 mL, Intravenous, ONCE, 1 dose Starting when released, Administer over 180 Minutes
Administer over at least 180 minutes. Administer throughout clinic visit beginning 60 minutes prior to
cyclophosphamide infusion.
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
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ZZtestonc,Andrew [2428787]
10/26/2017 11:33:11 AM Page 4 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
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 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
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. Administer rituximab prior to any chemotherapy. See Note 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.
fludarabine (FLUDARA) 55.5 mg in sodium chloride 0.9 % 100 mL bag
55.5 mg (30 mg/m2 × 1.85 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 30 minutes
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute. IV infusion rate 4 mg/minute. Administer prior to cyclophosphamide infusion.
cyclophosphamide (CYTOXAN) 1,260 mg in sodium chloride 0.9 % 250 mL bag
1,260 mg (750 mg/m2 × 1.68 m2 Treatment plan ideal BSA), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. NOTE - if mesna needed, place as separate order.
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN
starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN
starting S, Local Printer
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day -3 and Day -2., 8 mg, Disp-10 tab, R-0, 1 X DAILY starting S, Local
Printer
Take Home Medications (delete all that do not apply)
tacrolimus 0.5 MG cap
Take  by mouth every 12 hours. Begin on Day -3 and continue until Day +90 then taper per MD., R-0, EVERY 12
HOURS starting S
Dose = 0.06 mg/kg by mouth twice daily based on Treatment Plan Actual weight. Round to nearest 0.5 mg.
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ZZtestonc,Andrew [2428787]
10/26/2017 11:33:11 AM Page 5 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

tacrolimus 1 MG cap
Take  by mouth every 12 hours. Begin on Day -3 and continue until Day +90 then taper per MD., R-0, EVERY 12
HOURS starting S
Dose = 0.06 mg/kg by mouth twice daily based on Treatment Plan Actual weight. Round to nearest 0.5 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day -13.
Conditioning Regimen prior to BMT, Treatment Orders for Day -5, Cycle 1 –  Planned for 11/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkins Lymphoma, Chronic Lymphocytic Leukemia, Hodgkin’s Disease; THERAPY: rituximab 375
mg/m2 IV Day -13, Day -6, Day +1 and Day +8, fludarabine 30 mg/m2 IV Day -6, -5 and -4, cyclophosphamide 750
mg/m2 IV Day -6, -5 and -4; GRAFT VS. HOST DISEASE PROPHYLAXIS: tacrolimus 0.06 mg/kg by mouth twice daily
beginning Day -3 and continuing through Day +90; methotrexate 15 mg/m2 IV on Day +1, methotrexate 10 mg/m2 IV
on Day +3, +6, +11; CYCLE LENGTH: 25 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.
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.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Verify the patient is voiding prior to leaving the clinic and that the patient has voided frequently over the past 24 hours.
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water the day of and for two days after treatment.
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
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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ZZtestonc,Andrew [2428787]
10/26/2017 11:33:11 AM Page 6 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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
sodium chloride 0.9% BOLUS
2,000 mL, Intravenous, ONCE, 1 dose Starting when released, Administer over 180 Minutes
Administer over at least 180 minutes. Administer throughout clinic visit beginning 60 minutes prior to
cyclophosphamide infusion.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
fludarabine (FLUDARA) 55.5 mg in sodium chloride 0.9 % 100 mL bag
55.5 mg (30 mg/m2 × 1.85 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 30 minutes
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute. IV infusion rate 4 mg/minute. Administer prior to cyclophosphamide infusion.
cyclophosphamide (CYTOXAN) 1,260 mg in sodium chloride 0.9 % 250 mL bag
1,260 mg (750 mg/m2 × 1.68 m2 Treatment plan ideal BSA), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. NOTE - if mesna needed, place as separate order.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day -13.
Conditioning Regimen prior to BMT, Treatment Orders for Day -4, Cycle 1 –  Planned for 11/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkins Lymphoma, Chronic Lymphocytic Leukemia, Hodgkin’s Disease; THERAPY: rituximab 375
mg/m2 IV Day -13, Day -6, Day +1 and Day +8, fludarabine 30 mg/m2 IV Day -6, -5 and -4, cyclophosphamide 750
mg/m2 IV Day -6, -5 and -4; GRAFT VS. HOST DISEASE PROPHYLAXIS: tacrolimus 0.06 mg/kg by mouth twice daily
beginning Day -3 and continuing through Day +90; methotrexate 15 mg/m2 IV on Day +1, methotrexate 10 mg/m2 IV
on Day +3, +6, +11; CYCLE LENGTH: 25 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.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
10/26/2017 11:33:11 AM Page 7 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Verify the patient is voiding prior to leaving the clinic and that the patient has voided frequently over the past 24 hours.
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water the day of and for two days after treatment.
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
sodium chloride 0.9% BOLUS
2,000 mL, Intravenous, ONCE, 1 dose Starting when released, Administer over 180 Minutes
Administer over at least 180 minutes. Administer throughout clinic visit beginning 60 minutes prior to
cyclophosphamide infusion.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
fludarabine (FLUDARA) 55.5 mg in sodium chloride 0.9 % 100 mL bag
55.5 mg (30 mg/m2 × 1.85 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 30 minutes
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
IV push rate 10 mg/minute. IV infusion rate 4 mg/minute. Administer prior to cyclophosphamide infusion.
cyclophosphamide (CYTOXAN) 1,260 mg in sodium chloride 0.9 % 250 mL bag
1,260 mg (750 mg/m2 × 1.68 m2 Treatment plan ideal BSA), Intravenous, ONCE, 1 dose Starting when released
Administer over 120 minutes. NOTE - if mesna needed, place as separate order.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day -13.
Day 0 - Stem Cell Infusion, Cycle 1 –  Planned for 11/8/2017
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ZZtestonc,Andrew [2428787]
10/26/2017 11:33:11 AM Page 8 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkins Lymphoma, Chronic Lymphocytic Leukemia, Hodgkin’s Disease; THERAPY: rituximab 375
mg/m2 IV Day -13, Day -6, Day +1 and Day +8, fludarabine 30 mg/m2 IV Day -6, -5 and -4, cyclophosphamide 750
mg/m2 IV Day -6, -5 and -4; GRAFT VS. HOST DISEASE PROPHYLAXIS: tacrolimus 0.06 mg/kg by mouth twice daily
beginning Day -3 and continuing through Day +90; methotrexate 15 mg/m2 IV on Day +1, methotrexate 10 mg/m2 IV
on Day +3, +6, +11; CYCLE LENGTH: 25 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.
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.
Nursing Procedure, Assessment and Monitoring
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes times 4, starting at beginning of stem cell infusion and continue for 30 minutes
after completion of stem cell infusion. If patient experiences fever accompanied by chills or rigors, shortness of breath,
chest pain, hypo/hypertension, tachycardia and/or tachypnea, stop infusion and contact MD.  Once the patient returns
to baseline, infusion may be restarted with the rate at the discretion of the MD.
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
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications (delete all that do not apply)
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Day 0: Administer 30 minutes prior to stem cell infusion if patient and donor have major ABO incompatible blood
types.  Delete Pre-Medication section if patient and donor DO NOT have major ABO incompatible blood types.
diphenhydramine (BENADRYL) cap 25 mg
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ZZtestonc,Andrew [2428787]
10/26/2017 11:33:11 AM Page 9 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

25 mg, Oral, ONCE, 1 dose Starting when released
Day 0: Administer 30 minutes prior to stem cell infusion if patient and donor have major ABO incompatible blood
types.  Delete Pre-Medication section if patient and donor DO NOT have major ABO incompatible blood types.
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
hydrocortisone sodium succinate 10 MG/ML in sodium chloride 0.9% injection 100 mg
100 mg, Intravenous, ONCE PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
Note to All Staff (1)
STEM CELL INFUSION: Allogeneic stem cell product (refer to Product Verification Form) - Infuse over 15-30 minutes or
longer as directed by MD.  Record the infusion start and stop times on the Product Verification Form.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day -13.
Conditioning Regimen prior to BMT, Treatment Orders for Day +1, Cycle 1 –  Planned for 11/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkins Lymphoma, Chronic Lymphocytic Leukemia, Hodgkin’s Disease; THERAPY: rituximab 375
mg/m2 IV Day -13, Day -6, Day +1 and Day +8, fludarabine 30 mg/m2 IV Day -6, -5 and -4, cyclophosphamide 750
mg/m2 IV Day -6, -5 and -4; GRAFT VS. HOST DISEASE PROPHYLAXIS: tacrolimus 0.06 mg/kg by mouth twice daily
beginning Day -3 and continuing through Day +90; methotrexate 15 mg/m2 IV on Day +1, methotrexate 10 mg/m2 IV
on Day +3, +6, +11; CYCLE LENGTH: 25 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.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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ZZtestonc,Andrew [2428787]
10/26/2017 11:33:11 AM Page 10 of 16
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
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Day +1: Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Day +1: 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 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
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ZZtestonc,Andrew [2428787]
10/26/2017 11:33:11 AM Page 11 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Day +1: 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. Administer rituximab prior to any chemotherapy. See Note 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.
methotrexate PF (TREXALL) injection 28 mg
28 mg (rounded from 27.75 mg = 15 mg/m2 × 1.85 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE,
1 dose Starting when released
Day +1: Administer 24 hours after completion of stem cell infusion. Check with BMT Team prior to administration. IV
push rate 10 mg/minute.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day -13.
Treatment Orders for Day +3, Cycle 1 –  Planned for 11/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkins Lymphoma, Chronic Lymphocytic Leukemia, Hodgkin’s Disease; THERAPY: rituximab 375
mg/m2 IV Day -13, Day -6, Day +1 and Day +8, fludarabine 30 mg/m2 IV Day -6, -5 and -4, cyclophosphamide 750
mg/m2 IV Day -6, -5 and -4; GRAFT VS. HOST DISEASE PROPHYLAXIS: tacrolimus 0.06 mg/kg by mouth twice daily
beginning Day -3 and continuing through Day +90; methotrexate 15 mg/m2 IV on Day +1, methotrexate 10 mg/m2 IV
on Day +3, +6, +11; CYCLE LENGTH: 25 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.
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.
Nursing Procedure, Assessment and Monitoring
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
sodium chloride 0.9 % infusion
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ZZtestonc,Andrew [2428787]
10/26/2017 11:33:11 AM Page 12 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF (TREXALL) injection 18.5 mg
18.5 mg (10 mg/m2 × 1.85 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Check with BMT Team prior to administration. IV push rate 10 mg/minute.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day -13.
Treatment Orders for Day +6, Cycle 1 –  Planned for 11/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkins Lymphoma, Chronic Lymphocytic Leukemia, Hodgkin’s Disease; THERAPY: rituximab 375
mg/m2 IV Day -13, Day -6, Day +1 and Day +8, fludarabine 30 mg/m2 IV Day -6, -5 and -4, cyclophosphamide 750
mg/m2 IV Day -6, -5 and -4; GRAFT VS. HOST DISEASE PROPHYLAXIS: tacrolimus 0.06 mg/kg by mouth twice daily
beginning Day -3 and continuing through Day +90; methotrexate 15 mg/m2 IV on Day +1, methotrexate 10 mg/m2 IV
on Day +3, +6, +11; CYCLE LENGTH: 25 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.
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.
Nursing Procedure, Assessment and Monitoring
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
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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ZZtestonc,Andrew [2428787]
10/26/2017 11:33:11 AM Page 13 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Treatment Medications
methotrexate PF (TREXALL) injection 18.5 mg
18.5 mg (10 mg/m2 × 1.85 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Check with BMT Team prior to administration. IV push rate 10 mg/minute.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day -13.
Treatment Orders for Day +8, Cycle 1 –  Planned for 11/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkins Lymphoma, Chronic Lymphocytic Leukemia, Hodgkin’s Disease; THERAPY: rituximab 375
mg/m2 IV Day -13, Day -6, Day +1 and Day +8, fludarabine 30 mg/m2 IV Day -6, -5 and -4, cyclophosphamide 750
mg/m2 IV Day -6, -5 and -4; GRAFT VS. HOST DISEASE PROPHYLAXIS: tacrolimus 0.06 mg/kg by mouth twice daily
beginning Day -3 and continuing through Day +90; methotrexate 15 mg/m2 IV on Day +1, methotrexate 10 mg/m2 IV
on Day +3, +6, +11; CYCLE LENGTH: 25 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.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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
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ZZtestonc,Andrew [2428787]
10/26/2017 11:33:11 AM Page 14 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
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 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
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. Administer rituximab prior to any chemotherapy. See Note 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day -13.
Treatment Orders for Day +11, Cycle 1 –  Planned for 11/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkins Lymphoma, Chronic Lymphocytic Leukemia, Hodgkin’s Disease; THERAPY: rituximab 375
mg/m2 IV Day -13, Day -6, Day +1 and Day +8, fludarabine 30 mg/m2 IV Day -6, -5 and -4, cyclophosphamide 750
mg/m2 IV Day -6, -5 and -4; GRAFT VS. HOST DISEASE PROPHYLAXIS: tacrolimus 0.06 mg/kg by mouth twice daily
beginning Day -3 and continuing through Day +90; methotrexate 15 mg/m2 IV on Day +1, methotrexate 10 mg/m2 IV
on Day +3, +6, +11; CYCLE LENGTH: 25 days; COURSE: 1 cycle.
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ZZtestonc,Andrew [2428787]
10/26/2017 11:33:11 AM Page 15 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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.
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.
Nursing Procedure, Assessment and Monitoring
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
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
methotrexate PF (TREXALL) injection 18.5 mg
18.5 mg (10 mg/m2 × 1.85 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Check with BMT Team prior to administration. IV push rate 10 mg/minute.
Follow-Up
VERIFY APPOINTMENTS
Verify next appointment(s) have been scheduled. Follow up per provider order (generally twice weekly until count
recovery).
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ZZtestonc,Andrew [2428787]
10/26/2017 11:33:11 AM Page 16 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org