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CSC GI Cisplatin(28D:1) Fluorouracil(28D:1-4) VER 8-15-17 (HL 429)

CSC GI Cisplatin(28D:1) Fluorouracil(28D:1-4) VER 8-15-17 (HL 429) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI CISPLATIN(28D:1)/FLUOROURACIL(28D:1-4) VER: 8-15-17 –  Properties
Pre-Cycle –  8/1/2017 through 8/7/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction (Adjuvant)/Anal(Adjuvant/Advanced); THERAPY: CISplatin 75 mg/m2 IV
on Day 1, fluorouracil 1000 mg/m2/day administered as a continuous infusion IV over 96 hours on Day 1 through 4.
(Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 28 days; COURSE: 4 cycles.
Dose varies from reference 1. NOTE: Therapy for anal cancer patients who are NOT candidates for mitomycin based
therapy. NOTE: This protocol may be used with or without concurrent XRT.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S Approximate, Expires: S+365, Routine
BUN
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S Approximate, Expires: S+365, Routine
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Take Home Medications
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Zztestonc,Jeff J [2507481]
8/8/2017 2:32:46 PM Page 1 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for two days following chemotherapy., 80 mg, Disp-2 cap,
R-5, 1 X DAILY starting S, Local Printer
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy, 8 mg, Disp-24 tab, R-5, 1 X DAILY
starting S, Local Printer
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
Cycle 1 –  8/8/2017 through 9/4/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 8/8/2017
Treatment Plan Information
Reference Information (1)
ESOPHAGUS CANCER: Herskovic A, et al. NEJM 1992;326:1593-98.
Reference Information (2)
ANAL CANCER: Ajani J A, et al. J of Clin Oncol 2006;24(18S): 4009
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction (Adjuvant)/Anal(Adjuvant/Advanced); THERAPY: CISplatin 75 mg/m2 IV
on Day 1, fluorouracil 1000 mg/m2/day administered as a continuous infusion IV over 96 hours on Day 1 through 4.
(Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 28 days; COURSE: 4 cycles.
Dose varies from reference 1. NOTE: Therapy for anal cancer patients who are NOT candidates for mitomycin based
therapy. NOTE: This protocol may be used with or without concurrent XRT.
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 pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Creatinine greater than ULN.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Measure Intake And Output
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Zztestonc,Jeff J [2507481]
8/8/2017 2:32:46 PM Page 2 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

SEE COMMENTS Starting when released Until Specified
Measure intake and output: If IV intake is greater than 2000 mL and urine output is less than 500 mL between start of
cisplatin and discharge, notify provider.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 147 mg in sodium chloride 0.9 % 1,000 mL bag
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 to 90 minutes.
fluorouracil (ADRUCIL) home infusion bag 7,840 mg
7,840 mg (4,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Four Day Infusion: Fluorouracil Dose = 1000 mg/m2/Day administered as a single continuous infusion IV over 96 hours.
(Total dose = 4000 mg/m2 IV over 96 hours).
Follow-Up
DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and fluorouracil for 150 minutes.
Day 5 (Pump Disconnect), Cycle 1 –  Planned for 8/12/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
8/8/2017 2:32:46 PM Page 3 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction (Adjuvant)/Anal(Adjuvant/Advanced); THERAPY:
CISplatin 75 mg/m2 IV on Day 1, fluorouracil 1000 mg/m2/day administered as a continuous infusion
IV over 96 hours on Day 1 through 4. (Total dose = 4000 mg/m2 IV over 96 hours per cycle per home
infusion); CYCLE LENGTH: 28 days; COURSE: 4 cycles. Dose varies from reference 1. NOTE: Therapy for
anal cancer patients who are NOT candidates for mitomycin based therapy. NOTE: This protocol may
be used with or without concurrent XRT.
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.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 96-hour home infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  9/5/2017 through 10/2/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction (Adjuvant)/Anal(Adjuvant/Advanced); THERAPY: CISplatin 75 mg/m2 IV
on Day 1, fluorouracil 1000 mg/m2/day administered as a continuous infusion IV over 96 hours on Day 1 through 4.
(Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 28 days; COURSE: 4 cycles.
Dose varies from reference 1. NOTE: Therapy for anal cancer patients who are NOT candidates for mitomycin based
therapy. NOTE: This protocol may be used with or without concurrent XRT.
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
CBC WITHOUT DIFFERENTIAL
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Zztestonc,Jeff J [2507481]
8/8/2017 2:32:46 PM Page 4 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+28 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+28 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+365, Routine
BUN
Expected: S+28 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Creatinine greater than ULN.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
Measure intake and output: If IV intake is greater than 2000 mL and urine output is less than 500 mL between start of
cisplatin and discharge, notify provider.
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,Jeff J [2507481]
8/8/2017 2:32:46 PM Page 5 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 147 mg in sodium chloride 0.9 % 1,000 mL bag
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 to 90 minutes.
fluorouracil (ADRUCIL) home infusion bag 7,840 mg
7,840 mg (4,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Four Day Infusion: Fluorouracil Dose = 1000 mg/m2/Day administered as a single continuous infusion IV over 96 hours.
(Total dose = 4000 mg/m2 IV over 96 hours).
Follow-Up
DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and fluorouracil for 150 minutes.
Day 5 (Pump Disconnect), Cycle 2 –  Planned for 9/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction (Adjuvant)/Anal(Adjuvant/Advanced); THERAPY: CISplatin 75 mg/m2 IV
on Day 1, fluorouracil 1000 mg/m2/day administered as a continuous infusion IV over 96 hours on Day 1 through 4.
(Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 28 days; COURSE: 4 cycles.
Dose varies from reference 1. NOTE: Therapy for anal cancer patients who are NOT candidates for mitomycin based
therapy. NOTE: This protocol may be used with or without concurrent XRT.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
8/8/2017 2:32:46 PM Page 6 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 96-hour home infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  10/3/2017 through 10/30/2017 (28 days), Planned
Day 1, Cycle 3 –  Planned for 10/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction (Adjuvant)/Anal(Adjuvant/Advanced); THERAPY: CISplatin 75 mg/m2 IV
on Day 1, fluorouracil 1000 mg/m2/day administered as a continuous infusion IV over 96 hours on Day 1 through 4.
(Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 28 days; COURSE: 4 cycles.
Dose varies from reference 1. NOTE: Therapy for anal cancer patients who are NOT candidates for mitomycin based
therapy. NOTE: This protocol may be used with or without concurrent XRT.
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
CBC WITHOUT DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+28 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+365, Routine
BUN
Expected: S+28 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/8/2017 2:32:46 PM Page 7 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

CREATININE
Expected: S+28 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Creatinine greater than ULN.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
Measure intake and output: If IV intake is greater than 2000 mL and urine output is less than 500 mL between start of
cisplatin and discharge, notify provider.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
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Zztestonc,Jeff J [2507481]
8/8/2017 2:32:46 PM Page 8 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 147 mg in sodium chloride 0.9 % 1,000 mL bag
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 to 90 minutes.
fluorouracil (ADRUCIL) home infusion bag 7,840 mg
7,840 mg (4,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Four Day Infusion: Fluorouracil Dose = 1000 mg/m2/Day administered as a single continuous infusion IV over 96 hours.
(Total dose = 4000 mg/m2 IV over 96 hours).
Follow-Up
DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and fluorouracil for 150 minutes.
Day 5 (Pump Disconnect), Cycle 3 –  Planned for 10/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction (Adjuvant)/Anal(Adjuvant/Advanced); THERAPY: CISplatin 75 mg/m2 IV
on Day 1, fluorouracil 1000 mg/m2/day administered as a continuous infusion IV over 96 hours on Day 1 through 4.
(Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 28 days; COURSE: 4 cycles.
Dose varies from reference 1. NOTE: Therapy for anal cancer patients who are NOT candidates for mitomycin based
therapy. NOTE: This protocol may be used with or without concurrent XRT.
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.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 96-hour home infusion.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:32:46 PM Page 9 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  10/31/2017 through 11/27/2017 (28 days), Planned
Day 1, Cycle 4 –  Planned for 10/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction (Adjuvant)/Anal(Adjuvant/Advanced); THERAPY: CISplatin 75 mg/m2 IV
on Day 1, fluorouracil 1000 mg/m2/day administered as a continuous infusion IV over 96 hours on Day 1 through 4.
(Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 28 days; COURSE: 4 cycles.
Dose varies from reference 1. NOTE: Therapy for anal cancer patients who are NOT candidates for mitomycin based
therapy. NOTE: This protocol may be used with or without concurrent XRT.
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
CBC WITHOUT DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+28 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+365, Routine
BUN
Expected: S+28 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+28 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+28 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+28 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+28 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/8/2017 2:32:46 PM Page 10 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

MAGNESIUM
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL
or Creatinine greater than ULN.
Treatment Condition A
Check for mucositis, irritation of hands or feet, or diarrhea.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Measure Intake And Output
SEE COMMENTS Starting when released Until Specified
Measure intake and output: If IV intake is greater than 2000 mL and urine output is less than 500 mL between start of
cisplatin and discharge, notify provider.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
CISplatin (PLATINOL) 147 mg in sodium chloride 0.9 % 1,000 mL bag
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when
released
Administer over 60 to 90 minutes.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:32:46 PM Page 11 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

fluorouracil (ADRUCIL) home infusion bag 7,840 mg
7,840 mg (4,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Four Day Infusion: Fluorouracil Dose = 1000 mg/m2/Day administered as a single continuous infusion
IV over 96 hours. (Total dose = 4000 mg/m2 IV over 96 hours).
Follow-Up
DAY 5 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider;
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, Magnesium;
CHEMOTHERAPY ROOM APPOINTMENT: CISplatin and fluorouracil for 150 minutes.
Day 5 (Pump Disconnect), Cycle 4 –  Planned for 11/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Esophagus/Gastroesophageal Junction (Adjuvant)/Anal(Adjuvant/Advanced); THERAPY: CISplatin 75 mg/m2 IV
on Day 1, fluorouracil 1000 mg/m2/day administered as a continuous infusion IV over 96 hours on Day 1 through 4.
(Total dose = 4000 mg/m2 IV over 96 hours per cycle per home infusion); CYCLE LENGTH: 28 days; COURSE: 4 cycles.
Dose varies from reference 1. NOTE: Therapy for anal cancer patients who are NOT candidates for mitomycin based
therapy. NOTE: This protocol may be used with or without concurrent XRT.
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.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 96-hour home infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
8/8/2017 2:32:46 PM Page 12 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org