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CSC GI Hepatic Arterial Infusion Floxuridine (28D:1-14) VER 8-15-17 (HL3337)

CSC GI Hepatic Arterial Infusion Floxuridine (28D:1-14) VER 8-15-17 (HL3337) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI HEPATIC ARTERIAL INFUSION FLOXURIDINE (28D:1-14) VER: 8-15-17 –  Properties
Post-Surgery Heparin for HAI Pump Maintenance (may delete if not needed) –  8/10/2017 through
8/16/2017 (7 days), Planned
Day 1, Post-Surgery Heparin for HAI Pump Maintenance (may delete if not needed) –  Planned for
8/10/2017
Treatment Plan Information
Reference Information (1)
COLORECTAL CANCER: Kemeny N, et al. N Engl J Med 1999;341(27):2039-48.
Reference Information (2)
COLORECTAL CANCER: Kemeny N, et al. J Clin Oncol 2006;24(9):1395-1403.
Treatment Plan Summary
DISEASE: Colorectal Cancer (Advanced); THERAPY DELIVERED VIA CONTINUOUS HEPATIC ARTERIAL INFUSION PUMP
(DAY 1 THROUGH 14): floxuridine 0.1 to 0.25 mg/kg/day, leucovorin 4 mg/m2/day, dexamethasone 20 mg (fixed dose),
heparin 30,000 units (fixed dose), followed by THERAPY (DAY 15 THROUGH 28): heparin 30,000 units (fixed dose);
CYCLE LENGTH: 28 days; COURSE: until disease progression
Treatment Plan Summary (2)
FOR PATIENTS NEEDING HEPARIN FOR HAI PUMP MAINTENANCE ONLY use supportive care plan CSC SC GI HEPATIC
ARTERIAL INFUSION HEPARIN FOR HAI PUMP MAINTENANCE (7-14D:1).
Nursing Procedure, Assessment and Monitoring
NURSING COMMUNICATION
ONCE Starting when released
Calculate pump rate and enter information into the HAI Pump Rate Calculation order on Day 1 of the next cycle.
Pre-Medications
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Apply 30 minutes prior to to HAI port/pump access.
Treatment Medications
heparin 30,000 units in sodium chloride 0.9 % 30 mL injection
30,000 units, Intraarterial, ONCE, 1 dose Starting when released
Follow-Up
FOLLOW-UP
(Day 1, Cycle 1) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
drawn locally), Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: hepatic arterial
infusion pump refill (floxuridine/leucovorin) for 60 minutes.
Cycle 1 –  8/17/2017 through 9/13/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 8/17/2017
Treatment Plan Information
Reference Information (1)
COLORECTAL CANCER: Kemeny N, et al. N Engl J Med 1999;341(27):2039-48.
Reference Information (2)
COLORECTAL CANCER: Kemeny N, et al. J Clin Oncol 2006;24(9):1395-1403.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:19:00 AM Page 1 of 17
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: Colorectal Cancer (Advanced); THERAPY DELIVERED VIA CONTINUOUS HEPATIC ARTERIAL
INFUSION PUMP (DAY 1 THROUGH 14): floxuridine 0.1 to 0.25 mg/kg/day, leucovorin 4 mg/m2/day,
dexamethasone 20 mg (fixed dose), heparin 30,000 units (fixed dose), followed by THERAPY (DAY 15
THROUGH 28): heparin 30,000 units (fixed dose); CYCLE LENGTH: 28 days; COURSE: until disease
progression
Treatment Plan Summary (2)
FOR PATIENTS NEEDING HEPARIN FOR HAI PUMP MAINTENANCE ONLY use supportive care plan CSC SC GI HEPATIC
ARTERIAL INFUSION HEPARIN FOR HAI PUMP MAINTENANCE (7-14D:1).
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 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, ALT and AST.
Treatment Parameters
Evaluate liver function tests and confirm with MD that dose modifications have been addressed if Total Bilirubin greater
than or equal to 1.7 mg/dL or AST greater than or equal to 80 U/L for females and 100 U/L for males or ALT greater
than or equal to 160 U/L
Nursing Procedure, Assessment and Monitoring
HAI Pump Rate Calculation
HAI PUMP RATE CALCULATION:
(A) Volume withdrawn from pump: *** mL on ***/***/***
(B) Volume from pump infused: *** mL (30 mL minus answer in part A)
(C) Number of days since last refill: *** days
(D) Volume from pump infused per day (actual pump rate): *** mL/day (answer in part B divided by answer in part C)
Dose Calculation Instructions
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Zztestonc,Jeff J [2507481]
8/10/2017 9:19:00 AM Page 2 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Administering RN will add Health Link order group "ONC DUAL NURSE HAI PUMP REFILL VERIFICATION" (HL# 112676)
to patient's treatment plan and complete information during product verification. DO NOT PROPAGATE ADDITION OF
ORDER GROUP OR CHANGES TO SMART TEXT. INFORMATION IS CYCLE-SPECIFIC.
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.
Pre-Medications
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Apply 30 minutes prior to to HAI port/pump access.
Treatment Medications
Dose Modifications
To view Floxuridine Dose Modification Table, go to Onc Navigator and select Reference Links in the Orders section.
NOTE:
ONCE, 1 dose Starting when released
Authorizing prescriber to enter dose of floxuridine, leucovorin, dexamethasone and heparin to be given via hepatic
arterial infusion over 14 days.
floxuridine *** mg/kg/day (0.1 to 0.25 mg/kg/day) = *** mg/day = Total dose = *** mg over 14 days
leucovorin 4 mg/m2/day (or omit) = *** mg/day = Total dose = *** mg over 14 days
dexamethasone 20 mg (fixed dose)
heparin 30,000 units (fixed dose)
Pharmacist to enter order for hepatic arterial infusion pump refill by adding Health Link order group "ONC CSC HAI
FLOXURIDINE PHARMACIST PUMP REFILL ORDER" (HL# 110519) to treatment plan Treatment Medication section and
completing information. DO NOT PROPAGATE ADDITION OF ORDER GROUP OR CHANGES TO SMART TEXT.
INFORMATION IS CYCLE-SPECIFIC.
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
Follow-Up
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: hepatic arterial infusion pump refill (heparinized saline) for 60 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
drawn locally), Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: hepatic arterial
infusion pump refill (floxuridine/leucovorin) for 60 minutes
Day 15, Cycle 1 –  Planned for 8/31/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
8/10/2017 9:19:00 AM Page 3 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Reference Information (1)
COLORECTAL CANCER: Kemeny N, et al. N Engl J Med 1999;341(27):2039-48.
Reference Information (2)
COLORECTAL CANCER: Kemeny N, et al. J Clin Oncol 2006;24(9):1395-1403.
Treatment Plan Summary
DISEASE: Colorectal Cancer (Advanced); THERAPY DELIVERED VIA CONTINUOUS HEPATIC ARTERIAL INFUSION PUMP
(DAY 1 THROUGH 14): floxuridine 0.1 to 0.25 mg/kg/day, leucovorin 4 mg/m2/day, dexamethasone 20 mg (fixed dose),
heparin 30,000 units (fixed dose), followed by THERAPY (DAY 15 THROUGH 28): heparin 30,000 units (fixed dose);
CYCLE LENGTH: 28 days; COURSE: until disease progression
Treatment Plan Summary (2)
FOR PATIENTS NEEDING HEPARIN FOR HAI PUMP MAINTENANCE ONLY use supportive care plan CSC SC GI HEPATIC
ARTERIAL INFUSION HEPARIN FOR HAI PUMP MAINTENANCE (7-14D:1).
Nursing Procedure, Assessment and Monitoring
NURSING COMMUNICATION
ONCE Starting when released
Calculate pump rate and enter information into the HAI Pump Rate Calculation order on Day 1 of the next cycle.
Pre-Medications
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Apply 30 minutes prior to to HAI port/pump access.
Treatment Medications
heparin 30,000 units in sodium chloride 0.9 % 30 mL injection
30,000 units, Intraarterial, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  9/14/2017 through 10/11/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 9/14/2017
Treatment Plan Information
Reference Information (1)
COLORECTAL CANCER: Kemeny N, et al. N Engl J Med 1999;341(27):2039-48.
Reference Information (2)
COLORECTAL CANCER: Kemeny N, et al. J Clin Oncol 2006;24(9):1395-1403.
Treatment Plan Summary
DISEASE: Colorectal Cancer (Advanced); THERAPY DELIVERED VIA CONTINUOUS HEPATIC ARTERIAL INFUSION PUMP
(DAY 1 THROUGH 14): floxuridine 0.1 to 0.25 mg/kg/day, leucovorin 4 mg/m2/day, dexamethasone 20 mg (fixed dose),
heparin 30,000 units (fixed dose), followed by THERAPY (DAY 15 THROUGH 28): heparin 30,000 units (fixed dose);
CYCLE LENGTH: 28 days; COURSE: until disease progression
Treatment Plan Summary (2)
FOR PATIENTS NEEDING HEPARIN FOR HAI PUMP MAINTENANCE ONLY use supportive care plan CSC SC GI HEPATIC
ARTERIAL INFUSION HEPARIN FOR HAI PUMP MAINTENANCE (7-14D:1).
Consent
Verify Consent
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Zztestonc,Jeff J [2507481]
8/10/2017 9:19:00 AM Page 4 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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+14 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, ALT and AST.
Treatment Parameters
Evaluate liver function tests and confirm with MD that dose modifications have been addressed if Total Bilirubin greater
than or equal to 1.7 mg/dL or AST greater than or equal to 80 U/L for females and 100 U/L for males or ALT greater
than or equal to 160 U/L
Nursing Procedure, Assessment and Monitoring
HAI Pump Rate Calculation
HAI PUMP RATE CALCULATION:
(A) Volume withdrawn from pump: *** mL on ***/***/***
(B) Volume from pump infused: *** mL (30 mL minus answer in part A)
(C) Number of days since last refill: *** days
(D) Volume from pump infused per day (actual pump rate): *** mL/day (answer in part B divided by answer in part C)
Dose Calculation Instructions
Administering RN will add Health Link order group "ONC DUAL NURSE HAI PUMP REFILL VERIFICATION" (HL# 112676)
to patient's treatment plan and complete information during product verification. DO NOT PROPAGATE ADDITION OF
ORDER GROUP OR CHANGES TO SMART TEXT. INFORMATION IS CYCLE-SPECIFIC.
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
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Zztestonc,Jeff J [2507481]
8/10/2017 9:19:00 AM Page 5 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@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.
Pre-Medications
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Apply 30 minutes prior to to HAI port/pump access.
Treatment Medications
NOTE:
ONCE, 1 dose Starting when released
Authorizing prescriber to enter dose of floxuridine, leucovorin, dexamethasone and heparin to be given via hepatic
arterial infusion over 14 days.
floxuridine *** mg/kg/day (0.1 to 0.25 mg/kg/day) = *** mg/day = Total dose = *** mg over 14 days
leucovorin 4 mg/m2/day (or omit) = *** mg/day = Total dose = *** mg over 14 days
dexamethasone 20 mg (fixed dose)
heparin 30,000 units (fixed dose)
Pharmacist to enter order for hepatic arterial infusion pump refill by adding Health Link order group "ONC CSC HAI
FLOXURIDINE PHARMACIST PUMP REFILL ORDER" (HL# 110519) to treatment plan Treatment Medication section and
completing information. DO NOT PROPAGATE ADDITION OF ORDER GROUP OR CHANGES TO SMART TEXT.
INFORMATION IS CYCLE-SPECIFIC.
Follow-Up
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: hepatic arterial infusion pump refill (heparinized saline) for 60 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
drawn locally), Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: hepatic arterial
infusion pump refill (floxuridine/leucovorin) for 60 minutes
Day 15, Cycle 2 –  Planned for 9/28/2017
Treatment Plan Information
Reference Information (1)
COLORECTAL CANCER: Kemeny N, et al. N Engl J Med 1999;341(27):2039-48.
Reference Information (2)
COLORECTAL CANCER: Kemeny N, et al. J Clin Oncol 2006;24(9):1395-1403.
Treatment Plan Summary
DISEASE: Colorectal Cancer (Advanced); THERAPY DELIVERED VIA CONTINUOUS HEPATIC ARTERIAL INFUSION PUMP
(DAY 1 THROUGH 14): floxuridine 0.1 to 0.25 mg/kg/day, leucovorin 4 mg/m2/day, dexamethasone 20 mg (fixed dose),
heparin 30,000 units (fixed dose), followed by THERAPY (DAY 15 THROUGH 28): heparin 30,000 units (fixed dose);
CYCLE LENGTH: 28 days; COURSE: until disease progression
Treatment Plan Summary (2)
FOR PATIENTS NEEDING HEPARIN FOR HAI PUMP MAINTENANCE ONLY use supportive care plan CSC SC GI HEPATIC
ARTERIAL INFUSION HEPARIN FOR HAI PUMP MAINTENANCE (7-14D:1).
Nursing Procedure, Assessment and Monitoring
NURSING COMMUNICATION
ONCE Starting when released
Calculate pump rate and enter information into the HAI Pump Rate Calculation order on Day 1 of the next cycle.
Pre-Medications
lidocaine (LMX) 4% topical dressing kit
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Zztestonc,Jeff J [2507481]
8/10/2017 9:19:00 AM Page 6 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Topical, ONCE, 1 dose Starting when released
Apply 30 minutes prior to to HAI port/pump access.
Treatment Medications
heparin 30,000 units in sodium chloride 0.9 % 30 mL injection
30,000 units, Intraarterial, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  10/12/2017 through 11/8/2017 (28 days), Planned
Day 1, Cycle 3 –  Planned for 10/12/2017
Treatment Plan Information
Reference Information (1)
COLORECTAL CANCER: Kemeny N, et al. N Engl J Med 1999;341(27):2039-48.
Reference Information (2)
COLORECTAL CANCER: Kemeny N, et al. J Clin Oncol 2006;24(9):1395-1403.
Treatment Plan Summary
DISEASE: Colorectal Cancer (Advanced); THERAPY DELIVERED VIA CONTINUOUS HEPATIC ARTERIAL INFUSION PUMP
(DAY 1 THROUGH 14): floxuridine 0.1 to 0.25 mg/kg/day, leucovorin 4 mg/m2/day, dexamethasone 20 mg (fixed dose),
heparin 30,000 units (fixed dose), followed by THERAPY (DAY 15 THROUGH 28): heparin 30,000 units (fixed dose);
CYCLE LENGTH: 28 days; COURSE: until disease progression
Treatment Plan Summary (2)
FOR PATIENTS NEEDING HEPARIN FOR HAI PUMP MAINTENANCE ONLY use supportive care plan CSC SC GI HEPATIC
ARTERIAL INFUSION HEPARIN FOR HAI PUMP MAINTENANCE (7-14D:1).
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+14 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
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Zztestonc,Jeff J [2507481]
8/10/2017 9:19:00 AM Page 7 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, ALT and AST.
Treatment Parameters
Evaluate liver function tests and confirm with MD that dose modifications have been addressed if Total Bilirubin greater
than or equal to 1.7 mg/dL or AST greater than or equal to 80 U/L for females and 100 U/L for males or ALT greater
than or equal to 160 U/L
Nursing Procedure, Assessment and Monitoring
HAI Pump Rate Calculation
HAI PUMP RATE CALCULATION:
(A) Volume withdrawn from pump: *** mL on ***/***/***
(B) Volume from pump infused: *** mL (30 mL minus answer in part A)
(C) Number of days since last refill: *** days
(D) Volume from pump infused per day (actual pump rate): *** mL/day (answer in part B divided by answer in part C)
Dose Calculation Instructions
Administering RN will add Health Link order group "ONC DUAL NURSE HAI PUMP REFILL VERIFICATION" (HL# 112676)
to patient's treatment plan and complete information during product verification. DO NOT PROPAGATE ADDITION OF
ORDER GROUP OR CHANGES TO SMART TEXT. INFORMATION IS CYCLE-SPECIFIC.
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.
Pre-Medications
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Apply 30 minutes prior to to HAI port/pump access.
Treatment Medications
NOTE:
ONCE, 1 dose Starting when released
Authorizing prescriber to enter dose of floxuridine, leucovorin, dexamethasone and heparin to be given via hepatic
arterial infusion over 14 days.
floxuridine *** mg/kg/day (0.1 to 0.25 mg/kg/day) = *** mg/day = Total dose = *** mg over 14 days
leucovorin 4 mg/m2/day (or omit) = *** mg/day = Total dose = *** mg over 14 days
dexamethasone 20 mg (fixed dose)
heparin 30,000 units (fixed dose)
Pharmacist to enter order for hepatic arterial infusion pump refill by adding Health Link order group "ONC CSC HAI
FLOXURIDINE PHARMACIST PUMP REFILL ORDER" (HL# 110519) to treatment plan Treatment Medication section and
completing information. DO NOT PROPAGATE ADDITION OF ORDER GROUP OR CHANGES TO SMART TEXT.
INFORMATION IS CYCLE-SPECIFIC.
Follow-Up
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Zztestonc,Jeff J [2507481]
8/10/2017 9:19:00 AM Page 8 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: hepatic arterial infusion pump refill (heparinized saline) for 60
minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
drawn locally), Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: hepatic arterial
infusion pump refill (floxuridine/leucovorin) for 60 minutes
Day 15, Cycle 3 –  Planned for 10/26/2017
Treatment Plan Information
Reference Information (1)
COLORECTAL CANCER: Kemeny N, et al. N Engl J Med 1999;341(27):2039-48.
Reference Information (2)
COLORECTAL CANCER: Kemeny N, et al. J Clin Oncol 2006;24(9):1395-1403.
Treatment Plan Summary
DISEASE: Colorectal Cancer (Advanced); THERAPY DELIVERED VIA CONTINUOUS HEPATIC ARTERIAL INFUSION PUMP
(DAY 1 THROUGH 14): floxuridine 0.1 to 0.25 mg/kg/day, leucovorin 4 mg/m2/day, dexamethasone 20 mg (fixed dose),
heparin 30,000 units (fixed dose), followed by THERAPY (DAY 15 THROUGH 28): heparin 30,000 units (fixed dose);
CYCLE LENGTH: 28 days; COURSE: until disease progression
Treatment Plan Summary (2)
FOR PATIENTS NEEDING HEPARIN FOR HAI PUMP MAINTENANCE ONLY use supportive care plan CSC SC GI HEPATIC
ARTERIAL INFUSION HEPARIN FOR HAI PUMP MAINTENANCE (7-14D:1).
Nursing Procedure, Assessment and Monitoring
NURSING COMMUNICATION
ONCE Starting when released
Calculate pump rate and enter information into the HAI Pump Rate Calculation order on Day 1 of the next cycle.
Pre-Medications
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Apply 30 minutes prior to to HAI port/pump access.
Treatment Medications
heparin 30,000 units in sodium chloride 0.9 % 30 mL injection
30,000 units, Intraarterial, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  11/9/2017 through 12/6/2017 (28 days), Planned
Day 1, Cycle 4 –  Planned for 11/9/2017
Treatment Plan Information
Reference Information (1)
COLORECTAL CANCER: Kemeny N, et al. N Engl J Med 1999;341(27):2039-48.
Reference Information (2)
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Zztestonc,Jeff J [2507481]
8/10/2017 9:19:00 AM Page 9 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

COLORECTAL CANCER: Kemeny N, et al. J Clin Oncol 2006;24(9):1395-1403.
Treatment Plan Summary
DISEASE: Colorectal Cancer (Advanced); THERAPY DELIVERED VIA CONTINUOUS HEPATIC ARTERIAL INFUSION PUMP
(DAY 1 THROUGH 14): floxuridine 0.1 to 0.25 mg/kg/day, leucovorin 4 mg/m2/day, dexamethasone 20 mg (fixed dose),
heparin 30,000 units (fixed dose), followed by THERAPY (DAY 15 THROUGH 28): heparin 30,000 units (fixed dose);
CYCLE LENGTH: 28 days; COURSE: until disease progression
Treatment Plan Summary (2)
FOR PATIENTS NEEDING HEPARIN FOR HAI PUMP MAINTENANCE ONLY use supportive care plan CSC SC GI HEPATIC
ARTERIAL INFUSION HEPARIN FOR HAI PUMP MAINTENANCE (7-14D:1).
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+14 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, ALT and AST.
Treatment Parameters
Evaluate liver function tests and confirm with MD that dose modifications have been addressed if Total Bilirubin greater
than or equal to 1.7 mg/dL or AST greater than or equal to 80 U/L for females and 100 U/L for males or ALT greater
than or equal to 160 U/L
Nursing Procedure, Assessment and Monitoring
HAI Pump Rate Calculation
HAI PUMP RATE CALCULATION:
(A) Volume withdrawn from pump: *** mL on ***/***/***
(B) Volume from pump infused: *** mL (30 mL minus answer in part A)
(C) Number of days since last refill: *** days
(D) Volume from pump infused per day (actual pump rate): *** mL/day (answer in part B divided by answer in part C)
Dose Calculation Instructions
Administering RN will add Health Link order group "ONC DUAL NURSE HAI PUMP REFILL VERIFICATION" (HL# 112676)
to patient's treatment plan and complete information during product verification. DO NOT PROPAGATE ADDITION OF
ORDER GROUP OR CHANGES TO SMART TEXT. INFORMATION IS CYCLE-SPECIFIC.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:19:00 AM Page 10 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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.
Pre-Medications
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Apply 30 minutes prior to to HAI port/pump access.
Treatment Medications
NOTE:
ONCE, 1 dose Starting when released
Authorizing prescriber to enter dose of floxuridine, leucovorin, dexamethasone and heparin to be given via hepatic
arterial infusion over 14 days.
floxuridine *** mg/kg/day (0.1 to 0.25 mg/kg/day) = *** mg/day = Total dose = *** mg over 14 days
leucovorin 4 mg/m2/day (or omit) = *** mg/day = Total dose = *** mg over 14 days
dexamethasone 20 mg (fixed dose)
heparin 30,000 units (fixed dose)
Pharmacist to enter order for hepatic arterial infusion pump refill by adding Health Link order group "ONC CSC HAI
FLOXURIDINE PHARMACIST PUMP REFILL ORDER" (HL# 110519) to treatment plan Treatment Medication section and
completing information. DO NOT PROPAGATE ADDITION OF ORDER GROUP OR CHANGES TO SMART TEXT.
INFORMATION IS CYCLE-SPECIFIC.
Follow-Up
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: hepatic arterial infusion pump refill (heparinized saline) for 60 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
drawn locally), Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: hepatic arterial
infusion pump refill (floxuridine/leucovorin) for 60 minutes
Day 15, Cycle 4 –  Planned for 11/23/2017
Treatment Plan Information
Reference Information (1)
COLORECTAL CANCER: Kemeny N, et al. N Engl J Med 1999;341(27):2039-48.
Reference Information (2)
COLORECTAL CANCER: Kemeny N, et al. J Clin Oncol 2006;24(9):1395-1403.
Treatment Plan Summary
DISEASE: Colorectal Cancer (Advanced); THERAPY DELIVERED VIA CONTINUOUS HEPATIC ARTERIAL INFUSION PUMP
(DAY 1 THROUGH 14): floxuridine 0.1 to 0.25 mg/kg/day, leucovorin 4 mg/m2/day, dexamethasone 20 mg (fixed dose),
heparin 30,000 units (fixed dose), followed by THERAPY (DAY 15 THROUGH 28): heparin 30,000 units (fixed dose);
CYCLE LENGTH: 28 days; COURSE: until disease progression
Treatment Plan Summary (2)
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Zztestonc,Jeff J [2507481]
8/10/2017 9:19:00 AM Page 11 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

FOR PATIENTS NEEDING HEPARIN FOR HAI PUMP MAINTENANCE ONLY use supportive care plan CSC
SC GI HEPATIC ARTERIAL INFUSION HEPARIN FOR HAI PUMP MAINTENANCE (7-14D:1).
Nursing Procedure, Assessment and Monitoring
NURSING COMMUNICATION
ONCE Starting when released
Calculate pump rate and enter information into the HAI Pump Rate Calculation order on Day 1 of the next cycle.
Pre-Medications
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Apply 30 minutes prior to to HAI port/pump access.
Treatment Medications
heparin 30,000 units in sodium chloride 0.9 % 30 mL injection
30,000 units, Intraarterial, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  12/7/2017 through 1/3/2018 (28 days), Planned
Day 1, Cycle 5 –  Planned for 12/7/2017
Treatment Plan Information
Reference Information (1)
COLORECTAL CANCER: Kemeny N, et al. N Engl J Med 1999;341(27):2039-48.
Reference Information (2)
COLORECTAL CANCER: Kemeny N, et al. J Clin Oncol 2006;24(9):1395-1403.
Treatment Plan Summary
DISEASE: Colorectal Cancer (Advanced); THERAPY DELIVERED VIA CONTINUOUS HEPATIC ARTERIAL INFUSION PUMP
(DAY 1 THROUGH 14): floxuridine 0.1 to 0.25 mg/kg/day, leucovorin 4 mg/m2/day, dexamethasone 20 mg (fixed dose),
heparin 30,000 units (fixed dose), followed by THERAPY (DAY 15 THROUGH 28): heparin 30,000 units (fixed dose);
CYCLE LENGTH: 28 days; COURSE: until disease progression
Treatment Plan Summary (2)
FOR PATIENTS NEEDING HEPARIN FOR HAI PUMP MAINTENANCE ONLY use supportive care plan CSC SC GI HEPATIC
ARTERIAL INFUSION HEPARIN FOR HAI PUMP MAINTENANCE (7-14D:1).
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+14 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,Jeff J [2507481]
8/10/2017 9:19:00 AM Page 12 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, ALT and AST.
Treatment Parameters
Evaluate liver function tests and confirm with MD that dose modifications have been addressed if Total Bilirubin greater
than or equal to 1.7 mg/dL or AST greater than or equal to 80 U/L for females and 100 U/L for males or ALT greater
than or equal to 160 U/L
Nursing Procedure, Assessment and Monitoring
HAI Pump Rate Calculation
HAI PUMP RATE CALCULATION:
(A) Volume withdrawn from pump: *** mL on ***/***/***
(B) Volume from pump infused: *** mL (30 mL minus answer in part A)
(C) Number of days since last refill: *** days
(D) Volume from pump infused per day (actual pump rate): *** mL/day (answer in part B divided by answer in part C)
Dose Calculation Instructions
Administering RN will add Health Link order group "ONC DUAL NURSE HAI PUMP REFILL VERIFICATION" (HL# 112676)
to patient's treatment plan and complete information during product verification. DO NOT PROPAGATE ADDITION OF
ORDER GROUP OR CHANGES TO SMART TEXT. INFORMATION IS CYCLE-SPECIFIC.
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.
Pre-Medications
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Apply 30 minutes prior to to HAI port/pump access.
Treatment Medications
NOTE:
ONCE, 1 dose Starting when released
Authorizing prescriber to enter dose of floxuridine, leucovorin, dexamethasone and heparin to be given via hepatic
arterial infusion over 14 days.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:19:00 AM Page 13 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

floxuridine *** mg/kg/day (0.1 to 0.25 mg/kg/day) = *** mg/day = Total dose = *** mg over 14 days
leucovorin 4 mg/m2/day (or omit) = *** mg/day = Total dose = *** mg over 14 days
dexamethasone 20 mg (fixed dose)
heparin 30,000 units (fixed dose)
Pharmacist to enter order for hepatic arterial infusion pump refill by adding Health Link order group "ONC CSC HAI
FLOXURIDINE PHARMACIST PUMP REFILL ORDER" (HL# 110519) to treatment plan Treatment Medication section and
completing information. DO NOT PROPAGATE ADDITION OF ORDER GROUP OR CHANGES TO SMART TEXT.
INFORMATION IS CYCLE-SPECIFIC.
Follow-Up
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: hepatic arterial infusion pump refill (heparinized saline) for 60 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
drawn locally), Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: hepatic arterial
infusion pump refill (floxuridine/leucovorin) for 60 minutes
Day 15, Cycle 5 –  Planned for 12/21/2017
Treatment Plan Information
Reference Information (1)
COLORECTAL CANCER: Kemeny N, et al. N Engl J Med 1999;341(27):2039-48.
Reference Information (2)
COLORECTAL CANCER: Kemeny N, et al. J Clin Oncol 2006;24(9):1395-1403.
Treatment Plan Summary
DISEASE: Colorectal Cancer (Advanced); THERAPY DELIVERED VIA CONTINUOUS HEPATIC ARTERIAL INFUSION PUMP
(DAY 1 THROUGH 14): floxuridine 0.1 to 0.25 mg/kg/day, leucovorin 4 mg/m2/day, dexamethasone 20 mg (fixed dose),
heparin 30,000 units (fixed dose), followed by THERAPY (DAY 15 THROUGH 28): heparin 30,000 units (fixed dose);
CYCLE LENGTH: 28 days; COURSE: until disease progression
Treatment Plan Summary (2)
FOR PATIENTS NEEDING HEPARIN FOR HAI PUMP MAINTENANCE ONLY use supportive care plan CSC SC GI HEPATIC
ARTERIAL INFUSION HEPARIN FOR HAI PUMP MAINTENANCE (7-14D:1).
Nursing Procedure, Assessment and Monitoring
NURSING COMMUNICATION
ONCE Starting when released
Calculate pump rate and enter information into the HAI Pump Rate Calculation order on Day 1 of the next cycle.
Pre-Medications
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Apply 30 minutes prior to to HAI port/pump access.
Treatment Medications
heparin 30,000 units in sodium chloride 0.9 % 30 mL injection
30,000 units, Intraarterial, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 –  1/4/2018 through 1/31/2018 (28 days), Planned
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Zztestonc,Jeff J [2507481]
8/10/2017 9:19:00 AM Page 14 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Day 1, Cycle 6 –  Planned for 1/4/2018
Treatment Plan Information
Reference Information (1)
COLORECTAL CANCER: Kemeny N, et al. N Engl J Med 1999;341(27):2039-48.
Reference Information (2)
COLORECTAL CANCER: Kemeny N, et al. J Clin Oncol 2006;24(9):1395-1403.
Treatment Plan Summary
DISEASE: Colorectal Cancer (Advanced); THERAPY DELIVERED VIA CONTINUOUS HEPATIC ARTERIAL INFUSION PUMP
(DAY 1 THROUGH 14): floxuridine 0.1 to 0.25 mg/kg/day, leucovorin 4 mg/m2/day, dexamethasone 20 mg (fixed dose),
heparin 30,000 units (fixed dose), followed by THERAPY (DAY 15 THROUGH 28): heparin 30,000 units (fixed dose);
CYCLE LENGTH: 28 days; COURSE: until disease progression
Treatment Plan Summary (2)
FOR PATIENTS NEEDING HEPARIN FOR HAI PUMP MAINTENANCE ONLY use supportive care plan CSC SC GI HEPATIC
ARTERIAL INFUSION HEPARIN FOR HAI PUMP MAINTENANCE (7-14D:1).
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+14 Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, ALT and AST.
Treatment Parameters
Evaluate liver function tests and confirm with MD that dose modifications have been addressed if Total Bilirubin greater
than or equal to 1.7 mg/dL or AST greater than or equal to 80 U/L for females and 100 U/L for males or ALT greater
than or equal to 160 U/L
Nursing Procedure, Assessment and Monitoring
HAI Pump Rate Calculation
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Zztestonc,Jeff J [2507481]
8/10/2017 9:19:00 AM Page 15 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

HAI PUMP RATE CALCULATION:
(A) Volume withdrawn from pump: *** mL on ***/***/***
(B) Volume from pump infused: *** mL (30 mL minus answer in part A)
(C) Number of days since last refill: *** days
(D) Volume from pump infused per day (actual pump rate): *** mL/day (answer in part B divided by answer in part C)
Dose Calculation Instructions
Administering RN will add Health Link order group "ONC DUAL NURSE HAI PUMP REFILL VERIFICATION" (HL# 112676)
to patient's treatment plan and complete information during product verification. DO NOT PROPAGATE ADDITION OF
ORDER GROUP OR CHANGES TO SMART TEXT. INFORMATION IS CYCLE-SPECIFIC.
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.
Pre-Medications
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Apply 30 minutes prior to to HAI port/pump access.
Treatment Medications
NOTE:
ONCE, 1 dose Starting when released
Authorizing prescriber to enter dose of floxuridine, leucovorin, dexamethasone and heparin to be given via hepatic
arterial infusion over 14 days.
floxuridine *** mg/kg/day (0.1 to 0.25 mg/kg/day) = *** mg/day = Total dose = *** mg over 14 days
leucovorin 4 mg/m2/day (or omit) = *** mg/day = Total dose = *** mg over 14 days
dexamethasone 20 mg (fixed dose)
heparin 30,000 units (fixed dose)
Pharmacist to enter order for hepatic arterial infusion pump refill by adding Health Link order group "ONC CSC HAI
FLOXURIDINE PHARMACIST PUMP REFILL ORDER" (HL# 110519) to treatment plan Treatment Medication section and
completing information. DO NOT PROPAGATE ADDITION OF ORDER GROUP OR CHANGES TO SMART TEXT.
INFORMATION IS CYCLE-SPECIFIC.
Follow-Up
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: hepatic arterial infusion pump refill (heparinized saline) for 60 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if
drawn locally), Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: hepatic arterial
infusion pump refill (floxuridine/leucovorin) for 60 minutes
Day 15, Cycle 6 –  Planned for 1/18/2018
Treatment Plan Information
Reference Information (1)
COLORECTAL CANCER: Kemeny N, et al. N Engl J Med 1999;341(27):2039-48.
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Zztestonc,Jeff J [2507481]
8/10/2017 9:19:00 AM Page 16 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Reference Information (2)
COLORECTAL CANCER: Kemeny N, et al. J Clin Oncol 2006;24(9):1395-1403.
Treatment Plan Summary
DISEASE: Colorectal Cancer (Advanced); THERAPY DELIVERED VIA CONTINUOUS HEPATIC ARTERIAL INFUSION PUMP
(DAY 1 THROUGH 14): floxuridine 0.1 to 0.25 mg/kg/day, leucovorin 4 mg/m2/day, dexamethasone 20 mg (fixed dose),
heparin 30,000 units (fixed dose), followed by THERAPY (DAY 15 THROUGH 28): heparin 30,000 units (fixed dose);
CYCLE LENGTH: 28 days; COURSE: until disease progression
Treatment Plan Summary (2)
FOR PATIENTS NEEDING HEPARIN FOR HAI PUMP MAINTENANCE ONLY use supportive care plan CSC SC GI HEPATIC
ARTERIAL INFUSION HEPARIN FOR HAI PUMP MAINTENANCE (7-14D:1).
Nursing Procedure, Assessment and Monitoring
NURSING COMMUNICATION
ONCE Starting when released
Calculate pump rate and enter information into the HAI Pump Rate Calculation order on Day 1 of the next cycle.
Pre-Medications
lidocaine (LMX) 4% topical dressing kit
Topical, ONCE, 1 dose Starting when released
Apply 30 minutes prior to to HAI port/pump access.
Treatment Medications
heparin 30,000 units in sodium chloride 0.9 % 30 mL injection
30,000 units, Intraarterial, ONCE, 1 dose Starting when released
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]
8/10/2017 9:19:00 AM Page 17 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org