/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/gi/,

/clinical/cckm-tools/content/beacon-protocols/gi/name-96677-en.cckm

201708223

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,GI

CSC GI Irinotecan(21D:1) Panitumumab(21D:1) VER 8-15-17 (HL 5790)

CSC GI Irinotecan(21D:1) Panitumumab(21D:1) VER 8-15-17 (HL 5790) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI IRINOTECAN(21D:1)/PANITUMUMAB(21D:1) VER: 8-15-17 –  Properties
Pre-Cycle –  8/3/2017 through 8/9/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 9 mg/kg IV Day 1, irinotecan 300 to 350 mg/m2
IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Dose Modifications
For patients less than 70 years of age and ECOG performance status of 0 or 1, administer irinotecan 350 mg/m2 IV Day
1. For patients 70 years of age and greater or ECOG performance status of 2, administer irinotecan 300 mg/m2 IV Day 1.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
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
CALCIUM
Expected: S Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S Approximate, Expires: S+365, Routine
PHOSPHATE
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
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S Approximate, Expires: S+365, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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

UGT1A1 Lab Note
NOTE: It is recommended that testing for UGT1A1 (UDP glucuronosyltransferase) be considered prior
to the start of irinotecan therapy at irinotecan doses greater than or equal to 180mg/m2.
Take Home Medications
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
doxycycline hyclate 100 MG tab
Take 1 tab by mouth 2 times daily at mealtime., 100 mg, Disp-60 tab, R-5, 2 X DAILY (AT MEALTIME) starting S, Local
Printer
loperamide 2 MG cap
Take 2 tab by mouth with 1st loose stool followed by 1 tab every 2h or 2 tab every 4h until no diarrhea x12h. Max
dose=8 tab/day, Disp-30 cap, R-5, starting S, Local Printer
Counsel patient to purchase over the counter if not covered by insurance and provide instructions for use.
Cycle 1 –  8/10/2017 through 8/30/2017 (21 days), Planned
Day 1, Cycle 1 –  Planned for 8/10/2017
Treatment Plan Information
Reference Information (1)
COLON AND RECTAL CANCER (ADVANCED): Seymour MT, et al. Lancet Oncol 2013;14(8):749-59.
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 9 mg/kg IV Day 1, irinotecan 300 to 350 mg/m2
IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Dose Modifications
For patients less than 70 years of age and ECOG performance status of 0 or 1, administer irinotecan 350 mg/m2 IV Day
1. For patients 70 years of age and greater or ECOG performance status of 2, administer irinotecan 300 mg/m2 IV Day 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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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

Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be
treated in a location to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
Monitoring Parameters (2)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
See conditional orders for PRN doses.
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.
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
panitumumab 729 mg in sodium chloride 0.9 % 100 mL bag
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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

729 mg (9 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. Doses greater than 1000 mg should be administered over 90 minutes. For doses greater
than 1000 mg, dilute in 250 mL and administer over 90 minutes. Hypersensitivity reaction to panitumumab can occur.
For first and second dose, patient should be treated in a location to optimize emergency care. See Emergency
Medications.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
For patients less than 70 years of age and ECOG performance status of 0 or 1, administer 350 mg/m2. For patients 70
years of age and greater or ECOG performance status of 2, administer 300 mg/m2. Administer over 90 minutes.
If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is greater than 750 mg then use
Dextrose 5% in water 500 mL.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, PRN, 2 doses Starting when released, to prevent cholinergic syndrome, Administer over 1
Minutes
May repeat 1 time (Total of 2 doses). Total allowed atropine dose = 0.9 mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Magnesium, Phosphate, AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: panitumumab, irinotecan for 210 minutes.
Cycle 2 –  8/31/2017 through 9/20/2017 (21 days), Planned
Day 1, Cycle 2 –  Planned for 8/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 9 mg/kg IV Day 1, irinotecan 300 to 350 mg/m2
IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Dose Modifications
For patients less than 70 years of age and ECOG performance status of 0 or 1, administer irinotecan 350 mg/m2 IV Day
1. For patients 70 years of age and greater or ECOG performance status of 2, administer irinotecan 300 mg/m2 IV Day 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 WITH DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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

BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
PHOSPHATE
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
Monitoring Parameters (2)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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

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
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
See conditional orders for PRN doses.
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.
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
panitumumab 729 mg in sodium chloride 0.9 % 100 mL bag
729 mg (9 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. Doses greater than 1000 mg should be administered over 90 minutes. For doses greater
than 1000 mg, dilute in 250 mL and administer over 90 minutes. Hypersensitivity reaction to panitumumab can occur.
For first and second dose, patient should be treated in a location to optimize emergency care. See Emergency
Medications.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
For patients less than 70 years of age and ECOG performance status of 0 or 1, administer 350 mg/m2. For patients 70
years of age and greater or ECOG performance status of 2, administer 300 mg/m2. Administer over 90 minutes.
If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is greater than 750 mg then use
Dextrose 5% in water 500 mL.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, PRN, 2 doses Starting when released, to prevent cholinergic syndrome, Administer over 1
Minutes
May repeat 1 time (Total of 2 doses). Total allowed atropine dose = 0.9 mg.
Follow-Up
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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

DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium, Phosphate, AST, ALT, Total Bilirubin,
Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: panitumumab, irinotecan for 210
minutes.
Cycle 3 –  9/21/2017 through 10/11/2017 (21 days), Planned
Day 1, Cycle 3 –  Planned for 9/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 9 mg/kg IV Day 1, irinotecan 300 to 350 mg/m2
IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Dose Modifications
For patients less than 70 years of age and ECOG performance status of 0 or 1, administer irinotecan 350 mg/m2 IV Day
1. For patients 70 years of age and greater or ECOG performance status of 2, administer irinotecan 300 mg/m2 IV Day 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 WITH DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
PHOSPHATE
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
Monitoring Parameters (2)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
See conditional orders for PRN doses.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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

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
panitumumab 729 mg in sodium chloride 0.9 % 100 mL bag
729 mg (9 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. Doses greater than 1000 mg should be administered over 90 minutes. For doses greater
than 1000 mg, dilute in 250 mL and administer over 90 minutes. Hypersensitivity reaction to panitumumab can occur.
For first and second dose, patient should be treated in a location to optimize emergency care. See Emergency
Medications.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
For patients less than 70 years of age and ECOG performance status of 0 or 1, administer 350 mg/m2. For patients 70
years of age and greater or ECOG performance status of 2, administer 300 mg/m2. Administer over 90 minutes.
If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is greater than 750 mg then use
Dextrose 5% in water 500 mL.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, PRN, 2 doses Starting when released, to prevent cholinergic syndrome, Administer over 1
Minutes
May repeat 1 time (Total of 2 doses). Total allowed atropine dose = 0.9 mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Magnesium, Phosphate, AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: panitumumab, irinotecan for 210 minutes.
Cycle 4 –  10/12/2017 through 11/1/2017 (21 days), Planned
Day 1, Cycle 4 –  Planned for 10/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 9 mg/kg IV Day 1, irinotecan 300 to 350 mg/m2
IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Dose Modifications
For patients less than 70 years of age and ECOG performance status of 0 or 1, administer irinotecan 350 mg/m2 IV Day
1. For patients 70 years of age and greater or ECOG performance status of 2, administer irinotecan 300 mg/m2 IV Day 1.
Consent
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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

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 WITH DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
PHOSPHATE
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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

Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
Monitoring Parameters (2)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
See conditional orders for PRN doses.
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.
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
panitumumab 729 mg in sodium chloride 0.9 % 100 mL bag
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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

729 mg (9 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. Doses greater than 1000 mg should be administered over 90 minutes. For doses greater
than 1000 mg, dilute in 250 mL and administer over 90 minutes. Hypersensitivity reaction to panitumumab can occur.
For first and second dose, patient should be treated in a location to optimize emergency care. See Emergency
Medications.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
For patients less than 70 years of age and ECOG performance status of 0 or 1, administer 350 mg/m2. For patients 70
years of age and greater or ECOG performance status of 2, administer 300 mg/m2. Administer over 90 minutes.
If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is greater than 750 mg then use
Dextrose 5% in water 500 mL.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, PRN, 2 doses Starting when released, to prevent cholinergic syndrome, Administer over 1
Minutes
May repeat 1 time (Total of 2 doses). Total allowed atropine dose = 0.9 mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Magnesium, Phosphate, AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: panitumumab, irinotecan for 210 minutes.
Cycle 5 –  11/2/2017 through 11/22/2017 (21 days), Planned
Day 1, Cycle 5 –  Planned for 11/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 9 mg/kg IV Day 1, irinotecan 300 to 350 mg/m2
IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Dose Modifications
For patients less than 70 years of age and ECOG performance status of 0 or 1, administer irinotecan 350 mg/m2 IV Day
1. For patients 70 years of age and greater or ECOG performance status of 2, administer irinotecan 300 mg/m2 IV Day 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 WITH DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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

BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
PHOSPHATE
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
Monitoring Parameters (2)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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

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
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
See conditional orders for PRN doses.
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.
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
panitumumab 729 mg in sodium chloride 0.9 % 100 mL bag
729 mg (9 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. Doses greater than 1000 mg should be administered over 90 minutes. For doses greater
than 1000 mg, dilute in 250 mL and administer over 90 minutes. Hypersensitivity reaction to panitumumab can occur.
For first and second dose, patient should be treated in a location to optimize emergency care. See Emergency
Medications.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
For patients less than 70 years of age and ECOG performance status of 0 or 1, administer 350 mg/m2. For patients 70
years of age and greater or ECOG performance status of 2, administer 300 mg/m2. Administer over 90 minutes.
If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is greater than 750 mg then use
Dextrose 5% in water 500 mL.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, PRN, 2 doses Starting when released, to prevent cholinergic syndrome, Administer over 1
Minutes
May repeat 1 time (Total of 2 doses). Total allowed atropine dose = 0.9 mg.
Follow-Up
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium, Phosphate, AST, ALT, Total Bilirubin,
Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: panitumumab, irinotecan for 210
minutes.
Cycle 6 –  11/23/2017 through 12/13/2017 (21 days), Planned
Day 1, Cycle 6 –  Planned for 11/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Colon and Rectal Cancer (Advanced); THERAPY: panitumumab 9 mg/kg IV Day 1, irinotecan 300 to 350 mg/m2
IV Day 1; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Dose Modifications
For patients less than 70 years of age and ECOG performance status of 0 or 1, administer irinotecan 350 mg/m2 IV Day
1. For patients 70 years of age and greater or ECOG performance status of 2, administer irinotecan 300 mg/m2 IV Day 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 WITH DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+21 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+21 Approximate, Expires: S+365, Routine
BUN
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+21 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+21 Approximate, Expires: S+365, Routine
PHOSPHATE
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
ALT/SGPT
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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

Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+21 Approximate, Expires: S+365, Routine
CARCINOEMBRYONIC ANTIGEN
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
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.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to panitumumab can occur.  For first and second dose, patient should be treated in a location
to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor patient for dermatologic toxicity/rash from panitumumab. Advise patient to limit sun exposure (use sunscreen,
wear hats) and to contact provider if rash or other skin reaction occurs.
Monitoring Parameters (2)
Monitor patient during irinotecan infusion for cholinergic side effects (abdominal cramping, diarrhea, diaphoresis, or
weakness).
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
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
See conditional orders for PRN doses.
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
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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

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
panitumumab 729 mg in sodium chloride 0.9 % 100 mL bag
729 mg (9 mg/kg × 81 kg Treatment plan recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer with with low protein binding tubing and 0.2 or 0.22 micron filter. Flush line with Sodium Chloride 0.9% 50
mL after infusion complete. Doses greater than 1000 mg should be administered over 90 minutes. For doses greater
than 1000 mg, dilute in 250 mL and administer over 90 minutes. Hypersensitivity reaction to panitumumab can occur.
For first and second dose, patient should be treated in a location to optimize emergency care. See Emergency
Medications.
irinotecan CONVENTIONAL (CAMPTOSAR) in dextrose 5 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
For patients less than 70 years of age and ECOG performance status of 0 or 1, administer 350 mg/m2. For patients 70
years of age and greater or ECOG performance status of 2, administer 300 mg/m2. Administer over 90 minutes.
If dose is less than or equal to 750 mg then use Dextrose 5% in Water 250 mL.  If dose is greater than 750 mg then use
Dextrose 5% in water 500 mL.
Conditional Orders
atropine 0.4 MG/ML injection 0.3 mg
0.3 mg, Subcutaneous, PRN, 2 doses Starting when released, to prevent cholinergic syndrome, Administer over 1
Minutes
May repeat 1 time (Total of 2 doses). Total allowed atropine dose = 0.9 mg.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Magnesium, Phosphate, AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY
ROOM APPOINTMENT: panitumumab, irinotecan for 210 minutes.
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/10/2017 9:28:31 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