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/clinical/cckm-tools/content/beacon-protocols/gyn/name-96763-en.cckm

20180232

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UWHC,UWMF,

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

CSC GYN-INPT Ifosfamide(21D:1,2,3) Paclitaxel(21D:1) VER 1-31-18 (HL 2282)

CSC GYN-INPT Ifosfamide(21D:1,2,3) Paclitaxel(21D:1) VER 1-31-18 (HL 2282) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN-INPT IFOSFAMIDE(21D:1,2,3)/PACLITAXEL(21D:1) VER: 1-31-18 –  Properties
Cycle 1 –  1/31/2018 through 2/20/2018 (21 days), Planned
Day 1 through 3 (Inpatient), Cycle 1 –  Planned for 1/31/2018
Treatment Plan Information
Reference Information (1)
UTERINE SARCOMA: Homesley H, et al. J Clin Oncol. 2007;25(5):526-31.
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2
IV Day 1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours
after start of ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles
(adjuvant) or until disease progression or toxicity (advanced); NOTE: mesna dose must be adjusted if ifosfamide dose is
reduced (total reduced mesna dose = total reduced ifosfamide dose) and if patient is discharged early, order oral
mesna for remaining doses
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released
CREATININE
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALBUMIN
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+1 at 0500 for 3 occurrences
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, Albumin, Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL, Platelets less than 100K/µL, Creatinine
greater than 2 mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 1.5 X ULN, AST greater
than 3 X ULN, Albumin less than 3 gm/dL or Urine Hemoglobin greater than Trace.
Treatment Parameters (2)
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 1 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to ifosfamide
administration on Day 2 and 3.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note.  Notify authorizing prescriber if patient
has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations, incontinence,
palsy, diplopia or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
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, EVERY 24 HOURS, 3 doses Starting when released
Infuse 1000 mL throughout ifosfamide treatment.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 1 X DAILY, 3 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO.
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 2 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, 1 X DAILY PRN, For 4 days Starting when released until S+4, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, 1 X DAILY, 2 doses Starting S+1 As Scheduled
Give prior to chemotherapy on Day 2 and 3. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, 1 X DAILY PRN, For 3 days Starting when released, nausea/vomiting
Give prior to chemotherapy on Day 2 and 3 if patient unable to tolerate PO.
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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 265 mg in dextrose 5 % 500 mL non-PVC bag
265 mg (rounded from 264.6 mg = 135 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Infuse over 180 minutes (see titration instructions below). Use non-PVC tubing and 0.2 or 0.22 micron in-line filter
during administration. Hypersensitivity risk - See Emergency Meds.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
mesna in sodium chloride 0.9% (MESNEX) 20 MG/ML injection 1,305 mg
1,305 mg (rounded from 1,307.32 mg = 667 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Intravenous, 9 doses Starting when released, Administer over 15 Minutes
Administer over 15 minutes. Give prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide infusion on Day
1, 2 and 3. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide dose). If
patient discharged prior to completing all IV mesna doses, remaining doses must be given orally as take home
medication.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
EVERY 24 HOURS, 3 doses Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to
tolerate PO.
IV push slowly, max rate 5 mg/minute.
Take Home Medications
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 3 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

dexamethasone (DECADRON) 4 MG tab
Take 3 tabs 12&6 hrs prior to 2nd PACLItaxel dose and 2 tabs 12&6 hrs prior to 3rd PACLItaxel dose., Disp-10 tab,
R-0, starting S
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth twice daily X 2 days after ifosfamide then 1 tab every 8h as needed for nausea., Disp-30 tab,
R-5, starting S
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 3.5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of last dose of ifosfamide., 1,400 mg (rounded
from 1,307.32 mg = 667 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Order if patient has not completed all inpatient IV mesna doses. Mesna dose must be adjusted if ifosfamide dose is
reduced (total mesna dose = total ifosfamide dose). Round dose to nearest 200 mg.
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day 4 and continue until ANC is greater than 1000., 300
mcg, Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day 4 and continue until ANC is greater than 1000., 480
mcg, Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 10 (Lab Only), Cycle 1 –  Planned for 2/9/2018
Treatment Plan Information
Reference Information (1)
UTERINE SARCOMA: Homesley H, et al. J Clin Oncol. 2007;25(5):526-31.
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2
IV Day 1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours
after start of ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles
(adjuvant) or until disease progression or toxicity (advanced); NOTE: mesna dose must be adjusted if ifosfamide dose is
reduced (total reduced mesna dose = total reduced ifosfamide dose) and if patient is discharged early, order oral
mesna for remaining doses
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.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 4 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Normal, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  2/21/2018 through 3/13/2018 (21 days), Planned
Day 1 through 3 (Inpatient), Cycle 2 –  Planned for 2/21/2018
Treatment Plan Information
Reference Information (1)
UTERINE SARCOMA: Homesley H, et al. J Clin Oncol. 2007;25(5):526-31.
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2
IV Day 1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours
after start of ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles
(adjuvant) or until disease progression or toxicity (advanced); NOTE: mesna dose must be adjusted if ifosfamide dose is
reduced (total reduced mesna dose = total reduced ifosfamide dose) and if patient is discharged early, order oral
mesna for remaining doses
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released
CREATININE
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALBUMIN
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+1 at 0500 for 3 occurrences
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 5 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, Albumin, Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL, Platelets less than 100K/µL, Creatinine
greater than 2 mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 1.5 X ULN, AST greater
than 3 X ULN, Albumin less than 3 gm/dL or Urine Hemoglobin greater than Trace.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to ifosfamide
administration on Day 2 and 3.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient
has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations, incontinence,
palsy, diplopia or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
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, EVERY 24 HOURS, 3 doses Starting when released
Infuse 1000 mL throughout ifosfamide treatment.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, PRN - NOTIFY PHARMACY WHEN NEEDED Starting when released Until Discontinued, If PO not
taken at home.
For use in patients who did not take dexamethasone at home. Notify pharmacy that medication is needed
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 6 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 1 X DAILY, 3 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, 1 X DAILY PRN, For 4 days Starting when released until S+4, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, 1 X DAILY, 2 doses Starting S+1 As Scheduled
Give prior to chemotherapy on Day 2 and 3. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, 1 X DAILY PRN, For 3 days Starting when released, nausea/vomiting
Give prior to chemotherapy on Day 2 and 3 if patient unable to tolerate PO.
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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 265 mg in dextrose 5 % 500 mL non-PVC bag
265 mg (rounded from 264.6 mg = 135 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Infuse over 180 minutes (see titration instructions below). Use non-PVC tubing and 0.2 or 0.22 micron in-line filter
during administration. Hypersensitivity risk - See Emergency Meds.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
mesna in sodium chloride 0.9% (MESNEX) 20 MG/ML injection 1,305 mg
1,305 mg (rounded from 1,307.32 mg = 667 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Intravenous, 9 doses Starting when released, Administer over 15 Minutes
Administer over 15 minutes. Give prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide infusion on Day
1, 2 and 3. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide dose). If
patient discharged prior to completing all IV mesna doses, remaining doses must be given orally as take home
medication.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
EVERY 24 HOURS, 3 doses Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 7 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to
tolerate PO.
IV push slowly, max rate 5 mg/minute.
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 3.5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of last dose of ifosfamide., 1,400 mg (rounded
from 1,307.32 mg = 667 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Order if patient has not completed all inpatient IV mesna doses. Mesna dose must be adjusted if ifosfamide dose is
reduced (total mesna dose = total ifosfamide dose). Round dose to nearest 200 mg.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 10 (Lab Only), Cycle 2 –  Planned for 3/2/2018
Treatment Plan Information
Reference Information (1)
UTERINE SARCOMA: Homesley H, et al. J Clin Oncol. 2007;25(5):526-31.
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2
IV Day 1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours
after start of ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles
(adjuvant) or until disease progression or toxicity (advanced); NOTE: mesna dose must be adjusted if ifosfamide dose is
reduced (total reduced mesna dose = total reduced ifosfamide dose) and if patient is discharged early, order oral
mesna for remaining doses
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
Follow-Up
VERIFY APPOINTMENTS
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 8 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  3/14/2018 through 4/3/2018 (21 days), Planned
Day 1 through 3 (Inpatient), Cycle 3 –  Planned for 3/14/2018
Treatment Plan Information
Reference Information (1)
UTERINE SARCOMA: Homesley H, et al. J Clin Oncol. 2007;25(5):526-31.
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2
IV Day 1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours
after start of ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles
(adjuvant) or until disease progression or toxicity (advanced); NOTE: mesna dose must be adjusted if ifosfamide dose is
reduced (total reduced mesna dose = total reduced ifosfamide dose) and if patient is discharged early, order oral
mesna for remaining doses
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released
CREATININE
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALBUMIN
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+1 at 0500 for 3 occurrences
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, Albumin, Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL, Platelets less than 100K/µL, Creatinine
greater than 2 mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 1.5 X ULN, AST greater
than 3 X ULN, Albumin less than 3 gm/dL or Urine Hemoglobin greater than Trace.
Treatment Parameters (2)
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 9 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to ifosfamide
administration on Day 2 and 3.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient
has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations, incontinence,
palsy, diplopia or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
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, EVERY 24 HOURS, 3 doses Starting when released
Infuse 1000 mL throughout ifosfamide treatment.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, PRN - NOTIFY PHARMACY WHEN NEEDED Starting when released Until Discontinued, If PO not
taken at home.
For use in patients who did not take dexamethasone at home. Notify pharmacy that medication is needed
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 1 X DAILY, 3 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO.
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 10 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, 1 X DAILY PRN, For 4 days Starting when released until S+4, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, 1 X DAILY, 2 doses Starting S+1 As Scheduled
Give prior to chemotherapy on Day 2 and 3. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, 1 X DAILY PRN, For 3 days Starting when released, nausea/vomiting
Give prior to chemotherapy on Day 2 and 3 if patient unable to tolerate PO.
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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 265 mg in dextrose 5 % 500 mL non-PVC bag
265 mg (rounded from 264.6 mg = 135 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Infuse over 180 minutes (see titration instructions below). Use non-PVC tubing and 0.2 or 0.22 micron in-line filter
during administration. Hypersensitivity risk - See Emergency Meds.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
mesna in sodium chloride 0.9% (MESNEX) 20 MG/ML injection 1,305 mg
1,305 mg (rounded from 1,307.32 mg = 667 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Intravenous, 9 doses Starting when released, Administer over 15 Minutes
Administer over 15 minutes. Give prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide infusion on Day
1, 2 and 3. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide dose). If
patient discharged prior to completing all IV mesna doses, remaining doses must be given orally as take home
medication.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
EVERY 24 HOURS, 3 doses Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to
tolerate PO.
IV push slowly, max rate 5 mg/minute.
Take Home Medications (delete all that do not apply)
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 11 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

mesna (MESNEX) 400 MG tab
Take 3.5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of last dose of ifosfamide., 1,400 mg (rounded
from 1,307.32 mg = 667 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Order if patient has not completed all inpatient IV mesna doses. Mesna dose must be adjusted if ifosfamide dose is
reduced (total mesna dose = total ifosfamide dose). Round dose to nearest 200 mg.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 10 (Lab Only), Cycle 3 –  Planned for 3/23/2018
Treatment Plan Information
Reference Information (1)
UTERINE SARCOMA: Homesley H, et al. J Clin Oncol. 2007;25(5):526-31.
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2
IV Day 1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours
after start of ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles
(adjuvant) or until disease progression or toxicity (advanced); NOTE: mesna dose must be adjusted if ifosfamide dose is
reduced (total reduced mesna dose = total reduced ifosfamide dose) and if patient is discharged early, order oral
mesna for remaining doses
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  4/4/2018 through 4/24/2018 (21 days), Planned
Day 1 through 3 (Inpatient), Cycle 4 –  Planned for 4/4/2018
Treatment Plan Information
Reference Information (1)
UTERINE SARCOMA: Homesley H, et al. J Clin Oncol. 2007;25(5):526-31.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 12 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1,
ifosfamide 1600 mg/m2 IV Day 1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior
to ifosfamide and 4 hours and 8 hours after start of ifosfamide Day 1, 2 and 3; GROWTH FACTOR
REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles (adjuvant) or until disease progression or toxicity
(advanced); NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna
dose = total reduced ifosfamide dose) and if patient is discharged early, order oral mesna for
remaining doses
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released
CREATININE
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALBUMIN
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+1 at 0500 for 3 occurrences
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, Albumin, Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL, Platelets less than 100K/µL, Creatinine
greater than 2 mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 1.5 X ULN, AST greater
than 3 X ULN, Albumin less than 3 gm/dL or Urine Hemoglobin greater than Trace.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to ifosfamide
administration on Day 2 and 3.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient
has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 13 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion
complete for the first and second dose of PACLitaxel administration. Monitor vital signs every 30
minutes for all subsequent doses if previous doses tolerated.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations, incontinence,
palsy, diplopia or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
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, EVERY 24 HOURS, 3 doses Starting when released
Infuse 1000 mL throughout ifosfamide treatment.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 1 X DAILY, 3 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, 1 X DAILY PRN, For 4 days Starting when released until S+4, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, 1 X DAILY, 2 doses Starting S+1 As Scheduled
Give prior to chemotherapy on Day 2 and 3. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, 1 X DAILY PRN, For 3 days Starting when released, nausea/vomiting
Give prior to chemotherapy on Day 2 and 3 if patient unable to tolerate PO.
Emergency Medications
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 14 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 265 mg in dextrose 5 % 500 mL non-PVC bag
265 mg (rounded from 264.6 mg = 135 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Infuse over 180 minutes (see titration instructions below). Use non-PVC tubing and 0.2 or 0.22 micron in-line filter
during administration. Hypersensitivity risk - See Emergency Meds.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
mesna in sodium chloride 0.9% (MESNEX) 20 MG/ML injection 1,305 mg
1,305 mg (rounded from 1,307.32 mg = 667 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Intravenous, 9 doses Starting when released, Administer over 15 Minutes
Administer over 15 minutes. Give prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide infusion on Day
1, 2 and 3. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide dose). If
patient discharged prior to completing all IV mesna doses, remaining doses must be given orally as take home
medication.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
EVERY 24 HOURS, 3 doses Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to
tolerate PO.
IV push slowly, max rate 5 mg/minute.
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 3.5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of last dose of ifosfamide., 1,400 mg (rounded
from 1,307.32 mg = 667 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Order if patient has not completed all inpatient IV mesna doses. Mesna dose must be adjusted if ifosfamide dose is
reduced (total mesna dose = total ifosfamide dose). Round dose to nearest 200 mg.
Follow-Up
DAY 10 FOLLOW-UP
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 15 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 10 (Lab Only), Cycle 4 –  Planned for 4/13/2018
Treatment Plan Information
Reference Information (1)
UTERINE SARCOMA: Homesley H, et al. J Clin Oncol. 2007;25(5):526-31.
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2
IV Day 1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours
after start of ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles
(adjuvant) or until disease progression or toxicity (advanced); NOTE: mesna dose must be adjusted if ifosfamide dose is
reduced (total reduced mesna dose = total reduced ifosfamide dose) and if patient is discharged early, order oral
mesna for remaining doses
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  4/25/2018 through 5/15/2018 (21 days), Planned
Day 1 through 3 (Inpatient), Cycle 5 –  Planned for 4/25/2018
Treatment Plan Information
Reference Information (1)
UTERINE SARCOMA: Homesley H, et al. J Clin Oncol. 2007;25(5):526-31.
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2
IV Day 1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours
after start of ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles
(adjuvant) or until disease progression or toxicity (advanced); NOTE: mesna dose must be adjusted if ifosfamide dose is
reduced (total reduced mesna dose = total reduced ifosfamide dose) and if patient is discharged early, order oral
mesna for remaining doses
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 16 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
ONCE Starting when released
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released
CREATININE
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALBUMIN
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+1 at 0500 for 3 occurrences
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, Albumin, Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL, Platelets less than 100K/µL, Creatinine
greater than 2 mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 1.5 X ULN, AST greater
than 3 X ULN, Albumin less than 3 gm/dL or Urine Hemoglobin greater than Trace.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to ifosfamide
administration on Day 2 and 3.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient
has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations, incontinence,
palsy, diplopia or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 17 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@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.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, EVERY 24 HOURS, 3 doses Starting when released
Infuse 1000 mL throughout ifosfamide treatment.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 1 X DAILY, 3 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, 1 X DAILY PRN, For 4 days Starting when released until S+4, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, 1 X DAILY, 2 doses Starting S+1 As Scheduled
Give prior to chemotherapy on Day 2 and 3. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, 1 X DAILY PRN, For 3 days Starting when released, nausea/vomiting
Give prior to chemotherapy on Day 2 and 3 if patient unable to tolerate PO.
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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 18 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Treatment Medications
PACLItaxel (TAXOL) 265 mg in dextrose 5 % 500 mL non-PVC bag
265 mg (rounded from 264.6 mg = 135 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Infuse over 180 minutes (see titration instructions below). Use non-PVC tubing and 0.2 or 0.22 micron in-line filter
during administration. Hypersensitivity risk - See Emergency Meds.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
mesna in sodium chloride 0.9% (MESNEX) 20 MG/ML injection 1,305 mg
1,305 mg (rounded from 1,307.32 mg = 667 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Intravenous, 9 doses Starting when released, Administer over 15 Minutes
Administer over 15 minutes. Give prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide infusion on Day
1, 2 and 3. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide dose). If
patient discharged prior to completing all IV mesna doses, remaining doses must be given orally as take home
medication.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
EVERY 24 HOURS, 3 doses Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to
tolerate PO.
IV push slowly, max rate 5 mg/minute.
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 3.5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of last dose of ifosfamide., 1,400 mg (rounded
from 1,307.32 mg = 667 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Order if patient has not completed all inpatient IV mesna doses. Mesna dose must be adjusted if ifosfamide dose is
reduced (total mesna dose = total ifosfamide dose). Round dose to nearest 200 mg.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 10 (Lab Only), Cycle 5 –  Planned for 5/4/2018
Treatment Plan Information
Reference Information (1)
UTERINE SARCOMA: Homesley H, et al. J Clin Oncol. 2007;25(5):526-31.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 19 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1,
ifosfamide 1600 mg/m2 IV Day 1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior
to ifosfamide and 4 hours and 8 hours after start of ifosfamide Day 1, 2 and 3; GROWTH FACTOR
REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles (adjuvant) or until disease progression or toxicity
(advanced); NOTE: mesna dose must be adjusted if ifosfamide dose is reduced (total reduced mesna
dose = total reduced ifosfamide dose) and if patient is discharged early, order oral mesna for
remaining doses
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 –  5/16/2018 through 6/5/2018 (21 days), Planned
Day 1 through 3 (Inpatient), Cycle 6 –  Planned for 5/16/2018
Treatment Plan Information
Reference Information (1)
UTERINE SARCOMA: Homesley H, et al. J Clin Oncol. 2007;25(5):526-31.
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2
IV Day 1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours
after start of ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles
(adjuvant) or until disease progression or toxicity (advanced); NOTE: mesna dose must be adjusted if ifosfamide dose is
reduced (total reduced mesna dose = total reduced ifosfamide dose) and if patient is discharged early, order oral
mesna for remaining doses
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released
CREATININE
ONCE Starting when released
BILIRUBIN, TOTAL
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 20 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALBUMIN
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+1 at 0500 for 3 occurrences
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST, Albumin, Urinalysis
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL, Platelets less than 100K/µL, Creatinine
greater than 2 mg/dL or Creatinine Clearance less than 50 mL/min, Total Bilirubin greater than 1.5 X ULN, AST greater
than 3 X ULN, Albumin less than 3 gm/dL or Urine Hemoglobin greater than Trace.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to ifosfamide
administration on Day 2 and 3.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient
has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to PACLItaxel can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of PACLitaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations, incontinence,
palsy, diplopia or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
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]
1/31/2018 3:08:37 PM Page 21 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, EVERY 24 HOURS, 3 doses Starting when released
Infuse 1000 mL throughout ifosfamide treatment.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to PACLItaxel.
famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to PACLItaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 1 X DAILY, 3 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, 1 X DAILY PRN, For 4 days Starting when released until S+4, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, 1 X DAILY, 2 doses Starting S+1 As Scheduled
Give prior to chemotherapy on Day 2 and 3. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, 1 X DAILY PRN, For 3 days Starting when released, nausea/vomiting
Give prior to chemotherapy on Day 2 and 3 if patient unable to tolerate PO.
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 (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
PACLItaxel (TAXOL) 265 mg in dextrose 5 % 500 mL non-PVC bag
265 mg (rounded from 264.6 mg = 135 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Infuse over 180 minutes (see titration instructions below). Use non-PVC tubing and 0.2 or 0.22 micron in-line filter
during administration. Hypersensitivity risk - See Emergency Meds.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 22 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
mesna in sodium chloride 0.9% (MESNEX) 20 MG/ML injection 1,305 mg
1,305 mg (rounded from 1,307.32 mg = 667 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight),
Intravenous, 9 doses Starting when released, Administer over 15 Minutes
Administer over 15 minutes. Give prior to ifosfamide and 4 hours and 8 hours after start of ifosfamide infusion on Day
1, 2 and 3. Mesna dose must be adjusted if ifosfamide dose is reduced (total mesna dose = total ifosfamide dose). If
patient discharged prior to completing all IV mesna doses, remaining doses must be given orally as take home
medication.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (rounded from 3,136 mg = 1,600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
EVERY 24 HOURS, 3 doses Starting when released
Dose = 1200 mg/m2 if patient has received prior irradiation.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to
tolerate PO.
IV push slowly, max rate 5 mg/minute.
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 3.5 tabs by mouth 2 times daily. Take 4 & 8 hours after start of last dose of ifosfamide., 1,400 mg (rounded
from 1,307.32 mg = 667 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
Order if patient has not completed all inpatient IV mesna doses. Mesna dose must be adjusted if ifosfamide dose is
reduced (total mesna dose = total ifosfamide dose). Round dose to nearest 200 mg.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 10 (Lab Only), Cycle 6 –  Planned for 5/25/2018
Treatment Plan Information
Reference Information (1)
UTERINE SARCOMA: Homesley H, et al. J Clin Oncol. 2007;25(5):526-31.
Treatment Plan Summary
DISEASE: Uterine Sarcoma (Adjuvant or Advanced); THERAPY: PACLItaxel 135 mg/m2 IV Day 1, ifosfamide 1600 mg/m2
IV Day 1, 2 and 3 (1200 mg/m2 if prior irradiation), mesna 667 mg/m2 IV prior to ifosfamide and 4 hours and 8 hours
after start of ifosfamide Day 1, 2 and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 8 cycles
(adjuvant) or until disease progression or toxicity (advanced); NOTE: mesna dose must be adjusted if ifosfamide dose is
reduced (total reduced mesna dose = total reduced ifosfamide dose) and if patient is discharged early, order oral
mesna for remaining doses
IV Access
Insert and Maintain Peripheral IV
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Jeff J [2507481]
1/31/2018 3:08:37 PM Page 23 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Normal, Routine
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]
1/31/2018 3:08:37 PM Page 24 of 24
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org