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

/clinical/cckm-tools/content/beacon-protocols/gyn/name-96782-en.cckm

201706165

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UWHC,UWMF,

Tools,

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

CSC GYN Sacoma Trabectedin(21D:1) VER 5-1-17 (HL 6010)

CSC GYN Sacoma Trabectedin(21D:1) VER 5-1-17 (HL 6010) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN SARCOMA TRABECTEDIN(21D1) VER 5-1-17 (HL 6010) – Properties
Pre-Cycle – 6/6/2017 through 6/12/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
CK, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE, URINE
ONCE Starting when released
Treatment Conditions
Treatment Condition A
Verify ECHO or MUGA obtained at baseline and every 2 to 3 months during treatment.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tablet by mouth twice daily for 3 days and every 8 hours as needed thereafter., Disp-30 tab, R-5, starting S
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
Cycle 1 – 6/13/2017 through 7/3/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/13/2017 8:26:05 AM Page 1 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Reference Information (1)
LIPOSARCOMA/LEIOMYOSARCOMA: Demetri GD, et al. J Clin Oncol 2016;34(8):786-93.
Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
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, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total CK.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL or Total Bilirubin greater
than ULN or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Alkaline Phosphatase greater than 2.5 X ULN or Total
CK greater than 2.5 X ULN or LVEF less than lower limit of normal.
Treatment Condition A
Verify ECHO or MUGA obtained at baseline and every 2 to 3 months during treatment.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Treatment Medications
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Zztestonc,Jeff J [2507481]
6/13/2017 8:26:05 AM Page 2 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

trabectedin (YONDELIS) 2.95 mg in dextrose 5 % 500 mL home infusion bag
2.95 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
Give as a continuous infusion over 24 hours. Infuse through a central line with a 0.2 or 0.22 micron in-line filter.
Follow-Up
DAY 2 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, AST, ALT, Alkaline Phosphatase,
Total Bilirubin, Creatinine, Total CK; CHEMOTHERAPY ROOM APPOINTMENT: trabectedin for 60 minutes.
Day 2 (Pump Disconnect), Cycle 1 – Planned for 6/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 24-hour trabectedin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 1 – Planned for 6/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
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Zztestonc,Jeff J [2507481]
6/13/2017 8:26:05 AM Page 3 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+8 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+8 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 7/4/2017 through 7/24/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
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+20 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+20 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+20 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+20 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+20 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+20 Approximate, Expires-S+365, Routine
CK, TOTAL
Expected-S+20 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total CK.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL or Total Bilirubin greater
than ULN or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Alkaline Phosphatase greater than 2.5 X ULN or Total
CK greater than 2.5 X ULN or LVEF less than lower limit of normal.
Treatment Condition A
Verify ECHO or MUGA obtained at baseline and every 2 to 3 months during treatment.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Flush Venous Access Device per Guidelines
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Zztestonc,Jeff J [2507481]
6/13/2017 8:26:05 AM Page 4 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Treatment Medications
trabectedin (YONDELIS) 2.95 mg in dextrose 5 % 500 mL home infusion bag
2.95 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Give as a continuous infusion over 24 hours. Infuse through a central line with a 0.2 or 0.22 micron in-line filter.
Follow-Up
DAY 2 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, AST, ALT, Alkaline Phosphatase,
Total Bilirubin, Creatinine, Total CK; CHEMOTHERAPY ROOM APPOINTMENT: trabectedin for 60 minutes.
Day 2 (Pump Disconnect), Cycle 2 – Planned for 7/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Jeff J [2507481]
6/13/2017 8:26:05 AM Page 5 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 24-hour trabectedin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 2 – Planned for 7/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
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+8 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+8 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 7/25/2017 through 8/14/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
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+20 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+20 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+20 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 8:26:05 AM Page 6 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ALT/SGPT
Expected-S+20 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+20 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+20 Approximate, Expires-S+365, Routine
CK, TOTAL
Expected-S+20 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total CK.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL or Total Bilirubin greater
than ULN or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Alkaline Phosphatase greater than 2.5 X ULN or Total
CK greater than 2.5 X ULN or LVEF less than lower limit of normal.
Treatment Condition A
Verify ECHO or MUGA obtained at baseline and every 2 to 3 months during treatment.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Treatment Medications
trabectedin (YONDELIS) 2.95 mg in dextrose 5 % 500 mL home infusion bag
2.95 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Give as a continuous infusion over 24 hours. Infuse through a central line with a 0.2 or 0.22 micron in-line filter.
Follow-Up
DAY 2 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:26:05 AM Page 7 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, AST, ALT, Alkaline Phosphatase,
Total Bilirubin, Creatinine, Total CK; CHEMOTHERAPY ROOM APPOINTMENT: trabectedin for 60 minutes.
Day 2 (Pump Disconnect), Cycle 3 – Planned for 7/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 24-hour trabectedin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 3 – Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
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+8 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+8 Approximate, Expires-S+365, 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]
6/13/2017 8:26:05 AM Page 8 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Cycle 4 – 8/15/2017 through 9/4/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
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+20 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+20 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+20 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+20 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+20 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+20 Approximate, Expires-S+365, Routine
CK, TOTAL
Expected-S+20 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total CK.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL or Total Bilirubin greater
than ULN or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Alkaline Phosphatase greater than 2.5 X ULN or Total
CK greater than 2.5 X ULN or LVEF less than lower limit of normal.
Treatment Condition A
Verify ECHO or MUGA obtained at baseline and every 2 to 3 months during treatment.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Jeff J [2507481]
6/13/2017 8:26:05 AM Page 9 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Treatment Medications
trabectedin (YONDELIS) 2.95 mg in dextrose 5 % 500 mL home infusion bag
2.95 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Give as a continuous infusion over 24 hours. Infuse through a central line with a 0.2 or 0.22 micron in-line filter.
Follow-Up
DAY 2 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, AST, ALT, Alkaline Phosphatase,
Total Bilirubin, Creatinine, Total CK; CHEMOTHERAPY ROOM APPOINTMENT: trabectedin for 60 minutes.
Day 2 (Pump Disconnect), Cycle 4 – Planned for 8/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 24-hour trabectedin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:26:05 AM Page 10 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Lab Only - Day 10, Cycle 4 – Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
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+8 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+8 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 9/5/2017 through 9/25/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
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+20 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+20 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+20 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+20 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+20 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+20 Approximate, Expires-S+365, Routine
CK, TOTAL
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Zztestonc,Jeff J [2507481]
6/13/2017 8:26:05 AM Page 11 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+20 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total CK.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL or Total Bilirubin greater
than ULN or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Alkaline Phosphatase greater than 2.5 X ULN or Total
CK greater than 2.5 X ULN or LVEF less than lower limit of normal.
Treatment Condition A
Verify ECHO or MUGA obtained at baseline and every 2 to 3 months during treatment.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Treatment Medications
trabectedin (YONDELIS) 2.95 mg in dextrose 5 % 500 mL home infusion bag
2.95 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Give as a continuous infusion over 24 hours. Infuse through a central line with a 0.2 or 0.22 micron in-line filter.
Follow-Up
DAY 2 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, AST, ALT, Alkaline Phosphatase,
Total Bilirubin, Creatinine, Total CK; CHEMOTHERAPY ROOM APPOINTMENT: trabectedin for 60 minutes.
Day 2 (Pump Disconnect), Cycle 5 – Planned for 9/6/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/13/2017 8:26:05 AM Page 12 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 24-hour trabectedin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 5 – Planned for 9/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
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+8 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+8 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 9/26/2017 through 10/16/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/13/2017 8:26:05 AM Page 13 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
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+20 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+20 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+20 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+20 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+20 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+20 Approximate, Expires-S+365, Routine
CK, TOTAL
Expected-S+20 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total CK.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1500/µL or Platelets less than 100K/µL or Total Bilirubin greater
than ULN or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Alkaline Phosphatase greater than 2.5 X ULN or Total
CK greater than 2.5 X ULN or LVEF less than lower limit of normal.
Treatment Condition A
Verify ECHO or MUGA obtained at baseline and every 2 to 3 months during treatment.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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Zztestonc,Jeff J [2507481]
6/13/2017 8:26:05 AM Page 14 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
Treatment Medications
trabectedin (YONDELIS) 2.95 mg in dextrose 5 % 500 mL home infusion bag
2.95 mg (rounded from 2.94 mg = 1.5 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Give as a continuous infusion over 24 hours. Infuse through a central line with a 0.2 or 0.22 micron in-line filter.
Follow-Up
DAY 2 FOLLOW-UP
PROCEDURE: Pump disconnect for 15 minutes.
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, AST, ALT, Alkaline Phosphatase,
Total Bilirubin, Creatinine, Total CK; CHEMOTHERAPY ROOM APPOINTMENT: trabectedin for 60 minutes.
Day 2 (Pump Disconnect), Cycle 6 – Planned for 9/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 24-hour trabectedin infusion.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 10, Cycle 6 – Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/13/2017 8:26:05 AM Page 15 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Liposarcoma or Leiomyosarcoma (Unresectable or Metastatic); THERAPY: trabectedin 1.5 mg/m2 administered as a
continuous infusion IV over 24 hours (Total dose = 1.5 mg/m2 IV over 24 hours per cycle per home infusion) Day 1; CYCLE
LENGTH: 21 days; COURSE: until disease progression.
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+8 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+8 Approximate, Expires-S+365, 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]
6/13/2017 8:26:05 AM Page 16 of 16
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org