/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/head-and-neck/,

/clinical/cckm-tools/content/beacon-protocols/head-and-neck/name-96792-en.cckm

201711317

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Head and Neck

CSC HEAD NECK Concurrent XRT Cetuximab(21D:1,8,15) VER 11-10-17 (HL 977)

CSC HEAD NECK Concurrent XRT Cetuximab(21D:1,8,15) VER 11-10-17 (HL 977) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Head and Neck


CSC HEAD/NECK CONCURRENT XRT CETUXIMAB(21D:1,8,15) VER: 11/10/17 –  Properties
Pre-Cycle –  11/6/2017 through 11/12/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 11/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Locally Advanced Squamous Cell Head and Neck Cancer; THERAPY: cetuximab 400 mg/m2 IV (loading dose) 1
week prior to radiotherapy, and then cetuximab 250 mg/m2 IV once weekly for 5 to 7 weeks until the end of
radiotherapy; CYCLE LENGTH: 21 days; COURSE: 2 cycles or until the end of radiotherapy.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+365, Routine
BUN
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+396, Routine
CALCIUM
Expected: S Approximate, Expires: S+365, Routine
ALBUMIN
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
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S Approximate, Expires: S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed., 8 mg, Disp-20 tab, R-5, EVERY 8 HOURS PRN starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:39:23 AM Page 1 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

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
hydrocortisone (CORTIZONE) 1 % cream
Apply 3 times daily as needed (rash)., Disp-454 g, R-0, 3 X DAILY PRN starting S, E-Prescribe
magnesium elemental 250 MG tab
Take 1 tab by mouth 2 times daily. Do not take until told to by MD, 250 mg, Disp-60 tab, R-0, 2 X DAILY starting S,
E-Prescribe
Cycle 1 –  11/13/2017 through 12/3/2017 (21 days), Planned
Day 1, Cycle 1 –  Planned for 11/13/2017
Treatment Plan Information
Reference Information (1)
HEAD/NECK CANCER: Bonner JA, et al. N Engl J Med 2006;354:567-78.
Treatment Plan Summary
DISEASE: Locally Advanced Squamous Cell Head and Neck Cancer; THERAPY: cetuximab 400 mg/m2 IV (loading dose) 1
week prior to radiotherapy, and then cetuximab 250 mg/m2 IV once weekly for 5 to 7 weeks until the end of
radiotherapy; CYCLE LENGTH: 21 days; COURSE: 2 cycles or until the end of radiotherapy.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL
or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE
COMPLETION OF THE FIRST DOSE.
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 cetuximab infusion is
complete. Nurse should remain with the patient for the first 15 minutes of drug administration for the first and second
dose of cetuximab 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...
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:39:23 AM Page 2 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 15 Minutes
Administer 30 minutes PRIOR to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 400 mg/m2 (Treatment Plan)
400 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 120 Minutes
Infuse over 120 minutes through 0.2 or 0.22 micron in line filter. Do not dilute. Maximum rate 5 mL/minute.
Hypersensitivity reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE
COMPLETION OF THE FIRST DOSE. See Emergency Medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS: Magnesium, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: cetuximab for 90 minutes.
DAY 15 FOLLOW-UP
LABS: Magnesium, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: cetuximab for 90 minutes.
DAY 22 FOLLOW-UP
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:39:23 AM Page 3 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium, Glucose, and Total Bilirubin:
CHEMOTHERAPY ROOM APPOINTMENT: cetuximab for 90 minutes.
Day 8, Cycle 1 –  Planned for 11/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Locally Advanced Squamous Cell Head and Neck Cancer; THERAPY: cetuximab 400 mg/m2 IV (loading dose) 1
week prior to radiotherapy, and then cetuximab 250 mg/m2 IV once weekly for 5 to 7 weeks until the end of
radiotherapy; CYCLE LENGTH: 21 days; COURSE: 2 cycles or until the end of radiotherapy.
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
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Magnesium, Potassium
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE
COMPLETION OF THE FIRST DOSE.
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 cetuximab infusion is
complete. Nurse should remain with the patient for the first 15 minutes of drug administration for the first and second
dose of cetuximab administration.
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
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:39:23 AM Page 4 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes (if tolerated from previous doses) through 0.2 or 0.22 micron in line filter. Do not dilute.
Maximum rate 5 mL/minute. Hypersensitivity reaction to cetuximab can occur.  For first and second dose, patient
should be treated in a location to optimize emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60
MINUTES FOLLOWING THE COMPLETION OF THE FIRST DOSE. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 –  Planned for 11/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Locally Advanced Squamous Cell Head and Neck Cancer; THERAPY: cetuximab 400 mg/m2 IV (loading dose) 1
week prior to radiotherapy, and then cetuximab 250 mg/m2 IV once weekly for 5 to 7 weeks until the end of
radiotherapy; CYCLE LENGTH: 21 days; COURSE: 2 cycles or until the end of radiotherapy.
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
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
POTASSIUM
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:39:23 AM Page 5 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Magnesium, Potassium
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE
COMPLETION OF THE FIRST DOSE.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 30 minutes for the first hour until cetuximab infusion complete if first and second
administration without hypersensitivity reaction. If history of hypersensitivity reaction increase vital sign monitoring and
frequency of nursing assessment.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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,PedsBeiber [2668824]
11/13/2017 9:39:23 AM Page 6 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes (if tolerated from previous doses) through 0.2 or 0.22 micron in line filter. Do not dilute.
Maximum rate 5 mL/minute. Hypersensitivity reaction to cetuximab can occur.  For first and second dose, patient
should be treated in a location to optimize emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60
MINUTES FOLLOWING THE COMPLETION OF THE FIRST DOSE. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  12/4/2017 through 12/24/2017 (21 days), Planned
Day 1, Cycle 2 –  Planned for 12/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Locally Advanced Squamous Cell Head and Neck Cancer; THERAPY: cetuximab 400 mg/m2 IV (loading dose) 1
week prior to radiotherapy, and then cetuximab 250 mg/m2 IV once weekly for 5 to 7 weeks until the end of
radiotherapy; CYCLE LENGTH: 21 days; COURSE: 2 cycles or until the end of radiotherapy.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+7 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+7 Approximate, Expires: S+365, Routine
BUN
Expected: S+7 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+7 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+7 Approximate, Expires: S+365, Routine
ALBUMIN
Expected: S+7 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+7 Approximate, Expires: S+365, Routine
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:39:23 AM Page 7 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

AST/SGOT
Expected: S+7 Approximate, Expires: S+365, Routine
ALKALINE PHOSPHATASE
Expected: S+7 Approximate, Expires: S+365, Routine
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL
or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE
COMPLETION OF THE FIRST DOSE.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 30 minutes for the first hour until cetuximab infusion complete if first and second
administration without hypersensitivity reaction. If history of hypersensitivity reaction increase vital sign monitoring and
frequency of nursing assessment.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:39:23 AM Page 8 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes (if tolerated from previous doses) through 0.2 or 0.22 micron in line filter. Do not dilute.
Maximum rate 5 mL/minute. Hypersensitivity reaction to cetuximab can occur.  For first and second dose, patient
should be treated in a location to optimize emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60
MINUTES FOLLOWING THE COMPLETION OF THE FIRST DOSE. See Emergency Medications.
Follow-Up
DAY 8 FOLLOW-UP
LABS: Magnesium, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: cetuximab for 90 minutes.
DAY 15 FOLLOW-UP
LABS: Magnesium, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: cetuximab for 90 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin, Magnesium, Glucose, and Total Bilirubin:
CHEMOTHERAPY ROOM APPOINTMENT: cetuximab for 90 minutes.
Day 8, Cycle 2 –  Planned for 12/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Locally Advanced Squamous Cell Head and Neck Cancer; THERAPY: cetuximab 400 mg/m2 IV (loading dose) 1
week prior to radiotherapy, and then cetuximab 250 mg/m2 IV once weekly for 5 to 7 weeks until the end of
radiotherapy; CYCLE LENGTH: 21 days; COURSE: 2 cycles or until the end of radiotherapy.
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
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:39:23 AM Page 9 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained and resulted: Magnesium, Potassium
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE
COMPLETION OF THE FIRST DOSE.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 30 minutes for the first hour until cetuximab infusion complete if first and second
administration without hypersensitivity reaction. If history of hypersensitivity reaction increase vital sign monitoring and
frequency of nursing assessment.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:39:23 AM Page 10 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes (if tolerated from previous doses) through 0.2 or 0.22 micron in line filter. Do
not dilute. Maximum rate 5 mL/minute. Hypersensitivity reaction to cetuximab can occur.  For first and
second dose, patient should be treated in a location to optimize emergency care. PATIENT MUST
REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE COMPLETION OF THE FIRST DOSE.
See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 –  Planned for 12/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Locally Advanced Squamous Cell Head and Neck Cancer; THERAPY: cetuximab 400 mg/m2 IV (loading dose) 1
week prior to radiotherapy, and then cetuximab 250 mg/m2 IV once weekly for 5 to 7 weeks until the end of
radiotherapy; CYCLE LENGTH: 21 days; COURSE: 2 cycles or until the end of radiotherapy.
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
MAGNESIUM
Expected: S+7 Approximate, Expires: S+365, Routine
POTASSIUM
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Magnesium, Potassium
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cetuximab can occur.  For first and second dose, patient should be treated in a location to
optimize emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60 MINUTES FOLLOWING THE
COMPLETION OF THE FIRST DOSE.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Vital signs to be monitored every 30 minutes for the first hour until cetuximab infusion complete if first and second
administration without hypersensitivity reaction. If history of hypersensitivity reaction increase vital sign monitoring and
frequency of nursing assessment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:39:23 AM Page 11 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or
15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 15 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cetuximab (ERBITUX) bag 250 mg/m2 (Treatment Plan)
250 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes (if tolerated from previous doses) through 0.2 or 0.22 micron in line filter. Do not dilute.
Maximum rate 5 mL/minute. Hypersensitivity reaction to cetuximab can occur.  For first and second dose, patient
should be treated in a location to optimize emergency care. PATIENT MUST REMAIN IN TREATMENT AREA FOR 60
MINUTES FOLLOWING THE COMPLETION OF THE FIRST DOSE. See Emergency Medications.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,PedsBeiber [2668824]
11/13/2017 9:39:23 AM Page 12 of 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org