/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/hem---leukemia-and-lymphoma/,

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201605136

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UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Hem - Leukemia and Lymphoma

CSC Hem Inpt-Op Dexamethasone Etoposide Ifosfamide Methotrexate Pegaspargase Ver 2-2-16 (HL 4390)

CSC Hem Inpt-Op Dexamethasone Etoposide Ifosfamide Methotrexate Pegaspargase Ver 2-2-16 (HL 4390) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia and Lymphoma


CSC HEM INPT/OP DEXAMETHASONE/ETOPOSIDE/IFOSFAMIDE/METHOTREXATE/PEGASPARGASE VER: 2-2-16 –
Properties
Cycle 1 – 2/4/2016 through 3/2/2016 (28 days), Planned
Days 1 through 4 (Inpatient), Cycle 1 – Planned for 2/4/2016 through 2/7/2016
Treatment Plan Information
Reference Information (1)
LEUKEMIA AND LYMPHOMA: Yamaguchi M, et. al. Cancer Sci 2008;99:1016-20
Reference Information (2)
LEUKEMIA AND LYMPHOMA: National Comprehensive Cancer Network. Non-Hodgkin's Lymphoma
(Version 2.2013).
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2
IV Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by
mouth beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released
ELECTROLYTES
ONCE Starting when released
GLUCOSE
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released
CALCIUM
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
FIBRINOGEN
ONCE Starting when released
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 1 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

PTT
ONCE Starting when released
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours until Methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
EVERY 24 HOURS Starting S+1 at 0000 for 7 days
Methotrexate level daily, starting 24 hours after the start of the methotrexate infusion and continuing until methotrexate
level is undetectable.
CREATININE
NEXT AM Starting S+1 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+7 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine,
Calcium, Total Bilirubin, AST, ALT, Fibrinogen, PTT
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or platelets less than 50K/µL
or creatinine greater than 1.5 mg/dL or total bilirubin greater than or equal to 2 mg/dL or AST/ALT greater than or equal
to 5 x ULN
Treatment Parameters (2)
Do not start methotrexate until urine pH is greater than 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate and then
every 8 hours. If less than 7, give sodium bicarbonate 50 mEq IV. See Conditional Medications.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in
8 hours or three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
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 10 UNIT/ML lock flush injection 1-150 units
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 2 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@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 0.45 % 1,000 mL with sodium bicarbonate 50 mEq infusion
at 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 6 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium
Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 8 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or
fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 4 doses Starting when released
Days 1 through 4: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting, if unable to tolerate PO
Days 1 through 4: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE PRN, For 48 hours Starting when released, nausea/vomiting
Over 2-3 minutes. If unable to tolerate oral dose.
Treatment Medications
methotrexate PF 4,180 mg in dextrose 5 % 1,000 mL bag
4,180 mg (2,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 1: Administer over 6 hours.
leucovorin 418 mg in dextrose 5 % 500 mL bag
418 mg (200 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Administer over 30 minutes. Start 24 hours after the completion of the methotrexate infusion.
leucovorin tab 32.5 mg
32.5 mg (rounded from 31.35 mg = 15 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, EVERY 6
HOURS Starting S+1 at 0000
Start 6 hours after the first leucovorin dose.
dexamethasone (DECADRON) 40 mg in dextrose 5 % 50 mL bag
40 mg, Intravenous, 1 X DAILY, 3 doses Starting S+1 As Scheduled, for 30 Minutes
Day 2, 3, and 4. Administer over 30 minutes.
mesna (MESNEX) 627 mg in dextrose 5 % 50 mL bag
627 mg (300 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2, 3, and 4 ( total 9 doses). Administer prior to ifosfamide and 4 and 8 hours after ifosfamide.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (1,500 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2, 3, and 4: Administer over 30 minutes.
etoposide (VEPESID) 209 mg in sodium chloride 0.9 % 500 mL NSS bag
209 mg (100 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 3 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Day 2, 3, and 4. Administer over 30 minutes. Administer with non-PVC tubing.
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
IV push rate 10 mg/minute. Give 1 hour after the start of ifosfamide on days 2, 3, and 4
Treatment Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
NOTE:
PRN Starting when released Until Discontinued, Note
Hold tmp/sulfa while methotrexate level is detectable. Resume at discharge
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For urine pH
less than 7, for 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. May discontinue when methotrexate level is undetectable.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting,
If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Take Home Medications
sulfamethoxazole-trimethoprim (SMZ-TMP DS) 800-160 MG per tab
Take 1 tab by mouth 2 times daily Sat,Sun., 1 tab, Disp-16 tab, R-5, 2 X DAILY SAT, SUN starting S
Hold TMP/Sulfa during methotrexate infusion and until methotrexate level is undetectable.
Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than
*** after nadir., 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 ***. Continue until ANC is greater than
*** after nadir., 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.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 4 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
LABS: CBC with DIFF every Monday and Thursday starting ***.
DAY 7 FOLLOW-UP
RETURN TO CLINIC: for appointment with provider. LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, AST, ALT, Total Bilirubin, Fibrinogen, PTT, PT/INR, Ammonia, Lipase, Amylase, Triglycerides, Uric
Acid, LDH; CHEMOTHERAPY ROOM APPOINTMENT: pegaspargase for 90 minutes.
DAY 10 FOLLOW-UP
LABS: Creatinine, Potassium, Uric Acid, LDH, Fibrinogen, PT/INR, PTT
DAY 12 FOLLOW-UP
LABS: Creatinine, Potassium, Uric Acid, LDH, Fibrinogen, PT/INR, PTT
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, AST, ALT, Total Bilirubin,
Fibrinogen, PTT, PT/INR, Ammonia, Lipase, Amylase.
DAY 18 FOLLOW-UP
LABS: Fibrinogen, PT/INR, PTT.
DAY 22 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, AST, ALT, Total Bilirubin,
Fibrinogen, PTT, PT/INR, Ammonia, Lipase, Amylase.
Day 29 Follow-Up
(Day 1 of next cycle ) INPATIENT ADMISSION: B6/6.
Day 7, Cycle 1 – Planned for 2/10/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
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 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 5 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S Approximate, Expires-S+365, Routine
PTT
Expected-S Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S Approximate, Expires-S+365, Routine
AMMONIA
Expected-S Approximate, Expires-S+397, Routine
LIPASE
Expected-S Approximate, Expires-S+365, Routine
AMYLASE
Expected-S Approximate, Expires-S+365, Routine
TRIGLYCERIDE
Expected-S Approximate, Expires-S+365, Routine
URIC ACID
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, ALT, Creatinine.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after drug
administration. See vital signs and emergency medications. Patient should have Epipen and oral diphenhydramine
(Benadryl) available for home use.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Check blood pressure, heart rate, and respiratory rate 15 minutes before pegaspargase administration and for 1 hour
post-administration.
Patient Instructions(1)
Verify patient has Epipen to use in clinic for emergency needs.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 6 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to pegaspargase.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to pegaspargase.
hydrocortisone sodium succinate PF (SOLU-CORTEF) vial 100 mg
100 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to pegaspargase. Obtain from Accudose.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
pegaspargase (ONCASPAR) injection 5,227.5 units
5,227.5 units (rounded from 5,225 units = 2,500 Units/m2 × 2.09 m2 Treatment plan actual BSA),
Intramuscular, ONCE, 1 dose Starting when released
Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after drug administration. See
vital signs and emergency medications. Patient to remain in clinic for 1 hour of observation and vital signs post injection.
Patient should have Epipen and oral diphenhydramine (Benadryl) available for home use.
Take Home Medications
epINEPHrine (EPIPEN) 0.3 MG/0.3ML soln auto-injector
Give 0.3 mg intramuscularly as needed. Remind patient to bring to clinic., 0.3 mg, Disp-1 each, R-1, PRN
starting S
diphenhydramine (BENADRYL) 12.5 MG/5ML elixir
Take 20 mL by mouth as needed. Take at first sign of allergic reaction. Available over the counter., 50
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 7 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

mg, PRN starting S
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 2/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
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
CREATININE
Expected-S+3 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+3 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+3 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+3 Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S+3 Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S+3 Approximate, Expires-S+365, Routine
PTT
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 12, Cycle 1 – Planned for 2/15/2016
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 8 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
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
CREATININE
Expected-S+5 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+5 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+21, Expires-S+365, Routine
LD, TOTAL
Expected-S+5 Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S+5 Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S+5 Approximate, Expires-S+365, Routine
PTT
Expected-S+5 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 – Planned for 2/18/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 9 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
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+8 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+8 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+8 Approximate, Expires-S+365, Routine
BUN
Expected-S+8 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+8 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+8 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+8 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+8 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+8 Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S+8 Approximate, Expires-S+365, Routine
PTT
Expected-S+8 Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S+8 Approximate, Expires-S+365, Routine
AMMONIA
Expected-S+8 Approximate, Expires-S+397, Routine
LIPASE
Expected-S+8, Expires-S+365, Routine
AMYLASE
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,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 10 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Lab Only - Day 18, Cycle 1 – Planned for 2/21/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
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
FIBRINOGEN
Expected-S+11 Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S+11 Approximate, Expires-S+365, Routine
PTT
Expected-S+11 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 22, Cycle 1 – Planned for 2/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
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.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 11 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+15 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+15 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+15 Approximate, Expires-S+365, Routine
BUN
Expected-S+15 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+15 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+15 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+15 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+15 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+15 Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S+15 Approximate, Expires-S+365, Routine
PTT
Expected-S+15 Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S+15 Approximate, Expires-S+365, Routine
AMMONIA
Expected-S+15 Approximate, Expires-S+397, Routine
LIPASE
Expected-S+15 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+15 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 – 3/3/2016 through 3/30/2016 (28 days), Planned
Days 1 through 4 (Inpatient), Cycle 2 – Planned for 3/3/2016 through 3/6/2016
Treatment Plan Information
Reference Information (1)
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 12 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

LEUKEMIA AND LYMPHOMA: Yamaguchi M, et. al. Cancer Sci 2008;99:1016-20
Reference Information (2)
LEUKEMIA AND LYMPHOMA: National Comprehensive Cancer Network. Non-Hodgkin's Lymphoma
(Version 2.2013).
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released
ELECTROLYTES
ONCE Starting when released
GLUCOSE
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released
CALCIUM
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
FIBRINOGEN
ONCE Starting when released
PTT
ONCE Starting when released
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 13 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours until Methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
EVERY 24 HOURS Starting S+1 at 0000 for 7 days
Methotrexate level daily, starting 24 hours after the start of the methotrexate infusion and continuing until methotrexate
level is undetectable.
CREATININE
NEXT AM Starting S+1 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+7 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine,
Calcium, Total Bilirubin, AST, ALT, Fibrinogen, PTT
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or platelets less than 50K/µL
or creatinine greater than 1.5 mg/dL or total bilirubin greater than or equal to 2 mg/dL or AST/ALT greater than or equal
to 5 x ULN
Treatment Parameters (2)
Do not start methotrexate until urine pH is greater than 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate and then
every 8 hours. If less than 7, give sodium bicarbonate 50 mEq IV. See Conditional Medications.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in
8 hours or three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
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 10 UNIT/ML lock flush 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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 14 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

sodium chloride 0.45 % 1,000 mL with sodium bicarbonate 50 mEq infusion
at 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 6 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium
Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 8 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or
fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 4 doses Starting when released
Days 1 through 4: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting, if unable to tolerate PO
Days 1 through 4: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE PRN, For 48 hours Starting when released, nausea/vomiting
Over 2-3 minutes. If unable to tolerate oral dose.
Treatment Medications
methotrexate PF 4,180 mg in dextrose 5 % 1,000 mL bag
4,180 mg (2,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 1: Administer over 6 hours.
leucovorin 418 mg in dextrose 5 % 500 mL bag
418 mg (200 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Administer over 30 minutes. Start 24 hours after the completion of the methotrexate infusion.
leucovorin tab 32.5 mg
32.5 mg (rounded from 31.35 mg = 15 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, EVERY 6
HOURS Starting S+1 at 0000
Start 6 hours after the first leucovorin dose.
dexamethasone (DECADRON) 40 mg in dextrose 5 % 50 mL bag
40 mg, Intravenous, 1 X DAILY, 3 doses Starting S+1 As Scheduled, for 30 Minutes
Day 2, 3, and 4. Administer over 30 minutes.
mesna (MESNEX) 627 mg in dextrose 5 % 50 mL bag
627 mg (300 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2, 3, and 4 ( total 9 doses). Administer prior to ifosfamide and 4 and 8 hours after ifosfamide.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (1,500 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2, 3, and 4: Administer over 30 minutes.
etoposide (VEPESID) 209 mg in sodium chloride 0.9 % 500 mL NSS bag
209 mg (100 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2, 3, and 4. Administer over 30 minutes. Administer with non-PVC tubing.
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
IV push rate 10 mg/minute. Give 1 hour after the start of ifosfamide on days 2, 3, and 4
Treatment Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 15 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
NOTE:
PRN Starting when released Until Discontinued, Note
Hold tmp/sulfa while methotrexate level is detectable. Resume at discharge
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For urine pH
less than 7, for 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. May discontinue when methotrexate level is undetectable.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting,
If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Follow-Up
DAY 7 FOLLOW-UP
RETURN TO CLINIC: for appointment with provider. LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, AST, ALT, Total Bilirubin, Fibrinogen, PTT, INR, Ammonia, Lipase, Amylase, Triglycerides;
CHEMOTHERAPY ROOM APPOINTMENT: pegaspargase for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, AST, ALT, Total Bilirubin,
Fibrinogen, PTT, INR, Ammonia, Lipase, Amylase.
DAY 22 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, AST, ALT, Total Bilirubin,
Fibrinogen, PTT, INR, Ammonia, Lipase, Amylase.
Day 29 Follow-Up
(Day 1 of next cycle ) INPATIENT ADMISSION: B6/6.
Day 7, Cycle 2 – Planned for 3/9/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 16 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
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 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S Approximate, Expires-S+365, Routine
PTT
Expected-S Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S Approximate, Expires-S+365, Routine
AMMONIA
Expected-S Approximate, Expires-S+397, Routine
LIPASE
Expected-S Approximate, Expires-S+365, Routine
AMYLASE
Expected-S Approximate, Expires-S+365, Routine
TRIGLYCERIDE
Expected-S Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 17 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, ALT, Creatinine.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after drug
administration. See vital signs and emergency medications. Patient should have Epipen and oral diphenhydramine
(Benadryl) available for home use.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Check blood pressure, heart rate, and respiratory rate 15 minutes before pegaspargase administration and for 1 hour
post-administration.
Patient Instructions(1)
Verify patient has Epipen to use in clinic for emergency needs.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to pegaspargase.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to pegaspargase.
hydrocortisone sodium succinate PF (SOLU-CORTEF) vial 100 mg
100 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to pegaspargase. Obtain from Accudose.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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]
2/4/2016 12:04:07 PM Page 18 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Treatment Medications
pegaspargase (ONCASPAR) injection 5,227.5 units
5,227.5 units (rounded from 5,225 units = 2,500 Units/m2 × 2.09 m2 Treatment plan actual BSA),
Intramuscular, ONCE, 1 dose Starting when released
Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after drug administration. See
vital signs and emergency medications. Patient to remain in clinic for 1 hour of observation and vital signs post injection.
Patient should have Epipen and oral diphenhydramine (Benadryl) available for home use.
Take Home Medications
epINEPHrine (EPIPEN) 0.3 MG/0.3ML soln auto-injector
Give 0.3 mg intramuscularly as needed. Remind patient to bring to clinic., 0.3 mg, Disp-1 each, R-1, PRN
starting S
diphenhydramine (BENADRYL) 12.5 MG/5ML elixir
Take 20 mL by mouth as needed. Take at first sign of allergic reaction. Available over the counter., 50
mg, PRN starting S
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 2 – Planned for 3/17/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
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+8 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+8 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+8 Approximate, Expires-S+365, Routine
BUN
Expected-S+8 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 19 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

CREATININE
Expected-S+8 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+8 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+8 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+8 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+8 Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S+8 Approximate, Expires-S+365, Routine
PTT
Expected-S+8 Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S+8 Approximate, Expires-S+365, Routine
AMMONIA
Expected-S+8 Approximate, Expires-S+397, Routine
LIPASE
Expected-S+8, Expires-S+365, Routine
AMYLASE
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.
Lab Only - Day 22, Cycle 2 – Planned for 3/24/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
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.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 20 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+15 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+15 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+15 Approximate, Expires-S+365, Routine
BUN
Expected-S+15 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+15 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+15 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+15 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+15 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+15 Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S+15 Approximate, Expires-S+365, Routine
PTT
Expected-S+15 Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S+15 Approximate, Expires-S+365, Routine
AMMONIA
Expected-S+15 Approximate, Expires-S+397, Routine
LIPASE
Expected-S+15 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+15 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 – 3/31/2016 through 4/27/2016 (28 days), Planned
Days 1 through 4 (Inpatient), Cycle 3 – Planned for 3/31/2016 through 4/3/2016
Treatment Plan Information
Reference Information (1)
LEUKEMIA AND LYMPHOMA: Yamaguchi M, et. al. Cancer Sci 2008;99:1016-20
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 21 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Reference Information (2)
LEUKEMIA AND LYMPHOMA: National Comprehensive Cancer Network. Non-Hodgkin's Lymphoma
(Version 2.2013).
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released
ELECTROLYTES
ONCE Starting when released
GLUCOSE
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released
CALCIUM
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
FIBRINOGEN
ONCE Starting when released
PTT
ONCE Starting when released
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours until Methotrexate level is undetectable.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 22 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
EVERY 24 HOURS Starting S+1 at 0000 for 7 days
Methotrexate level daily, starting 24 hours after the start of the methotrexate infusion and continuing until methotrexate
level is undetectable.
CREATININE
NEXT AM Starting S+1 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+7 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine,
Calcium, Total Bilirubin, AST, ALT, Fibrinogen, PTT
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or platelets less than 50K/µL
or creatinine greater than 1.5 mg/dL or total bilirubin greater than or equal to 2 mg/dL or AST/ALT greater than or equal
to 5 x ULN
Treatment Parameters (2)
Do not start methotrexate until urine pH is greater than 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate and then
every 8 hours. If less than 7, give sodium bicarbonate 50 mEq IV. See Conditional Medications.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in
8 hours or three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
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 10 UNIT/ML lock flush 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 0.45 % 1,000 mL with sodium bicarbonate 50 mEq infusion
at 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 6 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 23 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 8 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or
fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 4 doses Starting when released
Days 1 through 4: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting, if unable to tolerate PO
Days 1 through 4: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE PRN, For 48 hours Starting when released, nausea/vomiting
Over 2-3 minutes. If unable to tolerate oral dose.
Treatment Medications
methotrexate PF 4,180 mg in dextrose 5 % 1,000 mL bag
4,180 mg (2,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 1: Administer over 6 hours.
leucovorin 418 mg in dextrose 5 % 500 mL bag
418 mg (200 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Administer over 30 minutes. Start 24 hours after the completion of the methotrexate infusion.
leucovorin tab 32.5 mg
32.5 mg (rounded from 31.35 mg = 15 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, EVERY 6
HOURS Starting S+1 at 0000
Start 6 hours after the first leucovorin dose.
dexamethasone (DECADRON) 40 mg in dextrose 5 % 50 mL bag
40 mg, Intravenous, 1 X DAILY, 3 doses Starting S+1 As Scheduled, for 30 Minutes
Day 2, 3, and 4. Administer over 30 minutes.
mesna (MESNEX) 627 mg in dextrose 5 % 50 mL bag
627 mg (300 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2, 3, and 4 ( total 9 doses). Administer prior to ifosfamide and 4 and 8 hours after ifosfamide.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (1,500 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2, 3, and 4: Administer over 30 minutes.
etoposide (VEPESID) 209 mg in sodium chloride 0.9 % 500 mL NSS bag
209 mg (100 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2, 3, and 4. Administer over 30 minutes. Administer with non-PVC tubing.
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
IV push rate 10 mg/minute. Give 1 hour after the start of ifosfamide on days 2, 3, and 4
Treatment Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 24 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
NOTE:
PRN Starting when released Until Discontinued, Note
Hold tmp/sulfa while methotrexate level is detectable. Resume at discharge
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For urine pH
less than 7, for 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. May discontinue when methotrexate level is undetectable.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting,
If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Follow-Up
DAY 7 FOLLOW-UP
RETURN TO CLINIC: for appointment with provider. LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, AST, ALT, Total Bilirubin, Fibrinogen, PTT, INR, Ammonia, Lipase, Amylase, Triglycerides;
CHEMOTHERAPY ROOM APPOINTMENT: pegaspargase for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, AST, ALT, Total Bilirubin,
Fibrinogen, PTT, INR, Ammonia, Lipase, Amylase.
DAY 22 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, AST, ALT, Total Bilirubin,
Fibrinogen, PTT, INR, Ammonia, Lipase, Amylase.
Day 29 Follow-Up
(Day 1 of next cycle ) INPATIENT ADMISSION: B6/6.
Day 7, Cycle 3 – Planned for 4/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 25 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following pegaspargase. Consider
transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
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 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S Approximate, Expires-S+365, Routine
PTT
Expected-S Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S Approximate, Expires-S+365, Routine
AMMONIA
Expected-S Approximate, Expires-S+397, Routine
LIPASE
Expected-S Approximate, Expires-S+365, Routine
AMYLASE
Expected-S Approximate, Expires-S+365, Routine
TRIGLYCERIDE
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, ALT, Creatinine.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 26 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after drug
administration. See vital signs and emergency medications. Patient should have Epipen and oral diphenhydramine
(Benadryl) available for home use.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Check blood pressure, heart rate, and respiratory rate 15 minutes before pegaspargase administration and for 1 hour
post-administration.
Patient Instructions(1)
Verify patient has Epipen to use in clinic for emergency needs.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to pegaspargase.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to pegaspargase.
hydrocortisone sodium succinate PF (SOLU-CORTEF) vial 100 mg
100 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to pegaspargase. Obtain from Accudose.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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]
2/4/2016 12:04:07 PM Page 27 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

pegaspargase (ONCASPAR) injection 5,227.5 units
5,227.5 units (rounded from 5,225 units = 2,500 Units/m2 × 2.09 m2 Treatment plan actual BSA),
Intramuscular, ONCE, 1 dose Starting when released
Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after drug administration. See
vital signs and emergency medications. Patient to remain in clinic for 1 hour of observation and vital signs post injection.
Patient should have Epipen and oral diphenhydramine (Benadryl) available for home use.
Take Home Medications
epINEPHrine (EPIPEN) 0.3 MG/0.3ML soln auto-injector
Give 0.3 mg intramuscularly as needed. Remind patient to bring to clinic., 0.3 mg, Disp-1 each, R-1, PRN
starting S
diphenhydramine (BENADRYL) 12.5 MG/5ML elixir
Take 20 mL by mouth as needed. Take at first sign of allergic reaction. Available over the counter., 50
mg, PRN starting S
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 3 – Planned for 4/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
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+8 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+8 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+8 Approximate, Expires-S+365, Routine
BUN
Expected-S+8 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+8 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 28 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

CALCIUM
Expected-S+8 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+8 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+8 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+8 Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S+8 Approximate, Expires-S+365, Routine
PTT
Expected-S+8 Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S+8 Approximate, Expires-S+365, Routine
AMMONIA
Expected-S+8 Approximate, Expires-S+397, Routine
LIPASE
Expected-S+8, Expires-S+365, Routine
AMYLASE
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.
Lab Only - Day 22, Cycle 3 – Planned for 4/21/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
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+15 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 29 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

ELECTROLYTES
Expected-S+15 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+15 Approximate, Expires-S+365, Routine
BUN
Expected-S+15 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+15 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+15 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+15 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+15 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+15 Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S+15 Approximate, Expires-S+365, Routine
PTT
Expected-S+15 Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S+15 Approximate, Expires-S+365, Routine
AMMONIA
Expected-S+15 Approximate, Expires-S+397, Routine
LIPASE
Expected-S+15 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+15 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 4 – 4/28/2016 through 5/25/2016 (28 days), Planned
Days 1 through 4 (Inpatient), Cycle 4 – Planned for 4/28/2016 through 5/1/2016
Treatment Plan Information
Reference Information (1)
LEUKEMIA AND LYMPHOMA: Yamaguchi M, et. al. Cancer Sci 2008;99:1016-20
Reference Information (2)
LEUKEMIA AND LYMPHOMA: National Comprehensive Cancer Network. Non-Hodgkin's Lymphoma
(Version 2.2013).
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 30 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released
ELECTROLYTES
ONCE Starting when released
GLUCOSE
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released
CALCIUM
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
FIBRINOGEN
ONCE Starting when released
PTT
ONCE Starting when released
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours until Methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 31 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

or equal to 7 for two consecutive occurrences.
METHOTREXATE
EVERY 24 HOURS Starting S+1 at 0000 for 7 days
Methotrexate level daily, starting 24 hours after the start of the methotrexate infusion and continuing until methotrexate
level is undetectable.
CREATININE
NEXT AM Starting S+1 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+7 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine,
Calcium, Total Bilirubin, AST, ALT, Fibrinogen, PTT
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or platelets less than 50K/µL
or creatinine greater than 1.5 mg/dL or total bilirubin greater than or equal to 2 mg/dL or AST/ALT greater than or equal
to 5 x ULN
Treatment Parameters (2)
Do not start methotrexate until urine pH is greater than 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate and then
every 8 hours. If less than 7, give sodium bicarbonate 50 mEq IV. See Conditional Medications.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in
8 hours or three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
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 10 UNIT/ML lock flush 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 0.45 % 1,000 mL with sodium bicarbonate 50 mEq infusion
at 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 6 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium
Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 8 HOURS Starting when released
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 32 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or
fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 4 doses Starting when released
Days 1 through 4: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting, if unable to tolerate PO
Days 1 through 4: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE PRN, For 48 hours Starting when released, nausea/vomiting
Over 2-3 minutes. If unable to tolerate oral dose.
Treatment Medications
methotrexate PF 4,180 mg in dextrose 5 % 1,000 mL bag
4,180 mg (2,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 1: Administer over 6 hours.
leucovorin 418 mg in dextrose 5 % 500 mL bag
418 mg (200 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Administer over 30 minutes. Start 24 hours after the completion of the methotrexate infusion.
leucovorin tab 32.5 mg
32.5 mg (rounded from 31.35 mg = 15 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, EVERY 6
HOURS Starting S+1 at 0000
Start 6 hours after the first leucovorin dose.
dexamethasone (DECADRON) 40 mg in dextrose 5 % 50 mL bag
40 mg, Intravenous, 1 X DAILY, 3 doses Starting S+1 As Scheduled, for 30 Minutes
Day 2, 3, and 4. Administer over 30 minutes.
mesna (MESNEX) 627 mg in dextrose 5 % 50 mL bag
627 mg (300 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2, 3, and 4 ( total 9 doses). Administer prior to ifosfamide and 4 and 8 hours after ifosfamide.
ifosfamide (IFEX) 3,135 mg in sodium chloride 0.9 % 250 mL bag
3,135 mg (1,500 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2, 3, and 4: Administer over 30 minutes.
etoposide (VEPESID) 209 mg in sodium chloride 0.9 % 500 mL NSS bag
209 mg (100 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2, 3, and 4. Administer over 30 minutes. Administer with non-PVC tubing.
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
IV push rate 10 mg/minute. Give 1 hour after the start of ifosfamide on days 2, 3, and 4
Treatment Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 33 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

NOTE:
PRN Starting when released Until Discontinued, Note
Hold tmp/sulfa while methotrexate level is detectable. Resume at discharge
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For urine pH
less than 7, for 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. May discontinue when methotrexate level is undetectable.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting,
If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Follow-Up
DAY 7 FOLLOW-UP
RETURN TO CLINIC: for appointment with provider. LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, AST, ALT, Total Bilirubin, Fibrinogen, PTT, INR, Ammonia, Lipase, Amylase, Triglycerides;
CHEMOTHERAPY ROOM APPOINTMENT: pegaspargase for 90 minutes.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, AST, ALT, Total Bilirubin,
Fibrinogen, PTT, INR, Ammonia, Lipase, Amylase.
DAY 22 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, AST, ALT, Total Bilirubin,
Fibrinogen, PTT, INR, Ammonia, Lipase, Amylase.
DAY 29 FOLLOW-UP
Per treating physician.
Day 7, Cycle 4 – Planned for 5/4/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 34 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S Approximate, Expires-S+365, Routine
PTT
Expected-S Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S Approximate, Expires-S+365, Routine
AMMONIA
Expected-S Approximate, Expires-S+397, Routine
LIPASE
Expected-S Approximate, Expires-S+365, Routine
AMYLASE
Expected-S Approximate, Expires-S+365, Routine
TRIGLYCERIDE
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, ALT, Creatinine.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 35 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Hypersensitivity Monitoring (1)
Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after drug
administration. See vital signs and emergency medications. Patient should have Epipen and oral diphenhydramine
(Benadryl) available for home use.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Check blood pressure, heart rate, and respiratory rate 15 minutes before pegaspargase administration and for 1 hour
post-administration.
Patient Instructions(1)
Verify patient has Epipen to use in clinic for emergency needs.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to pegaspargase.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to pegaspargase.
hydrocortisone sodium succinate PF (SOLU-CORTEF) vial 100 mg
100 mg, Intravenous, ONCE, 1 dose Starting when released
Administer prior to pegaspargase. Obtain from Accudose.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
pegaspargase (ONCASPAR) injection 5,227.5 units
5,227.5 units (rounded from 5,225 units = 2,500 Units/m2 × 2.09 m2 Treatment plan actual BSA),
Intramuscular, ONCE, 1 dose Starting when released
Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after drug administration. See
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 36 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

vital signs and emergency medications. Patient to remain in clinic for 1 hour of observation and vital signs post injection.
Patient should have Epipen and oral diphenhydramine (Benadryl) available for home use.
Take Home Medications
epINEPHrine (EPIPEN) 0.3 MG/0.3ML soln auto-injector
Give 0.3 mg intramuscularly as needed. Remind patient to bring to clinic., 0.3 mg, Disp-1 each, R-1, PRN
starting S
diphenhydramine (BENADRYL) 12.5 MG/5ML elixir
Take 20 mL by mouth as needed. Take at first sign of allergic reaction. Available over the counter., 50
mg, PRN starting S
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 4 – Planned for 5/12/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
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+8 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+8 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+8 Approximate, Expires-S+365, Routine
BUN
Expected-S+8 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+8 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+8 Approximate, Expires-S+365, Routine
AST/SGOT
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 37 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Expected-S+8 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+8 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+8 Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S+8 Approximate, Expires-S+365, Routine
PTT
Expected-S+8 Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S+8 Approximate, Expires-S+365, Routine
AMMONIA
Expected-S+8 Approximate, Expires-S+397, Routine
LIPASE
Expected-S+8, Expires-S+365, Routine
AMYLASE
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.
Lab Only - Day 22, Cycle 4 – Planned for 5/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: T-cell Lymphoma, Natural Killer (NK) Cell Leukemia; THERAPY: methotrexate 2000 mg/m2 IV
Day 1, leucovorin 200 mg/m2 IV 24 hours after completion of methotrexate infusion, then leucovorin 15 mg/m2 by mouth
beginning 6 hours after first leucovorin dose, dexamethasone 40 mg IV Days 2, 3 and 4, mesna 300 mg/m2 IV
immediately before ifosfamide, then 4 and 8 hours after each dose of ifosfamide Day 2, 3 and 4, ifosfamide 1500 mg/m2
IV Days 2, 3, and 4, etoposide 100 mg/m2 IV Day 2, 3, and 4, pegaspargase 2500 units/m2 IM Day 7; CYCLE LENGTH:
28 days; COURSE: maximum of 4 cycles.
Note to All Staff (1)
Monitor coagulation parameters (Fibrinogen, PT/INR, PTT) closely until normalized following
pegaspargase. Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen greater than 100 mg/dL
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+15 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+15 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 38 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

GLUCOSE
Expected-S+15 Approximate, Expires-S+365, Routine
BUN
Expected-S+15 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+15 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+15 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+15 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+15 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+15 Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S+15 Approximate, Expires-S+365, Routine
PTT
Expected-S+15 Approximate, Expires-S+365, Routine
PROTHROMBIN TIME/INR
Expected-S+15 Approximate, Expires-S+365, Routine
AMMONIA
Expected-S+15 Approximate, Expires-S+397, Routine
LIPASE
Expected-S+15 Approximate, Expires-S+365, Routine
AMYLASE
Expected-S+15 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,PedsBeiber [2668824]
2/4/2016 12:04:07 PM Page 39 of 39
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org