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CSC HEM Cytarabine(28D:1,3,5) Inpatient Continuous Stay VER 11-23-15 (HL 2007)

CSC HEM Cytarabine(28D:1,3,5) Inpatient Continuous Stay VER 11-23-15 (HL 2007) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM CYTARABINE(28D:1,3,5) INPATIENT CONTINUOUS STAY VER: 11-23-15 – Properties
Cycle 1 – 11/21/2016 through 12/18/2016 (28 days), Planned
Days 1 through 5, Cycle 1 – Planned for 11/21/2016 through 11/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia; THERAPY: cytarabine 3000 mg/m2 IV every 12 hours Day 1, 3 and 5 (Total of 6
doses/cycle); CYCLE LENGTH: 28 to 42 days; COURSE: up to 4 cycles
Note to All Staff
Consider dose reduction to 1500 mg/m2 for patients who have 2 of the following 3 criteria: Age greater than 40 years old; Creatinine
greater than or equal to 1.2 mg/dL; and/or 3 fold increase Alkaline Phosphatase. Dose reduction to 1000 mg/m2 or 1500 mg/m2 for
all patients greater than 60 years old.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
CREATININE
ONCE Starting when released, Routine
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC with DIFF, Creatinine, Alkaline Phosphatase.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor for cerebellar toxicity (incoordination, slurred speech) with neurology checks prior to each dose of cytarabine and as
needed. For any symptoms or concerns of toxicity, hold cytarabine and contact Hematology Fellow or Staff on call.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 48 HOURS, 3 doses Starting when released
Days 1, 3 and 5: Administer prior to first dose of cytarabine. May give IV if PO not tolerated.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
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ZZtestonc,Andrew [2428787]
11/21/2016 2:05:14 PM Page 1 of 3
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

16 mg, Intravenous, EVERY 48 HOURS PRN, For 6 days Starting when released until S+6, nausea/vomiting
Days 1, 3 and 5: Administer prior to first dose of cytarabine. Give IV when PO not tolerated.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 48 HOURS, 3 doses Starting when released
Days 1, 3 and 5: Administer prior to first dose of cytarabine. May give IV if PO not tolereated.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 48 HOURS PRN, For 6 days Starting when released until S+6, nausea/vomiting
Days 1, 3 and 5: Administer prior to first dose of cytarabine. Give IV when PO not tolerated.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 12 HOURS, 2 doses Starting S+1 at 0000
Day 2: May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 8 mg in sodium chloride 0.9 % 50 mL bag
8 mg, Intravenous, EVERY 12 HOURS PRN, For 48 hours Starting S+1 at 0000, nausea/vomiting
Day 2: May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 12 HOURS, 2 doses Starting S+3 at 0000
Day 4: May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 8 mg in sodium chloride 0.9 % 50 mL bag
8 mg, Intravenous, EVERY 12 HOURS PRN, For 48 hours Starting S+3 at 0000, nausea/vomiting
Day 4: May give IV if unable to tolerate PO.
pyridoxine (VITAMIN B-6) tab 100 mg
100 mg, Oral, EVERY 12 HOURS, 2 doses Starting when released
DAY 1: Administer prior to each dose of cytarabine.
pyridoxine (VITAMIN B-6) tab 100 mg
100 mg, Oral, EVERY 12 HOURS, 2 doses Starting S+2 at 0000
DAY 3: Administer prior to each dose of cytarabine.
pyridoxine (VITAMIN B-6) tab 100 mg
100 mg, Oral, EVERY 12 HOURS, 2 doses Starting S+4 at 0000
DAY 5: Administer prior to each dose of cytarabine.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY (BEFORE MEALS AND HS), For 5 days Starting S As Scheduled
Day 1-5: Instill one drop into each eye 4 times a day. First dose prior to chemotherapy on Day 1.
Treatment Medications
cytarabine PF (CYTOSAR) 5,370 mg in sodium chloride 0.9 % 250 mL bag
5,370 mg (3,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 12 HOURS, 2 doses Starting
when released
Day 1: Neurology checks prior to each cytarabine dose. Consider dose reduction to 1500 mg/m2 for patients who have 2 of the
following 3 criteria: Age greater than 40 years old, serum creatinine greater than or equal to 1.2 mg/dL, and/or 3 fold increase
alkaline phosphatase. Dose reduction 1000 mg/m2 or 1500 mg/m2 for all patients greater than 60 years old.
cytarabine PF (CYTOSAR) 5,370 mg in sodium chloride 0.9 % 250 mL bag
5,370 mg (3,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 12 HOURS, 2 doses Starting
S+2 at 0000
Day 3: Neurology checks prior to each cytarabine dose.Consider dose reduction to 1500 mg/m2 for patients who have 2 of the
following 3 criteria: Age greater than 40 years old, serum creatinine greater than or equal to 1.2 mg/dL, and/or 3 fold increase
alkaline phosphatase. Dose reduction 1000 mg/m2 or 1500 mg/m2 for all patients greater than 60 years old.
cytarabine PF (CYTOSAR) 5,370 mg in sodium chloride 0.9 % 250 mL bag
5,370 mg (3,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 12 HOURS, 2 doses Starting
S+4 at 0000
Day 5: Neurology checks prior to each cytarabine dose. Consider dose reduction to 1500 mg/m2 for patients who have 2 of the
following 3 criteria: Age greater than 40 years old, serum creatinine greater than or equal to 1.2 mg/dL, and/or 3 fold increase
alkaline phosphatase. Dose reduction 1000 mg/m2 or 1500 mg/m2 for all patients greater than 60 years old.
Treatment Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
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ZZtestonc,Andrew [2428787]
11/21/2016 2:05:14 PM Page 2 of 3
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
Conditional Orders
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.
Take Home Medications
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tablet by mouth twice daily on Days 6 and 7 and then every 8 hours as needed., Disp-30 tab, R-0, starting S, Local Printer
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ZZtestonc,Andrew [2428787]
11/21/2016 2:05:14 PM Page 3 of 3
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org