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201611326

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100

UWHC,UWMF,

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

CSC HEM Cytarabine(28-42D:1,3,5) Outpatient 3 Short Stays VER 11-23-15 (HL 2002)

CSC HEM Cytarabine(28-42D:1,3,5) Outpatient 3 Short Stays VER 11-23-15 (HL 2002) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM CYTARABINE(28-42D:1,3,5) OUTPATIENT 3 SHORT STAYS VER: 11-23-15 – Properties
Cycle 1 – 11/21/2016 through 12/18/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/21/2016
Treatment Plan Information
Reference Information (1)
ACUTE MYELOGENOUS LEUKEMIA: Mayer R, et al. New Eng J Med 1994;331(14):896-903.
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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:02:23 PM Page 1 of 5
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
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, EVERY 24 HOURS PRN, For 48 hours Starting when released, nausea/vomiting
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
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, ONCE PRN Starting when released Until Discontinued, nausea/vomiting
Administer prior to first dose of cytarabine. Give IV when PO not tolerated.
pyridoxine (VITAMIN B-6) tab 100 mg
100 mg, Oral, EVERY 12 HOURS, 2 doses Starting when released
Administer prior to each dose of cytarabine.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), EVERY 6 HOURS, 16 doses Starting when released
Day 1: Instill one drop into each eye 4 times a day. First dose prior to chemotherapy.
Patient to continue to use this bottle for remainder of therapy and RN to verify patient administration.
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
Neurology checks prior to each cytarabine dose. Consider dose reduction to 1.5 gm/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 reductuion to 1 gm/m2 or 1.5 gm/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
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
ondansetron (ZOFRAN) 8 MG tab
Take 1 tablet by mouth twice daily on Days 2, 4, 6, and 7 then every 8 hours as needed., Disp-30 tab, R-5, starting S
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
Follow-Up
DAY 3 FOLLOW-UP
Admit to B6/6 (short stay observation)
DAY 5 FOLLOW-UP
Admit to B6/6 (short stay observation)
DAY 29 FOLLOW-UP
(Day 1 of next cycle): Admit to B6/6 (short stay observation)
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ZZtestonc,Andrew [2428787]
11/21/2016 2:02:23 PM Page 2 of 5
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 3, Cycle 1 – Planned for 11/23/2016
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.
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, ONCE, 1 dose Starting when released
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, EVERY 24 HOURS PRN, For 48 hours Starting when released, nausea/vomiting
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
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, ONCE PRN Starting when released Until Discontinued, nausea/vomiting
Administer prior to first dose of cytarabine. Give IV when PO not tolerated.
pyridoxine (VITAMIN B-6) tab 100 mg
100 mg, Oral, EVERY 12 HOURS, 2 doses Starting when released
Administer prior to each dose of cytarabine.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), EVERY 6 HOURS, 16 doses Starting when released
Day 3 and 5: Instill one drop into each eye 4 times a day. First dose prior to chemotherapy. Use patient's own supply.
Patient to continue to use this bottle for remainder of therapy and RN to verify patient administration.
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
Neurology checks prior to each cytarabine dose. Consider dose reduction to 1.5 gm/m2 for patients who have 2 of the following 3
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ZZtestonc,Andrew [2428787]
11/21/2016 2:02:23 PM Page 3 of 5
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 reductuion to 1 gm/m2 or 1.5 gm/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
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.
Follow-Up
VERIFY APPOINTMENTS
Verify Day 5 appointment(s) have been scheduled: Admit to B6/6 (short stay observation)
Day 5, Cycle 1 – Planned for 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.
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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:02:23 PM Page 4 of 5
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

16 mg, Oral, ONCE, 1 dose Starting when released
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, EVERY 24 HOURS PRN, For 48 hours Starting when released, nausea/vomiting
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
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, ONCE PRN Starting when released Until Discontinued, nausea/vomiting
Administer prior to first dose of cytarabine. Give IV when PO not tolerated.
pyridoxine (VITAMIN B-6) tab 100 mg
100 mg, Oral, EVERY 12 HOURS, 2 doses Starting when released
Administer prior to each dose of cytarabine.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), EVERY 6 HOURS, 16 doses Starting when released
Day 3 and 5: Instill one drop into each eye 4 times a day. First dose prior to chemotherapy. Use patient's own supply.
Patient to continue to use this bottle for remainder of therapy and RN to verify patient administration.
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
Neurology checks prior to each cytarabine dose. Consider dose reduction to 1.5 gm/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 reductuion to 1 gm/m2 or 1.5 gm/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
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.
Follow-Up
VERIFY APPOINTMENTS
Verify Day 29 (Day 1 of next cycle) appointment(s) have been scheduled: Admit to B6/6 (short stay observation).
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ZZtestonc,Andrew [2428787]
11/21/2016 2:02:23 PM Page 5 of 5
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org