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

CSC Hem Mitoxantrone/Etoposide/Cytarabine(28-42D1-5) Inpatient Ver 11-23-15 (HL 1774)

CSC Hem Mitoxantrone/Etoposide/Cytarabine(28-42D1-5) Inpatient Ver 11-23-15 (HL 1774) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM MITOXANTRONE/ETOPOSIDE/CYTARABINE(28-42D:1-5) INPATIENT VER: 11-23-15 – Properties
Cycle 1 – 12/1/2015 through 12/28/2015 (28 days), Planned
Day 1-5, Cycle 1 – Planned for 12/1/2015
Treatment Plan Information
Reference Information (1)
ACUTE MYELOGENOUS LEUKEMIA/MYELODYSPLASTIC SYNDROME: Greenberg PL, et al. J Clin
Oncol 2004;22:1078-86.
Reference Information (2)
ACUTE MYELOGENOUS LEUKEMIA/MYELODYSPLASTIC SYNDROME: Kohrt HE, et al. Am J
Hematol 2010;85(11):877-81.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia (Relapsed or Refractory)/Myelodysplastic Syndrome (High
Risk); THERAPY: mitoxantrone 8 mg/m2/day IV Day 1 through 5, etoposide 100 mg/m2/day IV Day 1 through 5,
cytarabine 1000 mg/m2/day IV Day 1 through 5; CYCLE LENGTH: 28 to 42 days; COURSE: Maximum 2 cycles.
Note to End-User
Protocol built as one cycle. If subsequent cycles are needed, copy cycle 1 (or last cycle) and paste it into
the treatment plan as the next cycle with the desired start date.
Consent
Verify Consent
Verify informed consent has been obtained.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets and Hemoglobin.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Assess patient for signs of cerebellar toxicity (incoordination, slurred speech) with neurochecks prior to
each dose of cytarabine. Hold and notify MD for any concerns of toxicity.
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 0.9 % infusion
at 100 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Pre-Medications
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ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 5 doses Starting when released
Days 1 through 5: Administer prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting
Days 1 through 5: Administer IV if unable to tolerate PO. Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 5 doses Starting when released
Days 1 through 5: Administer prior to chemotherapy. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, 5 doses Starting when released, nausea/vomiting
Days 1 through 5: Administer IV if unable to tolerate PO. Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, 2 doses Starting S+5 at 0000
Days 6 and 7: May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+5 at 0000, nausea/vomiting
Days 6 and 7: Administer IV if unable to tolerate PO.
Treatment Medications
mitoxantrone (NOVANTRONE) 16.7 mg in sodium chloride 0.9 % injection 25 mL
16.7 mg (rounded from 16.72 mg = 8 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
EVERY 24 HOURS, 5 doses Starting when released
Day 1-5: Administer over at least 3 minutes in a freely running IV infusion
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, EVERY 24 HOURS, 5 doses
Starting when released
Administer daily on Day 1 through 5. Administer with non-PVC tubing.
cytarabine PF (CYTOSAR) 2,090 mg in sodium chloride 0.9 % 500 mL bag
2,090 mg (1,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous, EVERY 24 HOURS, 5
doses Starting when released
Day 1-5: Assess patient for signs of cerebellar toxicity (incoordination, slurred speech) with neurochecks prior to each
dose of cytarabine. Hold and notify MD for any concerns of toxicity.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, 20 doses Starting S As Scheduled
Day 1-5: Administer 1 drop in each eye 4 times daily.
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, EVERY 24 HOURS, 7 doses Starting when released
Day 1-7.
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 1 X DAILY (HS), 5 doses Starting when released
Treatment Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
posaconazole DELAYED RELEASE (NOXAFIL EC) EC tab 300 mg
300 mg, Oral, 1 X DAILY Starting when released
Take with food. Swallow whole. Do not crush, chew, or divide tablet.
Conditional Orders
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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 S+5 at 0000 Until Discontinued, nausea/vomiting
Start Day 6. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting S+5 at 0000 Until Discontinued, nausea/vomiting, for
3 Minutes
Start Day 6. Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
Take Home Medications (delete all that do not apply)
allopurinol (ZYLOPRIM) 300 MG tab
Take 1 tab by mouth one time daily. Take for 7 days., R-0, 1 X DAILY starting S
prednisolone (PRED FORTE) 1 % ophthalmic susp
1 drop in each eye 4 times daily. Use on Day 1 through 5., Disp-1 Bottle, R-0, 4 X DAILY starting S
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., Disp-60 tab, R-5, 2 X DAILY starting S
fluconazole (DIFLUCAN) 200 MG tab
Take 2 tabs by mouth one time daily., Disp-60 tab, R-5, 1 X DAILY starting S
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF
DAY 11 FOLLOW-UP
LABS: CBC with DIFF
DAY 15 FOLLOW-UP
LABS: CBC with DIFF
DAY 18 FOLLOW-UP
LABS: CBC with DIFF
DAY 22 FOLLOW-UP
LABS: CBC with DIFF
DAY 25 FOLLOW-UP
LABS: CBC with DIFF
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF; NOTE:
Admit to B6/6 through clinic for next Cycle.
Lab Only - Day 8, Cycle 1 – Planned for 12/8/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia (Relapsed or Refractory)/Myelodysplastic Syndrome (High
Risk); THERAPY: mitoxantrone 8 mg/m2/day IV Day 1 through 5, etoposide 100 mg/m2/day IV Day 1 through 5,
cytarabine 1000 mg/m2/day IV Day 1 through 5; CYCLE LENGTH: 28 to 42 days; COURSE: Maximum 2 cycles.
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Note to End-User
Protocol built as one cycle. If subsequent cycles are needed, copy cycle 1 (or last cycle) and paste it into
the treatment plan as the next cycle with the desired start date.
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
Follow-Up
VERIFY APPOINTMENTS
Verify Day 11 appointment(s) have been scheduled: LABS: CBC, DIFF
Lab Only - Day 11, Cycle 1 – Planned for 12/11/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia (Relapsed or Refractory)/Myelodysplastic Syndrome (High
Risk); THERAPY: mitoxantrone 8 mg/m2/day IV Day 1 through 5, etoposide 100 mg/m2/day IV Day 1 through 5,
cytarabine 1000 mg/m2/day IV Day 1 through 5; CYCLE LENGTH: 28 to 42 days; COURSE: Maximum 2 cycles.
Note to End-User
Protocol built as one cycle. If subsequent cycles are needed, copy cycle 1 (or last cycle) and paste it into
the treatment plan as the next cycle with the desired start date.
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
Follow-Up
VERIFY APPOINTMENTS
Verify Day 15 appointment(s) have been scheduled: LABS: CBC, DIFF
Lab Only - Day 15, Cycle 1 – Planned for 12/15/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia (Relapsed or Refractory)/Myelodysplastic Syndrome (High
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Risk); THERAPY: mitoxantrone 8 mg/m2/day IV Day 1 through 5, etoposide 100 mg/m2/day IV Day 1 through 5,
cytarabine 1000 mg/m2/day IV Day 1 through 5; CYCLE LENGTH: 28 to 42 days; COURSE: Maximum 2 cycles.
Note to End-User
Protocol built as one cycle. If subsequent cycles are needed, copy cycle 1 (or last cycle) and paste it into
the treatment plan as the next cycle with the desired start date.
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
Follow-Up
VERIFY APPOINTMENTS
Verify Day 18 appointment(s) have been scheduled: LABS: CBC, DIFF
Lab Only - Day 18, Cycle 1 – Planned for 12/18/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia (Relapsed or Refractory)/Myelodysplastic Syndrome (High
Risk); THERAPY: mitoxantrone 8 mg/m2/day IV Day 1 through 5, etoposide 100 mg/m2/day IV Day 1 through 5,
cytarabine 1000 mg/m2/day IV Day 1 through 5; CYCLE LENGTH: 28 to 42 days; COURSE: Maximum 2 cycles.
Note to End-User
Protocol built as one cycle. If subsequent cycles are needed, copy cycle 1 (or last cycle) and paste it into
the treatment plan as the next cycle with the desired start date.
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
Follow-Up
VERIFY APPOINTMENTS
Verify Day 22 appointment(s) have been scheduled: LABS: CBC, DIFF
Lab Only - Day 22, Cycle 1 – Planned for 12/22/2015
Treatment Plan Information
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Zztestonc,PedsBeiber [2668824]
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Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia (Relapsed or Refractory)/Myelodysplastic Syndrome (High
Risk); THERAPY: mitoxantrone 8 mg/m2/day IV Day 1 through 5, etoposide 100 mg/m2/day IV Day 1 through 5,
cytarabine 1000 mg/m2/day IV Day 1 through 5; CYCLE LENGTH: 28 to 42 days; COURSE: Maximum 2 cycles.
Note to End-User
Protocol built as one cycle. If subsequent cycles are needed, copy cycle 1 (or last cycle) and paste it into
the treatment plan as the next cycle with the desired start date.
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
Follow-Up
VERIFY APPOINTMENTS
Verify Day 25 appointment(s) have been scheduled: LABS: CBC, DIFF
Lab Only - Day 25, Cycle 1 – Planned for 12/25/2015
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia (Relapsed or Refractory)/Myelodysplastic Syndrome (High
Risk); THERAPY: mitoxantrone 8 mg/m2/day IV Day 1 through 5, etoposide 100 mg/m2/day IV Day 1 through 5,
cytarabine 1000 mg/m2/day IV Day 1 through 5; CYCLE LENGTH: 28 to 42 days; COURSE: Maximum 2 cycles.
Note to End-User
Protocol built as one cycle. If subsequent cycles are needed, copy cycle 1 (or last cycle) and paste it into
the treatment plan as the next cycle with the desired start date.
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
Follow-Up
VERIFY APPOINTMENTS
Verify Day 29 (Day 1 of next cycle) appointments have been scheduled: RETURN TO CLINIC for
appointment with provider; LABS: CBC, DIFF; NOTE: Admit to B6/6 through clinic for next Cycle.
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