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

/clinical/cckm-tools/content/beacon-protocols/hem---leukemia/name-96835-en.cckm

201605136

page

100

UWHC,UWMF,

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

CSC Hem Inpt/Outpt BFM Phase 1 (Induction) Ver 11-23-15 (HL 5900)

CSC Hem Inpt/Outpt BFM Phase 1 (Induction) Ver 11-23-15 (HL 5900) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM INPT/OUTPT BFM PHASE 1 (INDUCTION) VER: 11-23-15 – Properties
Cycle 1 – 12/2/2015 through 12/29/2015 (28 days), Planned
Days 1 through 4 (Inpatient) , Cycle 1 – Planned for 12/2/2015 through 12/5/2015
Treatment Plan Information
Reference Information (1)
LEUKEMIA: Gaynon P, et al. J Clin Oncol 1993;11(11): 2234-42.
Reference Information (2)
LEUKEMIA: Nachman J, et al. J Clin Oncol 1997;15(6): 2222-30.
Reference Information (3)
LEUKEMIA: Douer D, et al. Blood 2007;109:2744-50.
Reference Information (4)
LEUKEMIA; Wetzler M, et al. Blood 2007;109:4164-67.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; INDUCTION: THERAPY: cytarabine 70 mg IT Day 1 (or when
no peripheral blasts are present), DAUNOrubicin 25 mg/m2 IV Day 1, 8, 15 and 22, vinCRIStine 1.5 mg/m2 (maximum
dose = 2 mg) IV Day 1, 8, 15 and 22, predniSONE 20 mg/m2 by mouth three times daily Days 1 through 28 then taper,
pegaspargase 2500 units/m2 IM Day 3, methotrexate 12 mg IT Day 15, hydrocortisone 30 mg IT may be given with IT
chemotherapy; CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient will receive weekly or twice weekly IT chemotherapy until CSF is
negative for two consecutive lumbar punctures then per protocol.
Note to All Staff (2)
Monitor coagulation parameters (fibrinogen, PT, PTT) closely until normalized following pegasparagase.
Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen > 100 mg/dL
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
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Zztestonc,PedsBeiber [2668824]
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ONCE Starting when released
PROTHROMBIN TIME/INR
EVERY 24 HOURS Starting when released for 4 days
Draw daily until normalization and then twice weekly thereafter.
PTT
EVERY 24 HOURS Starting when released for 4 days
Draw daily until normalization and then twice weekly thereafter.
FIBRINOGEN
EVERY 24 HOURS Starting when released for 4 days
Draw daily until normalization and then twice weekly thereafter.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than or equal to 1.2 mg/dL or
AST or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Day 3: Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after
drug administration. See vital signs and emergency medications. There is a 1 hour observation and vital signs period
post injection.
Vital Signs
SEE COMMENTS Starting S+2 at 0000 Until Specified
Check blood pressure, heart rate, and respiratory rate every 15 minutes before pegaspargase administration and for 1
hour post-administration.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, nausea/vomiting, if unable to
tolerate PO
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Give 30 minutes prior to chemotherapy.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting S+2 at 0000
Day 3: Administer prior to pegaspargase.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting S+2 at 0000
Day 3: Administer prior to pegaspargase.
hydrocortisone sodium succinate 10 MG/ML in sodium chloride 0.9% injection 100 mg
100 mg, Intravenous, ONCE, 1 dose Starting S+2 at 0000
Day 3: Administer prior to pegaspargase.
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
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
cytarabine PF (CYTOSAR) 70 mg in sodium chloride 0.9 % 1.4 mL intraTHECAL injection
70 mg, Intrathecal, ONCE, 1 dose Starting when released
Day 1 (or when no peripheral blasts are present): Dose to be given by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Treatment Medications
prednisone (DELTASONE) tab 42 mg
42 mg (rounded from 41.8 mg = 20 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, 3 X DAILY (AT
MEALTIME), 84 doses Starting when released
Days 1 through 28: Begin predniSONE taper on Day 29. See take home medications section.
DAUNOrubicin (CERUBIDINE) injection 52 mg
52 mg (rounded from 52.25 mg = 25 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous, ONCE,
1 dose Starting when released
Day 1: **vesicant** Give over 5-10 minutes into running IV line
vinCRIStine (ONCOVIN) 3.1 mg in sodium chloride 0.9 % 25 mL bag
3.1 mg (rounded from 3.135 mg = 1.5 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
Day 1: MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
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Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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 S+2 at 0000
Day 3: Hypersensitivity to pegaspargase can occur and may be immediate or not appear for hours after drug
administration. See vital signs and emergency medications. There is a 1 hour observation and vital signs period post
injection.
Supportive Care Medications (delete all that do not apply)
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, 1 X DAILY, 10 doses Starting when released
Days 1 through 10
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
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY SAT, SUN Starting when released
senna-docusate (SENOKOT S) 8.6-50 MG per tab 2 tab
2 tab, Oral, 1 X DAILY (HS) Starting when released
Skip dose(s) if having loose stools.
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.
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
prednisone (DELTASONE) 10 MG tab
Take 6 tabs orally once x3 days then 4 tabs once x3days, 2 tabs once x2 days , 1 tab once x2 days,
Disp-36 tab, R-0, starting S
Begin predniSONE taper on Day 29.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF, BUN, Creatinine, Total Bilirubin, AST, ALT, Lipase, Amylase, Triglycerides,
PT/INR, PTT, Fibrinogen; CHEMOTHERAPY ROOM APPOINTMENT: DAUNOrubicin and vinCRIStine for 60 minutes.
DAY 10 FOLLOW-UP
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LABS: PT/INR, PTT, Fibrinogen.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, BUN, Creatinine, Total Bilirubin, AST, ALT, Lipase, Amylase, Triglycerides,
PT/INR, PTT, Fibrinogen; CHEMOTHERAPY ROOM APPOINTMENT: DAUNOrubicin, vinCRIStine, intrathecal
methotrexate, and intrathecal hydrocortisone for 120 Minutes.
DAY 18 FOLLOW-UP
LABS: PT/INR, PTT, Fibrinogen.
DAY 22 FOLLOW-UP
LABS: CBC with DIFF, BUN, Creatinine, Total Bilirubin, AST, ALT, Lipase, Amylase, Triglycerides;
CHEMOTHERAPY ROOM APPOINTMENT: DAUNOrubicin and vinCRIStine for 60 minutes.
DAY 29 FOLLOW-UP
Per treating physician.
Day 8, Cycle 1 – Planned for 12/9/2015
Treatment Plan Information
Reference Information (1)
LEUKEMIA: Gaynon P, et al. J Clin Oncol 1993;11(11): 2234-42.
Reference Information (2)
LEUKEMIA: Nachman J, et al. J Clin Oncol 1997;15(6): 2222-30.
Reference Information (3)
LEUKEMIA: Douer D, et al. Blood 2007;109:2744-50.
Reference Information (4)
LEUKEMIA; Wetzler M, et al. Blood 2007;109:4164-67.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; INDUCTION: THERAPY: cytarabine 70 mg IT Day 1 (or when
no peripheral blasts are present), DAUNOrubicin 25 mg/m2 IV Day 1, 8, 15 and 22, vinCRIStine 1.5 mg/m2 (maximum
dose = 2 mg) IV Day 1, 8, 15 and 22, predniSONE 20 mg/m2 by mouth three times daily Days 1 through 28 then taper,
pegaspargase 2500 units/m2 IM Day 3, methotrexate 12 mg IT Day 15, hydrocortisone 30 mg IT may be given with IT
chemotherapy; CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient will receive weekly or twice weekly IT chemotherapy until CSF is
negative for two consecutive lumbar punctures then per protocol.
Note to All Staff (2)
Monitor coagulation parameters (fibrinogen, PT, PTT) closely until normalized following pegasparagase.
Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen > 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
BUN
Expected-S Approximate, Expires-S+365, Routine
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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

 

CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, 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
PROTHROMBIN TIME/INR
Expected-S Approximate, Expires-S+365, Routine
PTT
Expected-S Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than or equal to 1.2 mg/dL or
AST or ALT greater than or equal to 2.5 X ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken prednisone and document in a progress note. Notify authorizing prescriber if
patient has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:59:35 AM Page 6 of 14
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

To establish line and for flushing
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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
prednisone (DELTASONE) tab 42 mg
42 mg (rounded from 41.8 mg = 20 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, ONCE, 1 dose
Starting when released
Omit dose if patient took predniSONE at home.
DAUNOrubicin (CERUBIDINE) injection 52 mg
52 mg (rounded from 52.25 mg = 25 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous, ONCE,
1 dose Starting when released
**vesicant** Give over 5-10 minutes into running IV line.
vinCRIStine (ONCOVIN) 3.1 mg in sodium chloride 0.9 % 25 mL bag
3.1 mg (rounded from 3.135 mg = 1.5 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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 12/11/2015
Treatment Plan Information
Reference Information (1)
LEUKEMIA: Gaynon P, et al. J Clin Oncol 1993;11(11): 2234-42.
Reference Information (2)
LEUKEMIA: Nachman J, et al. J Clin Oncol 1997;15(6): 2222-30.
Reference Information (3)
LEUKEMIA: Douer D, et al. Blood 2007;109:2744-50.
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Zztestonc,PedsBeiber [2668824]
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Reference Information (4)
LEUKEMIA; Wetzler M, et al. Blood 2007;109:4164-67.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; INDUCTION: THERAPY: cytarabine 70 mg IT Day 1 (or when
no peripheral blasts are present), DAUNOrubicin 25 mg/m2 IV Day 1, 8, 15 and 22, vinCRIStine 1.5 mg/m2 (maximum
dose = 2 mg) IV Day 1, 8, 15 and 22, predniSONE 20 mg/m2 by mouth three times daily Days 1 through 28 then taper,
pegaspargase 2500 units/m2 IM Day 3, methotrexate 12 mg IT Day 15, hydrocortisone 30 mg IT may be given with IT
chemotherapy; CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient will receive weekly or twice weekly IT chemotherapy until CSF is
negative for two consecutive lumbar punctures then per protocol.
Note to All Staff (2)
Monitor coagulation parameters (fibrinogen, PT, PTT) closely until normalized following pegasparagase.
Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen > 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
PROTHROMBIN TIME/INR
Expected-S+2 Approximate, Expires-S+365, Routine
PTT
Expected-S+2 Approximate, Expires-S+365, Routine
FIBRINOGEN
Expected-S+2 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 – Planned for 12/16/2015
Treatment Plan Information
Reference Information (1)
LEUKEMIA: Gaynon P, et al. J Clin Oncol 1993;11(11): 2234-42.
Reference Information (2)
LEUKEMIA: Nachman J, et al. J Clin Oncol 1997;15(6): 2222-30.
Reference Information (3)
LEUKEMIA: Douer D, et al. Blood 2007;109:2744-50.
Reference Information (4)
LEUKEMIA; Wetzler M, et al. Blood 2007;109:4164-67.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; INDUCTION: THERAPY: cytarabine 70 mg IT Day 1 (or when
no peripheral blasts are present), DAUNOrubicin 25 mg/m2 IV Day 1, 8, 15 and 22, vinCRIStine 1.5 mg/m2 (maximum
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:59:35 AM Page 8 of 14
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

dose = 2 mg) IV Day 1, 8, 15 and 22, predniSONE 20 mg/m2 by mouth three times daily Days 1 through 28 then taper,
pegaspargase 2500 units/m2 IM Day 3, methotrexate 12 mg IT Day 15, hydrocortisone 30 mg IT may be given with IT
chemotherapy; CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient will receive weekly or twice weekly IT chemotherapy until CSF is
negative for two consecutive lumbar punctures then per protocol.
Note to All Staff (2)
Monitor coagulation parameters (fibrinogen, PT, PTT) closely until normalized following pegasparagase.
Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen > 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+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+7, Expires-S+365, Routine
AMYLASE
Expected-S+7 Approximate, Expires-S+365, Routine
TRIGLYCERIDE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than or equal to 1.2 mg/dL or
AST or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
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
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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 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
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
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be administered by provider.
Treatment Medications
prednisone (DELTASONE) tab 42 mg
42 mg (rounded from 41.8 mg = 20 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, ONCE, 1 dose
Starting when released
Omit dose if patient took predniSONE at home.
DAUNOrubicin (CERUBIDINE) injection 52 mg
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:59:35 AM Page 10 of 14
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

52 mg (rounded from 52.25 mg = 25 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose Starting
when released
**vesicant** Give over 5-10 minutes into running IV line.
vinCRIStine (ONCOVIN) 3.1 mg in sodium chloride 0.9 % 25 mL bag
3.1 mg (rounded from 3.135 mg = 1.5 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 18, Cycle 1 – Planned for 12/19/2015
Treatment Plan Information
Reference Information (1)
LEUKEMIA: Gaynon P, et al. J Clin Oncol 1993;11(11): 2234-42.
Reference Information (2)
LEUKEMIA: Nachman J, et al. J Clin Oncol 1997;15(6): 2222-30.
Reference Information (3)
LEUKEMIA: Douer D, et al. Blood 2007;109:2744-50.
Reference Information (4)
LEUKEMIA; Wetzler M, et al. Blood 2007;109:4164-67.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; INDUCTION: THERAPY: cytarabine 70 mg IT Day 1 (or when
no peripheral blasts are present), DAUNOrubicin 25 mg/m2 IV Day 1, 8, 15 and 22, vinCRIStine 1.5 mg/m2 (maximum
dose = 2 mg) IV Day 1, 8, 15 and 22, predniSONE 20 mg/m2 by mouth three times daily Days 1 through 28 then taper,
pegaspargase 2500 units/m2 IM Day 3, methotrexate 12 mg IT Day 15, hydrocortisone 30 mg IT may be given with IT
chemotherapy; CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient will receive weekly or twice weekly IT chemotherapy until CSF is
negative for two consecutive lumbar punctures then per protocol.
Note to All Staff (2)
Monitor coagulation parameters (fibrinogen, PT, PTT) closely until normalized following pegasparagase.
Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen > 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
PROTHROMBIN TIME/INR
Expected-S+3 Approximate, Expires-S+365, Routine
PTT
Expected-S+3 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:59:35 AM Page 11 of 14
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

FIBRINOGEN
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.
Day 22, Cycle 1 – Planned for 12/23/2015
Treatment Plan Information
Reference Information (1)
LEUKEMIA: Gaynon P, et al. J Clin Oncol 1993;11(11): 2234-42.
Reference Information (2)
LEUKEMIA: Nachman J, et al. J Clin Oncol 1997;15(6): 2222-30.
Reference Information (3)
LEUKEMIA: Douer D, et al. Blood 2007;109:2744-50.
Reference Information (4)
LEUKEMIA; Wetzler M, et al. Blood 2007;109:4164-67.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; INDUCTION: THERAPY: cytarabine 70 mg IT Day 1 (or when
no peripheral blasts are present), DAUNOrubicin 25 mg/m2 IV Day 1, 8, 15 and 22, vinCRIStine 1.5 mg/m2 (maximum
dose = 2 mg) IV Day 1, 8, 15 and 22, predniSONE 20 mg/m2 by mouth three times daily Days 1 through 28 then taper,
pegaspargase 2500 units/m2 IM Day 3, methotrexate 12 mg IT Day 15, hydrocortisone 30 mg IT may be given with IT
chemotherapy; CYCLE LENGTH: 28 days; COURSE: 1 cycle
Note to All Staff
If CSF is positive for leukemia, patient will receive weekly or twice weekly IT chemotherapy until CSF is
negative for two consecutive lumbar punctures then per protocol.
Note to All Staff (2)
Monitor coagulation parameters (fibrinogen, PT, PTT) closely until normalized following pegasparagase.
Consider transfusing cryoprecipitate or fresh frozen plasma to keep fibrinogen > 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+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:59:35 AM Page 12 of 14
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
LIPASE
Expected-S+7, Expires-S+365, Routine
AMYLASE
Expected-S+7 Approximate, Expires-S+365, Routine
TRIGLYCERIDE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than or equal to 1.2 mg/dL or
AST or ALT greater than or equal to 2.5 X ULN.
Nursing Procedure, Assessment and Monitoring
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 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
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
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Zztestonc,PedsBeiber [2668824]
12/2/2015 10:59:35 AM Page 13 of 14
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
prednisone (DELTASONE) tab 42 mg
42 mg (rounded from 41.8 mg = 20 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, ONCE, 1 dose
Starting when released
Omit dose if patient took predniSONE at home.
DAUNOrubicin (CERUBIDINE) injection 52 mg
52 mg (rounded from 52.25 mg = 25 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous, ONCE,
1 dose Starting when released
**vesicant** Give over 5-10 minutes into running IV line.
vinCRIStine (ONCOVIN) 3.1 mg in sodium chloride 0.9 % 25 mL bag
3.1 mg (rounded from 3.135 mg = 1.5 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Ordered dose of 1.5 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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]
12/2/2015 10:59:35 AM Page 14 of 14
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison