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

/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/name-96856-en.cckm

201611326

page

100

UWHC,UWMF,

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

CSC HEM Cisplatin(21D:1) Cytarabine(21D:2) Dexamethasone(21D:1-4) Rituximab(21D:1) - R-DHAP VER 10-3-16 (HL 2019)

CSC HEM Cisplatin(21D:1) Cytarabine(21D:2) Dexamethasone(21D:1-4) Rituximab(21D:1) - R-DHAP VER 10-3-16 (HL 2019) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM INPT CISPLATIN(21D:1)/CYTARABINE(21D:2)/DEXAMETHASONE(21D:1-4)/RITUXIMAB(21D:1) - R-DHAP VER: 10-
3-16 – Properties
Cycle 1 – 11/21/2016 through 12/11/2016 (21 days), Planned
Days 1 through 5 (Inpatient) , Cycle 1 – Planned for 11/21/2016 through 11/25/2016
Treatment Plan Information
Reference Information (1)
NON-HODGKIN LYMPHOMA: Velasquez WS, et al. Blood 1988;71(1):117-22.
Reference Information (2)
NON-HODGKIN LYMPHOMA: Gisselbrecht C et al. J Clin Oncol 2010;28(27):4184-90.
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, dexamethasone 40 mg by mouth or IV daily Days 1
through 4, CISplatin 100 mg/m2 IV continuous infusion over 24 hours Day 1, cytarabine 2000 mg/m2 IV every 12 hours for a total of
two doses starting Day 2 after completion of CISplatin, GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 to 28 days;
COURSE: 4 to 6 cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
URIC ACID
ONCE Starting when released
POTASSIUM
ONCE Starting when released, Routine
LD, TOTAL
ONCE Starting when released
HEPATITIS B CORE AB, TOTAL
ONCE Starting when released
HEPATITIS B SURFACE AG
ONCE Starting when released
HEPATITIS B SURFACE AB
ONCE Starting when released
Pre-Labs (delete all that do not apply)
HEPATITIS B DNA, ULTRA QUANT, PCR
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ZZtestonc,Andrew [2428787]
11/21/2016 1:27:26 PM Page 1 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ONCE Starting when released
Draw if Hepatitis B Core AB is positive.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 50K/µL or
Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 2 mg/dL or AST greater than ULN or ALT greater than ULN
or Alkaline Phosphatase greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Monitoring Parameters (2)
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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 200 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Day 1: Start 6 hours prior to cisplatin.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Day 1: Administer prior to chemotherapy. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer first dose prior to start of chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, nausea/vomiting
Day 1: Administer IV if PO not tolerated. Administer first dose prior to start of chemotherapy.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:27:26 PM Page 2 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer first dose prior to start of chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, ONCE PRN Starting S+1 at 0000 Until Discontinued, nausea/vomiting
Day 2: Administer IV if PO not tolerated. Administer first dose prior to start of chemotherapy.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, For 2 days Starting S+1 As Scheduled
Days 2 and 3: Administer first dose prior to start of cytarabine.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 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
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Day 1: Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for
infusion rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact
MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, EVERY 24 HOURS, 4 doses Starting when released
Days 1 through 4: Administer first dose prior to CISplatin . May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 40 mg in dextrose 5 % 50 mL bag
40 mg, Intravenous, 1 X DAILY PRN, For 5 days Starting when released until S+4 at 2359, May give IV if unable to tolerate PO.
Days 1 through 4: Administer first dose prior to CISplatin. Administer over 30 to 60 minutes.
CISplatin (PLATINOL) 179 mg in sodium chloride 0.9 % 1,000 mL bag
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1: Administer as continuous infusion over 24 hours.
cytarabine PF (CYTOSAR) 3,580 mg in sodium chloride 0.9 % 250 mL bag
3,580 mg (2,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 12 HOURS, 2 doses Starting
S+1 at 0000
Day 2: First dose to be given after completion of CISplatin.
Supportive Care Medications (delete all that do not apply)
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, 1 X DAILY, For 10 days Starting S As Scheduled
Days 1 through 10: Administer daily during Cycle 1.
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, 1 X DAILY, For 10 days Starting S As Scheduled
Days 1 through 10: Administer daily during Cycle 1.
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 1 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
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ZZtestonc,Andrew [2428787]
11/21/2016 1:27:26 PM Page 3 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

400 mg, Oral, 1 X DAILY Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY SAT, SUN Include Now
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.,
Administer over 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 (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.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting *** and Creatinine, Potassium, Uric Acid,
and LDH twice weekly for one week starting ***
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin, AST, ALT, Alkaline Phosphatase; NOTE: Admit to B6/6 through clinic.
Cycle 2 – 12/12/2016 through 1/1/2017 (21 days), Planned
Days 1 through 5 (Inpatient) , Cycle 2 – Planned for 12/12/2016 through 12/16/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, dexamethasone 40 mg by mouth or IV daily Days 1
through 4, CISplatin 100 mg/m2 IV continuous infusion over 24 hours Day 1, cytarabine 2000 mg/m2 IV every 12 hours for a total of
two doses starting Day 2 after completion of CISplatin, GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 to 28 days;
COURSE: 4 to 6 cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
CREATININE
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ZZtestonc,Andrew [2428787]
11/21/2016 1:27:26 PM Page 4 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 50K/µL or
Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 2 mg/dL or AST greater than ULN or ALT greater than ULN
or Alkaline Phosphatase greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Monitoring Parameters (2)
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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 200 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Day 1: Start 6 hours prior to cisplatin.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:27:26 PM Page 5 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Day 1: Administer prior to chemotherapy. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer first dose prior to start of chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, nausea/vomiting
Day 1: Administer IV if PO not tolerated. Administer first dose prior to start of chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer first dose prior to start of chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, ONCE PRN Starting S+1 at 0000 Until Discontinued, nausea/vomiting
Day 2: Administer IV if PO not tolerated. Administer first dose prior to start of chemotherapy.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, For 2 days Starting S+1 As Scheduled
Days 2 and 3: Administer first dose prior to start of cytarabine.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 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
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Day 1: Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for
infusion rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact
MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, EVERY 24 HOURS, 4 doses Starting when released
Days 1 through 4: Administer first dose prior to CISplatin . May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 40 mg in dextrose 5 % 50 mL bag
40 mg, Intravenous, 1 X DAILY PRN, For 5 days Starting when released until S+4 at 2359, May give IV if unable to tolerate PO.
Days 1 through 4: Administer first dose prior to CISplatin. Administer over 30 to 60 minutes.
CISplatin (PLATINOL) 179 mg in sodium chloride 0.9 % 1,000 mL bag
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1: Administer as continuous infusion over 24 hours.
cytarabine PF (CYTOSAR) 3,580 mg in sodium chloride 0.9 % 250 mL bag
3,580 mg (2,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 12 HOURS, 2 doses Starting
S+1 at 0000
Day 2: First dose to be given after completion of CISplatin.
Supportive Care Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
ranitidine (ZANTAC) tab 150 mg
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ZZtestonc,Andrew [2428787]
11/21/2016 1:27:26 PM Page 6 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

150 mg, Oral, 1 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY SAT, SUN Include Now
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.,
Administer over 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
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting *** and Creatinine, Potassium, Uric Acid,
and LDH twice weekly for one week starting ***
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin, AST, ALT, Alkaline Phosphatase; NOTE: Admit to B6/6 through clinic.
Cycle 3 – 1/2/2017 through 1/22/2017 (21 days), Planned
Days 1 through 5 (Inpatient) , Cycle 3 – Planned for 1/2/2017 through 1/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, dexamethasone 40 mg by mouth or IV daily Days 1
through 4, CISplatin 100 mg/m2 IV continuous infusion over 24 hours Day 1, cytarabine 2000 mg/m2 IV every 12 hours for a total of
two doses starting Day 2 after completion of CISplatin, GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 to 28 days;
COURSE: 4 to 6 cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
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ZZtestonc,Andrew [2428787]
11/21/2016 1:27:26 PM Page 7 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 50K/µL or
Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 2 mg/dL or AST greater than ULN or ALT greater than ULN
or Alkaline Phosphatase greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Monitoring Parameters (2)
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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 200 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Day 1: Start 6 hours prior to cisplatin.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Day 1: Administer prior to chemotherapy. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer first dose prior to start of chemotherapy. If PO not tolerated may give IV.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:27:26 PM Page 8 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, nausea/vomiting
Day 1: Administer IV if PO not tolerated. Administer first dose prior to start of chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer first dose prior to start of chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, ONCE PRN Starting S+1 at 0000 Until Discontinued, nausea/vomiting
Day 2: Administer IV if PO not tolerated. Administer first dose prior to start of chemotherapy.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, For 2 days Starting S+1 As Scheduled
Days 2 and 3: Administer first dose prior to start of cytarabine.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 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
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Day 1: Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for
infusion rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact
MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, EVERY 24 HOURS, 4 doses Starting when released
Days 1 through 4: Administer first dose prior to CISplatin . May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 40 mg in dextrose 5 % 50 mL bag
40 mg, Intravenous, 1 X DAILY PRN, For 5 days Starting when released until S+4 at 2359, May give IV if unable to tolerate PO.
Days 1 through 4: Administer first dose prior to CISplatin. Administer over 30 to 60 minutes.
CISplatin (PLATINOL) 179 mg in sodium chloride 0.9 % 1,000 mL bag
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1: Administer as continuous infusion over 24 hours.
cytarabine PF (CYTOSAR) 3,580 mg in sodium chloride 0.9 % 250 mL bag
3,580 mg (2,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 12 HOURS, 2 doses Starting
S+1 at 0000
Day 2: First dose to be given after completion of CISplatin.
Supportive Care Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 1 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY SAT, SUN Include Now
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ZZtestonc,Andrew [2428787]
11/21/2016 1:27:26 PM Page 9 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.,
Administer over 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
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting *** and Creatinine, Potassium, Uric Acid,
and LDH twice weekly for one week starting ***
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin, AST, ALT, Alkaline Phosphatase; NOTE: Admit to B6/6 through clinic.
Cycle 4 – 1/23/2017 through 2/12/2017 (21 days), Planned
Days 1 through 5 (Inpatient) , Cycle 4 – Planned for 1/23/2017 through 1/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, dexamethasone 40 mg by mouth or IV daily Days 1
through 4, CISplatin 100 mg/m2 IV continuous infusion over 24 hours Day 1, cytarabine 2000 mg/m2 IV every 12 hours for a total of
two doses starting Day 2 after completion of CISplatin, GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 to 28 days;
COURSE: 4 to 6 cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/21/2016 1:27:26 PM Page 10 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 50K/µL or
Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 2 mg/dL or AST greater than ULN or ALT greater than ULN
or Alkaline Phosphatase greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Monitoring Parameters (2)
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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 200 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Day 1: Start 6 hours prior to cisplatin.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Day 1: Administer prior to chemotherapy. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer first dose prior to start of chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, nausea/vomiting
Day 1: Administer IV if PO not tolerated. Administer first dose prior to start of chemotherapy.
ondansetron (ZOFRAN) tab 16 mg
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ZZtestonc,Andrew [2428787]
11/21/2016 1:27:26 PM Page 11 of 13
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 S+1 at 0000
Day 2: Administer first dose prior to start of chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, ONCE PRN Starting S+1 at 0000 Until Discontinued, nausea/vomiting
Day 2: Administer IV if PO not tolerated. Administer first dose prior to start of chemotherapy.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, For 2 days Starting S+1 As Scheduled
Days 2 and 3: Administer first dose prior to start of cytarabine.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 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
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Day 1: Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for
infusion rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact
MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, EVERY 24 HOURS, 4 doses Starting when released
Days 1 through 4: Administer first dose prior to CISplatin . May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 40 mg in dextrose 5 % 50 mL bag
40 mg, Intravenous, 1 X DAILY PRN, For 5 days Starting when released until S+4 at 2359, May give IV if unable to tolerate PO.
Days 1 through 4: Administer first dose prior to CISplatin. Administer over 30 to 60 minutes.
CISplatin (PLATINOL) 179 mg in sodium chloride 0.9 % 1,000 mL bag
179 mg (100 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Day 1: Administer as continuous infusion over 24 hours.
cytarabine PF (CYTOSAR) 3,580 mg in sodium chloride 0.9 % 250 mL bag
3,580 mg (2,000 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 12 HOURS, 2 doses Starting
S+1 at 0000
Day 2: First dose to be given after completion of CISplatin.
Supportive Care Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 1 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY SAT, SUN Include Now
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
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ZZtestonc,Andrew [2428787]
11/21/2016 1:27:26 PM Page 12 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.,
Administer over 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
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting *** and Creatinine, Potassium, Uric Acid,
and LDH twice weekly for one week starting ***
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin, AST, ALT, Alkaline Phosphatase; NOTE: Admit to B6/6 through clinic.
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ZZtestonc,Andrew [2428787]
11/21/2016 1:27:26 PM Page 13 of 13
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org