/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-96887-en.cckm

201605136

page

100

UWHC,UWMF,

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

CSC Hem Rituximab With ICE Ver 2-2-16 (HL 3027)

CSC Hem Rituximab With ICE Ver 2-2-16 (HL 3027) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM INPT RITUXIMAB WITH ICE VER: 2-2-16 – Properties
Cycle 1 – 2/4/2016 through 2/17/2016 (14 days), Planned
Days 1 through 3, Cycle 1 – Planned for 2/4/2016 through 2/6/2016
Treatment Plan Information
Reference Information (1)
NON-HODGKIN LYMPHOMA: Moskowitz CH et al. J Clin Oncol 1999;12:3776-85
Reference Information (2)
NON-HODGKIN LYMPHOMA: Kewalramani T, et al. Blood 2004;103(10):3684-8.
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, etoposide 100
mg/m2/day IV Day 1 through 3, ifosfamide 5 gm/m2 with mesna 5 gm/m2 IV continuous infusion over 24 hours Day 2,
CARBOplatin (AUC = 5) IV Day 2 (maximum dose = 800mg); CYCLE LENGTH: 14 to 21 days; COURSE: up to 4
cycles. GROWTH FACTOR REQUIRED.
Note to All Staff (1)
Risk factors associated with ifosfamide neurotoxicity may include hypoalbuminemia, renal dysfunction
(Creatinine Clearance less than 60 mL/min), and prior history of ifosfamide-induced encephalopathy. Consider dose
reduction or methylene blue prophylaxis if present.
Note to All Staff (2)
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
BILIRUBIN, TOTAL
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
POTASSIUM
ONCE Starting when released, Routine
LD, TOTAL
ONCE Starting when released
URIC ACID
ONCE Starting when released
HEPATITIS B CORE AB, TOTAL
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AG
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AB
Expected-S Approximate, Expires-S+122, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 1 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Pre-Labs (delete all that do not apply)
HEPATITIS B DNA, ULTRA QUANT, PCR
Approximate, Expires-S+122, Routine
Draw if Hepatitis B Core AB is positive.
Pre-Labs
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+2 at 0000 until S+3 for 2 occurrences
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, Uric Acid,
Potassium, LDH.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or
equal to 50K/µL or Total Bilirubin greater that upper limits of normal.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to
ifosfamide administration.
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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated
in a location to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations,
incontinence, palsy, diplopia or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
Monitoring Parameters (3)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with
rituximab.
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 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.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 2 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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, For 3 days Starting when released until S+2 at 2359
Day 1 to 3: Begin infusion after the completion of Day 1 etoposide chemotherapy. Adjust maintenance fluid to keep total
fluid at 200 mL/hr and continue hydration throughout chemotherapy and for 6 hours after completion of ifosfamide.
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.
ondansetron (ZOFRAN) tab 8 mg
8 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) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 1 day Starting when released until S+1,
nausea/vomiting, for 3 Minutes
Day 1: Administer IV if PO not tolerated. Administer first dose prior to start of chemotherapy. Administer over 3 to 5
minutes.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous
Day 2: Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer prior to chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting
Day 2: Administer prior to chemotherapy. Administer IV if PO not tolerated.
dexamethasone (DECADRON) tab 12 mg
12 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.
dexamethasone (DECADRON) 10 MG/ML injection 12 mg
12 mg, Intravenous, EVERY 24 HOURS PRN, For 24 hours Starting S+1 at 0000, nausea/vomiting,
Chemotherapy pre-medication
Day 2: Administer IV if PO not tolerated. Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting S+2 at 0000
Day 3: Administer prior to the start of chemotherapy. If PO not tolerated, may give IV.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 1 day Starting S+2 at 0000 until S+3, nausea/vomiting,
for 3 Minutes
Day 3: Administer prior to start of chemotherapy. Administer IV if PO not tolerated. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, For 3 days Starting S+2 at 0000
Days 3, 4, and 5: Administer IV if PO not tolerated.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 3 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

8 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+2 at 0000, nausea/vomiting
Days 3, 4, and 5: Administer IV if PO not tolerated.
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
rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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.
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
Days 1, 2 and 3. Administer with non-PVC tubing over 60 minutes.
ifosfamide (IFEX) 10,450 mg, mesna (MESNEX) 10,450 mg in sodium chloride 0.9 % 1,000 mL bag
10,450 mg (5,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2: Begin continuous infusion over 24 hours.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous
Day 2: Maximum dose = 800 mg. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
Supportive Care Medications (delete all that do not apply)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer 1 hour after the start of ifosfamide. IV push rate 10 mg/minute.
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, 1 X DAILY, 10 doses Starting S As Scheduled
Days 1 through 10: Give daily for 10 days in Cycle 1
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 S+1 at 1100
ranitidine (ZANTAC) tab 150 mg
150 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 Starting when released
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 4 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@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., 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
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 4 and 5., 8 mg, Disp-4 tab, R-0, 1 X DAILY starting S,
Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8
HOURS PRN starting S, Local Printer
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
Verify Appointments
Verify appointment(s) have been scheduled: INTERIM LAB APPOINTMENTS: CBC with DIFF every
Monday and Thursday starting *** and Creatinine, Potassium, Uric Acid, and LDH twice weekly for one week starting ***;
RETURN TO CLINIC for appointment with provider on ***; LABS: CBC with DIFF, Creatinine; ADMIT TO B6/6 on *** for
inpatient chemotherapy treatment.
Cycle 2 – 2/18/2016 through 3/2/2016 (14 days), Planned
Days 1 through 3, Cycle 2 – Planned for 2/18/2016 through 2/20/2016
Treatment Plan Information
Reference Information (1)
NON-HODGKIN LYMPHOMA: Moskowitz CH et al. J Clin Oncol 1999;12:3776-85
Reference Information (2)
NON-HODGKIN LYMPHOMA: Kewalramani T, et al. Blood 2004;103(10):3684-8.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 5 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, etoposide 100
mg/m2/day IV Day 1 through 3, ifosfamide 5 gm/m2 with mesna 5 gm/m2 IV continuous infusion over 24 hours Day 2,
CARBOplatin (AUC = 5) IV Day 2 (maximum dose = 800mg); CYCLE LENGTH: 14 to 21 days; COURSE: up to 4 cycles.
GROWTH FACTOR REQUIRED.
Note to All Staff (1)
Risk factors associated with ifosfamide neurotoxicity may include hypoalbuminemia, renal dysfunction
(Creatinine Clearance less than 60 mL/min), and prior history of ifosfamide-induced encephalopathy. Consider dose
reduction or methylene blue prophylaxis if present.
Note to All Staff (2)
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
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+2 at 0000 until S+3 for 2 occurrences
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or
equal to 50K/µL or Total Bilirubin greater that upper limits of normal.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to
ifosfamide administration.
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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated
in a location to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations,
incontinence, palsy, diplopia or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 6 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
Monitoring Parameters (3)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with
rituximab.
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 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 200 mL/hr, Intravenous, CONTINUOUS, For 3 days Starting when released until S+2 at 2359
Day 1 to 3: Begin infusion after the completion of Day 1 etoposide chemotherapy. Adjust maintenance fluid to keep total
fluid at 200 mL/hr and continue hydration throughout chemotherapy and for 6 hours after completion of ifosfamide.
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.
ondansetron (ZOFRAN) tab 8 mg
8 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) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 1 day Starting when released until S+1,
nausea/vomiting, for 3 Minutes
Day 1: Administer IV if PO not tolerated. Administer first dose prior to start of chemotherapy. Administer over 3 to 5
minutes.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous
Day 2: Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer prior to chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting
Day 2: Administer prior to chemotherapy. Administer IV if PO not tolerated.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 7 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

dexamethasone (DECADRON) tab 12 mg
12 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.
dexamethasone (DECADRON) 10 MG/ML injection 12 mg
12 mg, Intravenous, EVERY 24 HOURS PRN, For 24 hours Starting S+1 at 0000, nausea/vomiting,
Chemotherapy pre-medication
Day 2: Administer IV if PO not tolerated. Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting S+2 at 0000
Day 3: Administer prior to the start of chemotherapy. If PO not tolerated, may give IV.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 1 day Starting S+2 at 0000 until S+3, nausea/vomiting,
for 3 Minutes
Day 3: Administer prior to start of chemotherapy. Administer IV if PO not tolerated. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, For 3 days Starting S+2 at 0000
Days 3, 4, and 5: Administer IV if PO not tolerated.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+2 at 0000, nausea/vomiting
Days 3, 4, and 5: Administer IV if PO not tolerated.
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
rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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.
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
Days 1, 2 and 3. Administer with non-PVC tubing over 60 minutes.
ifosfamide (IFEX) 10,450 mg, mesna (MESNEX) 10,450 mg in sodium chloride 0.9 % 1,000 mL bag
10,450 mg (5,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2: Begin continuous infusion over 24 hours.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous
Day 2: Maximum dose = 800 mg. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 8 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Supportive Care Medications (delete all that do not apply)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer 1 hour after the start of ifosfamide. IV push rate 10 mg/minute.
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 S+1 at 1100
ranitidine (ZANTAC) tab 150 mg
150 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 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.
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
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 4 and 5., 8 mg, Disp-4 tab, R-0, 1 X DAILY starting S,
Local Printer
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
Verify Appointments
Verify appointment(s) have been scheduled: INTERIM LAB APPOINTMENTS: CBC with DIFF every
Monday and Thursday starting ***; RETURN TO CLINIC for appointment with provider on ***; LABS: CBC with DIFF,
Creatinine; ADMIT TO B6/6 on *** for inpatient chemotherapy treatment.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 9 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Cycle 3 – 3/3/2016 through 3/16/2016 (14 days), Planned
Days 1 through 3, Cycle 3 – Planned for 3/3/2016 through 3/5/2016
Treatment Plan Information
Reference Information (1)
NON-HODGKIN LYMPHOMA: Moskowitz CH et al. J Clin Oncol 1999;12:3776-85
Reference Information (2)
NON-HODGKIN LYMPHOMA: Kewalramani T, et al. Blood 2004;103(10):3684-8.
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, etoposide 100
mg/m2/day IV Day 1 through 3, ifosfamide 5 gm/m2 with mesna 5 gm/m2 IV continuous infusion over 24 hours Day 2,
CARBOplatin (AUC = 5) IV Day 2 (maximum dose = 800mg); CYCLE LENGTH: 14 to 21 days; COURSE: up to 4 cycles.
GROWTH FACTOR REQUIRED.
Note to All Staff (1)
Risk factors associated with ifosfamide neurotoxicity may include hypoalbuminemia, renal dysfunction
(Creatinine Clearance less than 60 mL/min), and prior history of ifosfamide-induced encephalopathy. Consider dose
reduction or methylene blue prophylaxis if present.
Note to All Staff (2)
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
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+2 at 0000 until S+3 for 2 occurrences
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or
equal to 50K/µL or Total Bilirubin greater that upper limits of normal.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to
ifosfamide administration.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 10 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated
in a location to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations,
incontinence, palsy, diplopia or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
Monitoring Parameters (3)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with
rituximab.
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 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 200 mL/hr, Intravenous, CONTINUOUS, For 3 days Starting when released until S+2 at 2359
Day 1 to 3: Begin infusion after the completion of Day 1 etoposide chemotherapy. Adjust maintenance fluid to keep total
fluid at 200 mL/hr and continue hydration throughout chemotherapy and for 6 hours after completion of ifosfamide.
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.
ondansetron (ZOFRAN) tab 8 mg
8 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) injection 8 mg
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 11 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

8 mg, Intravenous, EVERY 24 HOURS PRN, For 1 day Starting when released until S+1, nausea/vomiting, for 3 Minutes
Day 1: Administer IV if PO not tolerated. Administer first dose prior to start of chemotherapy. Administer over 3 to 5
minutes.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous
Day 2: Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer prior to chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting
Day 2: Administer prior to chemotherapy. Administer IV if PO not tolerated.
dexamethasone (DECADRON) tab 12 mg
12 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.
dexamethasone (DECADRON) 10 MG/ML injection 12 mg
12 mg, Intravenous, EVERY 24 HOURS PRN, For 24 hours Starting S+1 at 0000, nausea/vomiting,
Chemotherapy pre-medication
Day 2: Administer IV if PO not tolerated. Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting S+2 at 0000
Day 3: Administer prior to the start of chemotherapy. If PO not tolerated, may give IV.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 1 day Starting S+2 at 0000 until S+3, nausea/vomiting,
for 3 Minutes
Day 3: Administer prior to start of chemotherapy. Administer IV if PO not tolerated. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, For 3 days Starting S+2 at 0000
Days 3, 4, and 5: Administer IV if PO not tolerated.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+2 at 0000, nausea/vomiting
Days 3, 4, and 5: Administer IV if PO not tolerated.
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
rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 12 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

hypotension, contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the
reaction occurred.
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
Days 1, 2 and 3. Administer with non-PVC tubing over 60 minutes.
ifosfamide (IFEX) 10,450 mg, mesna (MESNEX) 10,450 mg in sodium chloride 0.9 % 1,000 mL bag
10,450 mg (5,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2: Begin continuous infusion over 24 hours.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous
Day 2: Maximum dose = 800 mg. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
Supportive Care Medications (delete all that do not apply)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer 1 hour after the start of ifosfamide. IV push rate 10 mg/minute.
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 S+1 at 1100
ranitidine (ZANTAC) tab 150 mg
150 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 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.
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
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 4 and 5., 8 mg, Disp-4 tab, R-0, 1 X DAILY starting S,
Local Printer
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.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 13 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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
Verify Appointments
Verify appointment(s) have been scheduled: INTERIM LAB APPOINTMENTS: CBC with DIFF every
Monday and Thursday starting ***; RETURN TO CLINIC for appointment with provider on ***; LABS: CBC with DIFF,
Creatinine; ADMIT TO B6/6 on *** for inpatient chemotherapy treatment.
Cycle 4 – 3/17/2016 through 3/30/2016 (14 days), Planned
Days 1 through 3, Cycle 4 – Planned for 3/17/2016 through 3/19/2016
Treatment Plan Information
Reference Information (1)
NON-HODGKIN LYMPHOMA: Moskowitz CH et al. J Clin Oncol 1999;12:3776-85
Reference Information (2)
NON-HODGKIN LYMPHOMA: Kewalramani T, et al. Blood 2004;103(10):3684-8.
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, etoposide 100
mg/m2/day IV Day 1 through 3, ifosfamide 5 gm/m2 with mesna 5 gm/m2 IV continuous infusion over 24 hours Day 2,
CARBOplatin (AUC = 5) IV Day 2 (maximum dose = 800mg); CYCLE LENGTH: 14 to 21 days; COURSE: up to 4 cycles.
GROWTH FACTOR REQUIRED.
Note to All Staff (1)
Risk factors associated with ifosfamide neurotoxicity may include hypoalbuminemia, renal dysfunction
(Creatinine Clearance less than 60 mL/min), and prior history of ifosfamide-induced encephalopathy. Consider dose
reduction or methylene blue prophylaxis if present.
Note to All Staff (2)
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
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+2 at 0000 until S+3 for 2 occurrences
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 14 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or
equal to 50K/µL or Total Bilirubin greater that upper limits of normal.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to
ifosfamide administration.
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.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient should be treated
in a location to optimize emergency care. See Emergency Medications.
Monitoring Parameters (1)
Monitor for ifosfamide-related neurotoxicity (somnolence, agitation, confusion, delirium, hallucinations,
incontinence, palsy, diplopia or aphasia). Stop infusion and contact physician if toxicity is suspected.
Monitoring Parameters (2)
Monitor and notify physician for signs and symptoms of hemorrhagic cystitis (dysuria).
Monitoring Parameters (3)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with
rituximab.
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 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 200 mL/hr, Intravenous, CONTINUOUS, For 3 days Starting when released until S+2 at 2359
Day 1 to 3: Begin infusion after the completion of Day 1 etoposide chemotherapy. Adjust maintenance fluid to keep total
fluid at 200 mL/hr and continue hydration throughout chemotherapy and for 6 hours after completion of ifosfamide.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 15 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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.
ondansetron (ZOFRAN) tab 8 mg
8 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) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 1 day Starting when released until S+1,
nausea/vomiting, for 3 Minutes
Day 1: Administer IV if PO not tolerated. Administer first dose prior to start of chemotherapy. Administer over 3 to 5
minutes.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous
Day 2: Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer prior to chemotherapy. If PO not tolerated may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting
Day 2: Administer prior to chemotherapy. Administer IV if PO not tolerated.
dexamethasone (DECADRON) tab 12 mg
12 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.
dexamethasone (DECADRON) 10 MG/ML injection 12 mg
12 mg, Intravenous, EVERY 24 HOURS PRN, For 24 hours Starting S+1 at 0000, nausea/vomiting,
Chemotherapy pre-medication
Day 2: Administer IV if PO not tolerated. Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting S+2 at 0000
Day 3: Administer prior to the start of chemotherapy. If PO not tolerated, may give IV.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 1 day Starting S+2 at 0000 until S+3, nausea/vomiting,
for 3 Minutes
Day 3: Administer prior to start of chemotherapy. Administer IV if PO not tolerated. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, For 3 days Starting S+2 at 0000
Days 3, 4, and 5: Administer IV if PO not tolerated.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+2 at 0000, nausea/vomiting
Days 3, 4, and 5: Administer IV if PO not tolerated.
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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 16 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), 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.
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
Days 1, 2 and 3. Administer with non-PVC tubing over 60 minutes.
ifosfamide (IFEX) 10,450 mg, mesna (MESNEX) 10,450 mg in sodium chloride 0.9 % 1,000 mL bag
10,450 mg (5,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 2: Begin continuous infusion over 24 hours.
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous
Day 2: Maximum dose = 800 mg. Hypersensitivity reaction to CARBOplatin can occur. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications.
Supportive Care Medications (delete all that do not apply)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE, 1 dose Starting S+1 at 0000
Day 2: Administer 1 hour after the start of ifosfamide. IV push rate 10 mg/minute.
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 S+1 at 1100
ranitidine (ZANTAC) tab 150 mg
150 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 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.
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,
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 17 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 4 and 5., 8 mg, Disp-4 tab, R-0, 1 X DAILY starting S,
Local Printer
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
Verify Appointments
Verify appointment(s) have been scheduled: INTERIM LAB APPOINTMENTS: CBC with DIFF every
Monday and Thursday starting ***; RETURN TO CLINIC for appointment with provider on ***; LABS: CBC with DIFF,
Creatinine; ADMIT TO B6/6 on *** for inpatient chemotherapy treatment.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 10:05:28 AM Page 18 of 18
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org