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201706165

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UWHC,UWMF,

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Sarcoma

CSC Sarcoma Carboplatin(21D:1) Etoposide(21D:1(Oral)2,3) VER 5-1-17 (HL 3352)

CSC Sarcoma Carboplatin(21D:1) Etoposide(21D:1(Oral)2,3) VER 5-1-17 (HL 3352) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Sarcoma


CSC SARCOMA CARBOPLATIN(21D1)ETOPOSIDE(21D1,(ORAL)2,3) VER 5-1-17 (HL3352) – Properties
Pre-Cycle – 6/6/2017 through 6/12/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Merkel Cell Carcinoma (Adjuvant/Advanced); THERAPY: CARBOplatin (AUC = 5) IV Day 1, etoposide 100 mg/m2 IV
Day 1, etoposide 100 mg/m2 by mouth twice daily Day 2 and 3; CYCLE LENGTH: 21 Days; COURSE: 4 cycles (Adjuvant) or until
disease progression (Advanced).
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take only on Day 2, 3 and 4 of each cycle, 8 mg, Disp-24 tab, R-0, 1 X DAILY starting S
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
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
Cycle 1 – 6/13/2017 through 7/3/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Reference Information (1)
MERKEL CELL CARCINOMA: Pectasides M, et al. Cancer Invest;2006;(8):780-5.
Reference Information (2)
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Zztestonc,Jeff J [2507481]
6/13/2017 9:52:06 AM Page 1 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

MERKEL CELL CARCINOMA: Tai PT, et al. J Clin Oncol 2000;(12):2493-9.
Treatment Plan Summary
DISEASE: Merkel Cell Carcinoma (Adjuvant/Advanced); THERAPY: CARBOplatin (AUC = 5) IV Day 1, etoposide 100 mg/m2 IV
Day 1, etoposide 100 mg/m2 by mouth twice daily Day 2 and 3; CYCLE LENGTH: 21 Days; COURSE: 4 cycles (Adjuvant) or until
disease progression (Advanced).
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, 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
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Zztestonc,Jeff J [2507481]
6/13/2017 9:52:06 AM Page 2 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. 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.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded from 196 mg = 100 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
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),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
CARBOplatin and etoposide infusion for 150 minutes.
Lab Only - Day 10, Cycle 1 – Planned for 6/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Merkel Cell Carcinoma (Adjuvant/Advanced); THERAPY: CARBOplatin (AUC = 5) IV Day 1, etoposide 100 mg/m2 IV
Day 1, etoposide 100 mg/m2 by mouth twice daily Day 2 and 3; CYCLE LENGTH: 21 Days; COURSE: 4 cycles (Adjuvant) or until
disease progression (Advanced).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 7/4/2017 through 7/24/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/13/2017 9:52:06 AM Page 3 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Merkel Cell Carcinoma (Adjuvant/Advanced); THERAPY: CARBOplatin (AUC = 5) IV Day 1, etoposide 100 mg/m2 IV
Day 1, etoposide 100 mg/m2 by mouth twice daily Day 2 and 3; CYCLE LENGTH: 21 Days; COURSE: 4 cycles (Adjuvant) or until
disease progression (Advanced).
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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.
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
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Zztestonc,Jeff J [2507481]
6/13/2017 9:52:06 AM Page 4 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, 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
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. 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.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded from 196 mg = 100 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
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),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
CARBOplatin and etoposide infusion for 150 minutes.
Lab Only - Day 10, Cycle 2 – Planned for 7/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Merkel Cell Carcinoma (Adjuvant/Advanced); THERAPY: CARBOplatin (AUC = 5) IV Day 1, etoposide 100 mg/m2 IV
Day 1, etoposide 100 mg/m2 by mouth twice daily Day 2 and 3; CYCLE LENGTH: 21 Days; COURSE: 4 cycles (Adjuvant) or until
disease progression (Advanced).
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Zztestonc,Jeff J [2507481]
6/13/2017 9:52:06 AM Page 5 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 7/25/2017 through 8/14/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Merkel Cell Carcinoma (Adjuvant/Advanced); THERAPY: CARBOplatin (AUC = 5) IV Day 1, etoposide 100 mg/m2 IV
Day 1, etoposide 100 mg/m2 by mouth twice daily Day 2 and 3; CYCLE LENGTH: 21 Days; COURSE: 4 cycles (Adjuvant) or until
disease progression (Advanced).
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
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Zztestonc,Jeff J [2507481]
6/13/2017 9:52:06 AM Page 6 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, 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
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. 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.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
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Zztestonc,Jeff J [2507481]
6/13/2017 9:52:06 AM Page 7 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): etoposide (dispensed Day 1
of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded from 196 mg = 100 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
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),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
CARBOplatin and etoposide infusion for 150 minutes.
Lab Only - Day 10, Cycle 3 – Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Merkel Cell Carcinoma (Adjuvant/Advanced); THERAPY: CARBOplatin (AUC = 5) IV Day 1, etoposide 100 mg/m2 IV
Day 1, etoposide 100 mg/m2 by mouth twice daily Day 2 and 3; CYCLE LENGTH: 21 Days; COURSE: 4 cycles (Adjuvant) or until
disease progression (Advanced).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 8/15/2017 through 9/4/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Merkel Cell Carcinoma (Adjuvant/Advanced); THERAPY: CARBOplatin (AUC = 5) IV Day 1, etoposide 100 mg/m2 IV
Day 1, etoposide 100 mg/m2 by mouth twice daily Day 2 and 3; CYCLE LENGTH: 21 Days; COURSE: 4 cycles (Adjuvant) or until
disease progression (Advanced).
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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Zztestonc,Jeff J [2507481]
6/13/2017 9:52:06 AM Page 8 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
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.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
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Zztestonc,Jeff J [2507481]
6/13/2017 9:52:06 AM Page 9 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
CARBOplatin (PARAPLATIN) in dextrose 5 % 500 mL bag
(Target AUC = 5), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. 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.
etoposide (VEPESID) 196 mg in sodium chloride 0.9 % 500 mL NSS bag
196 mg (100 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded from 196 mg = 100 mg/m2 ×
1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally)
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),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT:
CARBOplatin and etoposide infusion for 150 minutes.
Lab Only - Day 10, Cycle 4 – Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Merkel Cell Carcinoma (Adjuvant/Advanced); THERAPY: CARBOplatin (AUC = 5) IV Day 1, etoposide 100 mg/m2 IV
Day 1, etoposide 100 mg/m2 by mouth twice daily Day 2 and 3; CYCLE LENGTH: 21 Days; COURSE: 4 cycles (Adjuvant) or until
disease progression (Advanced).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
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Zztestonc,Jeff J [2507481]
6/13/2017 9:52:06 AM Page 10 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
6/13/2017 9:52:06 AM Page 11 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org