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CSC Sarcoma CAV ALT With Etoposide Ifosfamide VER 5-1-17 (HL 969)

CSC Sarcoma CAV ALT With Etoposide Ifosfamide VER 5-1-17 (HL 969) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Sarcoma


CSC SARCOMA CAV ALT W ETOPOSIDE IFOSFAMIDE VER 5-1-17 (HL 969) – 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: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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+365, 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
URINALYSIS WITH MICROSCOPY
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for two days following chemotherapy., 80 mg, Disp-2 cap, R-5, 1 X DAILY starting S,
Local Printer
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take for 3 days following chemotherapy, 8 mg, Disp-24 tab, R-5, 1 X DAILY starting S, Local
Printer
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
Take Home Medications (delete all that do not apply)
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 1 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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.
Cycle 1 - CAV – 6/13/2017 through 7/3/2017 (21 days), Planned
Day 1, Cycle 1 - CAV – Planned for 6/13/2017
Treatment Plan Information
Reference Information (1)
SARCOMA: Grier HE, et al. N Engl J Med 2003;348:694-701.
Reference Information (2)
SARCOMA: Bernstein ML, et al. J Clin Oncol 2006;24:152-9.
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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 and resulted: WBC, ANC, Platelets, Creatinine, Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 9:53:21 AM Page 2 of 22
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 3.9 mg in sodium chloride 0.9 % 25 mL bag
3.9 mg (rounded from 3.92 mg = 2 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
mesna (MESNEX) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give just prior to cyclophosphamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of
cyclophosphamide.
cyclophosphamide (CYTOXAN) 2,352 mg in sodium chloride 0.9 % 250 mL bag
2,352 mg (1,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2 tabs by mouth 2 times daily. Take 4 & 8 hours after start of cyclophosphamide, 800 mg (rounded from 784 mg = 400
mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-5, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be 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, and Urinalysis; CHEMOTHERAPY ROOM
APPOINTMENT: ifosfamide and etoposide for 300 minutes.
Lab Only - Day 8, Cycle 1 - CAV – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
Ordered dose of 2 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 3 of 22
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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 - CAV – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 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 - etoposide, ifosfamide – 7/4/2017 through 7/24/2017 (21 days), Planned
Day 1, Cycle 2 - etoposide, ifosfamide – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 4 of 22
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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 5 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
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.
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 3 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide Day *** to ***., 1,200 mg (rounded from 1,176 mg =
600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-5, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and etoposide for 300 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and etoposide for 300 minutes.
DAY 4 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and etoposide for 300 minutes.
DAY 5 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and etoposide for 300 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be 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, and Urinalysis; CHEMOTHERAPY ROOM
APPOINTMENT: doxorubicin, cyclophosphamide, and vinCRIStine for 200 minutes.
Day 2, Cycle 2 - etoposide, ifosfamide – Planned for 7/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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 9:53:21 AM Page 6 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Pre-Labs
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 2 - etoposide, ifosfamide – Planned for 7/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 7 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
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.
Follow-Up
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 8 of 22
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.
Day 4, Cycle 2 - etoposide, ifosfamide – Planned for 7/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 9 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 2 - etoposide, ifosfamide – Planned for 7/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 10 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 2 - etoposide, ifosfamide – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 2 - etoposide, ifosfamide – Planned for 7/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
IV Access
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 11 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 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 - CAV – 7/25/2017 through 8/14/2017 (21 days), Planned
Day 1, Cycle 3 - CAV – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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+17 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+17 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+17 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+17 Approximate, Expires-S+365, Routine
BUN
Expected-S+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+17 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 12 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+17 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 147 mg
147 mg (75 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 3.9 mg in sodium chloride 0.9 % 25 mL bag
3.9 mg (rounded from 3.92 mg = 2 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3-5 Minutes
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
mesna (MESNEX) 784 mg in sodium chloride 0.9 % 50 mL bag
784 mg (400 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give just prior to cyclophosphamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of
cyclophosphamide.
cyclophosphamide (CYTOXAN) 2,352 mg in sodium chloride 0.9 % 250 mL bag
2,352 mg (1,200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes.
Ordered dose of 2 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 13 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Take Home Medications
mesna (MESNEX) 400 MG tab
Take 2 tabs by mouth 2 times daily. Take 4 & 8 hours after start of cyclophosphamide, 800 mg (rounded from 784 mg = 400
mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-5, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be 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, and Urinalysis; CHEMOTHERAPY ROOM
APPOINTMENT: ifosfamide and etoposide for 300 minutes.
Lab Only - Day 8, Cycle 3 - CAV – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 3 - CAV – Planned for 8/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 14 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 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 - etoposide, ifosfamide – 8/15/2017 through 9/4/2017 (21 days), Planned
Day 1, Cycle 4 - etoposide, ifosfamide – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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
URINALYSIS WITH MICROSCOPY
Expected-S+21 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 15 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, Urine Heme.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
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.
Take Home Medications
mesna (MESNEX) 400 MG tab
Take 3 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide Day *** to ***., 1,200 mg (rounded from 1,176 mg =
600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-5, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and etoposide for 300 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and etoposide for 300 minutes.
DAY 4 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and etoposide for 300 minutes.
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 16 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DAY 5 FOLLOW-UP
LABS: Urinalysis; CHEMOTHERAPY ROOM APPOINTMENT: ifosfamide and etoposide for 300 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be 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, and Urinalysis; CHEMOTHERAPY ROOM
APPOINTMENT: doxorubicin, cyclophosphamide, and vinCRIStine for 200 minutes.
Day 2, Cycle 4 - etoposide, ifosfamide – Planned for 8/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 17 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 4 - etoposide, ifosfamide – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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 9:53:21 AM Page 18 of 22
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 4 - etoposide, ifosfamide – Planned for 8/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 19 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 4 - etoposide, ifosfamide – Planned for 8/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 20 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: Urine Heme.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
mesna (MESNEX) 1,176 mg in sodium chloride 0.9 % 50 mL bag
1,176 mg (600 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give prior to start of ifosfamide. See Take Home Meds for mesna oral at 4 hours and 8 hours after the start of ifosfamide.
ifosfamide (IFEX) 3,530 mg in sodium chloride 0.9 % 250 mL bag
3,530 mg (rounded from 3,528 mg = 1,800 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 4 - etoposide, ifosfamide – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
IV Access
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Zztestonc,Jeff J [2507481]
6/13/2017 9:53:21 AM Page 21 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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+3 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 4 - etoposide, ifosfamide – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ewing's Sarcoma, Primitive Neuroectodermal Tumor of Bone, Peripheral Sarcoma of Bone (Neoadjuvant); THERAPY:
doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg/m2 (maximum dose = 2 mg) IV Day 1, cyclophosphamide 1200 mg/m2 IV Day 1,
mesna 400 mg/m2 IV prior to cyclophosphamide and 400 mg/m2 by mouth at 4 hours and 8 hours after start of cyclophosphamide
Day 1, alternating Cycles with ifosfamide 1800 mg/m2 IV Day 1 through 5, mesna 600 mg/m2 IV prior to ifosfamide and 600 mg/m2
by mouth at 4 hours and 8 hours after start of ifosfamide Day 1 through 5, etoposide 100 mg/m2 IV Day 1 through 5; GROWTH
FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 12 alternating cycles.
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+10 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+10 Approximate, Expires-S+365, Routine
Follow-Up
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 9:53:21 AM Page 22 of 22
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org