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CSC Sarcoma INPT Cisplatin(35D:1) Doxorubicin(35D:1-3) Methotrexate(35D:21,28)VER 5-1-17 (HL 975)

CSC Sarcoma INPT Cisplatin(35D:1) Doxorubicin(35D:1-3) Methotrexate(35D:21,28)VER 5-1-17 (HL 975) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Sarcoma


CSC SARCOMA INPT CISPLATIN(35D1)DOXORUBICIN(35D1-3)METHOTREXATE(35D21,28) VER 5-1-17 – Properties
Cycle 1 – 6/13/2017 through 7/17/2017 (35 days), Planned
Day 1 - Cisplatin and Infusional Doxorubicin, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Reference Information (1)
SARCOMA: Bacci G, et al. J Clin Oncol 1998;16:658-63.
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, 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 or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
Hydration
sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration* Infuse 1000 mL over 2 hours prior to CISplatin.
sodium chloride 0.9 % infusion
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 1 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Intravenous, Starting when released
Post chemotherapy hydration - MD to delete if not needed.
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer 30 minutes prior to CISplatin.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 8 hours Starting when released, nausea/vomiting, if unable to tolerate PO
Day 1: Administer 30 minutes prior to CISplatin.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer 30 minutes prior to CISplatin.
dexamethasone (DECADRON) 10 MG/ML injection 12 mg
12 mg, Intravenous, EVERY 24 HOURS PRN, For 8 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Day 1: Administer over 3-5 minutes. Administer 30 minutes prior to CISplatin.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
Day 2, 3 and 4. Administer daily for 3 days while on chemotherapy.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+1 at 0000, nausea/vomiting, if unable to tolerate PO
Day 2, 3 and 4: Administer daily as needed for 3 days while on chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
Day 2, 3 and 4: Administer daily for 3 days while on chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+1 at 0000, If unable to tolerate PO.
Day 2, 3, and 4: Administer daily for 3 days. Administer over 3-5 minutes.
Treatment Medications
CISplatin (PLATINOL) 235 mg in sodium chloride 0.9 % 1,000 mL bag
235 mg (rounded from 235.2 mg = 120 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 to 90 minutes.
doxorubicin CONVENTIONAL (ADRIAMYCIN) 49 mg in sodium chloride 0.9 % 500 mL infusion
49 mg (25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 3 doses Starting when
released
Continuous infusion over 24 hours for a total of 72 hours starting on Day 1 (Total dose over 72 hours = 75mg/m2)
Treatment Medications (delete all that do not apply)
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, EVERY 24 HOURS, 4 doses Starting when released
Physician to delete order if not needed.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 2 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral,
Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, 1 X DAILY PRN, 2 doses Starting when released, Urine output less than 400 mL per 4 hour period.
Days 1 and 2: Administer one dose. Notify MD if additional dose is required. IV push rate 10 mg/minute. IV infusion rate 4
mg/minute.
Take Home Medications
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid and drink by mouth at 8 AM, 12
PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of methotrexate treatment., Disp-1 Bottle, R-0,
starting S, No Print
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 21 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, and Urinalysis; INPATIENT CHEMOTHERAPY ADMISSION: High dose
methotrexate.
DAY 28 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, and Urinalysis; INPATIENT CHEMOTHERAPY ADMISSION: High dose
methotrexate.
DAY 36 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; INPATIENT CHEMOTHERAPY ADMISSION:
CISplatin and doxorubicin infusion.
Day 8 - Lab Only, Cycle 1 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 1 – Planned for 6/27/2017
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 3 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 21 - High Dose Methotrexate, Cycle 1 – Planned for 7/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
Additional Labs
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 4 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than or equal to
7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Total Bilirubin, Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than 1.5 mg/dL.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less than 7, give sodium bicarbonate
50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate and then every 8 hours until
methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and check urine pH every 2 hours until urine
pH is greater than or equal to 7 for two consecutive occurrences. See Conditional Medications and Additional Labs.
Nursing Communication
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 5 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in 8 hours or
three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Hydration
sodium chloride 0.9 % infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Prehydration - infuse over 2 hours prior to methotrexate.
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
at 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium Bicarbonate infusion
must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) injection 16 mg
16 mg, Intravenous, PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral therapy, Administer
over 3 Minutes
Give 30 minutes prior to chemotherapy. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, For 12 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Give 30 minutes prior to chemotherapy.
Treatment Medications
methotrexate PF 11,760 mg in dextrose 5 % 1,000 mL bag
11,760 mg (6,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Do not administer until urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+1 at 0000,
Administer over 3 Minutes
Start 24 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 29 mg
29 mg (rounded from 29.4 mg = 15 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, Administer over 3 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal to 0.5
µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg leucovorin PO
every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, for urine pH less than 7, Administer over 1
Minutes
IV push over 5 minutes.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 6 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm methotrexate level undetectable, 15 mg,
Disp-16 tab, R-0, EVERY 6 HOURS starting S
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid and drink by mouth at 8 AM, 12
PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of methotrexate treatment., Disp-1 Bottle, R-0,
starting S, No Print
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 28 - High Dose Methotrexate, Cycle 1 – Planned for 7/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 7 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than or equal to
7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Total Bilirubin, Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than 1.5 mg/dL.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less than 7, give sodium bicarbonate
50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate and then every 8 hours until
methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and check urine pH every 2 hours until urine
pH is greater than or equal to 7 for two consecutive occurrences. See Conditional Medications and Additional Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in 8 hours or
three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Hydration
sodium chloride 0.9 % infusion
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 8 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Prehydration - infuse over 2 hours prior to methotrexate.
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
at 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium Bicarbonate infusion
must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) injection 16 mg
16 mg, Intravenous, PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral therapy, Administer
over 3 Minutes
Give 30 minutes prior to chemotherapy. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, For 12 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Give 30 minutes prior to chemotherapy.
Treatment Medications
methotrexate PF 11,760 mg in dextrose 5 % 1,000 mL bag
11,760 mg (6,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Do not administer until urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+1 at 0000,
Administer over 3 Minutes
Start 24 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 29 mg
29 mg (rounded from 29.4 mg = 15 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, Administer over 3 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal to 0.5
µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg leucovorin PO
every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, for urine pH less than 7, Administer over 1
Minutes
IV push over 5 minutes.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 9 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm methotrexate level undetectable, 15 mg,
Disp-16 tab, R-0, EVERY 6 HOURS starting S
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 7/18/2017 through 8/21/2017 (35 days), Planned
Day 1 - Cisplatin and Infusional Doxorubicin, Cycle 2 – Planned for 7/18/2017
Treatment Plan Information
Reference Information (1)
SARCOMA: Bacci G, et al. J Clin Oncol 1998;16:658-63.
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, 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 or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 10 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
Hydration
sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration* Infuse 1000 mL over 2 hours prior to CISplatin.
sodium chloride 0.9 % infusion
Intravenous, Starting when released
Post chemotherapy hydration - MD to delete if not needed.
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer 30 minutes prior to CISplatin.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 8 hours Starting when released, nausea/vomiting, if unable to tolerate PO
Day 1: Administer 30 minutes prior to CISplatin.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer 30 minutes prior to CISplatin.
dexamethasone (DECADRON) 10 MG/ML injection 12 mg
12 mg, Intravenous, EVERY 24 HOURS PRN, For 8 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Day 1: Administer over 3-5 minutes. Administer 30 minutes prior to CISplatin.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
Day 2, 3 and 4. Administer daily for 3 days while on chemotherapy.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+1 at 0000, nausea/vomiting, if unable to tolerate PO
Day 2, 3 and 4: Administer daily as needed for 3 days while on chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
Day 2, 3 and 4: Administer daily for 3 days while on chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+1 at 0000, If unable to tolerate PO.
Day 2, 3, and 4: Administer daily for 3 days. Administer over 3-5 minutes.
Treatment Medications
CISplatin (PLATINOL) 235 mg in sodium chloride 0.9 % 1,000 mL bag
235 mg (rounded from 235.2 mg = 120 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 to 90 minutes.
doxorubicin CONVENTIONAL (ADRIAMYCIN) 49 mg in sodium chloride 0.9 % 500 mL infusion
49 mg (25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 3 doses Starting when
released
Continuous infusion over 24 hours for a total of 72 hours starting on Day 1 (Total dose over 72 hours = 75mg/m2)
Treatment Medications (delete all that do not apply)
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, EVERY 24 HOURS, 4 doses Starting when released
Physician to delete order if not needed.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 11 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral,
Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, 1 X DAILY PRN, 2 doses Starting when released, Urine output less than 400 mL per 4 hour period.
Days 1 and 2: Administer one dose. Notify MD if additional dose is required. IV push rate 10 mg/minute. IV infusion rate 4
mg/minute.
Take Home Medications
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid and drink by mouth at 8 AM, 12
PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of methotrexate treatment., Disp-1 Bottle, R-0,
starting S, No Print
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 21 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, and Urinalysis; INPATIENT CHEMOTHERAPY ADMISSION: High dose
methotrexate.
DAY 28 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, and Urinalysis; INPATIENT CHEMOTHERAPY ADMISSION: High dose
methotrexate.
DAY 36 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; INPATIENT CHEMOTHERAPY ADMISSION:
CISplatin and doxorubicin infusion.
Day 8 - Lab Only, Cycle 2 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 12 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 2 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 21 - High Dose Methotrexate, Cycle 2 – Planned for 8/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 13 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than or equal to
7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Total Bilirubin, Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than 1.5 mg/dL.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 14 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less than 7, give sodium bicarbonate
50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate and then every 8 hours until
methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and check urine pH every 2 hours until urine
pH is greater than or equal to 7 for two consecutive occurrences. See Conditional Medications and Additional Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in 8 hours or
three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Hydration
sodium chloride 0.9 % infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Prehydration - infuse over 2 hours prior to methotrexate.
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
at 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium Bicarbonate infusion
must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) injection 16 mg
16 mg, Intravenous, PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral therapy, Administer
over 3 Minutes
Give 30 minutes prior to chemotherapy. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, For 12 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Give 30 minutes prior to chemotherapy.
Treatment Medications
methotrexate PF 11,760 mg in dextrose 5 % 1,000 mL bag
11,760 mg (6,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Do not administer until urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+1 at 0000,
Administer over 3 Minutes
Start 24 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 29 mg
29 mg (rounded from 29.4 mg = 15 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, Administer over 3 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal to 0.5
µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg leucovorin PO
every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, for urine pH less than 7, Administer over 1
Minutes
IV push over 5 minutes.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 15 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm methotrexate level undetectable, 15 mg,
Disp-16 tab, R-0, EVERY 6 HOURS starting S
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid and drink by mouth at 8 AM, 12
PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of methotrexate treatment., Disp-1 Bottle, R-0,
starting S, No Print
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 28 - High Dose Methotrexate, Cycle 2 – Planned for 8/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 16 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than or equal to
7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Total Bilirubin, Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than 1.5 mg/dL.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less than 7, give sodium bicarbonate
50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate and then every 8 hours until
methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and check urine pH every 2 hours until urine
pH is greater than or equal to 7 for two consecutive occurrences. See Conditional Medications and Additional Labs.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 17 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been
given in 8 hours or three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Hydration
sodium chloride 0.9 % infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Prehydration - infuse over 2 hours prior to methotrexate.
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
at 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium Bicarbonate infusion
must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) injection 16 mg
16 mg, Intravenous, PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral therapy, Administer
over 3 Minutes
Give 30 minutes prior to chemotherapy. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, For 12 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Give 30 minutes prior to chemotherapy.
Treatment Medications
methotrexate PF 11,760 mg in dextrose 5 % 1,000 mL bag
11,760 mg (6,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Do not administer until urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+1 at 0000,
Administer over 3 Minutes
Start 24 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 29 mg
29 mg (rounded from 29.4 mg = 15 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, Administer over 3 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal to 0.5
µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg leucovorin PO
every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, for urine pH less than 7, Administer over 1
Minutes
IV push over 5 minutes.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 18 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm methotrexate level undetectable, 15 mg,
Disp-16 tab, R-0, EVERY 6 HOURS starting S
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 8/22/2017 through 9/25/2017 (35 days), Planned
Day 1 - Cisplatin and Infusional Doxorubicin, Cycle 3 – Planned for 8/22/2017
Treatment Plan Information
Reference Information (1)
SARCOMA: Bacci G, et al. J Clin Oncol 1998;16:658-63.
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Treatment Conditions
Verify Labs
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 19 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
Hydration
sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration* Infuse 1000 mL over 2 hours prior to CISplatin.
sodium chloride 0.9 % infusion
Intravenous, Starting when released
Post chemotherapy hydration - MD to delete if not needed.
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer 30 minutes prior to CISplatin.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 8 hours Starting when released, nausea/vomiting, if unable to tolerate PO
Day 1: Administer 30 minutes prior to CISplatin.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer 30 minutes prior to CISplatin.
dexamethasone (DECADRON) 10 MG/ML injection 12 mg
12 mg, Intravenous, EVERY 24 HOURS PRN, For 8 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Day 1: Administer over 3-5 minutes. Administer 30 minutes prior to CISplatin.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
Day 2, 3 and 4. Administer daily for 3 days while on chemotherapy.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+1 at 0000, nausea/vomiting, if unable to tolerate PO
Day 2, 3 and 4: Administer daily as needed for 3 days while on chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
Day 2, 3 and 4: Administer daily for 3 days while on chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+1 at 0000, If unable to tolerate PO.
Day 2, 3, and 4: Administer daily for 3 days. Administer over 3-5 minutes.
Treatment Medications
CISplatin (PLATINOL) 235 mg in sodium chloride 0.9 % 1,000 mL bag
235 mg (rounded from 235.2 mg = 120 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 to 90 minutes.
doxorubicin CONVENTIONAL (ADRIAMYCIN) 49 mg in sodium chloride 0.9 % 500 mL infusion
49 mg (25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 3 doses Starting when
released
Continuous infusion over 24 hours for a total of 72 hours starting on Day 1 (Total dose over 72 hours = 75mg/m2)
Treatment Medications (delete all that do not apply)
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 20 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, EVERY 24 HOURS, 4 doses Starting when released
Physician to delete order if not needed.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral,
Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, 1 X DAILY PRN, 2 doses Starting when released, Urine output less than 400 mL per 4 hour period.
Days 1 and 2: Administer one dose. Notify MD if additional dose is required. IV push rate 10 mg/minute. IV infusion rate 4
mg/minute.
Take Home Medications
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid and drink by mouth at 8 AM, 12
PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of methotrexate treatment., Disp-1 Bottle, R-0,
starting S, No Print
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 21 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, and Urinalysis; INPATIENT CHEMOTHERAPY ADMISSION: High dose
methotrexate.
DAY 28 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, and Urinalysis; INPATIENT CHEMOTHERAPY ADMISSION: High dose
methotrexate.
DAY 36 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; INPATIENT CHEMOTHERAPY ADMISSION:
CISplatin and doxorubicin infusion.
Day 8 - Lab Only, Cycle 3 – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 21 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 3 – Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 21 - High Dose Methotrexate, Cycle 3 – Planned for 9/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 22 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than or equal to
7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Total Bilirubin, Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 23 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or
equal to 100K/µL or Creatinine greater than 1.5 mg/dL.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less than 7, give sodium bicarbonate
50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate and then every 8 hours until
methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and check urine pH every 2 hours until urine
pH is greater than or equal to 7 for two consecutive occurrences. See Conditional Medications and Additional Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in 8 hours or
three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Hydration
sodium chloride 0.9 % infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Prehydration - infuse over 2 hours prior to methotrexate.
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
at 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium Bicarbonate infusion
must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) injection 16 mg
16 mg, Intravenous, PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral therapy, Administer
over 3 Minutes
Give 30 minutes prior to chemotherapy. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, For 12 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Give 30 minutes prior to chemotherapy.
Treatment Medications
methotrexate PF 11,760 mg in dextrose 5 % 1,000 mL bag
11,760 mg (6,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Do not administer until urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+1 at 0000,
Administer over 3 Minutes
Start 24 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 29 mg
29 mg (rounded from 29.4 mg = 15 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, Administer over 3 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal to 0.5
µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 24 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until Discontinued, High Dose
Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg
leucovorin PO every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, for urine pH less than 7, Administer over 1
Minutes
IV push over 5 minutes.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm methotrexate level undetectable, 15 mg,
Disp-16 tab, R-0, EVERY 6 HOURS starting S
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid and drink by mouth at 8 AM, 12
PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of methotrexate treatment., Disp-1 Bottle, R-0,
starting S, No Print
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 28 - High Dose Methotrexate, Cycle 3 – Planned for 9/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 25 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than or equal to
7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Total Bilirubin, Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than 1.5 mg/dL.
Treatment Parameters (2)
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 26 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less than 7, give sodium bicarbonate
50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate and then every 8 hours until
methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and check urine pH every 2 hours until urine
pH is greater than or equal to 7 for two consecutive occurrences. See Conditional Medications and Additional Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in 8 hours or
three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Hydration
sodium chloride 0.9 % infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Prehydration - infuse over 2 hours prior to methotrexate.
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
at 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium Bicarbonate infusion
must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) injection 16 mg
16 mg, Intravenous, PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral therapy, Administer
over 3 Minutes
Give 30 minutes prior to chemotherapy. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, For 12 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Give 30 minutes prior to chemotherapy.
Treatment Medications
methotrexate PF 11,760 mg in dextrose 5 % 1,000 mL bag
11,760 mg (6,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Do not administer until urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+1 at 0000,
Administer over 3 Minutes
Start 24 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 29 mg
29 mg (rounded from 29.4 mg = 15 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, Administer over 3 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal to 0.5
µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg leucovorin PO
every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Conditional Orders
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 27 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, for urine pH less than 7, Administer over 1
Minutes
IV push over 5 minutes.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm methotrexate level undetectable, 15 mg,
Disp-16 tab, R-0, EVERY 6 HOURS starting S
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 9/26/2017 through 10/30/2017 (35 days), Planned
Day 1 - Cisplatin and Infusional Doxorubicin, Cycle 4 – Planned for 9/26/2017
Treatment Plan Information
Reference Information (1)
SARCOMA: Bacci G, et al. J Clin Oncol 1998;16:658-63.
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 28 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, 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 or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
Hydration
sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration* Infuse 1000 mL over 2 hours prior to CISplatin.
sodium chloride 0.9 % infusion
Intravenous, Starting when released
Post chemotherapy hydration - MD to delete if not needed.
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer 30 minutes prior to CISplatin.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 8 hours Starting when released, nausea/vomiting, if unable to tolerate PO
Day 1: Administer 30 minutes prior to CISplatin.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer 30 minutes prior to CISplatin.
dexamethasone (DECADRON) 10 MG/ML injection 12 mg
12 mg, Intravenous, EVERY 24 HOURS PRN, For 8 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Day 1: Administer over 3-5 minutes. Administer 30 minutes prior to CISplatin.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
Day 2, 3 and 4. Administer daily for 3 days while on chemotherapy.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+1 at 0000, nausea/vomiting, if unable to tolerate PO
Day 2, 3 and 4: Administer daily as needed for 3 days while on chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
Day 2, 3 and 4: Administer daily for 3 days while on chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+1 at 0000, If unable to tolerate PO.
Day 2, 3, and 4: Administer daily for 3 days. Administer over 3-5 minutes.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 29 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Medications
CISplatin (PLATINOL) 235 mg in sodium chloride 0.9 % 1,000 mL bag
235 mg (rounded from 235.2 mg = 120 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 to 90 minutes.
doxorubicin CONVENTIONAL (ADRIAMYCIN) 49 mg in sodium chloride 0.9 % 500 mL infusion
49 mg (25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 3 doses Starting when
released
Continuous infusion over 24 hours for a total of 72 hours starting on Day 1 (Total dose over 72 hours = 75mg/m2)
Treatment Medications (delete all that do not apply)
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, EVERY 24 HOURS, 4 doses Starting when released
Physician to delete order if not needed.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral,
Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, 1 X DAILY PRN, 2 doses Starting when released, Urine output less than 400 mL per 4 hour period.
Days 1 and 2: Administer one dose. Notify MD if additional dose is required. IV push rate 10 mg/minute. IV infusion rate 4
mg/minute.
Take Home Medications
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid and drink by mouth at 8 AM, 12
PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of methotrexate treatment., Disp-1 Bottle, R-0,
starting S, No Print
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 21 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, and Urinalysis; INPATIENT CHEMOTHERAPY ADMISSION: High dose
methotrexate.
DAY 28 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, and Urinalysis; INPATIENT CHEMOTHERAPY ADMISSION: High dose
methotrexate.
DAY 36 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; INPATIENT CHEMOTHERAPY ADMISSION:
CISplatin and doxorubicin infusion.
Day 8 - Lab Only, Cycle 4 – Planned for 10/3/2017
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 30 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 4 – Planned for 10/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 21 - High Dose Methotrexate, Cycle 4 – Planned for 10/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 31 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than or equal to
7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 32 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Total Bilirubin, Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than 1.5 mg/dL.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less than 7, give sodium bicarbonate
50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate and then every 8 hours until
methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and check urine pH every 2 hours until urine
pH is greater than or equal to 7 for two consecutive occurrences. See Conditional Medications and Additional Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in 8 hours or
three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Hydration
sodium chloride 0.9 % infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Prehydration - infuse over 2 hours prior to methotrexate.
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
at 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium Bicarbonate infusion
must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) injection 16 mg
16 mg, Intravenous, PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral therapy, Administer
over 3 Minutes
Give 30 minutes prior to chemotherapy. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, For 12 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Give 30 minutes prior to chemotherapy.
Treatment Medications
methotrexate PF 11,760 mg in dextrose 5 % 1,000 mL bag
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 33 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

11,760 mg (6,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Do not administer until urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+1 at 0000,
Administer over 3 Minutes
Start 24 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 29 mg
29 mg (rounded from 29.4 mg = 15 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, Administer over 3 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal to 0.5
µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg leucovorin PO
every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, for urine pH less than 7, Administer over 1
Minutes
IV push over 5 minutes.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm methotrexate level undetectable, 15 mg,
Disp-16 tab, R-0, EVERY 6 HOURS starting S
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid and drink by mouth at 8 AM, 12
PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of methotrexate treatment., Disp-1 Bottle, R-0,
starting S, No Print
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 28 - High Dose Methotrexate, Cycle 4 – Planned for 10/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 34 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than or equal to
7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 35 of 56
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: CBC, ANC, Total Bilirubin, Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than 1.5 mg/dL.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less than 7, give sodium bicarbonate
50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate and then every 8 hours until
methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and check urine pH every 2 hours until urine
pH is greater than or equal to 7 for two consecutive occurrences. See Conditional Medications and Additional Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in 8 hours or
three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Hydration
sodium chloride 0.9 % infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Prehydration - infuse over 2 hours prior to methotrexate.
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
at 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium Bicarbonate infusion
must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) injection 16 mg
16 mg, Intravenous, PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral therapy, Administer
over 3 Minutes
Give 30 minutes prior to chemotherapy. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, For 12 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Give 30 minutes prior to chemotherapy.
Treatment Medications
methotrexate PF 11,760 mg in dextrose 5 % 1,000 mL bag
11,760 mg (6,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Do not administer until urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 98 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 36 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+1 at 0000,
Administer over 3 Minutes
Start 24 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 29 mg
29 mg (rounded from 29.4 mg = 15 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, Administer over 3 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal to 0.5
µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg leucovorin PO
every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, for urine pH less than 7, Administer over 1
Minutes
IV push over 5 minutes.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm methotrexate level undetectable, 15 mg,
Disp-16 tab, R-0, EVERY 6 HOURS starting S
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 10/31/2017 through 12/4/2017 (35 days), Planned
Day 1 - Cisplatin and Infusional Doxorubicin, Cycle 5 – Planned for 10/31/2017
Treatment Plan Information
Reference Information (1)
SARCOMA: Bacci G, et al. J Clin Oncol 1998;16:658-63.
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 37 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, 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 or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
Hydration
sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration* Infuse 1000 mL over 2 hours prior to CISplatin.
sodium chloride 0.9 % infusion
Intravenous, Starting when released
Post chemotherapy hydration - MD to delete if not needed.
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer 30 minutes prior to CISplatin.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 8 hours Starting when released, nausea/vomiting, if unable to tolerate PO
Day 1: Administer 30 minutes prior to CISplatin.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer 30 minutes prior to CISplatin.
dexamethasone (DECADRON) 10 MG/ML injection 12 mg
12 mg, Intravenous, EVERY 24 HOURS PRN, For 8 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Day 1: Administer over 3-5 minutes. Administer 30 minutes prior to CISplatin.
ondansetron (ZOFRAN) tab 16 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 38 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

16 mg, Oral, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
Day 2, 3 and 4. Administer daily for 3 days while on chemotherapy.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+1 at 0000, nausea/vomiting, if unable to tolerate PO
Day 2, 3 and 4: Administer daily as needed for 3 days while on chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
Day 2, 3 and 4: Administer daily for 3 days while on chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+1 at 0000, If unable to tolerate PO.
Day 2, 3, and 4: Administer daily for 3 days. Administer over 3-5 minutes.
Treatment Medications
CISplatin (PLATINOL) 235 mg in sodium chloride 0.9 % 1,000 mL bag
235 mg (rounded from 235.2 mg = 120 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 to 90 minutes.
doxorubicin CONVENTIONAL (ADRIAMYCIN) 49 mg in sodium chloride 0.9 % 500 mL infusion
49 mg (25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 3 doses Starting when
released
Continuous infusion over 24 hours for a total of 72 hours starting on Day 1 (Total dose over 72 hours = 75mg/m2)
Treatment Medications (delete all that do not apply)
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, EVERY 24 HOURS, 4 doses Starting when released
Physician to delete order if not needed.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral,
Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, 1 X DAILY PRN, 2 doses Starting when released, Urine output less than 400 mL per 4 hour period.
Days 1 and 2: Administer one dose. Notify MD if additional dose is required. IV push rate 10 mg/minute. IV infusion rate 4
mg/minute.
Take Home Medications
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid and drink by mouth at 8 AM, 12
PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of methotrexate treatment., Disp-1 Bottle, R-0,
starting S, No Print
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 21 FOLLOW-UP
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 39 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, and Urinalysis; INPATIENT CHEMOTHERAPY ADMISSION: High dose
methotrexate.
DAY 28 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, and Urinalysis; INPATIENT CHEMOTHERAPY ADMISSION: High dose
methotrexate.
DAY 36 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; INPATIENT CHEMOTHERAPY ADMISSION:
CISplatin and doxorubicin infusion.
Day 8 - Lab Only, Cycle 5 – Planned for 11/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 5 – Planned for 11/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 40 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 21 - High Dose Methotrexate, Cycle 5 – Planned for 11/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than or equal to
7 for two consecutive occurrences.
METHOTREXATE
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 41 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Total Bilirubin, Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than 1.5 mg/dL.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less than 7, give sodium bicarbonate
50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate and then every 8 hours until
methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and check urine pH every 2 hours until urine
pH is greater than or equal to 7 for two consecutive occurrences. See Conditional Medications and Additional Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in 8 hours or
three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Hydration
sodium chloride 0.9 % infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Prehydration - infuse over 2 hours prior to methotrexate.
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
at 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium Bicarbonate infusion
must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 42 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) injection 16 mg
16 mg, Intravenous, PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral therapy, Administer
over 3 Minutes
Give 30 minutes prior to chemotherapy. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, For 12 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Give 30 minutes prior to chemotherapy.
Treatment Medications
methotrexate PF 11,760 mg in dextrose 5 % 1,000 mL bag
11,760 mg (6,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Do not administer until urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+1 at 0000,
Administer over 3 Minutes
Start 24 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 29 mg
29 mg (rounded from 29.4 mg = 15 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, Administer over 3 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal to 0.5
µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg leucovorin PO
every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, for urine pH less than 7, Administer over 1
Minutes
IV push over 5 minutes.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm methotrexate level undetectable, 15 mg,
Disp-16 tab, R-0, EVERY 6 HOURS starting S
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid and drink by mouth at 8 AM, 12
PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of methotrexate treatment., Disp-1 Bottle, R-0,
starting S, No Print
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 3:56:50 PM Page 43 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Day 28 - High Dose Methotrexate, Cycle 5 – Planned for 11/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than or equal to
7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 44 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily
methotrexate levels when drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Total Bilirubin, Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than 1.5 mg/dL.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less than 7, give sodium bicarbonate
50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate and then every 8 hours until
methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and check urine pH every 2 hours until urine
pH is greater than or equal to 7 for two consecutive occurrences. See Conditional Medications and Additional Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in 8 hours or
three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Hydration
sodium chloride 0.9 % infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Prehydration - infuse over 2 hours prior to methotrexate.
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
at 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium Bicarbonate infusion
must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) injection 16 mg
16 mg, Intravenous, PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral therapy, Administer
over 3 Minutes
Give 30 minutes prior to chemotherapy. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 10 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 45 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

10 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, For 12 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Give 30 minutes prior to chemotherapy.
Treatment Medications
methotrexate PF 11,760 mg in dextrose 5 % 1,000 mL bag
11,760 mg (6,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Do not administer until urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+1 at 0000,
Administer over 3 Minutes
Start 24 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 29 mg
29 mg (rounded from 29.4 mg = 15 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, Administer over 3 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal to 0.5
µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg leucovorin PO
every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, for urine pH less than 7, Administer over 1
Minutes
IV push over 5 minutes.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm methotrexate level undetectable, 15 mg,
Disp-16 tab, R-0, EVERY 6 HOURS starting S
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 12/5/2017 through 1/8/2018 (35 days), Planned
Day 1 - Cisplatin and Infusional Doxorubicin, Cycle 6 – Planned for 12/5/2017
Treatment Plan Information
Reference Information (1)
SARCOMA: Bacci G, et al. J Clin Oncol 1998;16:658-63.
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 46 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, 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 or equal to 1,500/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than upper limits of normal.
Nursing Procedure, Assessment and Monitoring
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Monitor urine output and IV intake.
Hydration
sodium chloride 0.9 % 1,000 mL with potassium chloride 20 mEq infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
*Pre-hydration* Infuse 1000 mL over 2 hours prior to CISplatin.
sodium chloride 0.9 % infusion
Intravenous, Starting when released
Post chemotherapy hydration - MD to delete if not needed.
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer 30 minutes prior to CISplatin.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 47 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 8 hours Starting when released, nausea/vomiting, if unable to
tolerate PO
Day 1: Administer 30 minutes prior to CISplatin.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Day 1: Administer 30 minutes prior to CISplatin.
dexamethasone (DECADRON) 10 MG/ML injection 12 mg
12 mg, Intravenous, EVERY 24 HOURS PRN, For 8 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Day 1: Administer over 3-5 minutes. Administer 30 minutes prior to CISplatin.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
Day 2, 3 and 4. Administer daily for 3 days while on chemotherapy.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+1 at 0000, nausea/vomiting, if unable to tolerate PO
Day 2, 3 and 4: Administer daily as needed for 3 days while on chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
Day 2, 3 and 4: Administer daily for 3 days while on chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+1 at 0000, If unable to tolerate PO.
Day 2, 3, and 4: Administer daily for 3 days. Administer over 3-5 minutes.
Treatment Medications
CISplatin (PLATINOL) 235 mg in sodium chloride 0.9 % 1,000 mL bag
235 mg (rounded from 235.2 mg = 120 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
For 60 to 90 minutes.
doxorubicin CONVENTIONAL (ADRIAMYCIN) 49 mg in sodium chloride 0.9 % 500 mL infusion
49 mg (25 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 3 doses Starting when
released
Continuous infusion over 24 hours for a total of 72 hours starting on Day 1 (Total dose over 72 hours = 75mg/m2)
Treatment Medications (delete all that do not apply)
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, EVERY 24 HOURS, 4 doses Starting when released
Physician to delete order if not needed.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral,
Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, 1 X DAILY PRN, 2 doses Starting when released, Urine output less than 400 mL per 4 hour period.
Days 1 and 2: Administer one dose. Notify MD if additional dose is required. IV push rate 10 mg/minute. IV infusion rate 4
mg/minute.
Take Home Medications
sodium bicarbonate oral powder
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 48 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid and drink by mouth at 8 AM, 12
PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of methotrexate treatment., Disp-1 Bottle, R-0,
starting S, No Print
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 21 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, and Urinalysis; INPATIENT CHEMOTHERAPY ADMISSION: High dose
methotrexate.
DAY 28 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, and Urinalysis; INPATIENT CHEMOTHERAPY ADMISSION: High dose
methotrexate.
DAY 36 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; INPATIENT CHEMOTHERAPY ADMISSION:
CISplatin and doxorubicin infusion.
Day 8 - Lab Only, Cycle 6 – Planned for 12/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 - Lab Only, Cycle 6 – Planned for 12/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
IV Access
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 49 of 56
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 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 21 - High Dose Methotrexate, Cycle 6 – Planned for 12/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 50 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than or equal to
7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Total Bilirubin, Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than 1.5 mg/dL.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less than 7, give sodium bicarbonate
50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate and then every 8 hours until
methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and check urine pH every 2 hours until urine
pH is greater than or equal to 7 for two consecutive occurrences. See Conditional Medications and Additional Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in 8 hours or
three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Hydration
sodium chloride 0.9 % infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Prehydration - infuse over 2 hours prior to methotrexate.
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 51 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

at 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium Bicarbonate infusion
must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) injection 16 mg
16 mg, Intravenous, PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral therapy, Administer
over 3 Minutes
Give 30 minutes prior to chemotherapy. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, For 12 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Give 30 minutes prior to chemotherapy.
Treatment Medications
methotrexate PF 11,760 mg in dextrose 5 % 1,000 mL bag
11,760 mg (6,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Do not administer until urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+1 at 0000,
Administer over 3 Minutes
Start 24 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 29 mg
29 mg (rounded from 29.4 mg = 15 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, Administer over 3 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal to 0.5
µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg leucovorin PO
every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, for urine pH less than 7, Administer over 1
Minutes
IV push over 5 minutes.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
Take Home Medications
leucovorin 15 MG tab
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 52 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm methotrexate level undetectable, 15 mg,
Disp-16 tab, R-0, EVERY 6 HOURS starting S
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid and drink by mouth at 8 AM, 12
PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of methotrexate treatment., Disp-1 Bottle, R-0,
starting S, No Print
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 28 - High Dose Methotrexate, Cycle 6 – Planned for 1/1/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Osteosarcoma (Neoadjuvant/Advanced); THERAPY: CISplatin 120 mg/m2 IV Day 1; doxorubicin 25 mg/m2/day
continuous infusion IV over 24 hours on Day 1 through 3 for a total of 72 hours (total dose over 72 hours = 75 mg/m2); methotrexate
6 to 12 grams/m2 IV Day 21 and 28; leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by
leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by
mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L; CYCLE LENGTH: 35 days; COURSE: 6 to 12
cycles.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
ONCE Starting when released, Routine
ABSOLUTE NEUTROPHIL COUNT
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
URINALYSIS WITH MICROSCOPY
ONCE Starting when released
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 53 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater
than or equal to 7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Total Bilirubin, Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1,500/µL or Platelets less than or equal to 100K/µL or
Creatinine greater than 1.5 mg/dL.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less than 7, give sodium bicarbonate
50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate and then every 8 hours until
methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and check urine pH every 2 hours until urine
pH is greater than or equal to 7 for two consecutive occurrences. See Conditional Medications and Additional Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in 8 hours or
three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Hydration
sodium chloride 0.9 % infusion
at 500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Prehydration - infuse over 2 hours prior to methotrexate.
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
at 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium Bicarbonate infusion
must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 54 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
ondansetron (ZOFRAN) injection 16 mg
16 mg, Intravenous, PRN Starting when released Until Discontinued, nausea/vomiting, if unable to tolerate oral therapy, Administer
over 3 Minutes
Give 30 minutes prior to chemotherapy. Administer over 3 to 5 minutes.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, For 12 hours Starting when released, nausea/vomiting, If unable to tolerate PO
Give 30 minutes prior to chemotherapy.
Treatment Medications
methotrexate PF 11,760 mg in dextrose 5 % 1,000 mL bag
11,760 mg (6,000 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Do not administer until urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 98 mg
98 mg (50 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+1 at 0000,
Administer over 3 Minutes
Start 24 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 29 mg
29 mg (rounded from 29.4 mg = 15 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, Administer over 3 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal to 0.5
µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg leucovorin PO
every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, for urine pH less than 7, Administer over 1
Minutes
IV push over 5 minutes.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, Administer over 3 Minutes
Administer over 3 to 5 minutes. Total of 3 ondansetron doses per 24 hours (scheduled and PRN)
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm methotrexate level undetectable, 15 mg,
Disp-16 tab, R-0, EVERY 6 HOURS starting S
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Jeff J [2507481]
6/13/2017 3:56:50 PM Page 55 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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 3:56:50 PM Page 56 of 56
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org