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/clinical/cckm-tools/content/order-sets/ambulatory/general-surgery/name-98578-en.cckm

20180129

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,General Surgery

FDS - HIPEC Surgery - Adult - Preoperative [4997]

FDS - HIPEC Surgery - Adult - Preoperative [4997] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, General Surgery


FDS - HIPEC Surgery - Adult - Preoperative [4997]
for Adult Patients OnlyIntended
PreOp Day of Procedure
Isolation Status [97372]
Enhanced Contact Isolation - CDIFF [ISO0348] What is the reason for isolation?
Separate order must be placed for isolation cart., Pre-
Op Day Of Procedure
Contact Isolation - MDRO (MRSA) [ISO0334] CONTINUOUS
What is the Reason for Isolation? MRSA
Separate order must be placed for isolation cart., Pre-
Op Day Of Procedure
Contact Isolation - MDRO (VRE) [ISO0334] CONTINUOUS
What is the Reason for Isolation? VRE
Separate order must be placed for isolation cart., Pre-
Op Day Of Procedure
Isolation - Protective Precautions [240760]
Protective Precautions [ISO0349] What is the Reason for Isolation?
Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Protective - Positive Pressure Room
[NURCOM0109]
CONTINUOUS
Isolation - Contact - Multidrug Resistant
Organism (MDRO) [233557]
Contact Isolation - MDRO [ISO0334] CONTINUOUS
What is the Reason for Isolation? MDR
Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Isolation - Contact - Multidrug Resistant
Organism (XDR) [233558]
Contact Isolation - MDRO (XDR) [ISO0334] CONTINUOUS
What is the Reason for Isolation? XDR
Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Perioperative Normogyclemia Management - For First Day Surgery Patients Only (Single Response)
[216835]
equal to 6.4%diabetes history includes prediabetes and patients with A1C less than or No
Patients withOUT Diabetes [216834]
Glucose, POC [IPGLUCOSE] ONCE For 1 Occurrences, Routine, Glucose, POC
should always be ordered in conjunction with orders
for hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Pre-Op Day Of Procedure
Glucose, POC [IPGLUCOSE] EVERY 2 HOURS, Routine, Glucose, POC should
always be ordered in conjunction with orders for
hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Repeat POC glucose if previous reading greater
than or equal to 180 mg/dL. No recheck for reading
< 180 mg/dL, Pre-Op Day Of Procedure
Page 1 of 11
Printed by STRAKA, KEVIN F [KFS1] at 1/26/2018 2:32:24 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Other (Comment)
Notify based on: Blood Glucose
If blood glucose > (mg/dL): 179
If blood glucose < (mg/dL):
Pre-Op Day Of Procedure
Patients WITH Diabetes [216834]
Glucose, POC [IPGLUCOSE] ONCE For 1 Occurrences, Routine, Glucose, POC
should always be ordered in conjunction with orders
for hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Pre-Op Day Of Procedure
Glucose, POC [IPGLUCOSE] EVERY 2 HOURS, Routine, Glucose, POC should
always be ordered in conjunction with orders for
hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Repeat POC glucose if previous reading greater
than or equal to 180 mg/dL. No recheck for reading
< 180 mg/dL, Pre-Op Day Of Procedure
Notify Provider [NURCOM0001] Provider to Notify: Other (Comment)
Notify based on: Blood Glucose
If blood glucose > (mg/dL): 179
If blood glucose < (mg/dL):
Pre-Op Day Of Procedure
Medications - Hypoglycemia Treatment [212994]
URL:
Hypoglycemia Management (Adult) [191576]
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today For Until specified,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Pre-Op Day Of Procedure
Page 2 of 11
Printed by STRAKA, KEVIN F [KFS1] at 1/26/2018 2:32:24 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA
TREATMENT, Starting today For Until specified,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Per hypoglycemia treatment algorithm Recheck
glucose 15 minutes after providing treatment until
glucose is greater than or equal to 70 mg/dL. If
patient has been critically low (i.e., glucose less than
40 mg/dL), recheck glucose after 1 hour to ensure
glucose remains greater than or equal to 70mg/dL.
After resolution of mild hypoglycemia (i.e., glucose
40-69 mg/dL), consider rechecking after 1 hour if
patient has signs/symptoms of hypoglycemia or is at
risk for a subsequent hypoglycemic event (e.g.,
previously administered insulin still active, altered
renal status, altered mental status, NPO or
interrupted nutrition, or any other condition that
increases hypoglycemia risk), Pre-Op Day Of
Procedure
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Glucose,Other
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
Other: Nutritional status changes
Pre-Op Day Of Procedure
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If blood glucose less
than 40mg/dL and patient able to eat/swallow safely.
Give 30 grams of carbohydrate (8 oz. of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., Pre-Op Day Of Procedure
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If glucose is 40-69
mg/dL and patient able to eat/swallow safely
Give 15 grams of carbohydrate (4 oz of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., Pre-Op Day Of Procedure
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose 40-
69 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
Pre-Op Day Of Procedure
glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose
less than 40 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
Pre-Op Day Of Procedure
Page 3 of 11
Printed by STRAKA, KEVIN F [KFS1] at 1/26/2018 2:32:24 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

glucagon injection kit [107799] 1 mg, Subcutaneous, PRN, For blood glucose less
than 69 mg/dL and patient unable to eat/swallow
safely AND has NO IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Pre-Op Day Of Procedure
dextrose injection [800233] 12.5 g, Intravenous, PRN, For blood glucose 40-69
mg/dL and patient unable to eat/swallow safely AND
has IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Pre-Op Day Of Procedure
dextrose injection [800233] 25 g, Intravenous, PRN, For blood glucose less than
40 mg/dL and patient unable to eat/swallow safely
AND has IV access.
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Pre-Op Day Of Procedure
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
Pre-Op Day Of Procedure
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting 2/3/18 For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
Pre-Op Day Of Procedure
Non-Categorized Patient Care Orders [152995]
Glucose, POC [IPGLUCOSE] ONCE, Starting today For 1 Occurrences, Routine,
Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia management
and monitoring as indicated in the Hypoglycemia
Management (Adult) panel.
If Conditional, What Condition?
Pre-Op Day Of Procedure
Mattress Air Transfer Hovermat - Order for
Bariatric Patients [NURCOM0022]
ONCE, Pre-Op Day Of Procedure
Bariatric Bed-Mighty Air Sizewise (Specialty Bed)
[EQP0034]
CONTINUOUS, Starting today, Routine
Trapeze Needed:
Time Needed:
Last patient height? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date in
comment):
Send Request to CS?
Deliver Equipment To:
Pre-Op Day Of Procedure
Premedications for Needle Insertion [106313]
Page 4 of 11
Printed by STRAKA, KEVIN F [KFS1] at 1/26/2018 2:32:24 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30
minutes time prior to needing to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV
access; onset is immediate.
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Pre-Op Day Of Procedure
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, peripheral line
insertion - see Admin Instructions
Do NOT apply to area greater than 200 square
centimeters (maximum 2.5 g/site; maximum 4 sites
per hour, 6 times per day). Do NOT leave on longer
than 2 hours. Use for stable patient, no allergies to
lidocaine, with at least 30 minutes time prior to IV use
Pre-Op Day Of Procedure
sodium chloride (bacteriostatic) 0.9 % injection
[50585]
0.05-0.1 mL, Intradermal, PRN, peripheral line
insertion - see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into center
of wheal. Use if IV is needed within 30 minutes.
Pre-Op Day Of Procedure
Medications - Steroid Dosing for Transplant Patients [95452]
hydrocortisone sodium succinate injection
[800189]
100 mg, Intravenous, ON CALL For 1 Doses
Give one hour prior to surgery
Pre-Op Day Of Procedure
IV Fluids [236129]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Pre-Op Day Of Procedure
Laboratory [86275]
PROTHROMBIN TIME/INR [PT] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
POTASSIUM [K] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
Laboratory - Pregnancy Test [81397]
surgery is pelvic, renal, pregnancy test if female between menarche & menopause and any of: (1) Obtain
intercourse, (3) patient missed menses, (4) patient says abdominal, (2) patient had unprotected -or intra
pregnant. she "could" be
Urine, Pregnancy Test [UPREG] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
Tests [91574]
Page 5 of 11
Printed by STRAKA, KEVIN F [KFS1] at 1/26/2018 2:32:24 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

TYPE AND SCREEN [HCTS] STAT, Starting today For 1 Occurrences, Routine, As
good clinical practice and for patient safety, the
Transfusion Service will automatically crossmatch 2
packed RBCs on all patients with antibodies to ensure
blood would be available in the event it is needed. If
you would like to opt out of this automatic order for this
patient please contact the UWHC Blood Bank at (608)
263-8367 or The American Center Lab at (608) 234-
6600 as appropriate., Pre-Op Day Of Procedure
Blood Products [83983]
Red Blood Cells (Adult) [BLB0006] 1 UNIT, Starting today For 1 Occurrences, Routine
Reason for Order: R1 Life-threatening hemorrhage or
anticipated/ongoing surgical blood loss
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): SURGICAL USE
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Consent Status:
Pre-Op Day Of Procedure
Plasma (Adult) [BLB0003] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): SURGICAL USE
Date Product Needed:
Consent Status:
Pre-Op Day Of Procedure
Platelets (Adult) [BLB0004] 1 SINGLE, Starting today For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): SURGICAL USE
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Consent Status:
Pre-Op Day Of Procedure
Page 6 of 11
Printed by STRAKA, KEVIN F [KFS1] at 1/26/2018 2:32:24 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Cryoprecipitate (Adult) [BLB0005] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): SURGICAL USE
Date Product Needed:
Consent Status:
Fibrin Glue, mLs Needed:
Pre-Op Day Of Procedure
Diagnostic Tests and Imaging [113348]
ECG - 12 Lead [EKG0008] ONCE For 1 Occurrences, Routine
Reason for exam: Pre-operative
Disclaimer for University Hospital Only: A Stat status
for an ECG is in reference to the timing of the ECG.
The goal is to perform a STAT ECG within 10 minutes
of the order being placed. It is the responsibility of the
ordering provider to review the STAT ECGs. All ECGs
(stat or routine) will be formally reviewed within one
business day.
Pre-Operative, General Anesthesia
VTE Prophylaxis
VTE Prophylaxis [105649]
• If low risk for development of VTE - select VTE Prophylaxis - Reason Not Ordered
• If requires VTE prophylaxis AND
◦ LOW bleed risk - select pharmacologic agent only
◦ ABSOLUTE bleed risk - select mechanical agents only
◦ HIGH bleed risk - weigh risk of bleed vs risk of VTE development and select drug OR
mechanical agent
NOTE: Mechanical and pharmacologic agents should only be used together in patients
with a very high risk of VTE development
VTE Risk Factor Assessment Tool URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Sequential Compression Device (SCD) Panel
(TREATMENT AND SUPPLY) [206111]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
IntraOp
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
IntraOp
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
Pre-Op Day Of Procedure
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, ON CALL For 1 Doses
If patient scheduled for block, give after block placed
IntraOp
enoxaparin (LOVENOX) subcutanoeus injection
[800040]
40 mg, Subcutaneous, ON CALL For 1 Doses, IntraOp
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE For 1 Occurrences, Routine
Reason Not Ordered:
Pre-Op Day Of Procedure
Surgical Prophylaxis
Page 7 of 11
Printed by STRAKA, KEVIN F [KFS1] at 1/26/2018 2:32:24 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

First Line (Single Response) [154510]
Patients who are 40 - 120 kg - Cefazolin +
Metronidazole [227835]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are greater than 120 kg - Cefazolin
+ Metronidazole [227838]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Documented MRSA or history of MRSA or MRSE risk (Single Response) [146274]
Patients who are 40 - 120 kg Cefoxitin and
Vancomycin [241396]
cefoxitin (MEFOXIN) intraVENOUS [800022] 2 g, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are greater than 120 kg Cefoxitin
and Vancomycin [241399]
cefoxitin (MEFOXIN) intraVENOUS [800022] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients with IgE-mediated or Severe Reaction to Beta Lactams (Single Response) [146896]
Patients who are 40 - 120 kg [236149]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are 121 - 160 kg [236151]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are greater than 160 kg [236150]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients with IgE-mediated or severe reaction to Beta-lactam AND MRSA or history of MRSA or MRSE
Risk (Single Response) [146275]
Patients who are 40 - 120 kg [236152]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose - 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are greater than 120 kg [236153]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose - 2000 mg/dose [800084]
2 g, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
Page 8 of 11
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

IntraOp
Non-Categorized General Medications [133358]
CISplatin - Sodium Thiosulfate [219077] "Followed by" Linked Panel
CISplatin (PLATINOL) 1 MG/ML
intraPERITONEAL injection [785241]
16.7 mg/m2, Intraperitoneal, ONCE For 1 Doses
For Hyperthermic Intraperitoneal Chemotherapy
(HIPEC) ONLY. Inject into HIPEC machine reservoir
for circulation throughout peritoneal cavity.
Total approved dose = 50mg/m2 divided into 3
syringes of 16.7 mg/m2 each
CISplatin (PLATINOL) 1 MG/ML
intraPERITONEAL injection [785241]
16.7 mg/m2, Intraperitoneal, ONCE For 1 Doses
For Hyperthermic Intraperitoneal Chemotherapy
(HIPEC) ONLY. Inject into HIPEC machine reservoir
for circulation throughout peritoneal cavity.
Total approved dose = 50mg/m2 divided into 3
syringes of 16.7 mg/m2 each
CISplatin (PLATINOL) 1 MG/ML
intraPERITONEAL injection [785241]
16.7 mg/m2, Intraperitoneal, ONCE For 1 Doses
For Hyperthermic Intraperitoneal Chemotherapy
(HIPEC) ONLY. Inject into HIPEC machine reservoir
for circulation throughout peritoneal cavity.
Total approved dose = 50mg/m2 divided into 3
syringes of 16.7 mg/m2 each
sodium thiosulfate 25 % IV BOLUS bag [770036] 7.5 g/m2, Intravenous, ONCE For 1 Doses, for 10
Minutes
sodium thiosulfate in dextrose 5 % 1,000 mL 12hr
infusion bag [701023]
21 g/m2, Intravenous, ONCE For 1 Doses
PACLItaxel [219078] "And" Linked Panel
PACLItaxel (TAXOL) 6 MG/ML
intraPERITONEAL injection [785242]
115 mg/m2, Intraperitoneal, ONCE For 1 Doses
For Hyperthermic Intraperitoneal Chemotherapy
(HIPEC) ONLY. Inject into HIPEC machine reservoir
for circulation through peritoneal cavity
Total approved dose = 175mg/m2 divided into 2
syringes of 115 mg/m2 and 60 mg/m2 each
PACLItaxel (TAXOL) 6 MG/ML
intraPERITONEAL injection [785242]
60 mg/m2, Intraperitoneal, ONCE For 1 Doses
For Hyperthermic Intraperitoneal Chemotherapy
(HIPEC) ONLY. Inject into HIPEC machine reservoir
for circulation through peritoneal cavity
Total approved dose = 175mg/m2 divided into 2
syringes of 115 mg/m2 and 60 mg/m2 each
Mitomycin - 30 mg per meters squared [245304] "And" Linked Panel
mitomycin (MUTAMYCIN) in sodium chloride 0.9
% 1 mL intraperitoneal injection [700599]
20 mg/m2, Intraperitoneal, ONCE For 1 Doses
For Hyperthermic Intraperitoneal Chemotherapy
(HIPEC) ONLY. Inject into HIPEC machine reservoir
for circulation through peritoneal cavity
Total approved dose = 30mg/m2 divided into 2
syringes of 20mg/m2 and 10mg/m2 each
mitomycin (MUTAMYCIN) in sodium chloride 0.9
% 1 mL intraperitoneal injection [700599]
10 mg/m2, Intraperitoneal, ONCE For 1 Doses
For Hyperthermic Intraperitoneal Chemotherapy
(HIPEC) ONLY. Inject into HIPEC machine reservoir
for circulation through peritoneal cavity
Total approved dose = 30mg/m2 divided into 2
syringes of 20mg/m2 and 10mg/m2 each
Mitomvcin 40 mg FLAT dose [245305] "Followed by" Linked Panel
Page 9 of 11
Printed by STRAKA, KEVIN F [KFS1] at 1/26/2018 2:32:24 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

mitomycin (MUTAMYCIN) in sodium chloride 0.9
% 1 mL intraperitoneal injection [700599]
30 mg, Intraperitoneal, ONCE For 1 Doses
For Hyperthermic Intraperitoneal Chemotherapy
(HIPEC) ONLY. Inject into HIPEC machine reservoir
for circulation through peritoneal cavity
mitomycin (MUTAMYCIN) in sodium chloride 0.9
% 1 mL intraperitoneal injection [700599]
10 mg, Intraperitoneal, ONCE Starting H+45 Minutes
For 1 Doses
For Hyperthermic Intraperitoneal Chemotherapy
(HIPEC) ONLY. Inject into HIPEC machine reservoir
for circulation through peritoneal cavity
Diagnostic Tests and Imaging [86376]
Imaging in OR [R10000] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
IntraOp
Medications - Order for Patients Receiving Cisplatin [236128]
ondansetron (ZOFRAN) in sodium chloride 0.9 %
50 mL bag [700249]
16 mg, Intravenous, ONCE For 1 Doses, IntraOp
fosaprepitant (EMEND) in sodium chloride 0.9 %
250 mL bag [700967]
150 mg, Intravenous, ONCE For 1 Doses, IntraOp
dexamethasone (DECADRON) intraVENOUS
[800037]
10 mg, Intravenous, ONCE For 1 Doses, IntraOp
PostOp/Phase II
Medications - Steroid Dosing for Transplant Patients [95455]
hydrocortisone sodium succinate injection
[800189]
100 mg, Intravenous, ONCE For 1 Doses
Give 6 hours after surgery
Post-Op/Phase II
Diagnosis
Diagnosis - Pre Op [711]
Pre-operative general physical examination
[255759]
Other specified pre-operative examination
Diagnosis - Immunizations [101181]
Need for prophylactic vaccination against
Haemophilus influenzae type B [992472]
Diagnosis
Anthrax exposure [323600] Contact with or exposure to anthrax
Need for prophylactic vaccination against
Streptococcus pneumoniae (pneumococcus)
[V03.82.ICD-9-CM]
Need for prophylactic vaccination against
streptococcus pneumoniae(pneumococcus)
Need for prophylactic vaccination and inoculation
against influenza [V04.81.ICD-9-CM]
Need for prophylactic vaccination and inoculation
against influenza
Need for vaccination for meningococcus
[253964]
Need for other specified prophylactic vaccination
against single bacterialdisease
Level of Service
Office Visit - Established Patients [30779]
99211 - Level I LOS Code
99212 - Level II LOS Code
99213 - Level III LOS Code
99214 - Level IV LOS Code
Page 10 of 11
Printed by STRAKA, KEVIN F [KFS1] at 1/26/2018 2:32:24 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

99215 - Level V LOS Code
99211 - w/ Resident (GC) - Level I LOS Code
99212 - w/ Resident (GC) - Level II LOS Code
99213 - w/ Resident (GC) - Level III LOS Code
99214 - w/ Resident (GC) - Level IV LOS Code
99215 - w/ Resident (GC) - Level V LOS Code
Preoperative Exam (Global) [1265]
Preoperative H&P, No Charge, Surgical Package LOS Code
Page 11 of 11
Printed by STRAKA, KEVIN F [KFS1] at 1/26/2018 2:32:24 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org