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/clinical/cckm-tools/content/order-sets/inpatient/bmtoncologyhematology/name-124583-en.cckm

20180126

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,BMT/Oncology/Hematology

IP - Full Volume Exchange Transfusion - Sickle Cell - Pediatric - Supplemental [5407]

IP - Full Volume Exchange Transfusion - Sickle Cell - Pediatric - Supplemental [5407] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


IP - Full Volume Exchange Transfusion - Sickle Cell - Pediatric - Supplemental
[5407]
Pre-Procedure Orders
Treatment Conditions [135445]
Treatment Condition A [NURCOM0022] ONCE, Starting today For 1 Occurrences, Admin
Instructions: If hemoglobin is less than 8.5 g/dL, do
NOT phlebotomize. If hemoglobin is greater
than or equal to 8.5 g/dL, phlebotomize 10 mL/kg = ***
mL whole blood over 30 minutes. See
hydration orders if bolus is required prior to
phlebotomy.
Treatment Condition B [NURCOM0022] ONCE, Starting today For 1 Occurrences, Admin
Instructions: If ferritin level is greater than or equal to
500 ng/mL, then IV piggy back deferoxamine
15 mg/kg with PRBC infusion.
deferoxamine (DESFERAL) in sodium chloride
0.9 % 250 mL bag [700188]
15 mg/kg, Intravenous, ONCE For 1 Doses
Administer if Ferritin level is greater than or equal to
500 mg/mL. Max dose = 500 mg
Pre-Procedure Medications [135444]
acetaMINOPHEN (TYLENOL) disintegrating tab
[64412]
Oral, ONCE For 1 Doses
No more than 4 grams acetaminophen per 24 hours
for adults or 15 mg/kg per dose for peds < 40 kg
For patients unable to swallow tablets or take
suspension. Max dose = 640 mg
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
15 mg/kg, Oral, ONCE For 1 Doses
No more than 4 grams acetaminophen per 24 hours
for adults or 15 mg/kg per dose for peds < 40 kg.
For patients unable to swallow tablets. Max dose =
650 mg
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, ONCE For 1 Doses
No more than 4 grams acetaminophen per 24 hours
for adults or 15 mg/kg per dose for peds < 40 kg.
Max dose = 650 mg
diphenhydramine (BENADRYL) cap [36791] Oral, ONCE For 1 Doses
diphenhydramine (BENADRYL) elixir [36793] 1 mg/kg, Oral, ONCE For 1 Doses
For patients unable to swallow capsules.
Max dose = 25 mg
diphenhydramine (BENADRYL) injection [800106] 1 mg/kg, Intravenous, ONCE For 1 Doses
For patients unable to take PO
Max dose = 25 mg
hydrocortisone sodium succinate injection
[800189]
1 mg/kg, Intravenous, ONCE PRN For 1 Doses,
infusion reaction
Administer over 3 minutes
Max dose = 100 mg
General Medications
Non-Categorized General Medications [135446]
to Flush Venous Access Device per Guidelines Refer
sodium chloride flush 0.9% 10 mL injection
[785055]
Flush, PRN, flush/line care
Flush per VAD guidelines
heparin lock flush 10 UNIT/ML injection [75031] 1-150 units, Flush, PRN, flush/line care
Flush per VAD guidelines
heparin lock flush 100 UNIT/ML injection [64978] 500 units, Flush, PRN, flush/line care
Implanted port use ONLY to be used when de-
accessing port. Flush per VAD guidelines
Emergency Medications [135448]
Page 1 of 6
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:11:46 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection [800106] 1 mg/kg, Intravenous, ONCE PRN For 1 Doses,
infusion reaction
hydrocortisone sodium succinate injection
[800189]
1 mg/kg, Intravenous, ONCE For 1 Doses
Administer over 3 minutes
acetaMINOPHEN (TYLENOL) disintegrating tab
[64412]
Oral, ONCE PRN For 1 Doses, infusion reaction,
blood products
No more than 4 grams acetaminophen per 24 hours
for adults or 15 mg/kg per dose for peds < 40 kg
For patients unable to swallow tablets or take
suspension. Max dose = 640 mg.
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, ONCE PRN For 1 Doses, pain
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
Max dose = 650 mg.
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
15 mg/kg, Oral, ONCE PRN For 1 Doses, infusion
reaction, blood products
No more than 4 grams acetaminophen per 24 hours
for adults or 15 mg/kg per dose for peds < 40 kg
For patients unable to take tablets. Max dose = 650
mg
Patient Care Orders
Non-Categorized Patient Care Orders [153862]
Glucose, POC [IPGLUCOSE] SEE COMMENTS, 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?
Check blood glucose half way through transfusion and
then 2 hours post transfusion.
Notify [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Laboratory
Draw Half-Way Through Transfusion [153865]
Page 2 of 6
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:11:46 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] SPECIFIC TIME 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.
CBC WITH DIFFERENTIAL [CBC] SPECIFIC TIME For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] SPECIFIC TIME For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATINE [HCCREATN] SPECIFIC TIME For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL [TBIL] SPECIFIC TIME For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FERRITIN [FER] SPECIFIC TIME For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PLATELET COUNT [PLT] SPECIFIC TIME For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
RETICULOCYTE COUNT [RET] SPECIFIC TIME For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEMOGLOBIN [HGB] SPECIFIC TIME For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEMOGLOBIN VARIANT, A2 AND F,
QUANTITATION [HGBA2F]
SPECIFIC TIME For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Procedure Labs [181703]
TYPE AND SCREEN [HCTS] CONDITIONAL, 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.
Page 3 of 6
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:11:46 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

CBC WITH DIFFERENTIAL [CBC] CONDITIONAL, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] CONDITIONAL, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATINE [HCCREATN] CONDITIONAL, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL [TBIL] CONDITIONAL, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FERRITIN [FER] CONDITIONAL, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, 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.
PLATELET COUNT [PLT] CONDITIONAL, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
RETICULOCYTE COUNT [RET] CONDITIONAL, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEMOGLOBIN [HGB] CONDITIONAL, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEMOGLOBIN VARIANT, A2 AND F,
QUANTITATION [HGBA2F]
CONDITIONAL, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw 1 Hour After Transfusion [153866]
HEMOGLOBIN VARIANT, A2 AND F,
QUANTITATION [HGBA2F]
NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw 1 hour post infusion.
Blood Bank
Blood Bank - Transfuse [153878]
Page 4 of 6
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:11:46 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT, Starting today For Until
specified, Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose: 10
mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Transfuse Reconstituted Blood For Exchange
Transfusion [NURTRT0074]
ONCE For 1 Occurrences, Routine, Transfuse
reconstituted blood total volume of *** mLs over 2
hours at a rate of *** mL/hour. Every 10 minutes,
phlebotomize 1/12th of the total volume being
transfused, for a total of 12 phlebotomies.
Blood Bank - Transfuse [181697]
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT, Starting today For Until
specified, Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
Transfuse Reconstituted Blood For Exchange
Transfusion [NURTRT0074]
ONCE For 1 Occurrences, Routine, Transfuse
reconstituted blood total volume of *** mLs over 2
hours at a rate of *** mL/hour. Every 10 minutes,
phlebotomize 1/12th of the total volume being
transfused, for a total of 12 phlebotomies.
Blood Bank - Order Products [181700]
Red Blood Cells (Pediatric) [BLB0013] 1 UNIT, Starting today For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
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:
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):
Volume-Reduced (May be pre-selected based on
history):
Consent Status:
Blood Bank - Order Products [181702]
Page 5 of 6
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:11:46 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 1 UNIT, 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
Does this patient have hemoglobinopathy and/or
thalassemia?
Date Product Needed:
Consent Status:
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):
Indication for Irradiated Blood:
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Date Consent Obtained (Valid for 1 year):
Page 6 of 6
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:11:46 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org