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/clinical/cckm-tools/content/order-sets/inpatient/bmtoncologyhematology/name-124690-en.cckm

20180236

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100

UWHC,UWMF,

Tools,

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

IP - Partial Volume Exchange Transfusion - Hematology/Oncology - Pediatric - Supplemental [5075]

IP - Partial Volume Exchange Transfusion - Hematology/Oncology - Pediatric - Supplemental [5075] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


IP - Partial Volume Exchange Transfusion - Hematology/Oncology - Pediatric -
Supplemental [5075]
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
Treatment Medications
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.
Page 1 of 6
Printed by TAYLOR, ELAINE [ECT2] at 1/30/2018 3:23:58 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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
Treatment Medications (Single Response) [135801]
oxycodone (OXYCONTIN) 12hr ER tab - 10 mg
x1 [158267]
10 mg, Oral, ONCE For 1 Doses
oxycodone (OXYCONTIN) 12hr ER tab - 20 mg
x1 [158267]
20 mg, Oral, ONCE For 1 Doses
oxycodone tab - 10 mg x1 [45976] 10 mg, Oral, ONCE For 1 Doses
oxycodone tab - 20 mg x1 [45976] 20 mg, Oral, ONCE For 1 Doses
oxycodone soln - 10 mg x1 [45975] 10 mg, Oral, ONCE For 1 Doses
oxycodone soln - 20 mg x1 [45975] 20 mg, Oral, ONCE For 1 Doses
HYDROmorphone (DILAUDID) tab - x1 [38268] Oral, ONCE For 1 Doses
HYDROmorphone PF (DILAUDID) injection
[800120]
Intravenous, EVERY 2 HOURS PRN, pain
ketOROLAC (TORADOL) injection - x1 [800050] Intravenous, ONCE For 1 Doses
FENTanyl PF injection RANGE [750047] Intravenous, EVERY 2 HOURS PRN, pain, for 1
Minutes
MORPHine PF injection RANGE [750057] Intravenous, EVERY 2 HOURS PRN, pain, for 4
Minutes
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
Emergency Medications [135448]
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.
Page 2 of 6
Printed by TAYLOR, ELAINE [ECT2] at 1/30/2018 3:23:58 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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
Laboratory
Pre-Procedure Labs [135676]
TYPE AND SCREEN [HCTS] STAT - RN COLLECT, 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.
BUN [BUN] STAT - RN COLLECT, 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?
CBC WITH DIFFERENTIAL [CBC] STAT - RN COLLECT, 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?
CREATININE [CRET] STAT - RN COLLECT, 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?
BILIRUBIN, TOTAL [TBIL] STAT - RN COLLECT, 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?
FERRITIN [FER] STAT - RN COLLECT, 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?
PLATELET COUNT [PLT] STAT - RN COLLECT, 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?
RETICULOCYTE COUNT [RET] STAT - RN COLLECT, 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?
Page 3 of 6
Printed by TAYLOR, ELAINE [ECT2] at 1/30/2018 3:23:58 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

HEMOGLOBINAPATHY EVALUATION
[XHGBEV]
STAT - RN COLLECT, 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?
Post Procedure Labs [135681]
HEMOGLOBIN VARIANT, A2 AND F,
QUANTITATION [HGBA2F]
SPECIFIC TIME - RN COLLECT 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
HEMOGLOBIN [HGB] CONDITIONAL - RN COLLECT, 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? Obtain 1 hour after
PRBC infusion is complete.
Blood Bank
Blood Bank - Transfuse [135682]
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT 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: 2 Hours
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
RBCs, leukopoor filtered.
Blood Bank - Transfuse [186042]
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT 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: 2 Hours
RBCs, leukopoor filtered.
Blood Bank - Order Products [152491]
Page 4 of 6
Printed by TAYLOR, ELAINE [ECT2] at 1/30/2018 3:23:58 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 (Pediatric) [BLB0013] 1 UNIT For Until specified, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR10 Other
Specify Other Reason: Hemoglobin less than or equal
to 8 grams/Deciliter and patient has had a blood or
bone marrow transplant
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL USE
Date Product Needed: 1/30/2018
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): Yes
Indication for Irradiated Blood:
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: Consent Obtained
Date Consent Obtained (Valid for 1 year):
Starting when released Until Specified, Hemoglobin S
negative, phenotype matched
RBCs, leukopoor filtered.
Blood Bank - Order Products [186043]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For Until specified, Routine
Reason for Order: R8 Other
Specify Other Reason: Hemoglobin less than or equal
to 8 grams/Deciliter and patient has had a blood or
bone marrow transplant
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL USE
Date Product Needed: 1/30/2018
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): Yes
Indication for Irradiated Blood:
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Consent Status: Consent Obtained
Date Consent Obtained (Valid for 1 year):
Starting when released Until Specified, Hemoglobin S
negative, phenotype matched
RBCs, leukopoor filtered.
Page 5 of 6
Printed by TAYLOR, ELAINE [ECT2] at 1/30/2018 3:23:58 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [139216]
HEMOGLOBINAPATHY EVALUATION
[XHGBEV]
SPECIFIC TIME - RN COLLECT, 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?
One hour after transfer.
Page 6 of 6
Printed by TAYLOR, ELAINE [ECT2] at 1/30/2018 3:23:58 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org