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/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98215-en.cckm

201708216

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Hospital-wide

IP – Infliximab Infusion – Pediatric – Supplemental [1211]

IP – Infliximab Infusion – Pediatric – Supplemental [1211] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Infliximab Infusion - Pediatric - Supplemental [1211]
Evaluate Prior to Prescribing Infliximab
TB Evaluation [191787]
A TB evaluation with a negative result must be completed prior to initiation of infliximab therapy.
TB Evaluation Results [NURCOM0022] ONCE For 1 Occurrences, RN verify negative TB evaluation
within 6 months prior to the first dose of infliximab.
@BRIEFLAB
(QUGOLDQUL,QUGOLDMG,QFERONNIL,QUGOLDNONIL)
@
@BRIEFLAB(PPD)@
QUANTIFERON-TB GOLD [GM8455] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Patient Care Orders
Vital Signs [15212]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Obtain blood pressure, heart rate, temperature, and
respiratory rate prior to infusion, 15 minutes after
infusion started, 60 minutes after infusion started, and
at the completion of the infusion.
Non-Categorized Patient Care Orders [15213]
Measure Height [NURMON0052] SEE COMMENTS, Starting today, Routine, Measure
height each visit.
Measure Weight [NURMON0015] SEE COMMENTS, Starting today with First
Occurrence As Scheduled, Routine
Weigh With?
Weigh when?
Measure weight each visit.
Contingency Parameters [15214]
Page 1 of 4
Printed by WILLIAMS, HEATHER R [HRS0] at 7/31/2017 10:16:49 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Notify Provider [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):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: If heart rate changes by plus or minus 20
beats/minute from baseline,if blood pressure changes
by plus or minus 20 mmHg from baseline,patient
develops signs of an infusion reaction (flushing, hives,
dyspnea, wheezing).
Medications
Pre-infusion [16460]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
15 mg/kg, Oral, ONCE For 1 Doses
Administer 30 minutes prior to infliximab
NOTE: Recommended 15 mg/kg/dose (maximum 650
mg/dose)
acetaMINOPHEN (TYLENOL) tab - NOTE:
Suggested dose15 mg/kg [34149]
Oral, ONCE For 1 Doses
Administer 30 minutes prior to infliximab
NOTE: Recommended 15 mg/kg/dose (maximum 650
mg/dose)
cetirizine (ZYRTEC) syrup - NOTE: age = 2 - 5.99
years dose = 5 mg; age = greater than 6 years
dose = 10 mg [54047]
Oral, ONCE For 1 Doses
Dose based on age: 2 - 5.99 years = 5 mg
Greater than 6 years = 10 mg
Administer prior to infusion
cetirizine (ZYRTEC) tab - NOTE: age = 2 - 5.99
years dose = 5 mg; age = greater than 6 years
dose = 10 mg [51071]
Oral, ONCE For 1 Doses
Dose based on age: 2 - 5.99 years = 5 mg
Greater than 6 years = 10 mg
Administer prior to infusion
dexamethasone (DECADRON) intraVENOUS -
NOTE: Recommended 0.1 mg/kg/dose (maximum
4 mg/dose) [800037]
0.1 mg/kg, Intravenous, ONCE For 1 Doses
Administer 30 minutes prior to infliximab
Recommended 0.1 mg/kg/dose (maximum 4 mg/dose)
Infusion Agent [16461]
infliximab (REMICADE) intraVENOUS [800268] 5 mg/kg, Intravenous, ONCE
Administer with 0.2 or 0.22 micron filter
Administer at 10 mL/hr for 15 minutes, then 20 mL/hr
for 15 minutes, then 40 mL/hr for 15 minutes, then 80
mL/hr for 15 minutes, then 150 mL/hr for 30 minutes,
then 250 mL/hr until completed. For adverse
reactions, stop infusion.
Pharmacy to round dose to not less than 5 mg/kg or
greater than 10 mg/kg
Adverse Reactions [16462]
Page 2 of 4
Printed by WILLIAMS, HEATHER R [HRS0] at 7/31/2017 10:16:49 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
15 mg/kg, Oral, ONCE PRN For 1 Doses, pain/fever,
infusion reaction
Do not administer within 3 hours of previous dose.
Use if patient unable to swallow tablet
No more than 4 grams acetaminophen per 24 hours
for adults or 15 mg/kg per dose for peds < 40 kg
acetaMINOPHEN (TYLENOL) tab - NOTE dose
15 mg/kg per dose [34149]
Oral, ONCE PRN For 1 Doses, pain/fever, infusion
reaction
Do not administer within 3 hours of previous dose
No more than 4 grams acetaminophen per 24 hours
for adults or 15 mg/kg per dose for peds < 40 kg
diphenhydramine (BENADRYL) injection -
Maximum Dose = 50 mg [800106]
1 mg/kg, Intravenous, ONCE PRN For 1 Doses,
infusion reaction
dexamethasone (DECADRON) intraVENOUS
[800037]
0.1 mg/kg, Intravenous, ONCE PRN For 1 Doses,
infusion reaction
hydrocortisone sodium succinate injection
[800189]
1 mg/kg, Intravenous, ONCE PRN For 1 Doses,
infusion reaction
Laboratory
Draw Prior to Each Infusion [15215]
CBC WITH DIFFERENTIAL [CBC] CONDITIONAL - RN COLLECT, Starting today For
Until specified, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw prior to
infliximab infusion
ESR [ESR] CONDITIONAL - RN COLLECT, Starting today For
Until specified, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw prior to
infliximab infusion
Draw prior to each infusion.
AST/SGOT [AST] CONDITIONAL - RN COLLECT, Starting today For
Until specified, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw prior to
infliximab infusion
ALT/SGPT [ALT] CONDITIONAL - RN COLLECT, Starting today For
Until specified, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw prior to
infliximab infusion
GGT [GGT] CONDITIONAL - RN COLLECT, Starting today For
Until specified, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw prior to
infliximab infusion
ALKALINE PHOSPHATASE [ALKP] CONDITIONAL - RN COLLECT, Starting today For
Until specified, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw prior to
infliximab infusion
Page 3 of 4
Printed by WILLIAMS, HEATHER R [HRS0] at 7/31/2017 10:16:49 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL [TBIL] CONDITIONAL - RN COLLECT, Starting today For
Until specified, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw prior to
infliximab infusion
BILIRUBIN, DIRECT [DBIL] CONDITIONAL - RN COLLECT, Starting today For
Until specified, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw prior to
infliximab infusion
ALBUMIN [ALB] CONDITIONAL - RN COLLECT, Starting today For
Until specified, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw prior to
infliximab infusion
PROTEIN, TOTAL [TP] CONDITIONAL - RN COLLECT, Starting today For
Until specified, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw prior to
infliximab infusion
C REACTIVE PROTEIN [CRPN] CONDITIONAL - RN COLLECT, Starting today For
Until specified, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw prior to
infliximab infusion
FERRITIN [FER] CONDITIONAL - RN COLLECT, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw prior to
infliximab infusion
IRON AND TRANSFERRIN W/ TIBC,
SATURATION [FETRANS]
CONDITIONAL - RN COLLECT, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
INFLIXIMAB ACTIVITY AND NEUTRALIZING AB
[HCINFLIXNA]
CONDITIONAL - RN COLLECT, Starting today For
Until specified, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 4 of 4
Printed by WILLIAMS, HEATHER R [HRS0] at 7/31/2017 10:16:49 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org