/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/inpatient/,/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/,

/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98276-en.cckm

201606170

page

100

UWHC,UWMF,

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

IP - Eculizumab Non-Oncology Infusion - Pediatric - Supplemental [5793]

IP - Eculizumab Non-Oncology Infusion - Pediatric - Supplemental [5793] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


SmartSet: IP- ECULIZUMAB NON-ONCOLOGY INFUSION - PEDIATRIC -
SUPPLEMENTAL (ID:5793)
General Information
Display name: IP- ECULIZUMAB NON-ONCOLOGY INFUSION - PEDIATRIC - SUPPLEMENTAL
Type: General
Merge priority:
Version comment:
Content source:
Synonyms: 1. soliris
2. renal
3. peds
SmartSet notes:
Description: PROVIDER must be enrolled in eculizumab REMS program to order drug.
Web information: Title URL
1. Eculizumab Patient Medication Guide http://www.solirisrems.com/docs/Medication-Guide.pdf
2. Eculizumab REMS http://www.accessdata.fda.gov/scripts/cder/rems/index.cfm
Questionnaire:
Configuration
Patient Care Orders
Vital Signs
Vital Signs SEE COMMENTS For Until specified, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Monitor Vital Signs every 15 minutes during eculizumab
infusion and every 30 minutes until 1 hour post infusion. If
patient experiences fever accompanied by chills or rigors,
shortness of breath, chest pain, or hypotension, stop infusion
and contact MD.
Contingency Parameters
Notify Provider Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
Page 1 of 3
Pr i nt ed by SCHUHMACHER, KARI A [KAS18] at 9/22/2015 3:51:30 PM
Approved by: Dr. Sharon Bartosh, Kim Squires, NP, Kitty Montgomery, CNS, Jodie Hustad, RN, Josh Vanderloo, RPh, Kari Schuhmacher, Builder
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

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: Patient develops signs of an infusion reaction (flushing,
hives, dyspnea, wheezing)
Nursing Communication - Monitoring ONCE, Starting S For 1 Occurrences, Hypersensitivity to
eculizumab can occur. Monitor patient during infusion and for
one hour post infusion.
Nursing Communication - Pre-Treatment ONCE, Starting S For 1 Occurrences, Verify patient has
received appropriate meningococcal vaccine(s) at least 2
weeks prior to first dose of eculuzimab or consider
prophylaxis (penicillin daily throughout treatment and
continuing for 3 months after last dose).
If urgent treatment with eculizumab is necessary in an
unvaccinated patient, administer meningococcal vaccine as
soon as possible
Medications
Pre-infusion
acetaMINOPHEN (TYLENOL) tab Oral, ONCE For 1 Doses
Administer prior to eculizumab infusion.
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Maximum dose 650 mg
15 mg/kg, Oral, ONCE For 1 Doses
Administer prior to eclizumab infusion.
Pre-infusion Antihistamines
diphenhydramine (BENADRYL) elixir - NOTE:
Maximum dose 50 mg
1 mg/kg, Oral, ONCE For 1 Doses
Prior to immune globulin
diphenhydramine (BENADRYL) injection - NOTE:
Maximum dose 50 mg
1 mg/kg, Intravenous, ONCE For 1 Doses
Prior to immune globulin
cetirizine (ZYRTEC) syrup Oral, ONCE For 1 Doses
Administer prior to eculizumab infusion. (Dose based on age:
2 to 6 years: 2.5 mg, 6 to 12 years: 5 mg; Greater than12
years: 10 mg.)
cetirizine (ZYRTEC) tab Oral, ONCE For 1 Doses
Administer prior to eculizumab infusion. (Dose based on age:
2 to 6 years: 2.5 mg, 6 to 12 years: 5 mg; Greater than12
years: 10 mg.)
Emergency Medications
diphenhydramine (BENADRYL) injection 1 mg/kg, Intravenous, ONCE PRN For 1 Doses, itching,
infusion reaction
hydrocortisone sod suc in sodium chloride 0.9%
injection
Intravenous, ONCE PRN For 1 Doses, infusion reaction
albuterol 2.5 mg/0.5 mL neb soln 2.5 mg, Nebulization, PRN, dyspnea, other, infusion reaction
epINEPHrine (ANAPHYLAXIS) injection Intramuscular, PRN, shortness of breath, anaphylaxis,
infusion reaction
Treatment Medication
eculizumab (SOLIRIS) in sodium chloride 0.9 % 1 mL Intravenous, ONCE Starting S For 1 Doses
Page 2 of 3
Pr i nt ed by SCHUHMACHER, KARI A [KAS18] at 9/22/2015 3:51:30 PM
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

bag Hypersensitivity risk, see emergency medications. Administer
over *** hours. Dose should be administered over 1 to 4 hours
based on patient's prior tolerance to drug and provider
discretion.) (Dose = {Provider select dosing schedule based
on patient weight:7700044}
Criteria
Suggestions:
Filter: UWIP ORDER SET RESTRICTION - HOSPITAL ENCOUNTERS EXCEPT ED - NOT IP DC
[3000400]
Restrict SmartSet:
Settings
Discontinue action:
Deselect sections for
Pended/Held orders:
Pended/Held orders display:
Release date: Use System Definitions Setting
Disallow user override:
Page 3 of 3
Pr i nt ed by SCHUHMACHER, KARI A [KAS18] at 9/22/2015 3:51:30 PM
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

Eculizumab Indications and Dosing Smartlist and Dosing from Lexicomp Updated 150624 
 
 
 
View of option for patients greater than or equal to 40 kg: 
 
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison

 

Eculizumab Indications and Dosing Smartlist and Dosing from Lexicomp Updated 150624 
 
 
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison