Unique Plan Description: ONC Hyper CVAD Cycle B
Plan Selection Display: ONC Hyper CVAD Cycle B
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2023-11-10 11:41:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-08-07 14:47:40
Available at all facilities: Yes

ONC Hyper CVAD Cycle B
Activity
	Ambulate
		T;N, QID
			Comment: Out of bed and ambulating 5 times per day
Diet
	Advance Diet as Tolerated
		
Laboratory
	CBC with Diff
		T;N, Stat, spec type = Blood
		T;N, Routine, Q24H, spec type = Blood
	Basic Metabolic Panel
		T+1;0400, Routine, Q24H, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Stat, spec type = Blood
	Methotrexate Level
		T+2;0400, Routine, Q24H, spec type = Blood
	pH Urine
		T;N+240, Routine, Routine, spec type = Urine, Q3H
			Comment: After pre-hydration completed.
	Pregnancy Test Urine
		T;N, Stat, Stat, Urine Random, spec type = Urine
IV Solutions
Chemotherapy PreHydration
	Dextrose 5% w/Sodium bicarbonate 50 mEq IV 1000 mL
		1,000 mL, IV, 2 Dose(s)/Time(s), 500 ml/hr
			Comment: Prehydration, give total volume of 2000mL, for alkalization of urine
		50 mEq, EVERY BAG
	Dextrose 5% in Water
		1,000 mL, IV, T;N+240, 1 Dose(s)/Time(s), 125 ml/hr
			Comment: Start after pre-hydration complete, use as primary with methotrexate.  Start at 125ml/hr until methotrexate starts, then run at 25ml/hr as flush
	Dextrose 5% w/Sodium bicarbonate 100 mEq IV 1000 mL
		100 mEq, IVPB, Once, PRN see comment, infuse over 2 hr, T;N
			Comment: Start after 2 liters of prehydration completed if urine pH still < OR equal to 7.0
		1,000 mL, EVERY BAG
	Dextrose 5% w/Sodium bicarbonate 50 mEq IV 1000 mL
		1,000 mL, IV, T;N+540, 125 ml/hr
			Comment: Start after methotrexate complete and continue until discharge or until methotrexate level < 0.05mcmol/L
		50 mEq, EVERY BAG
	sodium bicarbonate 100mEq/100mL
		100 mL, IV, Routine, T;N+300
			Comment: Increase to 2mEq/hr when methotrexate started, continue until discharge or until methotrexate level < 0.05mcmol/LRun concurrently with D5W If urine pH <7.0, increase by 1mEq/hrIf urine pH at 7.0 to 8.0, keep at same rateIf urine pH >8.0, decrease by 1mEq/hr
		100 mEq, EVERY BAG, 1 mEq/hr
	Sodium Chloride 0.9%
		250 mL, IV, T+1;N+30, 1 Dose(s)/Time(s), 25 ml/hr
			Comment: DAY 2: use as primary/flush with cytarabine
		250 mL, IV, T+2;N+30, 1 Dose(s)/Time(s), 25 ml/hr
			Comment: DAY 3: use as primary/flush with cytarabine
Medications

	prochlorperazine
		10 mg, Tab, By Mouth, Q8H, PRN nausea and/or vomiting
			Comment: For nausea refractory to zofran
		10 mg, IV Push, Q8H, PRN nausea and/or vomiting
			Comment: For nausea refractory to ondansetron
	LORazepam
		0.5 mg, Injection, IV Push, Q6H, PRN anxiety
			Comment: Related to anticipatory nausea/vomiting
	leucovorin
		50 mg, INT, IVPB, Q6H, T;N+1020
			Comment: Start 24 hours after methotrexate started. Do not y-site with sodium bicarbonate infusion. Continue until methotrexate level <0.05 mcmol/L
Premeds
	palonosetron
		0.25 mg, Injection, IV Push, Once, T;+270
			Comment: Give on Days 1
	ondansetron
		8 mg, Tablet-Disintegrating, By Mouth, Q12H, T+1;1930, duration: 4 Dose(s)/Time(s)
			Comment: Give on Days 2 and 3, give 30 minutes prior to cytarabine doses
	methylPREDNISolone
		50 mg, Injection, IV Push, BID, T;N, duration: 6 Dose(s)/Time(s)
			Comment: Give on Days 1, 2, and 3
	dexAMETHasone 0.1% ophthalmic solution
		1 gtt, Solution, Eye, Both, QID, T;N, duration: 10 Day(s)
			Comment: 10 days total duration
	Emend for Injection
		150 mg, INT, IVPB, Once, infuse over 30 min(s), T;N+270
Chemotherapy Agent
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY background-color: rgb(198,241,255);margin:0; P margin:0 </STYLE><META name=GENERAT(NOTE)*
	methotrexate/sodium bicarb/D5W 1000mL
		1,000 mL, EVERY BAG
		1,000 mg/m2, IVPB, Once, T;N+300, Infuse Over 22 hr
			Comment: [1 grams/m2 dose] Start when urine pH is > 7
		50 mEq, EVERY BAG
		40 mL, EVERY BAG
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY background-color: rgb(198,241,255);margin:0; P margin:0 </STYLE><META name=GENERAT(NOTE)*
		3,000 mg/m2, IVPB, Once, T;N+300, 41.6 ml/hr
			Comment: [3 grams/m2 dose] Start when urine pH is > 7
		50 mEq, EVERY BAG
		40 mL, EVERY BAG
		1,000 mL, EVERY BAG
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY background-color: rgb(198,241,255);margin:0; P margin:0 </STYLE><META name=GENERAT(NOTE)*
		3,500 mg/m2, IVPB, Once, T;N+300, 41.6 ml/hr
			Comment: [3.5 grams/m2 dose] Start when urine pH is > 7
		50 mEq, EVERY BAG
		40 mL, EVERY BAG
		1,000 mL, EVERY BAG
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY background-color: rgb(198,241,255);margin:0; P margin:0 </STYLE><META name=GENERAT(NOTE)*
		4,000 mg/m2, IVPB, Once, T;N+300, 41.6 ml/hr
			Comment: [4 grams/m2 dose] Start when urine pH is > 7
		50 mEq, EVERY BAG
		40 mL, EVERY BAG
		1,000 mL, EVERY BAG
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY background-color: rgb(198,241,255);margin:0; P margin:0 </STYLE><META name=GENERAT(NOTE)*
		6,000 mg/m2, IVPB, Once, T;N+300, 41.6 ml/hr
			Comment: [6 grams/m2 dose] Start when urine pH is > 7
		50 mEq, EVERY BAG
		40 mL, EVERY BAG
		1,000 mL, EVERY BAG
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY background-color: rgb(198,241,255);margin:0; P margin:0 </STYLE><META name=GENERAT(NOTE)*
		8,000 mg/m2, IVPB, Once, T;N+300, 41.6 ml/hr
			Comment: [8 grams/m2 dose] Start when urine pH is > 7
		50 mEq, EVERY BAG
		40 mL
		1,000 mL, EVERY BAG
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY background-color: rgb(198,241,255);margin:0; P margin:0 </STYLE><META name=GENERAT(NOTE)*
	cytarabine/NS 1000 mL
		3,000 mg/m2, IVPB, Q12H, Routine, T+1;2000, 4 Dose(s)/Time(s), Infuse Over 3 hr
			Comment: Vesicant. Give every 12 hours, to run over 3 hours on days 2 and 3 [3 grams/m2]
		50 mL, EVERY BAG
		1,000 mL, EVERY BAG
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY background-color: rgb(198,241,255);margin:0; P margin:0 </STYLE><META name=GENERAT(NOTE)*
		1,000 mg/m2, IVPB, Q12H, Routine, T+1;2000, 4 Dose(s)/Time(s), Infuse Over 3 hr
			Comment: Vesicant. Give every 12 hours, to run over 3 hours on days 2 and 3 [1 grams/m2]
		50 mL, EVERY BAG
		1,000 mL, EVERY BAG
Patient Care

	Obtain Consent/Permit for:
		T;N, Chemotherapy
	Hazardous Drug Precautions
		T;N
	Intake and Output
		T;N, Q6H-Sch
			Comment: Notify oncologist if urine output <300mL/8H.
	Order Lab
		Urine pH q3H after pre-hydration completed. If pH < OR equal to 7, enter order for D5W with sodium bicarbonate 100mEq IV to run over 2 hours at 500 mL/hr. If urine pH still < OR equal to 7, notify provider.
	Notify MD
		Oncology, if weight gain >2kg from admission weight
		Oncology, if urine output <300mL in 8H
		Oncology, of methotrexate level result, daily
	IV-Maintain
		T;N
			Comment: Ensure 2 vascular access devices
	Oral Care
		T;N, BID
	Neuro Checks
		T;N, Q4H-Sch
	No NSAIDS (non steroidal anti-inflamatory)
		
	No PPI (proton pump inhibitor)
		
	No Sulfamethoxazole/Trimethoprim
		Except in prophylactic doses M/W/F
	Notify MD
		T;N, If infusion reaction occurs
	Initiate MD Plan for:
		T;N, Allergy Reaction protocol if patient experiences reaction to treatment
	Do not give medication
		Do not start methotrexate until urine ph greater than 7.0

CHEMO Reaction Protocol
Vital Signs
	Vital Signs
		Assess vital signs every 2 to 5 minutes until the patient is stable. Place patient into a recumbent position with elevation of the lower extremities if hypotensive
		<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY background-color: rgb(128,255,255);margin:0; P margin:0 </STYLE><META name=GENERAT(NOTE)*
		Reassess vital signs every 15 minutes x 2, then q30min x 2, or more frequently as needed, I&O, etc until stable
Activity
	Position Patient
		T;N
			Comment: If hypotensive, keep patient supine with legs elevated or bed in Trendelenburg.
IV Solutions
	Sodium Chloride 0.9% IVPB
		500 mL, Solution-Injection, IVPB, DAILY, PRN see comment, 999 ml/hr
			Comment: for reaction to chemotherapy
		1,000 mL, Solution-Injection, IVPB, DAILY, PRN see comment, 999 ml/hr
			Comment: for reaction to chemotherapy
Medications
	Benadryl
		50 mg, Injection, IV Push, DAILY, PRN see comment
			Comment: for moderate to severe reaction to chemotherapy
		25 mg, Injection, IV Push, DAILY, PRN see comment
			Comment: for moderate to severe reaction to chemotherapy
	Decadron (MH/WH)
		20 mg, Injection, IV Push, DAILY, PRN see comment
			Comment: for moderate to severe reaction to chemotherapy, 1st choice steroid
	SOLU-Medrol
		125 mg, Injection, IV Push, DAILY, PRN see comment
			Comment: for moderate to severe reaction to chemotherapy, 2nd choice steroid
	Solu-CORTEF
		100 mg, Injection, IV Push, DAILY, PRN see comment
			Comment: for moderate to severe reaction to chemotherapy, 3rd choice steroid
	EPINEPHrine
		0.5 mg, Injection, SUBCUTANEOUS, DAILY, PRN see comment
			Comment: for hypersensitivity reaction not resolved by diphenhydramine and/or anaphylactic				reactions to chemotherapy, may repeat every 10 minutes for up to 3 doses
		0.5 mg, Injection, IM-Intramuscular, DAILY, PRN see comment
			Comment: for hypersensitivity reaction not resolved by diphenhydramine and/or anaphylactic				reactions to chemotherapy, may repeat every 10 minutes for up to 3 doses
	meperidine
		25 mg, Syringe, IV Push, Once, PRN for see comment
			Comment: For chills and rigors
Patient Care
	Notify MD
		T;N, Contact the oncologist if any of the reaction protocol medications are administered to the patient.

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase