Unique Plan Description: ONC Methotrexate
Plan Selection Display: ONC Methotrexate
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2021-11-05 10:30:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-08-07 14:49:02
Available at all facilities: Yes

ONC Methotrexate
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+1;0400, Routine, Q24H, spec type = Blood
	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, 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 for 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+240
			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
Premeds
	ondansetron/dexamethasone/NS 50mL
		12 mg, IVPB, Once, Routine, 200 ml/hr, T;N+270
			Comment: Infuse over 15 minutes. Give 30 minutes prior to chemo
		12 mg, EVERY BAG
		50 mL, EVERY BAG
	Emend for Injection
		150 mg, INT, IVPB, Once, infuse over 30 min(s), T;N+270
Chemotherapy Agent
		3gm/m2 dose(NOTE)*
	methotrexate/sodium bicarb/D5W 1000mL
		3,000 mg/m2, IVPB, Once, T;N+300, 250 ml/hr
			Comment: Start when urine pH is > 7
		50 mEq, EVERY BAG
		40 mL, EVERY BAG
		1,000 mL, EVERY BAG
		3.5gm/m2 dose(NOTE)*
		50 mEq, EVERY BAG
		40 mL, EVERY BAG
		1,000 mL, EVERY BAG
		3,500 mg/m2, IVPB, Once, T;N+300, 250 ml/hr
			Comment: Start when urine pH is > 7
		4gm/m2 dose(NOTE)*
		50 mEq, EVERY BAG
		40 mL, EVERY BAG
		1,000 mL, EVERY BAG
		4,000 mg/m2, IVPB, Once, T;N+300, 250 ml/hr
			Comment: Start when urine pH is > 7
		6gm/m2 dose(NOTE)*
		50 mEq, EVERY BAG
		40 mL, EVERY BAG
		1,000 mL, EVERY BAG
		6,000 mg/m2, IVPB, Once, T;N+300, 250 ml/hr
			Comment: Start when urine pH is > 7
		8gm/m2 dose(NOTE)*
		50 mEq, EVERY BAG
		40 mL, EVERY BAG
		1,000 mL, EVERY BAG
		8,000 mg/m2, IVPB, Once, T;N+300, 250 ml/hr
			Comment: Start when urine pH is > 7
Medications

	ondansetron
		8 mg, Tablet-Disintegrating, By Mouth, BID, T+1;0900, duration: 4 Dose(s)/Time(s)
	dexAMETHasone
		8 mg, IV Push, DAILY, T+1;0900, duration: 2 Dose(s)/Time(s)
	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
		20 mg, INT, IVPB, Q6H, T+1;N+300
			Comment: start 24 hours after methotrexate started. Do not y-site with sodium bicarbonate infusion. Continue until methotrexate level <0.05 mcmol/L
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

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
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		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