Unique Plan Description: ONC R-EPOCH
Plan Selection Display: ONC R-EPOCH
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2022-09-06 08:13:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-07-18 12:03:49
Available at all facilities: Yes

ONC R-EPOCH
Vital Signs
	Vital Signs
		Prior to beginning rituximab-abbs infusion, then with each rate change and PRN
Laboratory
	CBC with Diff
		T;N, Stat, spec type = Blood
		T+1;N, Routine, Q24H, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Stat, spec type = Blood
		T+1;N, Routine, Q24H, spec type = Blood
	Hepatitis B Surface Antigen
		T;N, Stat, spec type = Blood
	Pregnancy Test Urine
		T;N, Stat, spec type = Urine
Diagnostic Tests
	Echo w Doppler resting
		Stat, Indication: Chemotherapy/follow-up exam
			Comment: Stat if not previously done, prior to administration of doxorubicin
IV Solutions
	Sodium chloride 0.9% Chemo Flush
		25 mL, IVPB, DAILY, 250 ml/hr, T;N+30, duration: 4 Day(s)
			Comment: use as primary/flush with rituximab-abbs, and etoposide/vincristine/doxorubicin
	Dextrose 5% in water Chemo flush
		25 mL, IV, Once, 250 ml/hr, T+4;N+60
			Comment: use as primary/flush with cyclophosphamide
Medications
	filgrastim
		5 mcg/kg, Injection, SUBCUTANEOUS, DAILY, T+5;1200
			Comment: start on day 6; round to 300 mcg or 480 mcg vial
	ondansetron
		8 mg, Tablet-Disintegrating, By Mouth, Q8H, PRN nausea and/or vomiting
			Comment: nausea or vomiting not relieved by prochlorperazine (if ordered) (give oral first if able)
		8 mg, Injection, IV Push, Q8H, PRN nausea and/or vomiting
			Comment: nausea or vomiting not relieved by prochlorperazine (if ordered) (give oral first if able)
	prochlorperazine
		10 mg, Tab, By Mouth, Q8H, PRN nausea and/or vomiting
			Comment: (give oral first if able)
		10 mg, Injection, IV Push, Q8H, PRN nausea and/or vomiting
			Comment: (give oral first if able)
Premeds
	acetaminophen
		1,000 mg, Tab, By Mouth, Once, T;N+90
			Comment: give 30 minutes prior to rituximab-abbs
		650 mg, Tab, By Mouth, Once, T;N+90
			Comment: give 30 minutes prior to rituximab-abbs
	diphenhydrAMINE
		50 mg, Injection, IV Push, Once, T;N+90
			Comment: give 30 minutes prior to rituximab-abbs
		25 mg, Injection, IV Push, Once, T;N+90
			Comment: give 30 minutes prior to rituximab-abbs
	palonosetron
		0.25 mg, Injection, IV Push, Q48H, T;N+300
			Comment: give on day 1, 3, 5. Start 30 minutes prior to 3 in 1 chemo (etoposide/vincristine/DOXOrubicin) On day 5 give 30 minutes prior to cyclophosphamide
	meperidine
		25 mg, Syringe, IV Push, Once, PRN for see comment
			Comment: for rigors related to monoclonal antibodies.
	fosaprepitant
		150 mg, INT, IVPB, Once, infuse over 30 min(s), T;N+60
			Comment: infuse over 30 min(s), give on day 1, 30 minutes prior to 3 in 1
Chemotherapy Agent
		Day 1(NOTE)*
	riTUXimab-abbs/NS 500mL
		500 mL, IV, Routine, T;N+60, 1 Dose(s)/Time(s), 50 mg/hr
			Comment: Initial infusion: Start an infusion rate of 50 mg/hour; if there is no infusion-related reaction, increase the rate by 50 mg/hour increments every 30 minutes, to a maximum rate of 400 mg/hour
		375 mg/m2, EVERY BAG
	etoposide/vinCRIStine/DOXOrubicin/NS1000mL
		1,000 mL, IV, T;N+330, 4 Dose(s)/Time(s), 43.3 ml/hr
		50 mg/m2, EVERY BAG
		0.4 mg/m2, EVERY BAG
		10 mg/m2, EVERY BAG
		40 mL, EVERY BAG
		Days 1-5(NOTE)*
	predniSONE
		60 mg/m2, Tab, By Mouth, BID, duration: 10 Dose(s)/Time(s)
		Day 5(NOTE)*
	cyclophosphamide/D5W 250mL
		750 mg/m2, IVPB, Once, T+4;N+90, Infuse Over 30 min(s)
			Comment: administer on day 5 after continuous chemotherapy completed
		25 mL, EVERY BAG
		250 mL, EVERY BAG
Patient Care

	Obtain Consent/Permit for:
		T;N, or verify Consent for Chemotherapy
	Hazardous Drug Precautions
		T;N
	IV-Maintain
		T;N
			Comment: insure 2 vascular access
	Oral Care
		BID
			Comment: Strict oral care
	Notify MD
		Any abnormal baseline vital signs or Symptoms of moderate to severe reaction or severe hypersensitivity.
		T;N, Contact Provider for further orders if allergic reaction protocol initiated.
	Initiate MD Plan for:
		T;N, Allergy Reaction protocol if patient experiences reaction to treatment.
Consults/Follow-up
	Pharmacy Consult
		Pharmacist allowed to round doses to nearest measurable volume (0.1 mL) and/or vial size if dose change is not greater than 5% of original calculated dose .

Allergy Reaction Protocol
Activity
	Position Patient
		T;N
			Comment: If hypotensive, keep patient supine with legs elevated or bed in trendelenberg
IV Solutions
	Sodium Chloride 0.9%
		500 mL, IV, Routine, Bolus
		1,000 mL, IV, Routine, 30 ml/hr
Medications
	Benadryl
		50 mg, Injection, IV Push, Once, PRN, allergic reaction, NOW
		25 mg, Injection, IV Push, Once, PRN, allergic reaction, NOW
	Decadron (MH/WH)
		20 mg, Injection, IV PUSH, Once, PRN, allergic reaction
	SOLU-Medrol
		125 mg, Injection, IV Push, Once
	EPINEPHrine
		0.5 mg, Injection, SUBCUTANEOUS, Once
		0.5 mg, Injection, IM-Intramuscular, Once
		0.5 mg, Injection, SUBCUTANEOUS, Q10MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.5 mg, Injection, IM-Intramuscular, Q10MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		For infants and children up to age 12 < 30kg(NOTE)*
		0.01 mg/kg, Injection, SUBCUTANEOUS, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.01 mg/kg, Injection, IM-Intramuscular, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		For infants and children up to age 12 > or equal to 30kg(NOTE)*
		0.3 mg, Injection, SUBCUTANEOUS, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.3 mg, Injection, IM-Intramuscular, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
Patient Care
	Pharmacy Consult
		T;N, Allergy Reaction Protocol was entered on this patient, please verify allergy, and add allergen to patient allergies in medical record
	Discontinue Medication
		T;N, Discontinue IV medication or infusion and remove tubing
	Notify MD
		T;N, Contact PCP for additional orders

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