_01440_adult_chemotheraphy - SCANNED TO PHARMACY STAT...

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Unformatted text preview: SCANNED TO PHARMACY STAT MEDICATION See page 2 & 3 for BSA nomogram, table of relative emetogenicity & standard dilutions. All parenteral chemotherapy orders are to be written on this form. A 2-hour minimum notice is required for chemotherapy orders. DIAGNOSIS PROTOCOL/REGIMEN ALLERGIES HEIGHT VENOUS ACCESS Peripheral PRE AND POST HYDRATION ORDERS: CYCLE BODY SURFACE AREA (M2) WEIGHT Central May hold hydration during chemotherapy D5½NS w/20mEq KCL + 8mEq MgSO4 at _____mL/hour __________________________________________________________________ Other Hydration: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ PREMEDICATIONS & ANTIEMETICS: PRE-CHEMOTHERAPY ANTIEMETICS PER ANTI-EMETIC PROTOCOL (“PRN” orders for serotonin-receptor antagonists automatically expire 48 hours after the completion of emetogenic chemotherapy) RESCUE “PRN” ANTIEMETICS Prochlorperazine ________ m g PO IVP LOW EMETOGENICITY Lorazepam ________ m g PO/SL IVP Q4H PRN mild/mod N/V Prochlorperazine 10mg PO Metoclopramide ________ m g PO IVPB Q4H PRN mod/sev N/V 30 minutes prior to each day of emetogenic chemo MODERATE EMETOGENICITY (dose range: 0.5-2mg/kg; give with diphenhydramine for doses >1mg/kg) Ondansetron 16mg PO (10mg IV) Dexamethasone 10mg PO (10mg IV) Lorazepam 1mg PO/SL (1mg IV) Diphenhydramine HIGH EMETOGENICITY Ondansetron Ondansetron 24mg PO (16mg IV) Dexamethasone 20mg IV Lorazepam 1mg PO/SL (1mg IV) Q4H PRN mild/mod N/V ________ m g PO IVP Q4H PRN mod/sev N/V IVP Q24H PRN refractory N/V (give with each dose of metoclopramide) 4mg, MRx1 Additional Orders: IV ANTIEMETICS ONLY OMIT DEXAMETHASONE DELAYED EMESIS PROPHYLAXIS (consider for cisplatin, cyclophosphamide, doxorubicin, daunorubicin, idarubicin, ifosfamide) Start 24 hours after start of first dose of above drug(s) Metoclopramide 20mg PO Q6H ATC x4 days Dexamethasone 8mg PO BID x2 days, then 4mg PO BID x2 days Solution, Volume and Infusion Rate are per pharmacy unless otherwise specified. DATES TO BE GIVEN DRUG (Generic names only. Do not abbreviate.) Mg/m2 /DOSE DOSE IN MG ROUTE (circle 1) INFUSE OVER FREQ. TOTAL# OF DOSES TOTAL DOSE PER CYCLE (MG) IV push IVPB IV infusion _______hr IV push IVPB IV infusion _______hr IV push IVPB IV infusion _______hr IV push IVPB IV infusion _______hr IV push IVPB IV infusion _______hr IV push IVPB IV infusion _______hr IV push IVPB IV infusion _______hr Nursing Only: Specify Hydration Start Time:___________________ & Start Time for First Chemo Drug:__________________ Date______________ Time_________ MD Signature________________________________________________________ Phone No._____________ Authorization for therapeutic substitution is given unless checked here Patient Identification Sutter Medical Center, Sacramento A Sutter Health Affiliate Adult Chemotherapy Order Form 01440 (12/17/08) Page 1 of 3 ORDERS CHEMOTHERAPY DILUTION & ADMINISTRATION Drug Reconstituted Conc. IV Push via Running IV Aldesleukin (Proleukin) Asparaginase (Elspar) Bleomycin (Blenoxane) Carboplatin (Paraplatin) Cisplatin (Platinol) Cladribine (Leustatin) Cyclophosphamide (Cytoxan) Cytarabine (Cytosar, ARA-C) Dacarbazine (DTIC) Dactinomycin (Cosmegen) Daunorubicin (Cerubidine) Docetaxel (Taxotere) 18 Million Unit/mL 10,000 Unit/mL 3 Unit/mL 10mg/mL 1mg/mL 1mg/mL 20mg/mL 100mg/mL or 20mg/mL 10mg/mL 500mcg/mL 5mg/mL 10mg/mL NR NR Over 10 min NR NR NR @ 1mL/min Over 2 min Over 1 min Over 2 min Over 2 min NR Doxorubicin (Adriamycin) Etoposide (VePesid, VP-16) 2mg/mL 20mg/mL @ 1mL/min NR Floxuridine (FUDR) Fludarabine (Fludara) Fluorouracil (5-FU, Adrucil) Gemcitabine (Gemzar) Idarubicin (Idamycin) Ifosfamide (Ifex) Irinotecan (Camptosar) Mechlorethamine (Mustargen, nitrogen mustard) Methotrexate (Mexate, MTX) Mithramycin (Plicamycin) Mitomycin (Mutamycin) Mitoxantrone (Novantrone) Paclitaxel (Taxol) 100mg/mL 25mg/mL 50mg/mL 38mg/mL 1mg/mL 50mg/mL 20mg/mL 1mg/mL NR NR @ 1mL/min Over 30 min Over 10 min NR NR Over 2 min 25mg/mL 500mcg/mL 0.5mg/mL 2mg/mL 6mg/mL Over 2 min NR @ 1mL/min NR NR 10mg/mL NR 100mg/mL 10mg/mL 10.4mg/mL 1mg/mL 1mg/mL 1mg/mL 10mg/mL @ 1mL/min NR Over 1 min NR Over 5-10 min Over 5-10 min Over 10 min Rituximab (Rituxan) Streptozocin (Zanosar) Teniposide (Vumon, VM-26) Thiotepa (Thioplex) Topotecan (Hycamtin) Vinblastine (Velban) Vincristine (Oncovin) Vinorelbine (Navelbine) NR = No Recommendation IV Infusion (over 24 hr) IVPB D5W 50mL/15 min D5W + 0.1% albumin NS 100mL/30 min NR NR NR D5W 100mL/60 min NR NS 250mL/2 hr NR* NR NS 500mL NS 100mL/60 min NR NS 100mL/30 min NS 1000mL NS 100mL/15-30 min NR* NR NR NS 100mL/30min NR <240mg NS 250mL/60 min NR >240mg NS conc. 0.3-0.9mg/mL/90 min NR NR* <200mg/NS 250mL/60 min NR* >200mg/NS 500mL/2 hr NR NS 1000mL NS 100mL/30 min NR NR NS 1000mL NS 100mL/30-60 min NR NR NR NS 100mL/60 min NS 1000mL D5W 250-500mL/90 min NR NR NR NS 250mL/2 hr NS 500mL/4 hr NR NS 50mL/15 min NS 250mL/3 hr 1-4mg/mL NS or D5W @ 50mg/hr, if ok increase by 50mg/hr increment Q 30min to max 400mg/hr NR NR NR NR NS 1000mL NS 100mL/30 min NS 500mL/2 hr NR NS 50-250mL/30 min NS 20-50mL/5-10 min NS 20-50mL/5-10 min NS Conc 0.5-2mg/mL/10 min NR NS 1000mL NR NR NR NR* NR NR * = See Combination Chemotherapy Table Combination Chemotherapy Table Chemotherapy Combination Regimen Cisplatin/Etoposide Doxorubicin/Decarbazine Doxorubicin/Vincristine Ifosfamide/Mesna IV Infusion (Over 24 Hours) NS 1000mL/24 hr NS 1000mL/24 hr NS 1000mL/24 hr NS 1000mL/24 hr Chemoprotective Agents Drug Amifostine (Ethyol) Dexrazoxane (Zinecard) Leucovorin (Wellcovorin) Mesna (Mesnex) Reconstituted Conc. 50mg/mL 10/mg/mL 10mg/mL 100mg/mL IV Push via Running IV Over 15 miin Over 5-15 min Over 2-5 min Over 15-30 min NR = No Recommendation 01440 (12/17/08) Page 2 of 3 IVPB NR NS conc. 1.3-5mg/mL/15 min NS conc. 20mg/mL/15-30 min * = See Combination Chemotherapy Table IV Infusion (over 24 hr) NR NR NR NR* TABLE OF RELATIVE EMETOGENICITY High Intermediate Doxorubicin (Adriamycin) (>60mg/m2) Carmustine (BiCNU) Cisplatin (>50mg/m2) Cyclophosphamide (Cytoxan) (>1gm/m2) Carboplatin (AUC >6) Cytarabine (Ara-C, Cytosar) (>500mg/m2) Dacarbazine (DTIC) Dactinomycin (Cosmegen) Daunorubicin (Cerubidine, DaunoXome) Epirubicin Hexamethylmelamine (Hexalen) Idarubicin (Idamycin) Ifosfamide (Ifex) Lomustine (CeeNU) Mechlorethamine (Mustargen) Melphalan (>100mg/m2) Streptozotocin (Zanosar) Thiotepa (>100mg/m2) Gemcitabine (Gemzar) Cisplatin (<50mg/m2) Cyclophosphamide (<1gm/m2) Cytarabine (<500mg/m2) Carboplatin (AUC <6) Docetaxel (Taxotere) Doxorubicin (<60mg/m2) Estramustine Etoposide (VP-16, Vepesid) Irinotecan (Camptosar) Mitomycin (Mutamycin) Mitoxantrone (Novantrone) Paclitaxel (Taxol) Plicamycin (Mithramycin) Procarbazine Teniposide (Vumon) Thiotepa (<100mg/m2) Topotecan (Hycamtin) Low I-asparaginase (Elspar) Bleomycin Busulphan (Myleran) Chlorambucil (Leukeran) Cladribine (2-CDA), Leustatin) Floxuridine (FUDR) Fludarabine (Fludara) Fluorouracil (5-FU) Hydroxyurea Melphalan (Alkeran) Mercaptopurine (Purinethol) Methotrexate Pentostatin Tamoxifen Thioguanine Vinblastine (Velban) Vincristine (Oncovin) Vinorelbine (Navelbine) Body Surface Area of Adults Nomogram for determination of body surface area from height and weight Height Body Surface Area A straight edge is placed from the patient’s height in the left column to his weight in the right column and this intersect on the body surface area column indicates his body surface area. 01440 (12/17/08) Page 3 of 3 From the formula of Du Bois, Arch, intern. Med. 17,863 (1916): S = W0.425 x H0.725 x 71.84, or log S = log W x 0.425 + log H x 0.725 + 1.8564 (S = body surface in cm2, W = weight in kg, H = height in cm) Reproduced from Documenta Geigy Scientific Tables, 7th Edition Courtesy CIBA-GEIGY Limited, Basle, Switzerland Weight ...
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This note was uploaded on 12/26/2009 for the course PHYS 341 taught by Professor Mavromatis during the Spring '09 term at American University of Beirut.

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