1. Diagnosis: 2. Co-Morbidities: Allergies: NKDA Allergic to:

Transcription

1 BMT NON -HODGKIN S LYMPHOMA Autologous Stem Cell Transplant Routine Plan 1. Diagnosis: 2. Co-Morbidities: Allergies: NKDA Allergic to: 3. Attending Physician: Notify on call Resident/Fellow Consult: Social Services Physical Therapy Dietary Psychotherapy Other 4. Status: BMT Other: Designation: In-Patient Telemetry 5. Code Status: Code Status: Full Code Code Status: DNR Do Not Resuscitate Code Status: DNI Do Not Intubate Code Status: DNR/DNI Do Not Resuscitate or Intubate Partial Resuscitative Effort 6. Condition: Full Admission Observation Stable Fair Serious Critical 7. Donor/Recipient Name: Stem Cell Source: Bone Marrow Peripheral Blood 8. Re-infuse autologous stem cells on Day 0 ( / / ). 9. Conditioning Regimen 10. NURSING: Vital Signs every 4hrs Other: Notify MD for Weigh on admission and daily Height on admission Abdominal Girth on admission & daily Strict Intake and output every shift Oral care every 2 hours while awake see medication list for Biotene Mouthwash orders. Diet: NPO Clear Liquids Full Liquids Mechanical Soft Regular Renal ADA AHA Other Activity: Bedrest Up with assist Bedside commode Bathroom privileges Ambulate Treatments: Page 1 of 5- Non-Hodgkin s Lymphoma Auto Stem Cell Transplant Routine Plan 09/01/2015 (#934 V-4)

2 11. ADMISSION LABORATORY/DIAGNOSTICS: (DO NOT REPEAT IF DONE IN THE EC UNLESS OTHERWISE INDICATED) Complete Blood Count with differential Complete metabolic panel Liver profile Lactate Dehydrogenase (LDH) Uric Acid If Dapsone ordered, G6PD level PRIOR TO ADMINISTRATION Magnesium BetaHCG qualitative for women less than or equal to 55 years of age without known hysterectomy. Obtain results prior to beginning the conditioning regimen. Sputum culture and sensitivity, gram stain (baseline), if available Urinalysis Urine Culture Blood Cultures-bacterial, fungal, viral HLA (Human Leukocyte Antigen) typing: A & B only for platelet transfusion (for autologous patients) Immunoglobulin quantification, IgG, IgA, IgM. Chest X-ray (Posterior-Anterior & Lateral) on admission EKG on admission Other REPEATING LABORATORY/DIAGNOSTIC STUDIES Complete Blood Count daily start differential on Day 0 Complete Metabolic Panel every Monday, Wednesday & Friday Liver profile every Monday, Wednesday & Friday Lactate Dehydrogenase every Monday, Wednesday & Friday Uric Acid every Monday, Wednesday & Friday Magnesium every Monday, Wednesday & Friday Basic Metabolic Panel every Tuesday, Thursday, Saturday & Sunday CMV PP65 every Monday. Start Day + 10 ( / / ). Portable Chest X-ray weekly Page 2 of 5- Non-Hodgkin s Lymphoma Auto Stem Cell Transplant Routine Plan 09/01/2015 (#934 V-4)

3 12. RESPIRATORY THERAPY: Inspirex Spirometer every 2 hours while awake instruct on use Respiratory Care Plan SaO 2 Monitoring every 4 hours. O liters per 13. PATIENT COUNSELING: Provide smoking cessation counseling for patients with history of smoking cigarettes within the past year. 14. IMMUNIZATIONS: DO NOT ADMINISTER FLU OR PNEUMOCOCCALVACCINE DURING BMT HOSPITALIZATION 15. FEBRILE GUIDELINES-(Febrile episode = Temperature greater than or equal to 100.4º F )- INFORM PHYSICIAN ON CALL WITH EACH OCCURRENCE For Temp greater than or equal to 100.4º F, obtain blood cultures bacterial x 2 (one peripheral & one central) and fungal and viral x1. (Label lumen) Repeat bacterial & fungal blood cultures every 48 hours as needed for febrile episode greater than or equal to 100.4º F. (Label lumen) Repeat viral blood cultures weekly for febrile episode. (Label lumen) Obtain Urine Culture & Sensitivity with first febrile episode. Portable chest x-ray with first febrile episode. 16. DIARRHEA PROTOCOL For diarrhea, obtain stool cultures, Giardia, Cryptococcus, Leukocytes and Clostridium Difficile (C-Diff). 17. BLOOD PRODUCT ADMINISTRATION PROTOCOL All blood products must be irradiated. Transfuse 1 unit PRBC for Hemoglobin less than 8 grams/deciliter. If CMV negative, give CMV negative blood. If CMV negative blood unavailable, may use CMV + blood. Recipient CMV Transfuse 1 unit single donor (SD) platelets if platelet count is less than 15,000 per BMT guidelines irradiated. Obtain platelet count 1 hour after each platelet transfusion completed. 18. INTRAVENOUS ACCESS: Maintain saline lock on peripheral IV(s) when not in use. Routine central line care and flushes Catheter type Trifusion catheter: Normal saline flush 10 ml IV Push as needed for flushing. Flush each lumen of the Trifusion catheter every shift and after each use. Follow each saline flush with heparin flush (100 units/ml) 3-5 ml per lumen. Heparin flush 100 units/ml 3-5mL IV Push as needed for flushing. Flush each lumen of the Trifusion catheter every shift and after each use. Follow each saline flush with heparin flush (100 units/ml) 3-5 ml per lumen. Page 3 of 5- Non-Hodgkin s Lymphoma Auto Stem Cell Transplant Routine Plan 09/01/2015 (#934 V-4)

4 19. CONTINUOUS IV FLUIDS: Start of chemotherapy through Day ( 3) (Start on: / / ) Initiate selected IV Fluid at 2000 ml/m²/24 hr = ml/24 hr = ( ml/hour) D5 ½ NS 1000mL + sodium bicarbonate 20 meq + potassium chloride 30 meq If diabetic: ½ NS 1000mL + sodium bicarbonate 20 meq + potassium chloride 30 meq Day ( 2) through Day 0 (Start on: / / ) Initiate selected IV Fluid at 3000 ml/m²/24 hr = ml/24 hr = ( ml/hour) D5 ½ NS 1000mL + sodium bicarbonate 20 meq + potassium chloride 30 meq + furosemide 10 mg If diabetic: ½ NS 1000mL + sodium bicarbonate 20 meq + potassium chloride 30 meq + furosemide 10 mg Day (+1) through Day (+4) (Start on: / / ) Initiate selected IV Fluid at 1500 ml/m²/24 hr = ml/24 hr = ( ml/hour) D5 ½ NS 1000mL + sodium bicarbonate 20 meq + potassium chloride 30 meq + furosemide 10 mg If diabetic: ½ NS 1000mL + sodium bicarbonate 20 meq + potassium chloride 30 meq + furosemide 10 mg 20. MEDICATIONS: Biotene Mouthwash ½ strength swish and spit every 2 hours while awake. Instruct patient on use. Allopurinol 300 mg by mouth daily. Discontinue 24 hours PRIOR to stem cell transplant. Ciprofloxin 500 mg by mouth twice daily. Initiate when Absolute Neutrophil Count (ANC) is less than 1000/mm 3. Discontinue if other gram negative coverage is initiated, or when ANC is greater than 1000/mm 3 for two consecutive days after stem cell transplant. Fluconazole 400 mg by mouth daily. Discontinue if another antifungal drug is initiated Acyclovir 400 mg by mouth three times daily. Initiate if Herpes Simplex Virus (HSV) is positive. HSV Sulfamethoxazole/trimethoprim (Bactrim DS) 800 mg/160 mg 1 tablet by mouth twice daily every Monday and Thursday. Initiate when ANC is greater than 500/mm 3 for 2 days or on Day (+30). If patient has sulfa allergy, order dapsone in place of sulfamethoxazole/trimethoprim. Dapsone 100 milligrams PO daily. Ensure G6PD level has resulted and been reviewed by physician prior to initiation of dapsone. Initiate dapsone when ANC is greater than 500/mm 3 for 2 days or on Day (+30). For weight 59 kg or less: Filgrastim (G-CSF) 300 mcg subcut daily. Start on Day (+5) ( / / ). Discontinue when ANC is greater than or equal to 2000/mm 3 for 2 consecutive days or when ANC is greater than 5000/mm 3 for 1 day. For weight 60 kg or more: Filgrastim (G-CSF) 480 mcg subcut daily. Start on Day (+5) ( / / ). Discontinue when ANC is greater than or equal to 2000/mm 3 for 2 consecutive days or when ANC is greater than 5000/mm 3 for 1 day. Page 4 of 5- Non-Hodgkin s Lymphoma Auto Stem Cell Transplant Routine Plan 09/01/2015 (#934 V-4)

5 Pantoprazole (Protonix) 40 mg by mouth daily. Discontinue on Day 0. Sucralfate (Carafate) 1 gram by mouth twice daily. Initiate on Day 0. Folic Acid 1 mg by mouth daily Multivitamin 1 tablet by mouth daily Ursodiol (Actigall) 300 mg by mouth twice daily Enoxaparin (Lovenox) 40 mg subcut every 24 hours. Discontinue if platelet count is less than or equal to 50,000. Lanolin lip moisturizer, apply to dry lips as needed. Activate Adult Discomfort Medication Plan MAGNESIUM REPLACEMENT Refer to UMC Adult Electrolyte Replacement Order set POTASSIUM REPLACEMENT -- Refer to UMC Adult Electrolyte Replacement Order set PHOSPHORUS REPLACEMENT Refer to UMC Adult Electrolyte Replacement Order set CALCIUM REPLACEMENT THE FOLLOWING DOES NOT APPLY TO PATIENTS WITH RENAL OR ADRENAL INSUFFICIENCY: Use caution in cases of concomitant digoxin therapy. For every 1 g/dl decrease of serum albumin less than 4.0 g/dl, add 0.8 mg/dl to total serum calcium. Corrected calcium (mg/dl) = serum calcium + 0.8(4 serum albumin) For corrected calcium level below 6 mg/dl: Notify physician. For corrected calcium level 6-7 mg/dl: Give calcium gluconate 3 grams IVPB over 120 minutes. Recheck level 4 hours after infusion completed. For corrected calcium level 7-8 mg/dl: Give calcium gluconate 2 grams IVPB over 60 minutes. For corrected calcium level mg/dl: Give calcium gluconate 1 gram IVPB over 60 minutes. 21. CONSENTS Obtain consents for blood/platelet transfusion and high dose chemotherapy. Review consent for autologous stem cell transplant prior to initiating high dose chemotherapy. If not available, notify the transplant coordinator. 22. CONDITIONING REGIMEN SEE SEPARATE SHEET. 23. OTHER ORDERS Page 5 of 5- Non-Hodgkin s Lymphoma Auto Stem Cell Transplant Routine Plan 09/01/2015 (#934 V-4)