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: 2025-02-19 11:10:44
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
		16 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 > 7Extremely Hazardous Drug | Antineoplastic |  PPE Requirements: Dispensed From Pharmacy In Rx Crush Bag, Double Gloves, Gown, Face Shield If Tube Admin Or Splashing Risk.
		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 > 7Extremely Hazardous Drug | Antineoplastic |  PPE Requirements: Dispensed From Pharmacy In Rx Crush Bag, Double Gloves, Gown, Face Shield If Tube Admin Or Splashing Risk.
		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 > 7Extremely Hazardous Drug | Antineoplastic |  PPE Requirements: Dispensed From Pharmacy In Rx Crush Bag, Double Gloves, Gown, Face Shield If Tube Admin Or Splashing Risk.
		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 > 7Extremely Hazardous Drug | Antineoplastic |  PPE Requirements: Dispensed From Pharmacy In Rx Crush Bag, Double Gloves, Gown, Face Shield If Tube Admin Or Splashing Risk.
		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 > 7Extremely Hazardous Drug | Antineoplastic |  PPE Requirements: Dispensed From Pharmacy In Rx Crush Bag, Double Gloves, Gown, Face Shield If Tube Admin Or Splashing Risk.
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
		<!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, IV Large Volume, IVPB, DAILY, PRN for see comment, 999 ml/hr
			Comment: for reaction to chemotherapy
		1,000 mL, IV Large Volume, IVPB, DAILY, PRN for 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
	morphine  IV
		2 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