USE BALL POINT PEN – PRESS FIRMLY P H Y S I C I A N ‘ S O R D E R CARONDELET HEALTH NETWORK STAT/NOW HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS (Check Box to Left) CHEMOEMBOLIZATION PRE PROCEDURE ORDERS - CSJ / CSM * LIST ALL ALLERGIES: (Medication, food, latex and/or Contrast Dye) * Required on Admission Orders PATIENT STATUS: Inpatient Outpatient (check if applicable) 1 VERIFY/WITNESS CONSENT FOR: 2. 3. Diagnosis:___________________________________________________ Vital Signs: Routine for Department 4. Activity: 5. Nursing Orders: Strict Intake and Output Foley to gravity drainage Notify Radiologist if INR greater than 1.5, if platelets less than 50,000, and if Creatinine greater than 1.5 mg/dL Contact attending physician for patient on insulin or oral hypoglycemic medication Diet: NPO 8 hours prior to procedure except for medications NPO after midnight for solids and NPO for clear liquids for 2 hours pre-procedure except for routine medications IV: 0.9% Sodium Chloride at 200 mL/hour Pre Medications: Start at 0700 on:_______________(Date) DiphenhydrAMINE (BENADRYL) 25 mg 50 mg IV x 1 dose ceFAZolin (KEFZOL) • If patient less than 120 kg, 2 grams IV push x 1 dose • If patient greater than or equal to 120 kg, 3 grams IV push x 1 dose If allergic to Penicillin/Cephalosporin use: Ciprofloxacin (CIPRO) 400 mg IVPB x 1 dose metroNIDAZOLE (FLAGYL) 500 mg IVPB x 1 dose Dexamethasone (DECADRON) 10 mg IV x 1 dose Ondansetron (ZOFRAN) 4 mg IV push x 1 dose Chemoembolization Medication: Mitomycin 10 mg /Doxorubicin (ADRIAMYCIN) 50 mg /Cisplatin (PLATINOL) 100 mg /Omnipaque 350 (IOHEXOL) 8.5 mL /0.9% Sodium Chloride 1.5 mL (Total Volume 10 mL) Doxorubicin (ADRIAMYCIN) _____ mg in micron beads in vial (if greater than 75 mg, use 2 vials): 70-150 microns 100-300 microns 300-500 microns 500-700 microns Doxorubicin (ADRIAMYCIN) _____ mg in quadraspheres (if greater than 75 mg, use 2 vials): 30-60 microns, 120-240 mixed 50-100 microns, 200-400 mixed 100-150 microns, 400-600 mixed 150-200 microns, 600-800 mixed Irinotecan 100 mg in 100-300 micron beads in vial Octreotide 500 mcq IV given between 1 and 2 hours pre-procedure 6. 7. 8. As tolerated Physician Signature: Date Signed: Physician Printed Name / License # / Telephone #: PATIENT IDENTIFICATION MEC Approval CHN6015 CSJ – 4/24/14 Time Signed: CSM – 4/24/14 Expires – 04/2017 Page 1 of 2 UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED P H Y S I C I A N ‘ S USE BALL POINT PEN – PRESS FIRMLY CARONDELET HEALTH NETWORK HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS STAT/NOW (Check Box to Left) CHEMOEMBOLIZATION PRE PROCEDURE ORDERS - CSJ / CSM 9. Labs: CBC with differential PT / INR / PTT Basic Metabolic Panel Liver Function Test Urine Pregnancy Test, unless post-menopausal Finger Stick Blood Glucose (if patient diabetic) 10. Other: CEA Platelets only Alpha FetoProtein Tumor Marker Chromagranin-A O R D E R Physician Signature: Date Signed: Physician Printed Name / License # / Telephone #: PATIENT IDENTIFICATION MEC Approval CHN6015 CSJ – 4/24/14 Time Signed: CSM – 4/24/14 Expires – 04/2017 Page 2 of 2 UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED