Oncology Rapid Pre-hydration for (Page 1 of 2)

DATE _____/_____/______TIME ______DD MM YYYY BSA:______m2

WEIGHT:______kg HEIGHT:______cm ALLERGY CAUTION sheet reviewed

Exclusion Criteria Less than 6 months of age Patients with a history of severe renal, cardiac or pulmonary impairment Patients without central venous access Patients with diabetes insipidus Patients who are on study, where the study protocol has specific pre-hydration At the discretion of the ordering physician

Admit/Transfer/Discharge Chemotherapy Protocol: ______Discontinue previous pre-hydration orders Refer to pre-printed order for chemotherapy and other supportive care

Pre-hydration for: doses greater than or equal to 1000 mg/m2 ifosfamide

Patient Care Measuring urine specific gravity is not required prior to proceeding with chemotherapy

IV Infusions For multiple day chemotherapy, pre-hydrate on first day of chemotherapy only Normal saline ______mL IV (750 mL/m2) over 1 hour on Day ______(Date:______)

Pre-hydration for high-dose Refer to Rapid Pre-hydration Algorithm on Page 2

Patient Care

Check urine pH and specific gravity qvoid per Rapid Pre-hydration algorithm on page 2

IV Infusions Pre-hydration Bolus Lactated Ringers solution ______mL/h (750 mL/m2) IV over 1 hour on Day ______(Date:______)

2nd Bolus Lactated Ringers solution ______mL (300 mL/m2) IV over 30 minutes PRN

Ongoing Pre- Hydration Lactated Ringers solution at ______mL/h (200 mL/m2/h) IV until urine pH is greater than or equal to 7 and urine specific gravity is less than or equal to 1.010

Medications If urine pH is less than 7 Sodium bicarbonate ______mEq IV q1h PRN to raise the urine pH relatively quickly pre-methotrexate (0.5 to 1 mEq/kg/dose) (Maximum: 3 doses)

Signature:______Print Name:______

College ID:______Pager:______

PTN Review Date June 9, 2020 PTN# OncRPHv2 SHOP# C-05-09-60516 Exp Date: February 11, 2023 Page 1 of 2 Rapid Pre-hydration for high-dose Methotrexate Algorithm

Give Pre-hydration Bolus as ordered, then check urine pH and Specific Gravity (SG)

If pH ≥ 7 If SG ≤ 1.010 If pH ≥ 7 If pH < 7 AND BUT BUT AND SG ≤ 1.010 PH < 7 SG > 1.010 SG > 1.010

. Give Sodium Bicarbonate as . Give Sodium . nd ordered Give 2 Bolus as Bicarbonate as ordered ordered nd . Run ongoing pre- . Give 2 Bolus as hydration as ordered ordered

. Recheck urine pH . Recheck urine pH . Recheck SG qvoid and SG qvoid qvoid until ≥ 7 . Run ongoing pre- . Run ongoing pre- hydration as hydration as ordered until SG is ordered until pH ≤ 1.010 is ≥ 7 AND SG ≤ 1.010

When pH ≥ 7 When pH ≥ 7 When pH ≥ 7 AND AND AND SG ≤ 1.010 SG ≤ 1.010 SG ≤ 1.010

Proceed with Chemotherapy as ordered

PTN Review Date: June 9, 2020 PTN# OncRPHv2 SHOP# C-05-09-60516 Exp Date: February 11, 2023 Page 2 of 2