Arthritis & Rheumatology Clinic

CYCLOPHOSPHAMIDE INFUSION PROTOCOL.

Patient Name: Age:

Diagnosis: Date:
Weight (Kg):

Body surface area - BSA (m2) =

Hb _____________ TLC ____________ Platelets ________________

ALT ____________ Creatinine__________

Indication = _______________________

Prescribed dose of Cyclophosphamide (500mg to 1grm per m2) =

Total Dose given= Prescribed dose X BSA

NURSING ORDER
Monitor Vitals every Half hour
Monitor intake and output of patient before and after the infusion

PREMEDICATION (GIVEN BEFORE STARTING CYCLOPHOSPHAMIDE)

1: Tab Avil 50 mg 1 tab, or Syp Benadryl 2 Spoons STAT

2: Inj Onset 8mg IV diluted STAT
3: Inj Decadron 4 mg IM STAT
4: Inj Mesna _________ in ________ ml of NS and infuse over ______ hour
5. In Case, Mesna is not available, Give N.S 400 CC before and after Cyclophosphamide
Infusion.

INFUSION ORDERS

1: inj Cyclophosphamide ____________ in 200 cc of 0.9% Saline and infuse over 1 hour
2: Inj Lasix 20 mg IV STAT
3: Inj Mesna _________ in ________ of 0.9% Saline ans infuse over 2 hours.

POST INFUSION ORDERS:

Encourage Oral fluids and pass urine frequently,

Urine DR to R/O Hematuria
Follow up CBC on 10th day, and keep report with you

SIGNATURE AND NAME OF PHYSICIAN