In a session targeting novice bone marrow
transplant (BMT) nurses, the Oncology Nursing Society (ONS) outlined
what nurses should expect in treating BMT cases, from pretransplant
to posttransplant, as well as related insurance and psychological
issues affecting patients and families.
Speakers explained that advances in marrow transplantation, including
histocompatibility testing, conditioning regimens, and control of
graft-vs-host disease (GVHD), have brought this procedure into
widespread use. By 1986, when it was clear that BMT succeeded in
treating cases of acute leukemia and severe aplastic anemia by
increasing survival rates from less than 20% to over 70%, 200 BMT
centers performed more than 5,000 transplants annually.
Pretreatment and Treatment Phases
Of critical importance is education of the patient and family; ONS
strongly encourages oncology nurses to repeatedly explain procedures
and assess patient and family understanding.This is an essential
element of treatment that will need to be repeated throughout therapy.
During the treatment phase, patients will be admitted to a hospital
or an outpatient facility where staff will take their history,
conduct a physical examination, review the transplant protocol, and
perform daily care routines. Patients will undergo a preparative
conditioning regimen that will assess their physiologic readiness to
receive the bone marrow graft, destroy their immune system to allow
for donor cell acceptance, and eliminate malignant cells.
The specific regimen depends on the patients disease and
previous treatment. Radiation is used for immunosuppressive effects
and the ability to penetrate chemotherapy-resistant sites. High-dose
chemotherapy is used for antineoplastic and immunosuppressive
effects. Common agents are carmustine (BCNU), busulfan (Myleran),
semustine (CCNU), cyclophosphamide (Cytoxan, Neosar), cytarabine
(Ara-C), cisplatin (Platinol), carboplatin (Paraplatin), daunorubicin
(Cerubidine), doxorubicin, etoposide, and melphalan (Alkeran).
Immunotherapy may be used for immunosuppression in severe aplastic
anemia or immune deficiency disorders.
On the day of an autologous transplant, infusion of marrow or stem
cells occurs 24 to 48 hours after high-dose chemotherapy; preparation
includes using intravenous (IV) fluids, explaining the procedure to
the patient, and premedicating the patient with steroids, analgesics,
antihistamines, and anti-anxiety agents. Dimethyl sulfoxide (DMSO)
will also be used to preserve stem cells and autologous marrow.
The patient receives the marrow or cells by IV push or infusion and
is then placed on telemetry and monitored frequently. Side effects
can include hematuria, increased bilirubin and creatinine,
arrhythmias, hypertension, or allergic reactions to DMSO (eg, chills,
fever, dyspnea, nausea and vomiting). If this happens, IV fluids and
diuretics may be given following the infusion.
Allogeneic transplant preparation involves premedicating the patient
with antiemetics, antipyretics and antihistamines; monitoring for
baseline vital signs at regular intervals; and placing the patient on
a cardiac monitor or pulse oximeter throughout the procedure and for
24 hours thereafter.
At the time of administration, staff must check the marrow to verify
the medical record number and the patients name, spike the bag
of marrow with straight administration set tubing, and prime and
attach it directly to the patients central line. An IV pump and
or piggybacking into other tubing are never used.
Blood return from the line should be ascertained before infusing bone
marrow through the line. T-celldepleted marrow or stem cell
product is infused over 30 minutes to 1 hour, and non-T-celldepleted
marrow is infused over 3 to 4 hours.
Good nursing is critical during the posttransplant phase, when
patients are the sickest. Engraftment and recovery may occur at
different rates due to the nature of the primary disease, previously
administered chemotherapy and radiation, choice of preparative
regimen, choice of GVHD prophylaxis, viral complications, and the use
of antimicrobial agents. Marrow cellularity gradually increases over
2 to 4 weeks.
Infection caused by various host factors or exogenous bacterial,
viral, or fungal factors is a posttransplant complication. Risk
factors for infection are hematologic-lymphoid disease, induction or
previous treatment, preparative treatment, prolonged neutropenia
and/or immune deficiency, altered mucosal barriers, microorganism
colonization, and prolonged use of antibiotics.
To assess the development of infection, staff should conduct a
comprehensive physical examination every 4 to 8 hours, paying special
attention to the catheter site, lungs, integument, oral mucosa, and
rectal area; check vital signs at least every 4 hours; and obtain
complete blood count with absolute neutrophil count (ANC) daily.
Bleeding, another posttransplant complication, may occur from severe
thrombocytopenia and anemia secondary to preparative regimen-induced
myelosuppression; delayed patient engraftment due to GVHD,
cyclosporine (Neoral, Sandimmune) prophylaxis, or marrow purging;
poor graft function related to bone marrow-suppressive medications;
coagulation abnormalities resulting from hepatotoxicity, GVHD,
disseminated intravascular coagulation, and/or sepsis; and platelet autoantibodies.
Risk factors for bleeding include GVHD and the use of cyclosporine
prophylaxis, veno-occlusive disease (VOD) with impaired production of
coagulation factors, altered mucosal barriers, failed or delayed
engraftment, and viral infections.
What Nurses Can Do to Avoid Complications
Nurses can take various steps to prevent posttransplant
complications. These include instituting infection control practices;
promoting meticulous personal hygiene to include oral and perineal
areas; administering and monitoring the patients response to
antifungal, antiviral, and antibacterial prophylaxis and treatment;
carefully watching central venous catheters; imposing dietary
restrictions; obtaining cultures promptly as needed; avoiding
unnecessary invasive procedures (ie, enemas, rectal temperatures,
bladder catheterizations, venipunctures, and finger sticks);
administering cytomegalovirus-negative blood products or utilizing
Pall filters in seronegative patients; and, once again, educating the
patient and family about infection signs and symptoms, prophylaxis,
and treatment. Washing ones hands is still the single most
important way to prevent infection.
Nursing management dictates avoiding unnecessary invasive procedures
and medications (aspirin, for example) that inhibit platelet
function; initiating bleeding precautions if platelets are less than
20,000/mm³; administering blood products prior to invasive
procedures; testing urine, stool, and emetic fluid for occult blood;
encouraging the use of soft mouth care products; giving prophylactic
medications that protect from bleeding; administering IV hydration
and/or bladder irrigations to prevent hemorrhagic cystitis; and
applying extra pressure to sites of invasive procedures.
Patients often suffer mouth pain from oral mucositis, usually
beginning just prior to transplant, peaking during the second week,
and gradually receding as blood counts return; patients treated with
total-body irradiation report higher levels of pain. The drug of
choice is usually morphine, preferably administered by the patient
rather than by continuous infusion to minimize side effects.
Veno-occlusive disease is a complication of damage to terminal
hepatic venules and surrounding hepatocytes, endothelial injury and
subsequent obstruction of hepatic venules and sinusoids, increased
platelet consumption, and deposition of clotting factors and
fibrinogen in vital organs.
With an overall incidence of 21%, VOD is a risk in the presence of
hepatitis prior to transplant, repeated courses and higher doses of
chemotherapy, hepatotoxic irradiation, immunosuppressive drugs that
are hepatotoxic, elevated serum glutamic-oxaloacetic transaminase
(SGOT) and alkaline phosphatase prior to transplant, infection or
sepsis, and estrogen-progesterone therapy. Clinical signs and
symptoms include hepatomegaly, upper right quadrant pain, sudden
weight gain, ascites, jaundice, elevated bilirubin, high ammonia
levels, coagulation abnormalities, and encephalopathy.
The focus of nursing management is to maintain intravascular volume
and renal perfusion; to administer diuretics and monitor their
effectiveness; to maintain restrictions of sodium, protein, and
fluids; to check daily weight and abdominal girth; to avoid
delivering medications that are hepatotoxic or alter mentation; to
administer red blood cells and albumin; and to strictly monitor input
A major cause of morbidity and mortality in allogeneic
transplantation is GVHD. Approximately 50% of patients undergoing a
matched sibling transplant will develop the disease to some degree.
Even more recipients undergoing matched unrelated transplants will
develop GVHD, and 25% of those who do will die.
Causes include histoincompatibility between the donor and host and
inability of the immunocompromised host to reject the donor cells.
Risk factors include HLA compatibility, a recipient older than 20
years, gender mismatch (female to male, especially if the female has
been pregnant), disease status, and prior herpesvirus infection.
Onset of acute GVHD can occur any time up to 100 days (generally, 2
to 5 weeks) after engraftment, and typically involving the skin,
liver, and gastrointestinal tract. Its severity is graded by staging
each of the organs involved.
Prophylaxis for GVHD, involving cyclosporine administered in
conjunction with other immunosuppressive agents, is aimed at
eliminating the donor T-cells or blocking their activation, and is
always used with allogeneic marrow transplant. It is usually
discontinued 6 months after the transplant if there is no evidence of
Since treatment for acute GVHD is very difficult and many patients go
on to develop the chronic form, therapy with glucocorticoid steroids,
antithymocyte globulin (ATG), zomazyme (anti-CDS antibody immunotoxin
conjugate), and OKT3 (monoclonal antibody specific for CD3) should be aggressive.
Historically, the onset of chronic GVHD is defined as beginning 100
days after the transplant, but it has been documented as early as 70
days or as late as 15 months posttransplant. It usually involves the
skin, liver, mouth, eyes, sinuses, vagina, and gastrointestinal
tract. Two current theories are that it is a late form of acute GVHD
or an alloreactivity reaction, or is the result of dysfunctional
The chronic form can be classified three ways: continuous or
progressive (acute GVHD, merging into chronic), quiescent (chronic,
occurring after a period during which no GVHD was evident), or de
novo (chronic, presenting with no preceding acute GVHD).
Chronic GVHD is the single major determinant of long-term quality of
life following BMT, but patients with limited disease have a
favorable prognosis. Patients with extensive disease, however,
especially if multiple organs are involved, have an unfavorable
prognosis despite treatment with cyclosporine and steroids.
The ONS stresses that patients be made aware of the ramifications of
their disease and the special issues surrounding BMT. To ensure that
patients fully understand these issues, nurses should be present for
physician/patient discussions to assess the level of understanding,
encourage and answer patient questions, present reinforcing
information, inform the patient of nursing interventions, monitor the
patients level of anxiety, and support the patients decisions.
Bone marrow transplantation can subject patients and families to
severe psychological stress. Limited insurance may force patients to
fight or beg for their life, a physically and emotionally draining
experience that is ultimately detrimental to patients. At least 40%
of transplant patients experience a major depression and must combat
anxiety and fear of death as well. The period before a transplant is
particularly difficult because patients know that they have no choice
and that this is their last chance of survival.
Nurses need to discuss what the patients support systems are,
especially if they are far away from home; determine whether they are
depressed; and explore with them the impact that the transplant will
have on their lives.
While there is little information in the literature on the
psychological implications of the donor/recipient relationship, there
is evidence that patients often feel an indebtedness that they cannot
repay; this can lead to conflict. If they do not progress well, they
usually experience added guilt and anxiety.
Nurses must continually assess what is happening with the
patient and make sure that they keep the family informed. Family
members too are sufferingrearranging their lifestyles to visit,
coping with the ill family member, and trying to motivate the patient
in dealing with setbacks. Weekly or biweekly meetings with the family
in a neutral setting can be very helpful for dealing with these issues.