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| Centers of Excellence - Bonemarrow Transplants |
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BONE MARROW TRANSPLANTS
The BMT Unit was Started in November 2004 and has completed more than 75 Allogeneic stem cell Transplants till date which is the largest number in Karnataka. The unit also caters to International Patients for both autologous and allogeneic transplants.
Dr.Sharat Damodar
M.D.,D.N.B.E.,D.M.
Consultant Haematologist &
Bone Marrow Transplant Physician
About our Team:
Nurses
The nurses on the BMT team are specially trained to care for bone marrow transplant and immunology patients. They work closely with doctors in the divisions of hematology/oncology and immunology to:
- Assess your patient's needs
- Plan the care required
- Provide treatment
Nurse coordinators
The BMT nurse coordinator will help plan all the activities needed to prepare for your patient's transplant. The nurse coordinator will follow the care during your stay in the hospital, and in the follow-up clinic after transplant has been completed Doctors
You will get to know several doctors during your stay at the hospital for a bone marrow transplant.
• The staff transplant doctor works with you and the BMT team to make all the major decisions about your patient medical care and to decide on the right procedures and medicines to use.
Dieticians The dietician monitors the nutritional needs, and daily food and fluid intake. He or she will meet with BMT team every day and give suggestions about oral and tube feeding as well as intravenous(IV) or parenteral nutrition(TPN). If any special nutritional needs, the dietician will meet with you. Social workers A social worker can also provide support and counseling as you adjust to the hospitalization of your patient.
About our unit: The BMT unit has different rules about visiting, diet and patient activity than other patient units in the hospital. These are all meant to protect the patient from infection. Rooms - High Efficiency Particulate Air (HEPA) Filtered room
Because your patient immune system will be rendered ineffective in preparation for a bone or marrow transplant, special isolation rooms are needed to protect him or her from infection. There are 4 laminar air flow rooms. These rooms:
Are not sterile, but they are the cleanest rooms possible
• Have special air flow that filters the air in the room 500 times an hour.
• Are entered through an anteroom that is considered very clean.
• Require that anyone entering the room wear a special gown and perform a special hand wash called a scrub.
You will be shown how to scrub and gown before entering HEPA room. Your patient will be placed in a HEPA room from the day of conditioning for the transplant and will not leave the room until the doctor decides that it is appropriate. The attached bathroom is for patient use only. Only the water from the geyser is to be used.
Each HEPA room has a TV and telephone. We encourage kids to bring favorite toys, pictures and games, although stuffed toys are not allowed.
Food may not be kept in the HEPA rooms because of the risk of infection
Parents may not eat their meals in HEPA rooms. Only patients may eat in these rooms. The small refrigerator in the anteroom is used for your patient drug that needs to be kept cold. Food items should not be kept in this refrigerator.
After the transplant, once your patient new bone marrow starts to grow and his or her blood counts begin to rise, the doctor will decide whether your patient can be discharged.
At the time of discharge they are allowed to come out with a mask on for walks. All rooms in our unit are cleaned daily. Please keep your wash room tidy Please do not keep your personal things on the vanity. You may stay overnight if your patient is
1.In the preparation phase for transplant
2.Readmitted
3.An autologous transplant recipient Parents may use the public wash room, but not those in the regular rooms.
Pantry and meals
When your patient is admitted to the HEPA room, he or she will be placed on a special low-bacteria diet. No food from home is allowed for the duration of isolation. Food is supplied at the timely manner from the hospital dietary.
Protective isolation
Protective isolation is used to protect the transplant patient from infection caused by bacteria, viruses and fungus. This form of isolation include the use of
- A special isolation room called a positive pressure HEPA filtered room.
- An air filtration system (HEPA)
- Gown
- Very good hand washing
- Special cleaning procedures
- A nurse will explain to you all the special things that you need to do before entering this room.
Hand washing
To prevent the spread of infection from person to person, all hospital staff, parents and everyone else entering the room must wash their hands in the scrub sink in the anteroom. A full two minutes scrub should be done first thing in the day, after meals and after bathroom breaks. At other times, a 15- second hand wash.
Personal items and supplies
All supplies and personal items brought into room must be clean. No special cleaning or sterilizing technique are needed except when equipment is shared among patients, such as scales, blood pressure machine or toys. Shared equipment must be wiped off with a towel that has been soaked with disinfectant. Anything that falls on the floor must be removed from the room and cleaned with disinfectant before it may be brought back to the room. Toys brought from home should be washed with soap and water at home and then wiped off with disinfectant just before they are brought into the room.
Clothing and gowns
All staff and parents are required to wear sterile dress in the room. We suggest that you wear light weight clothes (sterile) under this gown. Masks and gloves.
The nursing staff wear masks when they do any sterile procedure, like changing the CVL dressing or the CVL caps. They do not wear masks for routine care. While inside the room it is must to wear cap and the mask.
Transporting the isolated patient
If your patient needs to leave the room for a test or procedure else where in the hospital, he or she must wear a mask and cap.
Step down isolation
Once your patient transplanted bone marrow starts to grow, or engraft, his or her white blood cell count will rise. Once the part of the white blood cell count called the poly count has stayed above 0.5 for 2 days, strict protective isolation measures can be somewhat relaxed. This phase of transplant is called step down isolation.
In step down isolation, you will still have to wash your hands before visiting your child. This does not have to be a 2 minute scrub., but a good hand wash with bact-stat soap. No gown are required.
Nutrition guidelines
During bone marrow transplantation, the bone marrow is destroyed by high doses of chemotherapy. This leaves at risk for developing infection, what we call immunocompromised.
When your patient is admitted to the isolation room, he or she will be placed on a low bacteria diet. Most foods contain certain types and amount of bacteria. The purpose of the low bacteria diet is to reduce the total bacterial content of foods and to keep your patient from eating potentially harmful foods. A low bacteria diet is not complicated, but it does restrict the use of some specific food.
Foods brought into the hospital
- Home prepared foods are NOT allowed.
- Commercially packaged items are ONLY allowed after they have been approved by the dietician or nurse.
Food storage
Food should NOT be left at room temperature for longer than two hours Eating well is very important- it keeps the body healthy and help the new marrow grow. You should encourage your patient to eat and drink, even if it is only in small amount. To assess your patient nutrient intake, we will place him or her on daily calorie counts please tell the nurse what your patient is eating and drinking. There may be times when your patient may not feel well enough to eat. To maintain his or her nutrition, TPN (Total Parenteral Nutrition) may be started. TPN is a mixture of protein, fat, sugar, vitamins and minerals that is delivered through central line into the blood stream.
- No restaurant food, take out, cafeteria food or vendor food is allowed
- All foods must be cooked thoroughly. Avoid rare to medium cooked meats and fish
- Herbs, spices and pepper should not be added to food after it is cooked, but are allowed when cooked into the food.
- Avoid raw fruits and vegetables including salads, garnishes, stir- fried vegetables, egg rolls and any food items where vegetables are not completely cooked.
- Avoid foil- sealed plastic cups of juices because they do not have a best before date.
- Avoid food containing raw eggs including soft cooked eggs.
- Dried fruits, nuts and seeds. Are not allowed unless cooked in a food item.
Foods allowed in addition to the menu
These foods are available in addition to what is on the low bacteria menu. Please write your choices clearly on the menu that is provided.
- Mashed potatoes/ Dal
- Plain rice
- Any vegetables
- Rice/ Rava Kanji
- Tomato Soup
When you are ready to go home, the dietitian will review the low bacteria discharge diet with you, and answer any questions or concerns you may have.
Treatment Procedures
Chemotherapy A few weeks before your patient has a blood or marrow transplant he or she will be started on chemotherapy drugs. These drugs will help:
1)Destroy all the cells in the old bone marrow, including both healthy and diseased cells.
2)Suppress the immune system
The type of chemotherapy drugs will depend on your patient diagnosis. Each drug has different side effects. Some of the short term effects of chemotherapy include:
- Nausea and vomiting
- Diarrhea
- Blood in the urine
- Hair loss
- Mouth sores
- Fluid retentions
- Bleeding from any place in the body.
- Medication can be given to help your patient to relax, and to help control the nausea and vomiting.
You will notice that nurses wear gloves when handling body fluids. This is because chemotherapy drugs leave the body in body fluid. It is important for your own protection that you wear gloves when handling body fluids during the time that your child is receiving chemotherapy and for a short while afterwards.
Central venous lines
If your child does not have a double lumen central venous catheter, he or she will need one for the transplant period. The double lumen catheter is a flexible catheter, or small tube, that is inserted through the skin and tissue in the chest into a major vein. The tube, called a central venous line or CVL, is inserted about 2 weeks before your patient has a blood or marrow transplant. The placement of the CVL requires minor surgery under general anaesthetic.
This CVL remain in place for the entire transplant period. It may be used to give intravenous (IV) fluid, chemotherapy, medication, blood and platelet transfusion and nutritional fluid. It will also be used for drawing blood for daily tests. Sometime the CVL will remain in place for a while after your patient goes home. Your patient may need to visit our clinic weekly or more frequently for blood product transfusion before you leave the hospital, one of the BMTU nurse will teach you how to care for the line at home.
When the transplant doctor decides that the line is no longer needed, it will be removed in the operating room. Usually, this is a day- surgery procedure so no overnight stay is needed.
The major risk of a CVL is that it can become infected. If this happens, the transplant physician will decide whether the CVL must be removed.
Transplants
The transplant procedure is actually fairly simple, the stem cells or bone marrow cells to be transplanted are given through the CVL. The procedure is just like getting a blood transfusion, except that there are a few extra precautions taken.
1)Just before the infusion of the new bone marrow, your patient may be given medication to help avoid any allergic reactions.
2)A monitor will be used to check your patient breathing, heart rate and blood pressure during the procedure. The nurse will monitor your child closely throughout the infusion of stem cells or bone marrow.
3) A doctor is available on the unit and will check in periodically. Medications may be given to deal with problems that may arise, such as high blood pressure or a fast heart rate.
While receiving the transplant infusion, he or she may read or watch TV. The infusion will last several hours. After the infusion is finished, the monitor may be taken off. Breathing, heart rate and blood pressure will be checked every few hours, although your nurse will not be in the room the whole time. The following pages describes, in a little more detail, the particular type of transplant your patient is having.
Autologous bone marrow transplant: Autologous means own or belonging to self. An autologous blood or marrow transplant is the transfusion of stem cells or bone marrow taken from your own body. These cells may be stored up to 5 years, after which time they will be destroyed if not used.
Peripheral blood stem cell or bone marrow transplant: For this your patient will have had several apheresis treatments before being admitted to hospital for BMT. An apheresis procedure removes stem cells from the blood circulating in the body. These cells are responsible for making blood and for developing the immune system, which helps the body fight infection. After these cells are collected, they are frozen and stored in a cryopreservation lab. For your patient transplant, the frozen stem cells are transported to the BMTU, thawed and then given to the patient through his or her CVL.
Complications and their treatments:
After the infusion of stem cells or bone marrow, it takes 4 to 6 weeks for the new bone marrow to grow and function as it should. During this time, your patient runs the greatest risk of bleeding, or of having infections and other complications.
Bleeding
Infections
Mucositis
Pneumonia
Veno-occlusive disease
Graft-versus-host disease (GVHD) It occurs when the new bone marrow, called graft, does not recognize the person who receives it, called the host. The graft then sends out fighter white blood cells, called lymphocytes, to attack the host.
It can be mild, moderate or severe and can involve the skin, the liver or the bowel. Rashes and diarrhea are symptoms. Sometimes tissue samples of symptomatic areas are taken to diagnose the disease. This complication is seen with allogenic transplants, in which the transplant comes from either a related or un related donor. GVHD may settle down in a month or two. Occasionally it last much longer
It may be necessary for your patient to be transferred to ITU. The ITU is the best place if he or she needs special monitoring, mechanical help to breathe or very close medical and nursing attention. The medical and nursing staff will keep you well informed about whether your patient is likely to be transferred to the ITU. The transplant physician will continue to work with the intensive care staff to provide the necessary care.
White blood cells: Blood cells that fight infection and provide protection (immunity) against disease. The total WBC count include the number of polys, lymphocytes, monocytes, eosinophils and basophils. Normal Count - 4500-11000/mm3
Polys: Polys are fighter white blood cells that help prevent bacterial and fungal infection. Normal Count - 1500-7800/mm3
Platelets: Platelets are blood cells that help clot blood to stop bleeding. Normal Count - 150,000-400,000/mm3 Hemoglobin: Hemoglobin is a measure of the number of red blood cells that carry oxygen. Normal Count - 12-14 gm% Keeping track of blood count Many parents like to keep a record of their patient counts during the transplant period. To make easier for you, we have provided this work sheet. Care at home Care at home:
Any of the following sign or symptoms of infection should be reported immediately to your doctor or BMT coordinator.
Signs to watch for Sign or symptoms of infection
1)A fever above 38. 5 C or 101 F. Do not give your patient paracetamol, which will hide a fever, without speaking to a physician.
2)Any breathing or respiratory problems, or a cough, runny nose, sore throat or cold. 3)Stomach complaints, such as diarrhea, nausea, vomiting or cramps.
Signs or symptoms of GVHD ( for patients with a donor transplant only)
- A new rash on the body, palms of the hands, or soles of the feet.
- Watery diarrhea.
- Loss of appetite with weight loss.
- Jaundice, a yellow colour in the whites of the eyes or in the skin.
Visitors
Visitors at home are allowed but they must be carefully screened. Family and friends should not visit if they are ill. Visiting children have greater chance carrying contagious diseases because they are more exposed to them in the school environment. Chickenpox, measles, mumps and cold sores are of particular concern.
Please report any known exposure to these diseases to the BMT coordinator as soon as possible.
Skin care
Make sure your patient bathes or showers every day using non-irritating soap and shampoo. Always clean the tub with a cleanser first. If skin is dry apply Vaseline or paraffin oil to the skin.
Protect your patient skin from the sun, especially if your patient had radiation or has GVHD. Follow these guidelines.
1)Cover your patient skin as much as possible with clothing.
2) Make sure your patient wears a hat, especially until his or her hair has grown back.
3)Use lots of sunscreen on your patient skin.
Mouth care
Make sure your child cares his or her mouth at least 3 times a day, preferably after meals.
1) If your patient platelets are lower than 100,000 use toothette. If your patient platelets are higher, use a soft toothbrush. Use any mild toothpaste with fluoride.
2)Make sure that the areas where the gums meet the upper and lower cheek are brushed thoroughly.
3)Report any white patches, called thrush, or mouth sores to your patient physician.
Medications
Your patient will still need medications at home. Your patient nurse and the pharmacist will explain the medication to you. Before you leave the hospital, please be sure that you understand what all the medications are for and how to give them.
Some of these medications can be expensive. Before your patient is admitted to the hospital, it is important that you discuss your health insurance with the BMT coordinator to make sure that these medications are covered.
A final note
Going home is exciting for every one in the family, but it can also be bit scary. Up until now, the hospital staff has helped care for your patient. Once your patient is discharged from the hospital, you feel like you are on your own.
Remember that you will be coming back to the hospital for check-ups every week at first. The BMT coordinator or doctor is only a phone call away. We urge you to call if you have any concerns- no matter how small they may seem.
If your patient has complications, he or she may need to be readmitted to the hospital. We will try very hard to keep your patient at home, rather than have to readmit him or her to the hospital.
Good luck at home, and please let us know if you need anything. We're here to help.
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