BONE MARROW TRANSPLANT FOR 3RD YEAR NURSING STUDENTS

1. BONE MARROW
TRANSPLANT
SUDESHNA BANERJEE DUTTA
LECTURER

2. DEFINITION
Bone Marrow Transplantation (BMT) is an advanced
procedure to replace bone marrow that has been
destroyed by treatment with high doses of anticancer
drugs or radiation.
✓ It’s also known as stem cell transplant
✓ Transplantation may be autologous (an individual's own
marrow saved before treatment), allogeneic (marrow
donated by someone else), or syngeneic (marrow donated
by an identical twin).

3. INDICATIONS OF BMT
Aplastic Anemia- a disorder in which the marrow stops
making new blood cells
Leukemia, Lymphoma
Damaged bone marrow due to Chemotherapy
Congenital Neutropenia- is an inherited disorder that
causes recurring infections
Sickle Cell Anemia- an inherited blood disorder that
causes misshapen red blood cells

4. TYPES OF BMT
There are 3 kinds of bone marrow transplants:
Autologus bone marrow transplant:
Stem cells are removed from the patients before they
receive high-dose chemotherapy or radiation treatment.
The stem cells are stored in a freezer. (-50 degree C)
After high-dose chemotherapy or radiation treatments, the
stems cells are put back in the body to make normal blood
cells. This is called a rescue transplant.

5. Allogenic bone marrow transplant:
Stem cells are removed from another person, called a
donor.
Most times, the donor's genes must at least partly match
patient’s genes.
A brother or sister is most likely to be a good match.
Sometimes parents, children, and other relatives are good
matches.
Donors who are not related to the patients, yet still match,
may be found through national bone marrow registries.

6. Syngeneic bone marrow transplant:
A procedure in which a patient
receives blood-forming stem cells (cells
from which all blood cells develop) donated
by his or her healthy identical twin.

7. SOURCES OF STEM CELLS
The two broad types of stem cells found in people are, adult
stems cells and embryonic stem cells.
Adult stem cells
•Cord blood, umbilical
cord blood
•Bone marrow
•Blood, peripheral
blood stem cells
Embryonic stem
cells
•Human embryos
•Fetal tissue

8. Donor stem cells can be collected in 2 ways:
BONE MARROW HARVEST:
This minor surgery is done under general or
local anesthesia.
The bone marrow is removed from the
bilateral posterior iliac bones by multiple
needle aspirations.
The amount of marrow collected is 10-15
ml/kg and depends on the weight of the
person who is receiving it.

9. LEUKAPHERESIS:
During leukapheresis, blood is removed from the
donor through an IV line.
The part of white blood cells that contains stem
cells is then separated in a machine and removed
to be later given to the recipient.
The red blood cells are returned to the donor.

10. PREPARING FOR A BONE MARROW
TRANSPLANT
Prior to transplant patient will undergo several tests to
discover what type of bone marrow cells is needed.
Patient also undergoes radiation or chemotherapy to kill
off all cancer cells before getting the new stem cells.
Bone marrow transplants take up to a week.
During treatments, the immune system will be
compromised, affecting its ability to fight infections.
Therefore, patient will have to stay in a special section of
the hospital that’s reserved for people receiving bone
marrow transplants. This reduces the risk of being
exposed to anything that could cause an infection.

11. PRE-TRANSPLANT INVESTIGATIONS
Physical examination
Chest x-ray
Electrocardiogram (EKG or ECG)
Ultrasound
Blood tests – Blood count, blood and tissue type, immune
system function
Renal function studies
Mammogram – Presence of breast cancer
Pap smear – Presence of cervical cancer
Dental Evaluations

12. HISTOCOMPATIBILITY LABORATORY
TESTS
➢ TISSUE TYPING – Ensures proper organ match. This test
is done on white blood cells which have special "markers"
which give a "tissue type". Tissue type is inherited from
parents.
The white blood cells have proteins called HLA markers
on their surface. HLA stands for HUMAN LEUCOCYTE
ANTIGEN.
If the bone marrow donor's HLA markers are very similar
to the patient’s, there is less chance that patient’s
immune system will reject their donor’s blood cells.

13. HISTOCOMPATIBILITY CONT…
➢ PANEL REACTIVE ANTIBODY (PRA) - Immune system
activity test. A higher immune system activity means your
body fights foreign objects (like a transplanted organ or
cells) more vigorously.
Blood transfusions, pregnancy, previous transplant(s) or a
current infection can cause your immune system to be
more aggressive.

14. BLOOD TYPE COMPATIBILITY CHART

15. PREPARING FOR BMT-CONDITIONING
• Several days prior to the transplant, patient receives high-
dose chemotherapy and/or total body irradiation (TBI).
The preparative regimen will take place in the hospital or
in an out-patient clinic over a three to seven day period.
• Doses of total body irradiation used in bone marrow
transplantation typically range from 10 to 12 Gy
• The most common TBI schedules include twice daily 2-Gy
fractions given over 3 days (total dose 12 Gy)

16. • If the preparative regimen is strong enough to
disable the immune system, the transplant is
called a MYELOABLATIVE transplant.
• If the preparative regimen is less intensive and
does not completely disable your immune system
the transplant is called a REDUCED
INTENSITY OR NONMYELOABLATIVE transplant.

17. RISKS/COMPLICATIONS IN BMT
✓ Chest pain
✓ Drop in blood pressure
✓ Fever, chills, flushing
✓ Headache
✓ Hives (Allergies)
✓ Nausea
✓ Pain
✓ Shortness of breath
✓ Anemia

18. RISKS CONT…
• Graft failure, which means that the new donated
cells do not settle into the body.
• Graft-versus-host disease (GVHD), a condition in
which the donor cells attack patient’s body
• Infections
• Inflammation and soreness in the mouth, throat,
esophagus, and ulcerated stomach.

19. PROCEDURE
MOBILIZATION
➢ Before stem cells are collected, a procedure called
mobilization or priming is done.
➢ Mobilization is done by administering chemotherapy.
➢ The most common chemotherapy agent used for
autologus peripheral blood stem cell mobilization is
CYCLOPHOSPHAMIDE.

20. COLLECTION
➢ The stem cells are harvested from the bone marrow or
peripheral blood of a donor at an approved collection
center and then transported to the transplantation center
by a trained courier.
➢ Marrow stem cells are collected by repeated bone marrow
aspirations from the posterior and anterior iliac crests of
the donor in an operating room under general anesthesia.
The amount of marrow collected is based on patient
weight (10- 15 ml marrow per kg patient weight).

21. ➢ The procedure takes an average of 1-3 hours. In
the operating room, the marrow is filtered to
remove bone particles and large fat globules and
then poured into transfusion bags for further
processing and freezing.
➢ Stem cells are collected from the patient/donor’s
peripheral blood through a technique called
APHERESIS.

22. ➢ Three to four collections, each lasting 2-4 hours,
usually are required to collect enough stem cells
for transplantation.
➢ The stem cells are then processed and frozen for
autologous transplantation.
➢ Often they are infused immediately into the
patient in an allogeneic donation.

23. PURGING
➢ The aim of purging is to remove contaminating
malignant cells while leaving stem cells intact to
reconstitute the hematopoietic system.
➢ Methods of eliminating malignant cells include the
use of chemical agents and antibody purging.
(MONOCLONAL ANTIBODIES combined with
cytocidal agents)

24. • Antibody or chemical purging has the potential to
damage stem cells and may lead to prolonged
neutropenia and delayed return of T and B cell
function after transplantation

25. CRYOPRESERVATION
➢ Previously harvested marrow and or blood stem
cells are freezed.
➢ DIMETHYL SULFOXIDE is added before freezing
to protect the cell membranes during freezing and
thawing.

26. CONDITIONING
In allogeneic and autologous transplants, the
purpose of conditioning is to eradicate
malignant cells and decrease the risk of relapse.
2 types:
✓ MYELOABLATIVE
✓ NON-MYELOABLATIVE

27. MYELOABLATIVE
➢ Regimen is strong enough to disable the immune system.
➢ In allogeneic transplants a combination
of cyclophosphamide with total body irradiation is
conventionally employed.
➢ This treatment also has an immunosuppressive effect that
prevents rejection of the HSC by the recipient’s immune
system.
➢ The post-transplant prognosis often includes acute and
chronic graft-versus- host disease that may be life-
threatening.

28. NON-MYELOABLATIVE
➢ Non-myeloablative allogeneic transplantation,
also termed reduced-intensity conditioning (RIC),
uses doses of chemotherapy and radiation too
low to eradicate all the bone marrow cells of the
recipient.
➢ Instead, non-myeloablative transplants run lower
risks of serious infections and transplant-related
mortality.

29. INFUSION
➢ Methods of infusion of stem cells vary depending
on the type of transplant.
➢ Autologous stem cells are collected,
cryopreserved with DMSO, frozen, and stored
previously
➢ On transplant day the cells must be thawed prior
to transplantation or re-infusion.

30. ➢ Premedication with an antiemetic and an
antihistamine helps to alleviate many of the
following side effects related to DMSO: nausea,
vomiting, flushing, chest discomfort, abdominal
pressure, occasional hypotension/bradycardia.
➢ Patients should be well hydrated before and after
the infusion of stem cells to prevent renal
complications from the DMSO load.

31. RECOVERY
➢ Hematopoietic recovery after transplant or engraftment
occurs following the blood counts when the white blood
cell, platelet, and RBC counts gradually increase.
➢ Engraftment is generally defined as a granulocyte count
greater than 500/mm3 and platelet greater than
20,000/mm3
➢ Following autologous stem cell transplant, counts usually
recover in approximately 8 to 10 days.

32. ➢ Since, the blood counts do not fall as low after
non-myeloablative transplant, engraftment occurs
more quickly.
➢ Recovery of blood cell counts after umbilical cord
blood transplant occurs more slowly, at
approximately day 28 for neutrophils and day 60
for platelets.

33. NURSING MANAGEMENT OF PATIENT
WITH BMT
ACUTE PAIN RELATED TO USE OF CHEMICAL AGENTS
AS EVIDENCED BY FACIAL GRIMACES
➢ Investigate reports of pain. Note changes in degree (use
scale of 0–10) and site.
➢ Provide quiet environment and reduce stressful stimuli.
Limit or reduce noise, lighting, constant interruptions.
➢ Place in position of comfort and support joints, extremities
with pillows.
➢ Assist with and provide diversional activities, relaxation
techniques.
➢ Analgesics: acetaminophen (Tylenol) & Opioids: codeine,
morphine etc.

34. ACTIVITY INTOLERANCE RELATED TO GENERALIZED
WEAKNESS AS EVIDENCED BY VERBAL REPORT
OF FATIGUE OR WEAKNESS
➢ Evaluate reports of fatigue, noting inability to participate
in activities or ADLs.
➢ Provide quiet environment and uninterrupted rest periods.
Encourage rest periods before meals.
➢ Recommend small, nutritious, high-protein meals and
snacks throughout the day.
➢ Provide supplemental oxygen.

35. KNOWLEDGE DEFICIT RELATED TO LACK OF
INFORMATION AS EVIDENCED BY FREQUENT
QUESTIONING.
➢ Provide psychological support by establishing a trusting
relationship to promote communication.
➢ Allow the patient and family to discuss or verbalize the
doubts. Let the family participate in patient care as much
as possible.

36. RISK FOR INFECTION RELATED TO INADEQUATE
SECONDARY DEFENSES I.E. BONE MARROW
SUPPRESSION
➢ Place patient in a private room. Limit visitors as indicated.
➢ Good hand washing protocol for all personnel and visitors.
➢ Closely monitor temperature. Observe for fever associated with
tachycardia, hypotension.
➢ Prevent chilling. Force fluids, administer tepid sponge bath.
➢ Use strict sterile technique when starting IV.
➢ Encourage increased intake of foods high in protein and fluids
with adequate fiber.

37. RISK FOR FLUID VOLUME DEFICIT RELATED TO
EXCESSIVE LOSSES, E.G., VOMITING,
HEMORRHAGE, DIARRHEA
➢ Weigh daily.
➢ Monitor BP and HR.
➢ Evaluate skin turgor, capillary refill, and general condition
of mucous membranes.
➢ Limit oral care to mouthwash if indicated. Avoid
mouthwashes with alcohol.
➢ Administer IV fluids as indicated.