blood disorders

1. CHAPTER VI
Therapies for Blood Disorders
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2. SPLENECTOMY
 The spleen is a fist-sized organ located in the upper
left quadrant of the abdomen. It includes a central
white pulp where storage and some proliferation of
lymphocytes and other leukocytes occurs, and a
peripheral red pulp involved in fetal erythropoiesis,
and later in erythrocyte destruction and the
conversion of hemoglobin to bilirubin. It may be
surgically removed because of trauma or to treat
certain hemolytic or malignant disorders with
accompanying splenomegaly. A laparoscopic
technique may be used to remove a normal to
slightly enlarged spleen in benign conditions, such
as idiopathic thrombocytopenic purpura, hemolytic
anemia, or sickle cell disease 2
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3. PREOPERATIVE MANAGEMENT
 Stabilization of preexisting condition:
 For trauma: volume replacement with I.V. fluids, evacuation
of stomach contents via nasogastric tube to prevent
aspiration, urinary catheterization to monitor urine output,
assessment for pneumothorax or hemothorax and possible
chest tube placement.
 For hemolytic or malignant disorder with accompanying
thrombocytopenia: coagulation studies, administration of
coagulation factors (eg, vitamin K, fresh-frozen plasma,
cryoprecipitate), platelet and red cell transfusions.
 Preoperative pulmonary evaluation and teaching.
 For patient undergoing elective splenectomy, polyvalent
pneumococcal vaccine 10 to 14 days before procedure.
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4. POSTOPERATIVE MANAGEMENT
 Prevention of respiratory complications:
hypoventilation and limited diaphragmatic
movement, atelectasis of left lower lobe,
pneumonia, left pleural effusion.
 Monitoring for hemorrhage.
 Administration of opioids for pain and observance
for adverse effects.
 Monitoring for fever.
 Postsplenectomy fever mild, transient fever is expected.
 Persistent fever may indicate subphrenic abscess or
hematoma
 Monitoring daily platelet count: thrombocytosis
(elevation of platelet count) may appear a few days
after splenectomy and may persist during first 2
weeks. 4
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5. POTENTIAL COMPLICATIONS
 Pancreatitis and fistula formation: tail of pancreas is
anatomically close to splenic hilum.
 Hemorrhage.
 Atelectasis and pneumonia.
 Overwhelming postsplenectomy infection (OPSI)
increased risk of developing a life-threatening bacterial
infection with encapsulated organisms, such as
Streptococcus pneumoniae, Neisseria meningitidis, or
Haemophilus influenzae type b. The incidence of OPSI
is 0.23% to 0.42% per year with a lifetime risk of 5%. An
OPSI is a medical emergency, and requires immediate
I.V. antibiotics in an intensive care setting. I.V.
immunoglobulins are also used. 5
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6. NURSING DIAGNOSES
 Ineffective Breathing Pattern related to pain and
guarding of surgical incision
 Risk for Deficient Fluid Volume related to
hemorrhage caused by surgery of highly vascular
organ
 Risk for Injury (thromboembolism) related to
thrombocytosis
 Risk for Infection related to surgical incision and
removal of the spleen
 Acute Pain related to surgical incision
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7. NURSING INTERVENTIONS
1. Maintaining Effective Breathing
 Assess breath sounds and report absent,
diminished, or adventitious sounds.
 Assist with aggressive chest physiotherapy and
incentive spirometry.
 Encourage early and progressive mobilization.
2. Monitoring for Hemorrhage
 Monitor vital signs frequently and as condition
warrants.
 Measure abdominal girth and report abdominal
distention.
 Assess for pain and report increasing pain.
 Prepare patient for surgical reexploration if bleeding
is suspected.
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8. NURSING INTERVENTIONS
3. Avoiding Thromboembolic Complications
 Monitor platelet count daily, report abnormal result promptly.
 If elevated, assess for possible thromboembolism.
 Assess skin color, temperature, and pulses.
 Advise patient to report chest pain, shortness of breath, pain, or
weakness.
 Report signs of thromboembolism immediately.
4. Preventing Infection
 Assess surgical incision daily or if increased pain, fever, or foul smell.
 Maintain meticulous hand washing and change dressings using
sterile technique.
 Teach patient to report signs of infection (fever, malaise) immediately.
 Educate patient and family regarding OPSI, including plan for
postsplenectomy immunizations, recognition of symptoms, use of
prophylactic and standby antibiotics.
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9. NURSING INTERVENTIONS
5. Relieving Pain
 Administer opioids or teach self-administration, as
prescribed and as necessary to maintain level of
comfort.
 Warn patient of adverse effects, such as nausea and
drowsiness; watch for hypotension and decreased
respirations.
 Teach the use of nonpharmacologic methods, such as
the use of music, relaxation breathing, progressive
muscle relaxation, distraction, and imagery to help to
manage pain.
 Document dosage of medications and response to
medication.
 Make sure patient has analgesics for use postdischarge.
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10. NURSING INTERVENTIONS
6. Patient Education and Health Maintenance
 Teach care of incision.
 Encourage to gradually increase activity according
to guidelines given by surgeon.
 Advise proper rest, nutrition, and stress avoidance
while recovering from surgery.
 Encourage follow-up as directed by surgeon and
primary care provider to maintain immunizations.
 Encourage patient to seek prompt medical attention
for any infections and to contact health care
provider immediately for high fever. 10
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11. EVALUATION: EXPECTED OUTCOMES
 Respirations unlabored, breath sounds clear
 Vital signs stable, abdominal girth unchanged
 Pulses strong, extremities warm and without pallor
or cyanosis
 Afebrile, no purulent drainage from incision
 Verbalizes decreased pain
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12. Autologous Transfusion
 Before elective procedures, the patient may donate
blood to be set aside for later transfusion. Patients may
donate one unit every 3 to 4 days up to 3 days prior to
surgery provided hemoglobin greater than 11 g/dL.
 Autologous RBCs can also be salvaged during some
surgical procedures or after trauma-induced
hemorrhage by use of automated cell-saver devices or
by manual suction equipment.
 Autologous blood products must be clearly labeled and
identified.
 Autologous transfusion eliminates the risks of
alloimmunization, immune-mediated transfusion
reactions, and transmission of disease, making it the
safest transfusion choice.
BLOOD DONATION
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13. NURSING ALERT
Patients who do not meet
standard criteria for blood
donation may still be eligible to
donate autologous blood
before elective surgeries. The
nurse should encourage
suitable candidates to consider
this underused option.
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14. BLOOD DONATION
Homologous Transfusion
 With this most common option, volunteer donors'
blood products are assigned to patients randomly.
 Before donation, volunteer donors receive
information about the process, potential adverse
effects, tests that will be performed on donated
blood, post donation instructions, and education
regarding risk for human immunodeficiency virus
(HIV) infection and signs and symptoms.
 Donors are screened against eligibility criteria
designed to protect donor and recipient
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15. BLOOD DONATION
Directed Transfusion
 In directed transfusion, blood products are donated
by a person for transfusion to a specified recipient.
 This option may be used in certain circumstances
(eg, a parent who provides sole transfusion support
for a child), but in general, no evidence exists that
directed donation reduces transfusion risks.
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16. General Blood Donor Eligibility Criteria
Age 17 years
Weight Minimum 110 lb (49.9 kg)
Vital signs Afebrile, normotensive, pulse 50-100, blood pressure < 180/100
mm Hg
Hemoglobin 12.5 g/dL
History Travel, exposures, and past illnesses or events may defer or
disallow blood donation. Examples: travel to malarial areas, living
in areas exposed to bovine spongiform encephalopathy, blood
transfusion or tattoo within 12 months, recent surgery or
pregnancy, corneal transplant, history of hepatitis or unexplained
jaundice, history or most cancers, history of behaviors at high risk
for human immunodeficiency virus.
Immunizations Recent attenuated and live vaccines generally result in deferral.
Illnesses A variety of current illnesses may defer or disallow blood
donation. Examples: clotting disorders, sickle cell disease,
systemic lupus erythematosus, multiple sclerosis, Lyme disease.
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17. COMPLICATIONS OF BLOOD DONATION
 Excessive bleeding at the donor’s venipuncture site is
sometimes caused by a bleeding disorder in the donor but
more often results from a technique error:
1. laceration of the vein,
2. excessive tourniquet pressure, or
3. failure to apply enough pressure after the needle is
withdrawn.
 Fainting is common after blood donation and may be related
to emotional factors, a vasovagal reaction, or prolonged
fasting before donation.
 Because of the loss of blood volume, hypotension and
syncope may occur when the donor assumes an erect
position.
 A donor who appears pale or complains of faintness should
immediately lie down or sit with head lowered below the
knees; he or she should be observed for another 30 minutes.
 Angina chest pain may be precipitated in patients with
unsuspected coronary artery disease.
 Seizures can occur in donors with epilepsy, although the
incidence is very low.
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18. BLOOD PRODUCT SCREENING
SEROLOGIC TESTING
 Routine laboratory testing is performed to assess
the compatibility of a particular blood product with
the recipient before release of the blood product
from the blood bank.
 ABO group and Rh type: determines the presence of A,
B, and D antigens on the surface of the patient's RBCs.
 Direct Coombs' test: determines the antibody attached
to the patient's RBCs.
 Crossmatch (compatibility test): detects agglutination of
donor RBCs caused by antibodies in the patient's
serum.
 Indirect Coombs' test: identifies lower molecular weight
antibodies (IgG) directed against blood group antigens.
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19. ABO and Rh Compatibility Chart
WHOLE BLOOD
Donor
Recipient A B O AB Rh positive Rh
negative
A [check
mark]
B [check
mark]
O [check
mark]
AB [check
mark]
Rh positive [check
mark]
[check
mark]
Rh
negative
[check
mark]
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20. ABO and Rh Compatibility Chart
RED BLOOD CELLS
Donor
Recipient A B O AB Rh positive Rh
negative
A [check
mark]
[check
mark]
B [check
mark]
[check
mark]
O [check
mark]
AB [check
mark]
[check
mark]
[check
mark]
[check
mark]
Rh positive [check
mark]
[check
mark]
Rh
negative
[check
mark]
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21. ABO and Rh Compatibility Chart
PLASMA
Donor
Recipient A B O AB Rh positive Rh
negative
A [check
mark]
[check
mark]
B [check
mark]
[check
mark]
O [check
mark]
[check
mark]
[check
mark]
[check
mark]
AB [check
mark]
Rh positive [check
mark]
[check
mark]
Rh
negative
[check
mark]
[check
mark]
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22. SCREENING FOR INFECTIOUS DISEASES
 Hepatitis: tests for the presence of hepatitis B core and
surface antibodies and hepatitis C viral titer.
 HIV-1 and HIV-2: tests for prior exposure to the virus.
 Cytomegalovirus (CMV): tests for the antibody against CMV.
 Syphilis: tests for the presence of antibody against the
spirochete.
 Bacteria: contamination of blood products with bacteria may
occur during and after collection of blood. This risk is
managed by maintenance of sterile technique during
phlebotomy and blood processing procedures, correct
storage techniques, visual inspection of blood products, and
limitation on shelf life.
 Other infections that may be transmitted via blood
transfusions include human T-cell lymphoma virus (HTLV) 1
and 2, malaria, babesiosis, Chagas' disease, and yersinia.
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23. ADMINISTRATION OF WHOLE BLOOD AND
BLOOD COMPONENTS
Whole blood and blood components are administered
to:
 Increase the amount of oxygen being delivered to
the tissues and organs,
 Prevent or stop bleeding because of platelet
defects or because of deficiencies or coagulation
abnormalities,
 Combat infection caused by decreased or defective
WBCs or antibodies.
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24. WHOLE BLOOD
 COMPOSITION
Cells and plasma, hematocrit about 40%
 INDICATIONS AND CONSIDERATIONS
Volume replacement and oxygen-carrying capacity;
usually used only in significant bleeding (> 25%
blood volume lost)
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25. WHOLE BLOOD
Nursing and Patient Care Considerations
 For rapid infusions of large volumes of whole blood, additional
steps may be taken to deliver product rapidly and safely.
 A small-pore filter may be used to remove microaggregates
(platelets, WBCs) that have been identified in the lungs of
massively transfused patients.
 An approved blood warmer may be indicated to prevent
hypothermia and cardiac arrhythmias associated with the rapid
infusion of refrigerated solutions.
 Electromechanical infusion devices to deliver blood at high flow
rates can hemolyze RBCs and should be used with caution.
 Observe closely for the most common acute complication
associated with whole blood transfusion circulatory overload
(rise in venous pressure, distended neck veins, dyspnea,
cough, crackles at bases of lungs).
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26. PACKED RBCS
 COMPOSITION:
RBCs with little plasma (hematocrit about75%); some
platelets and WBCs remain
 INDICATIONS AND CONSIDERATIONS
↑ RBC mass Symptomatic anemia: platelets in the
unit are not functional; WBCs the unit may cause
reaction and are not functional
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27. PACKED RBCS
Nursing and Patient Care Considerations
 Infuse at the prescribed rate. Generally, a unit can be
given to an adult in 90 to 120 minutes. Pediatric patients
are usually transfused at a rate of 2 to 5 mL/kg per hour.
 To reduce the risk of bacterial contamination and sepsis,
RBCs must be transfused within 4 hours of leaving the
blood bank.
 Observe closely (particularly during first 15 to 30
minutes) for the most common acute complications
associated with packed RBCs, allergic and febrile
transfusion reactions. Signs and symptoms of the more
serious, but rare, hemolytic transfusion reaction are
usually manifested during infusion of the first 50 mL.
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28. PLATELET
COMPOSITION INDICATIONS AND
CONSIDERATIONS
Platelets—random Platelets (5.5 × 1010
platelets /unit)
Plasma; some RBCs,
WBCs
Bleeding due to severe ↓
platelets
Prevent bleeding when platelets
<5,000–10,000/mm3
Survival ↓ in presence of fever,
chills, infection
Repeated treatment →↓survival
due to alloimmunization
Platelets—single
donor
Platelets (3 × 1011
platelets /unit)
1 unit is equivalent to 6–
8 units of random
platelets
Used for repeated treatment: ↓
alloimmunization risk by
limiting exposure to multiple
donors
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29. PLATELET
Nursing and Patient Care Considerations
 Infuse at the rate prescribed. Generally, the infusion
can be completed within 20 to 60 minutes,
depending on total volume.
 Observe closely for the most common acute
complications associated with platelet transfusions,
allergic and febrile transfusion reactions.
 Bacterial contamination of platelets, usually skin
commensals from the donor's arm, occurs in 4 to 10
per 10,000 units and limits the shelf life of platelet
products.
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30. PLASMA (FRESH OR FRESH-FROZEN)
COMPOSITION INDICATIONS AND
CONSIDERATIONS
Plasma (FFP) Plasma; all coagulation
factors Complement
Bleeding in patients with
coagulation factor deficiencies;
plasmapheresis
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31. PLASMA (FRESH OR FRESH-FROZEN)
Nursing and Patient Care Considerations
 Infuse at the rate prescribed. Generally, the infusion
can be completed within 15 to 30 minutes,
depending on total volume.
 Observe closely for the most common acute
complication associated with plasma infusion,
volume overload.
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32. CRYOPRECIPITATE
COMPOSITION INDICATIONS AND
CONSIDERATIONS
Cryoprecipitate Fibrinogen ≥ 150
mg/bag, AHF (VIII:C)
80–110 units/bag,
von Willebrand
factor; fibronectin
von Willebrand’s disease
Hypofibrinoginemia
Hemophilia A
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33. CRYOPRECIPITATE
Nursing and Patient Care Considerations
 Infuse at the rate prescribed. Generally, the infusion
can be completed within 3 to 15 minutes.
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34. ALBUMIN
COMPOSITION INDICATIONS AND
CONSIDERATIONS
Albumin Albumin 5%, 25% Hypoproteinemia; burns;
volume expansion by 5% to
↑ blood volume; 25%
→↓hematocrit
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35. ALBUMIN
Nursing and Patient Care Considerations
 These products may be distributed by the
pharmacy rather than by the blood bank.
 Check order and product insert to ensure proper
dosage and administration route.
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36. GRANULOCYTES (PHERESED)
COMPOSITION INDICATIONS AND
CONSIDERATIONS
Granulocytes Neutrophils (>1 ×
1010/unit); lymphocytes;
some RBCs and
platelets
Severe neutropenia in
selected patients;
controversial
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37. GRANULOCYTES (PHERESED)
Nursing and Patient Care Considerations
 Product must be ABO compatible and, if possible, Rh
compatible because of the high erythrocyte content.
 Transfuse granulocytes as soon as they are available.
WBCs have a short survival time, and therapeutic
benefit is directly related to dose and viability.
 Premedicate per order to prevent adverse effects,
generally with antihistamine and acetaminophen.
Steroids may also be required.
 Begin the transfusion slowly and increase to the rate
prescribed and as tolerated. The recommended length
of infusion is 1 to 2 hours.
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38. GRANULOCYTES (PHERESED)
 Observe the patient closely throughout the transfusion
for signs and symptoms of febrile, allergic, and
anaphylactic reactions, which may be severe. Have
emergency medications and equipment readily
available.
 Agitate the bag approximately every 15 minutes to
prevent granulocytes from clumping at the bottom of the
bag.
 Do not administer amphotericin products immediately
before or after granulocyte transfusion because
pulmonary insufficiency has been reported with
concurrent administration of amphotericin and
granulocytes. Many institutions recommend a 4-hour
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39. STANDARDS OF CARE GUIDELINES
BLOOD TRANSFUSION
When administering whole blood or blood components,
ensure the following:
 Follow up on results of complete blood count and report
to health care provider so appropriate blood product can
be ordered based on patient's condition.
 Contact the blood bank with health care provider's order
and ensure timely delivery of blood product.
 Establish a patent I.V. line with compatible I.V. fluid.
 Use appropriate administration setup, filter, warmer, etc.
 Obtain baseline vital signs.
 Make sure proper blood product is given to the right
patient.
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40. STANDARDS OF CARE GUIDELINES
BLOOD TRANSFUSION
 Transfuse at prescribed rate during prescribed time, as
tolerated by patient.
 Observe for acute reactions:allergic, febrile, septic,
hemolytic, air embolism, and circulatory overload by
assessing vital signs, breath sounds, edema, flushing,
urticaria, vomiting, headache, back pain.
 Notify patient's health care provider or available house
officer if signs of reaction or other abnormality arise.
 Be aware of delayed reactions and educate patient on
risk and what to look for: hemolytic, iron overload, graft-
versus-host disease, hepatitis, and other infectious
diseases.
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41. ADMINISTERING BLOOD AND BLOOD
COMPONENTS
EQUIPMENT
 Tourniquet
 Iodine-containing skin antiseptic
 Needle or venous catheter
 Y-type blood infusion set
 Filter
 Normal saline
 Blood product as described
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42. Nursing Action Rationale
Preparatory phase
1. Inform the patient of the procedure,
blood product to be given,
approximate length of time, and
desired outcome.
1. Instruct the patient to report unusual
symptoms immediately.
2. Obtain and record baseline vital
signs.
2. If the patient's clinical status permits,
delay transfusion if baseline
temperature is greater than 101.7 ‫آ‬
° F
(38.7 ‫آ‬
° C).
3. Prepare infusion site. Select a large
vein that allows patient some
degree of mobility. Start the
prescribed I.V. infusion.
3. Antecubital veins are not
recommended for lengthy infusions.
Prolonged restriction of arm
movement is uncomfortable and
inconvenient for the patient. In the
event of an acute reaction, the I.V.
catheter should be maintained with
normal saline.
DRUG ALERT Crystalloid solutions other than 0.9% saline and all medications
are incompatible with blood products. They may cause agglutination or
hemolysis.
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43. Nursing Action Rationale
Preparatory phase
4. Obtain blood product from blood bank.
Inspect for abnormal color,
cloudiness, clots, and excess air.
Read instructions on the product label
regarding storage and infusion. Check
expiration date.
4. Platelets are normally cloudy. If the
transfusion cannot begin
immediately, return product to
blood bank. Blood out of proper
storage (above 50 ‫آ‬
° F [10 ‫آ‬
° C]) for
more than 30 minutes cannot be
reissued. Never store blood in
unauthorized refrigerators, such as
those on the nursing unit.
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44. Nursing Action Rationale
Preparatory phase
5. Verify patient identification. 5. The majority of acute fatal
transfusion reactions are caused by
clerical errors. Patient and product
verification is the single most
important function of the nurse. It is
strongly recommended that two
qualified individuals perform this
task. Do not proceed with the
transfusion if there is a
discrepancy. Contact the blood
bank immediately.
a. Ask the patient to state his or her
full name and compare with name
on the wrist band. If the patient is
unable to state his or her name,
verify identity with an individual
familiar with the patient.
b. Compare the name and ID
number on the wristband with the
bag tag, transfusion form, and
medical order.
c. Confirm ABO and Rh compatibility
by comparing the bag label, bag
tag, medical record, and
transfusion form.
d. Check bag labels for expiration
date and satisfactory serologic
testing.
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45. Nursing Action Rationale
Performance phase
1. Start infusion slowly (ie, 2 mL/minute).
Remain at bedside 15-30 minutes. If
there are no signs of adverse effect,
increase flow to the prescribed rate.
1. Institutional policy may vary
regarding flow rates and patient
monitoring. Signs of a severe
transfusion reaction (ie, acute
hemolytic, anaphylactic) are usually
manifested during infusion of the
initial 50-100 mL.
2. Observe the patient closely and check
vital signs at least hourly until 1 hour
after transfusion. Report signs of
adverse effect to health care provider
immediately.
2. Acute reactions may occur at any
time during the transfusion
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46. Nursing Action Rationale
Performance phase
3. Record the following information on the
patient's chart:
3. Facts relating to the transfusion
should be charted exactly.
a. Time and names of persons starting
and ending the transfusion.
b. Names of individuals verifying
patient ID.
c. Unique product identification
number.
c. It must be possible to trace
each transfusion product to the
original blood donor.
d. Product and volume infused.
e. Immediate response for example,
“no apparent reaction.
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47. TRANSFUSION REACTIONS
 Every transfusion of blood components can result in
an adverse effect. Reactions can be placed into two
general categories: acute and delayed.
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48. ACUTE REACTIONS
 Acute reactions may occur during the infusion or within
minutes to hours after the blood product has been
infused.
 Acute reactions include allergic, febrile, septic, and
hemolytic reactions, air embolism, and circulatory
overload. Patients who also receive multiple blood
products within a short time frame may also be at risk
for hyperkalemia, hypocalcemia, and hypothermia.
 Because reactions may exhibit similar clinical
manifestations, every symptom should be considered
potentially serious and the transfusion should be
discontinued until the cause is determined.
 When a reaction is suspected, the health care provider
should be notified immediately and blood bags with
tubing from all products recently transfused should be
returned to the blood bank for evaluation.
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49. ACUTE REACTIONS
 The following samples should also be obtained if an acute
reaction is suspected.
 A clotted blood sample to examine serum for hemoglobin and
confirm RBC group and type.
 An anticoagulated blood sample for a direct Coombs' test to
determine the presence of antibody on the RBCs.
 The first voided urine sample to test for hemoglobinuria.
 Precautions must be taken to avoid the hemolysis of RBCs
during venipuncture and sample collection because this could
lead to invalid test results. Whenever possible, blood samples
should be drawn from a fresh venipuncture and not from
existing needles or catheters.
 If the only symptoms are those resulting from a mild allergic
reaction (eg, urticaria), extensive evaluation may not be
necessary. In the event of a severe reaction (eg, hypotension,
tachypnea), more tests may be required to determine the
cause of the reaction.
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50. Acute Reactions to Blood Transfusion
ACUTE
REACTION CAUSE
CLINICAL
MANIFESTATIONS MANAGEMENT PREVENTION
Allergic Sensitivi
ty to
plasma
protein
or donor
antibody,
which
reacts
with
recipient
antigen.
•Flushing
•Itching, rash
•Urticaria, hives
•Asthmatic
wheezing
•Laryngeal edema
•Anaphylaxis
•Stop transfusion immediately.
Keep vein open (KVO) with
normal saline. Notify health
care provider and blood bank.
•Give antihistamine as directed
(diphenhydramine).
•Observe for
anaphylaxis–prepare
epinephrine if respiratory
distress is severe.
•If hives are the only clinical
manifestation, the transfusion
can sometimes continue at a
slower rate.
•Send blood samples and
blood bags to blood bank.
Collect urine samples for
testing.
•Before
transfusion,
ask patient
about past
reactions. If
patient has
history of
anaphylaxis,
alert health
care provider,
have
emergency
drugs
available, and
remain at
bedside for the
first 30
minutes. 50
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51. Acute Reactions to Blood Transfusion
ACUTE REACTION CAUSE
CLINICAL
MANIFESTATIONS MANAGEMENT PREVENTION
Febrile, non-
hemolytic
Hypersensitivity to
donor white blood
cells, platelets, or
plasma proteins.
•Sudden chills
and fever
•Headache
•Flushing
•Anxiety
•Stop transfusion
immediately and
KVO with normal
saline. Notify health
care provider and
blood bank.
•Send blood
samples and blood
bags to blood bank.
Collect urine
samples for testing.
•Check temperature
‫آ‬
½ hour after chill
and as indicated
thereafter.
•Give antipyretics as
prescribed treat
symptomatically.
•Give
antipyretic
(acet-
aminophen or
aspirin) before
transfusion as
directed.
•Leukocyte-
poor blood
products may
be
recommended
for future
transfusions.
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52. Acute Reactions to Blood Transfusion
ACUTE
REACTION CAUSE
CLINICAL
MANIFESTATIONS MANAGEMENT PREVENTION
Septic
reactions
Transfusion
of blood or
components
contaminated
with bacteria.
•Rapid onset of
chills
•High fever
•Vomiting,
diarrhea
•Marked
hypotension
•Stop transfusion
immediately and
KVO with normal
saline. Notify health
care provider and
blood bank.
•Obtain cultures of
patient's blood and
return blood bags
with administration
set to blood bank for
culture.
•Treat septicemia as
directed antibiotics,
I.V. fluids,
vasopressors,
steroids.
•Do not permit blood to
stand at room
temperature longer
than necessary. Warm
temperatures promote
bacterial growth.
•Inspect blood for gas
bubbles, clotting, or
abnormal color before
transfusion
•Complete infusions
within 4 hours. Change
administration set after
4 hours of use.
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53. Acute Reactions to Blood Transfusion
ACUTE
REACTION CAUSE
CLINICAL
MANIFESTATION
S MANAGEMENT PREVENTION
Circulatory
overload
Fluid
administered at
a rate or
volume greater
than the
circulatory
system can
accommodate.
Increased
blood in
pulmonary
vessels and
decreased lung
compliance.
•Rise in
venous
pressure
•Distended
neck veins
•Dyspnea
•Cough
•Crackles at
base of
lungs
•Stop transfusion
and KVO with
normal saline.
Notify health care
provider.
•Place patient
upright with feet in
dependent
position.
•Administer
prescribed
diuretics, oxygen,
morphine, and
aminophylline.
•Concentrated blood
products should be
given whenever
positive.
•Transfuse at a rate
within the circulatory
reserve of the patient.
•Monitor central
venous pressure of
patient with heart
disease.
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54. Acute Reactions to Blood Transfusion
ACUTE
REACTION CAUSE
CLINICAL
MANIFESTATIONS MANAGEMENT PREVENTION
Hemolytic
reaction
•Infusion of
incompatible
blood products:
Antibodies in
recipient's
plasma attach to
transfused red
blood cells
(RBCs),
hemolyzing the
cells either in
circulation or in
the
reticuloendotheli
al system.
•Chills; fever
•Lower back
pain
•Feeling of
head fullness;
flushing
•Oppressive
feeling
•Stop transfusion
immediately KVO
with 0.9% saline.
•Notify health care
provider and blood
bank.
•Treat shock, if
present
•Draw testing
samples, collect
urine sample.
•Meticulously verify
patient
identificationâ from
sample collection to
product infusion.
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55. Acute Reactions to Blood Transfusion
ACUTE
REACTION CAUSE
CLINICAL
MANIFESTATIONS MANAGEMENT PREVENTION
Hemolytic
reaction
•Antibodies in
donor plasma
attach to
recipient RBCs,
causing
hemolysis (may
result from
infusion of
incompatible
plasma less
severe than
incompatible
RBCs).
•Tachycardia,
tachypnea
•Hypotension,
vascular collapse
•Hemoglobinuria,
hemoglobinemia
•Bleeding
•Acute renal
failure
•Maintain blood
pressure with I.V.
colloid solutions.
Give diuretics as
prescribed to
maintain urine flow,
glomerular filtration,
and renal blood flow.
•Insert indwelling
catheter to monitor
hourly urine output.
Patient may require
dialysis if renal
failure occurs.
•Begin infusion
slowly and
observe closely
for 30 minutes
consequences
are in
proportion to
the amount of
incompatible
blood
transfused.
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56. DELAYED REACTIONS
 Delayed reactions occur days to years after the
transfusion.
 Delayed reactions include delayed hemolytic
reactions, iron overload (hemosiderosis), GVHD,
infectious diseases (eg, hepatitis B, hepatitis C,
CMV, Epstein-Barr virus, malaria, HIV, HTLV).
 Symptoms of a delayed reaction can vary from mild
to severe. Diagnosis may be complicated by the
long incubation period between transfusion and
reaction and the complexity of diagnostic tests.
56
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57. Delayed Reactions To Transfusion Therapy
DELAYED
REACTION CAUSE
CLINICAL
MANIFESTATIONS MANAGEMENT PREVENTION
Delayed
hemolytic
reaction
The destruction
of transfused
red blood cells
by antibody not
detectable
during
crossmatch, but
formed rapidly
after
transfusion.
Rapid
production may
occur because
of antigen
exposure during
previous
transfusions or
pregnancy.
•Fever
•Mild jaundice
•Decreased
hematocrit
•Generally, no acute
treatment is
required, but
hemolysis may be
severe enough to
cause shock and
renal failure. If this
occurs, manage as
outlined under acute
hemolytic reactions.
•The
crossmatch
blood sample
should be
drawn within 3
days of blood
transfusion.
Antibody
formation may
occur within 90
days of
transfusion or
pregnancy.
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58. Delayed Reactions To Transfusion Therapy
DELAYED
REACTION CAUSE
CLINICAL
MANIFESTATIONS MANAGEMENT PREVENTION
Iron
overload
(hemosider
osis)
Deposition of
iron in the heart,
endocrine
organs, liver,
spleen, skin,
and other major
organs as a
result of
multiple, long-
term
transfusions
(aplastic
anemia,
thalassemia).
•Diabetes
•Decreased
thyroid function
•Arrhythmias
•Heart failure and
other symptoms
related to major
organ failure
•Treat
symptomatically.
•Deferoxamine
(Desferal), which
chelates and
removes
accumulated iron
through the kidneys;
administered I.V.,
I.M., or S.C.
58
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59. Delayed Reactions To Transfusion Therapy
DELAYED
REACTION CAUSE
CLINICAL
MANIFESTATIONS MANAGEMENT PREVENTION
Graft-
versus-host
disease
Engraftment of
lymphocytes in
the bone
marrow of
immunosuppres
sed patients,
setting up an
immune
response of the
graft against the
host.
•Erythematous
skin rash
•Liver function test
abnormalities
•Profuse, watery
diarrhea
•Immunosuppressio
n with
corticosteroids,
cyclosporine A.
•Symptomatic
management of
pruritus, pain
•Fluid and electrolyte
replacement for
diarrhea
•Transfuse with
irradiated blood
products.
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60. Delayed Reactions To Transfusion Therapy
DELAYED
REACTION CAUSE
CLINICAL
MANIFESTATIONS MANAGEMENT PREVENTION
Infectious diseases
Hepatitis B Hepatitis B virus
transmitted from
blood donor to
recipient via
infected blood
products.
•Elevated liver
enzymes
(ALT/AST)
•Anorexia, malaise
•Nausea and
vomiting
•Fever
•Dark urine
•Jaundice
•Usually resolves
spontaneously within
4-6 weeks. Can
result in permanent
liver damage. Treat
symptomatically.
•Screen blood
donors,
temporarily
rejecting those
who may have
had contact
with the virus.
Those with a
history of
hepatitis after
age 11 are
permanently
deferred;
pretest all
blood products
(EIA).
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61. Delayed Reactions To Transfusion Therapy
DELAYED
REACTION CAUSE
CLINICAL
MANIFESTATIONS MANAGEMENT PREVENTION
Infectious diseases
Hepatitis C
(formerly
non-A, non-
B hepatitis)
Hepatitis C virus
transmitted from
blood donor to
recipient via
infected blood
products.
•Similar to serum
B hepatitis, but
symptoms are
usually less
severe. Chronic
liver disease and
cirrhosis may
develop.
•Symptoms usually
mild. Interferon and
ribavirin may be
used to treat chronic
liver disease.
•Pretest all
blood donors
(ALT, anti-HBc
antibody, anti-
hepatitis C
antibody).
Epstein-
Barr virus,
cytomegalo
virus,
malaria
Transmitted
through infected
blood products.
•Fever
•Fatigue
•Hepatomegaly
•Splenomegaly
•Rest and supportive
management.
•Question
prospective
blood donors
regarding
colds, flu,
foreign travel.
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62. Delayed Reactions To Transfusion Therapy
DELAYED
REACTION CAUSE
CLINICAL
MANIFESTATIONS MANAGEMENT PREVENTION
Infectious diseases
Acquired
immunodefi
ciency
syndrome
(AIDS)
Human
immunod
eficiency
virus
(HIV)
transmitt
ed from
blood
donor to
recipient
via
infected
blood
products.
•Night sweats
•Unexplained
weight loss
•Lymphadenopathy
•Pneumocystis
pneumonia
•Kaposi's sarcoma
•Diarrhea
•Combination
antiretroviral
therapy.
•Test each donor for HIV
antibody.
•Reject prospective high-
risk donors: males who
have had sex with another
male since 1977; users of
self-injected I.V. drugs;
male or female partners of
prostitutes; hemophiliacs
or their sexual partners;
sexual partners of those
with AIDS or high risk for
AIDS; immigrants from
Haiti or sub-Saharan
Africa.
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63. Delayed Reactions To Transfusion Therapy
DELAYED REACTION CAUSE
CLINICAL
MANIFESTATIONS MANAGEMENT PREVENTION
Infectious diseases
Human T-
lymphotropic
virus type 1
(HTLV-1)
associated
myelopathy and
tropical spastic
paraparesis
(HAM/TSP) Adult
T-cell leukemia
HTLV-1
transmitted
from blood
donor to
recipient via
blood
products.
•Signs of
neuromuscular
disease
•Signs of T-cell
leukemia
•HTLV-1-infected
individuals have a
low risk of
developing disease
. Incubation period
10-20 years.
•Should disease
occur, treat
symptomatically.
•Screen all
prospective
blood donors
for anti-HTLV-1
antibody.
Syphilis Spirochetem
ia caused by
Treponema
pallidum.
Incubation
4-18 weeks.
•Presence of
chancre
•Regional
lymphadenopath
y
•Generalized
rash
•Penicillin therapy •Test blood
before
transfusion
(rapid plasma
reagin).
Organism will
not remain
viable in blood
stored 24-48
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64. Delayed Reactions To Transfusion Therapy
DELAYED REACTION CAUSE
CLINICAL
MANIFESTATIONS MANAGEMENT PREVENTION
Infectious diseases
Syphilis Spirochetem
ia caused by
Treponema
pallidum.
Incubation
4-18 weeks.
•Presence of
chancre
•Regional
lymphadenopath
y
•Generalized
rash
•Penicillin therapy •Test blood
before
transfusion
(rapid plasma
reagin).
Organism will
not remain
viable in blood
stored 24-48
hours at 39.2 ‫آ‬
°
F (4 ‫آ‬
° C).
64
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65. BLOOD AND MARROW STEM CELL
TRANSPLANTATION
 Blood and marrow stem cell transplantation are
potentially lifesaving treatments with application in
many malignant and nonmalignant disorders.
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66. TYPES OF STEM CELL TRANSPLANT
Autologous BoneMarrow Transplantation
Bone marrow is removed from the patient during an
operative harvesting procedure, frozen, and
reinfused after the patient has undergone high-dose
chemotherapy and possibly radiotherapy.
Advantages: readily available, usually lower
morbidity and mortality than allogeneic bone
marrow transplantation (BMT).
Disadvantages: operative procedure, marrow must
be disease free, sufficient quantity of cellular
marrow must be aspirable, in most cases has
higher rate of relapse than allogeneic bone marrow
transplantation. 66
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67. TYPES OF STEM CELL TRANSPLANT
Syngeneic Bone Marrow Transplantation
Bone marrow is removed from an identical twin during
an operative harvesting procedure and infused into
the patient, who has undergone high-dose
chemotherapy and possibly radiotherapy.
Advantages: patient's marrow does not need to be
harvestable (eg, aplastic anemia, myelofibrosis),
generally lower morbidity and mortality than
allogeneic BMT.
Disadvantages: higher relapse rate than in
allogeneic BMT.
67
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68. TYPES OF STEM CELL TRANSPLANT
Allogeneic Bone Marrow Transplantation
Bone marrow is removed from a donor who is most
commonly a sibling or other close relative (related) but
may be a volunteer donor (unrelated).
Advantages: patient's marrow does not need to be
harvestable (eg, aplastic anemia, myelofibrosis, genetic
disorders), lowest rate of relapse.
Disadvantages: risk for GVHD, generally higher morbidity
and early mortality than other types of BMT. Unrelated
and HLA-mismatched transplants have higher risk of
GVHD and infectious complications, and risk of graft
rejection or failure.
68
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69. TYPES OF STEM CELL TRANSPLANT
Autologous or Allogeneic Peripheral Blood Stem Cell Transplantation
 Although hematopoietic stem cells are primarily found in the bone
marrow, they can also be found in the peripheral circulation in smaller
numbers.
 Most peripheral blood stem cell transplantations are autologous.
 Peripheral blood stem cells are collected using one or more apheresis
procedures after the patient or donor has been treated to increase the
number of circulating stem cells by methods such as timed
administration of chemotherapy and growth factors. The cells are frozen
and stored, and later reinfused into the patient after high-dose
chemotherapy and possibly radiotherapy.
Advantages: patient's marrow does not need to be harvestable (as in
hypocellular or tumor-contaminated bone marrow); there is no operative
risk to the patient or donor. Peripheral blood stem cell transplantation has
a low risk of morbidity and mortality and eliminates lengthy hospital
stays. The product may be used alone or in conjunction with autologous
or allogeneic bone marrow.
Disadvantages: for allogeneic donors, the long-term risks of boosting
healthy bone marrow production with growth factors, and in some cases
chemotherapy, are not yet known. 69
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70. TYPES OF STEM CELL TRANSPLANT
Umbilical Cord Blood Stem Cell Transplantation
Umbilical cord blood is rich in stem cells, and may be
stored at birth for later autologous use, related
allogeneic use, or unrelated allogeneic use.
Advantages: may provide lifesaving allogeneic stem
cells from new sibling to older child, no risk to the
donor.
Disadvantages: may have higher risk of graft failure
than other types of transplants; number of stem
cells may be insufficient for older patients.
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71. INDICATIONS FOR BONE MARROW
TRANSPLANTATION
ALLOGENEIC
Nonmalignant
 Aplastic anemia
 Myelofibrosis
 Wiskott-Aldrich syndrome
 Thalassemia
 Severe combined
immunodeficiency
diseases
 Mucopolysaccharidoses
 Sickle cell disease
Malignant
 Acute myeloid leukemia
 Acute lymphocytic
leukemia
 Hodgkin's lymphoma
 Non-Hodgkin's lymphoma
 Myelofibrosis
 Multiple myeloma
 Selected solid tumors
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72. INDICATIONS FOR BONE MARROW
TRANSPLANTATION
Autologous
 Acute myeloid leukemia
 Acute lymphocytic leukemia
 Hodgkin's lymphoma
 Non-Hodgkin's lymphoma
 Multiple myeloma
 Selected solid tumors
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73. HARVESTING OF BONE MARROW AND
PERIPHERAL BLOOD STEM CELLS
Evaluation of Recipient
 Eligibility criteria include age (generally younger than age 55 for
allogeneic, younger than age 65 for autologous and syngeneic bone
marrow transplantation, and younger than age 70 for peripheral blood
stem cell transplantation) and availability of suitable stem cell source.
 Before undergoing transplantation, an extensive workup ensures that
the patient's disease is treatable with stem cells and that the patient
has no limitations that will increase the risk of mortality.
 Specific criteria may vary among transplant centers and treatment
protocols, but generally include:
 Disease-specific evaluation of severity and extent of current disease
manifestations.
 Adequate cardiac function: generally left ventricular ejection fraction greater
than 45%.
 Adequate pulmonary function: generally, forced expiratory capacity and forced
vital capacity greater than 50%.
 Adequate renal function: generally, creatinine less than 2 mg/dL.
 Adequate hepatic function: generally, bilirubin less than 2 mg/dL.
 No active infections (including HIV).
 No coexisting severe or uncontrolled medical conditions. 73
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74. EVALUATION OF BLOOD AND MARROW DONORS
 Because bone marrow donation for allogeneic or
syngeneic BMT is an elective procedure with no
benefit to the donor, great care is taken to ensure
that the potential donor is fit for surgery and
understands the potential risks. Autologous bone
marrow donors must generally meet the same
criteria. Evaluation includes:
 Thorough medical history and physical examination
 Chest X-ray
 Electrocardiogram
 Laboratory evaluation (complete blood count [CBC],
chemistry profile, testing for CMV, hepatitis B and C,
HIV, HTLV, and syphilis, ABO and Rh determination,
coagulation studies). 74
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75. EVALUATION OF BLOOD AND MARROW
DONORS
 Informed consent including potential donor complications must
be obtained.
 Relatively common complications include:
 Bruising.
 Pain at aspiration sites.
 Mild bleeding.
 Rare complications include:
 Adverse effects of anesthesia (general, spinal, or epidural).
 Infection of aspiration sites.
 Persistent pain.
 Transient neuropathies.
 Because of the significant loss of blood volume and RBCs during
the harvest procedure, donors are advised to give one or two
units of autologous blood 1 to 3 weeks before surgery, which may
be reinfused during marrow collection if needed.
 Evaluation of donors for peripheral blood stem cell
transplantation is similar, but less stringent. The apheresis
procedure is similar to donating platelets. 75
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76. STEM CELL COLLECTION PROCEDURE
BONE MARROW HARVEST (AUTOLOGOUS,
SYNGENEIC, OR ALLOGENEIC)
 Performed under epidural, spinal, or general anesthesia
under sterile conditions in operating room.
 An aspiration needle is used to puncture the skin and
puncture the iliac crest multiple times without exiting the
skin, removing marrow in 2- to 5-mL aliquots (samples).
 Marrow is drawn up into heparinized syringes and
filtered to remove fibrin clots and other debris.
 Marrow may be infused immediately, treated and
infused, or frozen in a preservative solution containing
dimethyl sulfoxide (DMSO) until needed.
 Bone marrow donation is a relatively safe operative
procedure with few serious complications.
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77. POSTHARVEST CARE OF THE BONE MARROW
DONOR
 Procedure is generally done as same-day care, with
discharge after recovery from anesthesia.
 Observe for potential complications (bleeding,
hypotension caused by fluid loss).
 Instruct patient to resume normal activities gradually
during the week after donation.
 Instruct patient to keep aspiration sites clean and dry
and observe for signs of infection (redness, swelling,
warmth or discharge at sites, fever, malaise).
 Provide adequate analgesia and instruct patient about
pain management.
 Arrange follow-up appointment with primary care
provider in 2 to 3 weeks for a CBC.
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78. HARVESTING OF PERIPHERAL BLOOD STEM CELLS
 Involves donor preparation by priming hematopoietic
system with timed chemotherapy and sequential growth
factors to increase number of circulating stem cells.
 Large-bore central catheter suitable for apheresis
procedures is inserted.
 One to ten apheresis procedures may be needed to
collect sufficient numbers of suitable cells.
 Cells are frozen in a preservative solution that contains
DMSO until needed.
 Acute complications of apheresis include citrate toxicity,
which may be managed by increasing dietary calcium
intake 2 to 3 days before procedure and by using
calcium-based antacids during procedure. Blood
calcium levels are carefully monitored throughout the
procedure and I.V. calcium given as needed.
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79. PREPARATION AND PERFORMANCE OF
THE TRANSPLANT
PREPARATION OF RECIPIENT
 A long-term central catheter is inserted for multiple I.V.
treatments, including blood products, total parenteral nutrition,
and blood-drawing.
 High-dose chemotherapy or radiotherapy is administered to:
 Destroy residual tumor cells.
 Suppress immune response against new stem cells.
 Create space within donor marrow for new stem cells.
 Symptoms immediately associated with high-dose
chemotherapy or radiotherapy regimens used in blood and
marrow stem cell transplantation may include:
 Severe nausea and vomiting (with most regimens).
 Cardiomyopathy, hemorrhagic cystitis (with cyclophosphamide
[Cytoxan]).
 Seizures (with busulfan [Myleran]).
 Fever, generalized erythema, parotitis (with total body irradiation).
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80. POSTTRANSPLANT CARE
General Considerations
 Significant complications that require specialized
medical and nursing care may occur during the first
few weeks and months after blood and marrow
stem cell transplantation.
 Risk is highest in mismatched unrelated allogeneic BMT.
 Followed by matched unrelated and mismatched related
allogeneic BMT.
 Followed by matched related allogeneic BMT.
 Followed by syngeneic BMT.
 Followed by autologous BMT.
 Followed by autologous peripheral blood stem cell
transplantation. 80
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81. POSTTRANSPLANT CARE
 Nursing care is aimed at early identification and
treatment of problems, and includes:
 Comprehensive physical and psychosocial assessment.
 Immediate notification of health care provider of any abnormal
assessment parameters found.
 Early recognition and intervention for life-threatening
complications, such as sepsis, respiratory failure, GI bleeding,
renal and hepatic failure, and veno-occlusive disease.
 Prevention of infection.
 Prevention of bleeding.
 Expert symptom management of problems that may occur
after blood and marrow stem cell transplantation, such as
nausea, vomiting, pain, fatigue, anxiety, and delirium.
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82. HEMATOPOIETIC COMPLICATIONS
 Blood and marrow stem cell transplant patients,
particularly allogeneic recipients, are at risk for life-
threatening bacterial, viral, and fungal infections
because of their profound immunosuppression.
 Transplant patients are usually cared for in a protective
environment, which ranges from single HEPA-filtered
rooms to strict laminar airflow and isolation in sterile
environment.
 In an ambulatory or home setting, the patient and family
must pay strict attention to methods of preventing
infection, including wearing high-filtration masks, hand
washing, safe food handling, and avoidance of crowded
areas and exposure to illnesses.
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83. HEMATOPOIETIC COMPLICATIONS
 Blood and marrow stem cell recipients are at high risk
for nosocomial blood stream infections related to long-
term central venous catheters, neutropenia, and
immunosuppression. Strict adherence to an evidence-
based procedure for insertion and management of
central venous catheters is essential in this population.
 Additional preventive interventions vary widely and
include elaborate disinfection procedures; modified or
sterile diets; prophylactic antibiotics, antivirals, and
antifungals; surveillance cultures.
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84. HEMATOPOIETIC COMPLICATIONS
 The megakaryocyte is generally the last cell
produced by new stem cells, and platelet counts
may take months to return to normal.
 Blood and marrow stem cell transplant patients require
frequent assessment for signs and symptoms of overt or
covert bleeding, protection from injury, and support with
platelet products.
 Anemia is a common complication caused by loss
of RBCs through aging, destruction, bleeding, and
routine phlebotomy. Blood and marrow stem cell
transplant patients require frequent RBC
transfusions. 84
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85. GI COMPLICATIONS
 Mucositis may develop because of high-dose chemotherapy
and radiation therapy that destroy rapidly dividing cells,
including cells lining the mouth, esophagus, and GI tract.
Management includes meticulous oral hygiene, local and
systemic analgesia, and antimicrobial therapy.
 Nausea and vomiting may arise from multiple causes,
including high-dose chemotherapy, infection, GI bleeding,
acute GVHD, and medications. Management includes
pharmacologic and nonpharmacologic interventions,
replacement of fluids and electrolytes, and support of
nutritional requirements.
 Diarrhea may have multiple causes, including high-dose
chemotherapy, infection, GI bleeding, GVHD, and
medications. Management includes cautious use of
antidiarrheals, replacement of fluids and electrolytes, support
of nutritional requirements, protection of perirectal skin from
excoriation.
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86. RENAL AND GENITOURINARY COMPLICATIONS
 Renal failure may arise from multiple causes,
including drug toxicity, infection, and ischemia.
Management includes maintenance of fluid and
electrolyte balance, monitoring of drug levels, and
hemodialysis or continuous venovenous
hemodialysis.
 Hemorrhagic cystitis may occur as a result of high-
dose cyclophosphamide (Cytoxan) or with certain
viral infections, such as adenovirus and BK virus.
Management includes hydration, blood product
support, continuous bladder irrigation, and rare
invasive procedures, such as instillation of alum or
formalin, or surgery. 86
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87. HEPATIC COMPLICATIONS
 Veno-occlusive disease (VOD) may occur as a result of
damage to the liver from high-dose chemotherapy and
radiation therapy; incidence is approximately 20%.
 Signs and symptoms include hepatomegaly (generally
painful), bilirubinemia, weight gain.
 May progress to hepatic encephalopathy,
coagulopathies, coma and death in up to 50% of
patients with veno-occlusive disease.
 Management is generally aimed at preventing further
damage and at treating symptoms. The antithrombotic
and thrombolytic agent defibrotide may be administered
for severe VOD; however, the risk of bleeding is high
with the administration of this agent.
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88. PULMONARY COMPLICATIONS
 Life-threatening pulmonary infections in stem cell recipients
include bacterial pneumonias, fungal infections, including
aspergillosis, viral infections such as CMV (especially in
allogeneic recipients), RSV and, less commonly,
Pneumocystis carinii pneumonia (PCP), legionnaires' disease,
toxoplasmosis, and tuberculosis.
 Preventive measures include hand hygiene, encouragement of
exercise, deep breathing, and coughing; administration of CMV-
screened and/or leuko-reduced blood products, high-dose acyclovir
(Zovirax) or ganciclovir (Cytovene),
and IVIG for allogeneic BMT patients at high risk for CMV;
prophylactic co-trimoxazole (Bactrim) for patients at risk for PCP.
Staff, patient, and family education regarding risk factors and
transmission of these infectious agents may help prevent primary
and nosocomial infections.
 Supportive care if symptomatic includes pulmonary hygiene, oxygen
therapy, and mechanical ventilation.
 Noninfectious pulmonary disease includes idiopathic
pneumonitis, diffuse alveolar hemorrhage, pulmonary fibrosis,
and bronchiolitis obliterans. 88
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89. GRAFT-VERSUS-HOST DISEASE
 Acute GVHD occurs in 40% to 60% of allogeneic
recipients even with HLA matching, generally within first
3 months after transplant as a manifestation of the
immune response of activated donor T lymphocytes
against the recipient's cells and organs.
 Primarily affects the skin, liver, and GI tract; may also affect
conjunctivae and lungs.
 Severity ranges from mild and self-limited erythematous rash
to widespread blistering of skin, profuse watery diarrhea, and
liver failure.
 Prophylaxis generally includes immunosuppression with such
medications as cyclosporine (Neoral), tacrolimus (FK506),
and methotrexate (Trexall); may also include T-cell depletion
of bone marrow.
 Treatment generally includes increased doses of routine
immunosuppressive drugs and additional drugs, such as
corticosteroids, antithymocyte globulin, and monoclonal
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90. GRAFT-VERSUS-HOST DISEASE
 Chronic GVHD occurs in approximately 20% of long-
term survivors; usually appears within first year after
allogeneic blood and marrow stem cell transplant.
 It has many similarities to autoimmune disorders such as
scleroderma.
 It affects the skin, mouth, salivary glands, eyes,
musculoskeletal system, liver, esophagus, GI tract, and
vagina.
 Treatment generally consists of corticosteroids and other
immunosuppressive drugs, such as mycophenolate
(CellCept) and thalidomide (Thalomid).
 Immune system frequently suppressed beyond the effects of
medications; patient is at risk for infections, particularly from
encapsulated bacteria, and should receive prophylaxis with
suitable antibiotic such as penicillin.
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91. LONG-TERM SEQUELAE AND SURVIVORSHIP
ISSUES
 Long-term, disease-free survival varies from 5% to 10%
for patients with resistant, aggressive leukemias or
lymphomas to 75% to 80% for aplastic anemia.
 Long-term complications of blood and marrow stem cell
transplantation include:
 Relapse of original disease.
 Secondary malignancy.
 Sterility.
 Endocrine dysfunction, including reduced levels of human
growth hormone, estrogens and testosterone.
 Cataracts (risk increased with radiation therapy,
corticosteroids).
 Chronic GVHD (allogeneic).
 Aseptic necrosis (risk increased with corticosteroids).
Encephalopathy (risk increased with cranial irradiation and
intrathecal chemotherapy).
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92. LONG-TERM SEQUELAE AND SURVIVORSHIP ISSUES
 Survivorship issues after this intensive and potentially life-
threatening treatment include:
 Feelings of isolation, guilt, and loss.
 Altered family dynamics.
 Delayed puberty, decreased libido, early menopause, and other physical
problems that have an impact on sexual relationships.
 Readjustment to school or work setting.
 Financial burden of blood and marrow stem cell transplantation
 Chronic health problems and fatigue.
 Difficulty obtaining adequate health insurance.
 Despite the complex issues blood and marrow stem cell
transplant survivors face as they return to the task of living,
several quality-of-life studies have demonstrated that the majority
rate their quality of life highly, would choose to undergo
transplant again, and frequently state that their experiences have
added new dimensions of meaning and purpose to their lives.
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