Autologous Blood Stem Cell Transplant Program - In Hospital

 

Your Health Care Team

There are many health care professionals on the health care team and we consider you and your family as members of this team. As a team member, we encourage you to ask questions and share information with other members of the health care team.

 

The following-is a list of your professional health care team members and some information about their roles in your care.

 

Doctors

·         You will be admitted under one attending transplant doctor. Although this doctor may change during your hospital stay, there will always be an attending transplant doctor supervising your care

·         The attending doctor and his/her colleagues will be involved in all stages of your transplant

·         There are several other doctors who may be responsible for your care on the weekends

·         Some of the transplant doctors will also provide your care in the outpatient clinic at TBCC after your discharge.

 

All medical staff work together and each doctor that cares for you has knowledge about you and your transplant. There is a doctor "on call" 24 hours a day.

 

Nurses

·         The nursing staff work together as part of your health care team in caring for you through your transplant. They will teach you more about the transplant process, the care that you will receive during treatment and how to care for yourself.

·         The nurses encourage patients to take an active role in their own care and as well, encourage family members to assist with some of the care.

·         The nurses in hospital work eight hour shifts during the day, evening and night.

·         Nurses working with transplant patients at TBCC will continue to provide your care when you are an outpatient.

 

Dieticians

·         Dieticians are available to assist you throughout your transplant and after. They will assist you while you are an inpatient on PCU 57, or in the BMT clinic at TBCC.

·         The dieticians work together to share information and make sure that your nutritional needs are met, both in hospital and out.

 

Physical Therapists

·         Physical therapists work with the health care team to assess problems relating to muscles and bones, and use exercise to help treat these problems.

·         A physical therapist will see you before, during and possibly after your transplant

 

Occupational Therapists

·         The occupational therapist will help you regain independence, prevent disability and maintain health following your transplant. Because of your treatment and long hospitalization, you may need help to maintain everyday activities, or learn new skills to stay as independent as possible.

 

Spiritual Care Services

·         A spiritual care representative is available at all times and may be contacted through your nurse. Every effort will be made to put you in touch with a minister of your faith if you prefer.

 

Psychologists/Social Workers

·         Psychologists are involved in many aspects of patient and family care. This team member will help you deal with emotional concerns you or your family may have.

·         Social workers are available in both institutions.

·         The social worker acts as a resource counsellor. Issues such as financial and accommodation needs, as well as availability of community resources, can be addressed at your request.

 

Transfusion Medicine Technicians

·         These team members ^provide many services to you before, during and after your transplant.

·         They provide necessary transfusion products required before and after transplant, care for your stem cells; prepare the stem
cells for infusion and monitor your need for blood products in the days following the reinfusion of your stem cells.

 

Pharmacists

·         TBCC pharmacists prepare all intravenous medications given in the BMT outpatient clinic.

·         They teach patients about these drugs as well as about the bone marrow stimulants such as G-CSF Pharmacists on PCU 57
review and prepare the medications you receive while on PCU57 or 57B day hospital.

 

Laboratory Technicians

·         Laboratory technicians perform tests on your blood after it has been taken by the nurse. This includes tests done to determine stem cell counts and readiness for apheresis.

 

Apheresis Nurses

·         These team member is responsible for the collection or harvest of stem cells from the blood. More information about apheresis is found in the Appendix.

 

Rules and Guidelines for Family and Visitors to Protect Patients

·         The Foothills Medical Centre is a non-smoking environment.

·         There are no set visiting hours; however we encourage families not to become too tired. (Visiting hours for patients in rooms with 2 or 3 beds are generally between 11am and 9pm.)

·         Each day family members should leave the unit to get a break from the hospital, to care for their own hygiene and to get a restful sleep. Patients also need time to rest.You will be called if any problems occur

·         Please respect rest periods set up by the patient or nursing staff.

·         Family members should make sure that the nursing staff has their correct phone number(s) on file for emergency use.

·         Before entering and exiting a patient's room, everyone is expected to thoroughly wash their hands. Hand washing is the single most effective way to prevent the spread of infection.

·         Families and visitors are asked not to use the bathroom or shower in the patient's room. There is a danger of infection to both the patient and family member. There are public washrooms on PCU 57.

·         Patients and family members are asked not to visit other patient rooms. This helps to prevent the spread of infection. Transplant patients may walk around the nursing unit, but should avoid other patients and families, as well as areas where people gather.

·         Family members or visitors should not visit the unit if they:

·            have a cold (even a mild one)

·            have a fever or cough

·            are feeling unwell

·         Children are often exposed to many viruses. Ensure that a visiting child is well and has not been exposed to other children who may be ill (especially chicken-pox, measles, etc).

·         Fresh flowers, dried flowers, baskets and plants are not allowed in the patient's room. They may have germs on them that can cause infections. Balloons and silk flowers are good alternatives.

 

Daily Routine for the Transplant Patient in Hospital

 

The following information gives you an idea of what an average day is like following your transplant. Included in this information are the daily routines, as well as possible procedures and tests which may be done.

·         4:00 am - 5:00 am: daily blood specimens are drawn by the nurse, from your central venous catheter (CVC). Early morning testing is necessary so that the results are available early in the day. Results are reviewed by the medical staff who then make necessary adjustments in your care.

·         Daily weight check is done before eating, to see if you are retaining fluid and to make decisions about your need for fluids.

·         8:45 a.m. - 9:00 a.m.: usual breakfast time

·         Daily shower.

·         Your nurse will do an assessment of your condition. This includes the following:

·       Checking your vital signs. These are measurements of your temperature, pulse, respirations and blood pressure. Vital signs are routinely checked every four hours, and more often if your condition needs it.

·       Listening to your heart and lungs and possibly your abdomen with a stethoscope. This is done to check for normal and abnormal sounds in these organs.

·       Checking your mouth for signs of redness soreness or infection. About 7 to 14 days after your transplant it is expected that you will have some inflammation of the mucous membrane lining the mouth and throat. This is due to the effects of chemotherapy and/or radiotherapy. This inflammation may be reduced by frequent mouth care which you will be taught

·       Asking you about symptoms of pain, nausea, vomiting or diarrhea which you may have. Examining the central venous catheter (CVC) and the skin around the catheter.

·       Changing the dressing on your CVC as needed.

 

·         Doctors' visits (rounds) are usually done sometime in the morning. There may be a group of doctors involved with your care. They will come to check your condition, perhaps listen to your chest and talk about your progress. They will order any changes in your care as necessary.

·         12:45 p.m.: usual lunch time.

·         Procedures will be done at any time during the day as needed. These include:

·       drawing blood from your CVC for testing.

·       giving medications through your CVC (these are usually given to prevent or fight infection).

·       giving fluids through your CVC to maintain your body fluid needs.

·       giving blood products through your CVC such as blood or platelets. The need for either product depends on the result of your daily blood count. It is normal to have some transfusions after transplant. Blood products are given whenever they become available from the blood bank or at a time convenient to the schedule of that day.

·       chest x-ray, which is routinely done each week, or more often if necessary.

·       measurement of how much you drink is recorded every shift.

·       measurement of the amount of your urine, stool and emesis is also recorded every shift. Samples are taken and sent to the lab for testing as necessary.

 

·         A rest or quiet time is usually taken during the afternoon. You and your nurse can plan this time together.

·         It is recommended that you are up and about every day for at least a short period of time.

·         You may feel that you are always connected to an infusion through your CVC. You may arrange with your nurse to be "unhooked" for awhile so that you may go for a walk. If this is not possible, you may walk with the pump.

·         5:45 p.m.: usual supper time.

·         Repeat assessment by your nurse is done sometime in the evening shift

·         9:00 p.m. - 10:00 p.m.: settling in for the night.

·         If you have trouble sleeping, be sure to mention this to your nurse. 11:00 p.m. - 7:00 a.m.: hourly rounds done by the nurse.

·         Your nurse will check your vital signs again sometime during this shift.

·         If it is needed, nutritional formula, known as parenteral nutrition (TPN) is given at this time through the CVC. Usually this is started in the evening and runs through the night.

 

The Transplant Procedure

 
Conditioning

The conditioning part of the procedure involves the use of high doses of chemotherapy with or without radiotherapy.

 

High Dose Chemotherapy

·         Chemotherapy is used to "condition" or prepare your body to receive the stem cell transplant.

·         This preparation is given before transplant day and can take between one and seven days.

·         The drugs will be given in high doses to destroy cancer cells that cause your disease. However the high doses destroy the stem cells in your marrow causing your blood counts to drop. The doses and kinds of drugs that you receive will depend on the diagnosis that you have. The nurse or pharmacist will give you more information about the drugs you will be getting.

 

The side effects that have been discussed earlier will begin to occur and last until your normal body cells repair themselves. In the meantime, many side effects can be well controlled with medications.

 

Side Effects of Conditioning

 

Nausea and Vomiting

Most transplant patients experience nausea and/or vomiting at some time during their transplant.

 

Both nausea and vomiting are controlled by certain centers in your brain, and cannot be controlled by you.

 

Some causes of nausea and vomiting during transplant are:

·         chemotherapy

·         pain

·         some medications

 

Medications used to treat nausea and vomiting are called antiemetics. They are given before you receive radiation and chemotherapy, and may continue to be given on a regular schedule. You may only need antiemetics occasionally, in which case please let your nurse know when you do.

 

Some medications used to control nausea are:

·         Stemetil®

·         Ondansetron (Zofran®)

·         Maxeran®

 

Antiemetics have some side effects. Usually they cause sleepiness or tiredness, but can cause restlessness, shakiness or a jittery feeling. If you experience any side-effects, please inform your nurse. Some reactions can be controlled by lowering the drug dose, switching to another antiemetic, or treating the reaction with medication.

 

Diarrhea

Diarrhea can be a side effect of the conditioning therapy you receive. Treatment will include the use of medications, fluid replacement and changes in your diet.

 

Hair Loss

All transplant patients have some hair loss. This usually occurs ten to fourteen days after conditioning treatment, and the loss is usually complete in a short period of time. Patients who have had only chemotherapy for conditioning, will likely have their hair grow back. However, there may be a color change, or a change between curly and straight.

 

Bleeding

Until the stem cells restore your marrow, your blood counts will be low. Bleeding may occur as the result of a low platelet count, usually below 20 (20,000). It is important that you tell your nurse if any of the following signs and symptoms occur:

·         easy bruising

·         presence of petechiae (tiny red spots on the skin)

·         bleeding from the nose or gums

·         blood in the urine or stool

·         pain in the abdomen

·         headache

 

You will be given a platelet infusion to keep your platelet count high enough to reduce the risk of bleeding.

To reduce the risk of bleeding, it is important to:

·         use only a soft toothbrush

·         always blow your nose gently

·         shave only with an electric razor

·         never take aspirin® or products containing aspirin®

·         avoid straining when having a bowel movement

·         avoid enemas, douches, using rectal thermometers or intramuscular injections a avoid any stressful physical activity such as contact sports.

 

Medications for Supportive Core

Most of the medications you receive during your transplant are given to help relieve the side effects of treatment.

Medications include those which treat or prevent:

·         nausea and vomiting

·         diarrhea

·         pain

·         infection

·         side effects of blood products

 

Side effects can occur with most medications. Because each person is unique, the same drugs can cause different reactions in different people.

 

Infusion of Stem Cells

You family and friends are welcome to be with you during your stem cell infusion. Taking pictures is allowed and encouraged.

 

On the day that your stem cells are infused, you will receive intravenous fluids and medications to prepare for this. Stem cells are infused into your CVC much like a blood transfusion.

 

During the infusion, several health team members will be present. Blood bank staff will thaw the stem cells in your room. Nursing staff will infuse these and check your vital signs. If the stem cell product has been frozen, there will be an odour and an unpleasant taste with the infusion. This may last 24 hours. Staff will provide mints for you to suck, which help you to manage the taste.

 

You may cough or have a tickle in the throat.

 

If you experience shortness of breath, you may be given oxygen and a drug called Ventolin® to help you breathe.

 

Some patients feel anxious at this time. A medication can be given to control this symptom.

 

Recovery

Your recovery is monitored by checking your blood counts every day.

 

Blood Counts and Engraftment

The stem cells that were infused on transplant day begin to establish themselves in your bone marrow.

 

They multiply in number and grow from immature to mature cells, before entering your blood. Although this process varies from person to person, it usually starts from two to three weeks after transplant.

·         You may receive G-CSF to "prompt" your white blood cells to recover. This is a delicate stage of your recovery. During this time, you have very few cells to protect you from infection or bleeding. However as time passes, your counts will increase giving you more protection.

·         White blood cells (WBC) usually begin to recover first. These cells help the body fight infection.

·         Red blood cells (RBC) Hemoglobin (hgb) is the substance of the RBC that carries oxygen to all body tissues. Carbon dioxide waste is removed from the tissues by this cell. Anemia occurs when there are not enough red blood cells in the body.

·         Platelets (Pits) These cells help control bleeding. They generally take longer to recover than WBC.

·         Each morning blood will be drawn from your CVC and sent to the lab for a count to measure the white count, hemoglobin and platelets. You may wish to keep your own record of your daily counts and watch them rise. Remember that a blood count does not have to be normal, values can be somewhat low without significant risk.

·         Normal values for these counts are:

WBC        4.0 - 10.0

Hgb         120 - 160

Pits         140 - 440

Based on the results of your counts, you may receive a blood product transfusion.

 

Nutrition During Transplant

Good nutrition is needed for healing and helping your new marrow grow. Getting enough calories, proteins, vitamins and minerals will help prevent muscle and weight loss and may help you feel better. Every patient having a stem cell transplant is assessed by a dietician in hospital before the transplant is done. As part of the health care team, the dietician’s role is to assist you with your nutritional needs.

 

While in hospital, you will be given three meals a day following guidelines for the immunosuppressed patient. As well, snacks are available from a special fridge on the patient care unit which are suitable when one is immunosuppressed.

 

You will be asked to help record the fluid that you drink. This is written on an "In and Out" sheet. Recording this information is important and becomes part of your daily assessment. It allows us to calculate the amount of fluid you consume.

 

 

Eating Problems

During transplant, people develop varying degrees of nausea, mouth pain, dry mouth, taste changes and loss of appetite. The dietician will be available to discuss ways you can meet your nutritional needs with nutritional supplements and food selections.

 

You may need added nutritional support

If you are unable to eat for several days or have severe diarrhea, your body can become depleted of important nutrients and fluid. When this situation arises, total parenteral nutrition (TPN) will be given. TPN is a liquid source of calories, protein, fats, vitamins and minerals. It provides you with the necessary nutrients until you are able to get these from your diet. TPN is given through your central venous catheter, usually late evening and during the night.