Blood & Marrow Transplantation

 Laurl at ONS 

Welcome! We will begin shortly.

 Laurl at ONS 

Welcome to the ONS Hot Topic Chats! Today’s expert is Kim Schmit-Pokorny, who will be talking with us about any and all questions you have regarding Blood and Marrow Transplantation. Welcome Kim!

 kschmit 

Hello Everyone! Anyone have any questions?

 kschmit 

Where is everyone from? What is your practice setting?

 wesi 

Hi,

 wesi 

I am an RN in a BMT unit at Dartmouth Hitchcock

 kschmit 

I'm from the Univ of Nebraska Medical Center.

 Therese 

Hi, I work in an outpt. oncology clinic and am about to take the OCN, in Lacey WA

 wesi 

Do any of your unit's have evidenced based documentation regarding Post transplant BMT diets?

 Therese 

I thought I might learn more about transplant issues

 Laurl at ONS 

Welcome - we just began - please ask your burning questions!

 kschmit 

Regarding diets: For our autos - we don't have any limitations.

 kschmit 

However, for allos we restrict their fresh fruits/vegs, and other

 kschmit 

We do have a diet from our dietitian - I could attach that after the chat.

 Therese 

And restaurant food?

 kschmit 

We do limit restaurant food for allos.

 mhammer 

Do you just restrict during the neutropenic phase?

 Kay 

Hello everyone

 kschmit 

We have different standards for the autos/allos - used to be the same…

 kschmit 

However, we changed practices once we started seeing there wasn't a lot of support in the literature for limiting autos.

 kschmit 

For allos we restrict from admission to about Day +100 - or however long they are neutropenic.

 kschmit 

What are you doing out there?

 mhammer 

I'm at NYU - doing research and looking at glycemic status.

 kschmit 

We are doing some work with hyperglycemia too.

 mhammer 

Recently completed a study at the University of Washington w/the Fred Hutch center looking at allos

 mhammer 

Found a significant association between abnormal glycemic levels and infection and death.

 kschmit 

Just in the past year we started following patients blood sugar levels - and now have a study and algorithm.

 kschmit 

We have started to see the association between infection and death too!

 mhammer 

Great to have similar findings in different places!

 mhammer 

Does the algorithm work well?

 kschmit 

Even with somewhat 'low' "hi" blood sugars - in the 200's - there has been some correlation.

 kschmit 

We have been using it for about 1 year. I think one of our PA's presented some info on it at the Tandem meetings in Tampa.

 kschmit 

The algorithm helps the nurses to have standing orders for insulin - seems to work pretty well.

 mhammer 

That's great - thanks

 kschmit 

Would it be helpful to talk about differences between auto/allos? Or other questions?

 Kay 

Do you use tunneled/non tunneled central line for auto and allos?

 kschmit 

We mainly used tunneled caths on both.

 kschmit 

For the autos, we use the tunneled double lumen aphaeresis cath to collect stem cells

 kschmit 

and use the same cath, in autos, for transplant.

 kschmit 

For allos - we usually put in a tunneled double lumen.

 wesi 

We use three lumen tunneled cath for both auto/allo.

 kschmit 

Unless the allos already have a cath - we might put in a PICC.

 Kay 

We do too. For allos we use 3 or 4 lumen non tunneled cath

 wesi 

How is your line infection rate?

 kschmit 

Do you use the 3 or 4 lumens for aphaeresis?

 Kay 

Have use used PICC or periph line for transplant.

 kschmit 

We use more PICC than peripheral lines

 kschmit 

For our 2 lumen caths - we do have some infections.

 Kay 

Have you used PICC or peripheral IV for the transplant transfusion?

 kschmit 

Right now we are doing a big push to sort out line infections.

 kschmit 

Trying to see if the infection is from insertion - or more during transplant.

 kschmit 

Our transplant inpatients are starting a 3/week chorhexadine wash - can't spell

 kschmit 

For the transplant infusion we usually use a tunneled line. however.

 wesi 

How do you draw blood cultures from central lines - we remove the white lumen and draw directly from the line? if this is increasing infection rate?

 kschmit 

We have given numerous transplant infusions thru PICCs and peripheral IVs.

 kschmit 

We would like the peripheral IV to be big enough to infuse blood…

 kschmit 

Which in our center is at least a 22 gauge needle.

 Kay 

Thank you

 kschmit 

Blood cultures - we draw thru the cap -

 Kay 

How often are you changing central line dressings?

 kschmit 

We use an interlock system – can’t think of the name right now.

 kschmit 

Not sure if drawing directly thru the line or cap is causing more infections,

 wesi 

We change CVAD dressings q 7days or prn.

 kschmit 

My guess is that any time you accessing a line, there is a possibility of infection.

 kschmit 

We change our dressings every 7 days too and prn.

 kschmit 

Seems like there is a lot of variation in dressing changes.

 kschmit 

ONS recommendations say change every 5-7 days, gauze every other day or prn.

 kschmit 

ONS recommendations say cap change every week.

 kschmit 

When do you refer patients for transplant?

 kschmit 

Depends on diagnosis…

 kschmit 

NMDP (Nat'l Marrow Donor Program) has some great guidelines.

 kschmit 

See their Quick Reference Guidelines: Transplant Consultation and Post Transplant Care on their website.

 kschmit 

Seems like early referral is the best - even if they need to still get some salvage chemo prior to txplant.

 kschmit 

What kind of transplants are you doing?

 Kay 

allo, auto, mud

 kschmit 

MUD - Matched unrelated Donors

 Kay 

Yes

 kschmit 

Just for the group: Allo = related or unrelated donors

 kschmit 

Auto = donating your own cells

 kschmit 

Are you doing a lot of outpatient transplants?

 Kay 

I am at University of Illinois Hospital. We are not doing any outpatient transplants.

 kschmit 

There was a big push for outpatients for a number of years - seems like it is backing off.

 wesi 

We are doing Muds, autos, OP's, full allos. Most OP's are admitted after cells infusion

 kschmit 

We have a Cooperative Care Model for our 'outpatients'.

 kschmit 

Basically the Coop Care is a hotel-like room in the same building as the outpatient clinic and treatment center.

 kschmit 

Patients and their care partner stay in the hotel room, then come to the treatment center for everything.

 kschmit 

Wesi: Do your OP's stay in hotels or at home? both?

 Kay 

Are the stem cells infused in outpatient setting also?

 kschmit 

We infuse cells in our outpatient treatment center.

 kschmit 

Patients love the freedom - and we still are able to watch them pretty close.

 Kay 

Are they treated in same area as other oncology patients?

 kschmit 

Yes - in our ctr - our treatment center is for all onc/hem patients. Same nurses..

 kschmit 

What are you using for mobilization of stem cells?

 kschmit 

We use Neupogen only for our Non-Hodgkin's lymphoma and Hodgkin's patients.

 Kay 

We have used cytoxan followed by Neupogen. Just started Mozibil-not sure of spelling…

 kschmit 

For myeloma pts we use cytoxan and Neupogen.

 kschmit 

We are using Mozibil or plerixafor (originally known as AMD 3100)

 kschmit 

Plerixafor works pretty well - we try to save it for the hard to mobilize patients or poor collectors due to the cost…

 kschmit 

Though we have had a few patients fail plerixafor.

 oncnurse 

What is the admin protocol for plerixafor?

 kschmit 

Plerixafor is used with Neupogen. Give Neupogen for 4 days. On the evening of the 4th day, give plerixafor

 kschmit 

Plerixafor needs to be given about 8-12 hours prior to the collection…

 kschmit 

Then on the 5th day, we give a dose of Neupogen, then collect.

 kschmit 

I have heard of some centers using plerixafor with all patients.

 kschmit 

Currently, we are doing 1-2 collections just with Neupogen. If they are 'poor', we then give plerixafor the evening prior to the 3rd collection.

 kschmit 

As I talk with centers around the country - there is a lot of variation in use of plerixafor

 oncnurse 

How is it that auto can use their own cells?

 kschmit 

If autos have a diagnosis like NHL or HD - there is a good chance that they don't have circulating tumor cells.

 kschmit 

So, the cells can be collected from the patient. And…

 kschmit 

the patients don't have to go thru the more rigorous allo transplant.

 kschmit 

However - there are some NHL's - like Mantle cell in which an allo transplant might be better than an auto.

 kschmit 

Allo txplant might give a patient with Mantle cell NHL a better prognosis - but they also need to deal with the possible graft-versus-host side effects.

 kschmit 

Most leukemia patients (by nature of leukemia cells in the blood) can't collect auto cells.

 kschmit 

However, there are a few protocols out there looking at auto transplants for leuk patients.

 kschmit 

HD = Hodgkin's disease NHL = Non-Hodgkin's lymphoma just FYI

 oncnurse 

Thanks good review

 oncnurse 

What about use of cord blood?

 kschmit 

The use of cord blood is definitely rising!

 kschmit 

Most of them are from unrelated cord blood donors.

 kschmit 

There are many cord blood banks - and the NMDP - Nat'l Marrow Donor Program

 kschmit 

NMDP helps to facilitate finding the banked cord bloods.

 kschmit 

What is unique about cord blood - is that the match sometimes doesn't have to be as close as a bone marrow or peripheral blood donor

 kschmit 

So, there is opportunity for more matches and more transplants.

 kschmit 

Minnesota (and maybe others) are doing double cord transplants.

 kschmit 

Some how both of the cords help the patient engraft (recover WBC, immune system).

 kschmit 

But only 1 of the cords actually takes 'over' and the patient has ends up with that matching (immune system).

 kschmit 

I get a lot of calls from people wanting to harvest cord blood from their baby.

 kschmit 

They can choose store it for them selves - or they can donate to one of the banks.

 Therese 

Very interesting!

 kschmit 

Anybody doing cord blood transplants out there?

 Laurl at ONS 

It’s about five minutes before the end of our chat- please don’t stop asking questions! However, when you can, please take a moment after the chat to cut and paste this URL into a browser window and take our very brief survey-we’d love to hear what you think of these chats! The URL is http://research.zarca.com/k/RsTUTRsSWPsXYTYUsPsP

 oncnurse 

What about long term survivor issues?

 kschmit 

Oh there are many! But that is also wonderful - people are living longer following txplant.

 oncnurse 

How about second malignancies?

 kschmit 

Unfortunately patients do get 2nd malignancies. We have seen a handful of patients who had an auto for NHL or HD - now have leukemia or myelodysplastic syndrome (MDS).

 Kay 

How often will these chats take place? It has been great!

 kschmit 

Any time patients get chemo or radiation - they can develop a 2nd malignancy.

 Laurl at ONS 

Glad you have enjoyed them! There are three more chats in this series: Tomorrow at 6pm Eastern; Thur at 8:30 am Eastern, and 3pm Eastern next Monday. There are many more topics coming up this year - keep checking the Hot Topic chat website at www.ons.org- CNE Central- Index- Chats!

 kschmit 

We have had several patients develop the 2nd malignancy years (more than 7-10) following transplant. We have actually transplanted some of them again.

 Laurl at ONS 

The next after this series is on Caregiver and Nursing Stress.

 Kay 

Sounds like a great topic.

 kguthrie 

We have had several patients of late with previous history of breast cancer that received an auto now with AML needing an allo.

 Laurl at ONS 

We have great speakers lined up for the whole year (just like Kim!)

 kschmit 

Oh yes - we used to do a lot of breast cancer txplants. And, unfortunately some are now needing another transplant for MDS or leukemia.

 kguthrie 

The other thing with double cords is that it takes 2 to get enough for an adult.

 kschmit 

Good point!!! - adults probably need 2 cords to engraft.

 kguthrie 

That's exactly right.

 Laurl at ONS 

Thanks for a great chat!! I am sorry to cut it off, but we are out of time - please come to the next chat tomorrow eve, and tell your co-workers! Thank you all for your participation.

 Laurl at ONS 

Thanks Kim!

 kschmit 

Thanks everyone!

 kguthrie 

Thanks.

 Kay 

Thanks .