Congress Abstracts 2003

40

ENGRAFTMENT SYNDROME POST NONMYELOABLATIVE ALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANTATION: NURSING’S ROLE IN EARLY DETECTION AND TREATMENT. Kathleen Castro, RN, MS, AOCN^®, Claude Kasten-Sportes, Jeanne Odom, RN, Kelli Scheerer, RN, BS, OCN^®, Michael Bishop, MD, and Daniel Fowler, MD, National Cancer Institute, Bethesda, MD.

The advent of non-myeloablative hematopoietic stem cell transplantation (NM-HSCT) has decreased the early morbidity and mortality associated with the procedure, thus allowing more patients to be transplanted. Although non-myeloablative preparative regimens decrease toxicities such as nausea, vomiting, and mucositis, NM-HSCT is still associated with transplant complications such as GVHD and engraftment syndrome (ES). Our purpose is to outline nursing’s role in early detection and treatment of ES. The pathophysiology of ES likely includes initiation by alloreactive T cells, with subsequent inflammatory cytokine production, neutrophil degranulation, and oxidation, which clinically manifests as fever, rash, pulmonary infiltration, and generalized capillary leak. Diagnostic criteria used to define ES are: temperature of > 38.3 C with no infectious etiology, erythematous rash not attributable to medication, and noncardiogeneic pulmonary edema with oxygen desaturation. Twenty patients received a non-myeloablative conditioning regimen (cyclophosphamide and fludarabine) followed by HSCT from a 5/6 or 6/6 HLA-matched sibling. Eight of 20 patients (40%) experienced ES at the time of neutrophil recovery (median, day 8 post-SCT). Systemic steroid therapy (Methyprednisolone 250 mg q 6 hours) was initiated for patients who experienced pulmonary symptoms and/or a decrease in oxygen saturation (typically < 92%). A rapid steroid taper and close monitoring resulted in clinical recovery in all patients. Early detection and treatment for ES is crucial for positive patient outcomes. Nurses must be aware of this complication and its early symptoms in order to detect subtle, but significant changes in patient status and promptly inform the physician. Our nursing assessment during the engraftment period focuses on fluid, respiratory and skin assessment, as well as every 2–4 hour monitoring of vital signs, especially pulse oximetry, temperature, and BID weights. A well-established baseline of pulse oximetry and weight is critical in the detection of early changes. Engraftment syndrome and GVHD likely share pathophysiologic mechanisms and, as such, nursing attention should also be focused on signs and symptoms of GVHD, in particular, gut involvement. In conclusion, engraftment syndrome is a life threatening complication during non-myeloablative transplant, which requires astute nursing assessment and rapid intervention to improve patient outcomes.