A clinical guide to stem cell and bone marrow transplantation - part 3 pps

Protozoa Pneumocystis carinii Pulmonary Toxoplasma gondii Pulmonary, CNS (continued) Page 84 Table 3.1 (continued) Organism Common Site 4–12 Months Post-Transplant Viral CMV, echoviruses, RSV, varicella zoster virus (VZV) Integument, pulmonary, hepatic Bacterial Gram-positive (Streptococcus pneumoniae, Haemophilus influenzae, pneumococci Sinopulmonary, blood Fungal Aspergillus Sinopulmonary Coccidioidomycosis Sinopulmonary Protozoa P carinii Pulmonary T gondii Pulmonary, CNS Greater than 12 Months Post-Transplant Viral VZV Integument Bacterial Gram-positive (streptococci, H influenzae, encapsulated bacteria Sinopulmonary, blood Reprinted with permission from Ezzone and Camp-Sorrell, 1994 P II Antimicrobial Prophylaxis A Table 3.2 outlines common BMT infection control practices Table 3.2 Common Infection Control Practices Type of isolation Room preparation Nursing management Laminar air flow room (LAFR): Sterile or clean Housekeeping practices per Meticulous hand washing institutional protocol prior to entering the unit, upon entering the patient room, and after leaving the patient room Weekly air and water cultures Diet May include masks, head covers, gowns, gloves, and shoe covers; varies among BMT centers Sterile food (steri LAFR) May include masks, head covers, gowns, gloves, and shoe covers; varies among BMT centers Sterile or low-bac diet Indirect care: Nursing care performed from anteroom through the cutain (e.g., infusion of IV solutions and blood, oral medication, diet) Private room Proper attire Direct care: Physical assessment, treatments, and vital signs performed in patient zone Sterile patient zone separated from an anteroom by a transparent curtain High efficiency particle air (HEPA) filtration with continuous horizontal or positive pressure air flow Sterile supplies (sterile LAFR) Strict protective isolation Housekeeping practices per Meticulous hand washing institutional protocol prior to entering the unit, upon entering the patient room, and after leaving the patient room Routine air and water cultures Private room (continued) P Table 3.2 (continued) Type of isolation Nursing management HEPA and/or positive air pressure Simple protective isolation Room preparation Proper attire Diet Direct and indirect nursing care provided at the bedside Housekeeping practices per Meticulous hand washing With or without masks, Low-bacterial die institutional protocol prior to entering the unit, upon gowns, or gloves; varies entering the patient room, and among BMT centers after leaving the patient room Routine air and water cultures Direct and indirect nursing care provided at the bedside Private room HEPA and/or positive air pressure Decontamination Surveillance cultures Visitor restrictions Skin: Daily bath/shower with an antimicrobial soap such as chlorhexidine Institutional protocol for cultures of stool, urine, blood, sputum, wound, skin, throat, nares, vaginal area, perirectal area, and catheter exit site Screen visitors for cold/flu/viral symptom transmissible diseases such as chicken pox herpes, or influenza Application of topical antibacterial and/or antifungal powders and/or ointments to axilla, groin, vaginal, and perirectal area Restrict visitation by children younger th age 12 Gastrointestinal, nonabsorbable oral antibiotics Follow hand washing and isolation procedures Vaginal: Daily antimicrobial douche Restrict visitors who have recently recei live or attenuated virus vaccine for at least hours Recontamination with nonpathogenic normal flora Discourage visitors from bringing coats, or purses into the patient's room Reprinted with permission from Ezzone and Camp-Sorrell, 1994 Page 87 B Isolation: Filtered air to 0.3 µm is indicated for BMT patients Options include Laminar airflow room (LAF) a) LAF with sterile environment, bacteriologic monitoring, skin cleansing, topical antibiotics, sterile diet, and oral nonabsorbable antibiotics b) LAF with a clean environment, fever surveillance, meticulous hygiene, lowmicrobial diet, and sometimes oral nonabsorbable antibiotics Hepafiltration in protective isolation rooms C Gut decontamination: 80% of acute transplant infections are caused by Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Staphylococcus aureus, and Candida species, the incidence of which may be diminished by gut decontamination Combination therapy for bacterial and fungal gut decontamination using oral nonabsorbable antibiotics is most often used Table 3.3 outlines agents used most often in combination with one another Table 3.3 Oral Nonabsorbable Antibiotics Used in Gut Decontamination Agent Preparation Dosage* Vancomycin caps 125 mg/cap 1–4 caps PO tid Polymyxin caps 62.5 mg/cap 1–4 caps PO tid Gentamicin IV preparation 200–250 mg PO qd Ciprofloxacin 250-, 500-, 750-mg tabs tabs PO bid Co-trimoxazole (trimethoprimsulfamethoxazole) 80 mg/400 mg/tab or 10-mL suspension 160 mg/800 mg/tab PO bid Nystatin suspension 100,000 U/mL 5–10mL tid-qid/1–3 million U/d Clotrimazole 10 mg/troche PO 4–5 times/d Nystatin tabs 500,000 U/tab PO qid Fluconazole 50-, 100-, 200-mg tabs > 50 kg, 200–400 mg/d Peridex oral rinse * See Chapter for specific pediatric dosage adjustments 5–15mL PO 3–5 times/d Page 88 Therapy is initiated pretransplant and continued until engraftment is achieved These agents are emetogenic Ciprofloxacin and fluconazole in combination may be used in patients who not tolerate other agents D Antibacterial prophylaxis (see Chapter for further dosage and toxicity information) Gut decontamination and sterile or low-microbial diet The following foods are excluded on a typical low-microbial diet: a) Fresh fruit and vegetables b) Hand-squeezed juices c) Shellfish d) Buffet foods e) Microwaved foods from scratch (reheating OK) f) Yogurt g) Raw fish (sushi) h) Cheeses with live culture i) Stir-fried foods (e.g., Chinese) j) Restaurant foods (some centers) Meticulous oral and perineal care Skin decontamination with antibacterial soap Meticulous central venous catheter site care Avoidance of procedures that risk hematogenous spread of bacteria from the gastrointestinal and genitourinary tracts, especially while neutropenic Ciprofloxacin (Cipro) a) Dosage: 750 mg PO bid b) Duration: Started with pretransplant conditioning and continued while neutropenic until onset of first fever c) Found to reduce fever duration, antibiotic days, and number of antibiotics needed while neutropenic Co-trimoxazole (trimethoprim-sulfamethoxazole; Bactrim, Septra) Page 89 a)Dosage: (1) Adults: double-strength tablet PO bid (2) Children: to 10 mg/kg bid b) Duration: Stopped just prior to transplant day c) Its use in antimicrobial prophylaxis is declining, since it self-selects for overgrowth of some gram-positive and gram-negative organisms Intravenous immune globulin a) Dosage: 150 to 500 mg/kg/dose IV b) Duration (1) Autologous: Dose generally given to times pretransplant, then once a month for to doses Dose may be given based on IgG less than 500 mg/dL (2) Allogeneic: If patient and donor are cytomegalovirus (CMV) negative, dose generally given to times pretransplant, then once a month for to doses Dose may be given based on IgG less than 500 mg/dL If patient and/or donor is CMV positive, to doses pretransplant, and once a week thereafter until day +100 to +120 post-transplant, Dose then may be given monthly thereafter if patient develops chronic GVHD or by institution standard c) May prevent or modify infections other than CMV, such as bacteremias 4, Colony-stimulating factors6, 7, a) Granulocyte-macrophage colony-stimulating factor (GM-CSF); Leukine (Prokine) is a multilineage colony-stimulating factor glycoprotein used to stimulate early progenitor cells of all three cell lineages (red cells, platelets, and white cells) Decreases period of neutropenia and thus decreases the number of neutropeniaassociated infections Dosage: 250 µg/m2d IV over at least Page 90 hours Infusion generally started two to four hours after marrow/peripheral blood stem cell (PBSC) infusion Continued until absolute neutrophil count is greater than 7000 to 10,000/µL b) Granulocyte colony-stimulating factor (G-CSF; Neupogen) is a lineage specific colony-stimulating factor used to stimulate neutrophil progenitor cells Decreases period of neutropenia and thus decreases the number of neutropenia-associated infections Dosage: to 10 µg/d IV Infusion generally started the evening or day following marrow/PBSC infusion; may also be started around day +7 to +8 posttransplant c) Interleukin-3 (IL-3) is used to stimulate the earliest progenitor cells of all cell lineages (red cell, platelets, and white cells) May decrease the period of neutropenia and thus decrease the number of neutropenia-associated infections Currently used in clinical trials focusing on the combination use of IL-3 and GM-CSF Dosage: 2.5 to 5.0 µg/kg/day SQ or IV Generally given prior to GM-CSF administration 10 Chronic GVHD on immunosuppressives a) Adults: Penicillin, ampicillin, or amoxicillin, 250 mg PO bid b) Children (< 40 kg): 20 to 40 mg/kg PO bid E Antifungal prophylactic medications (see Chapter for further dosage and toxicity information) Topical antifungals are generally used pretransplant for gut decontamination Are discontinued when systemic antifungals we starred Used post-transplant When systemic antifungals are discontinued (autologous or PBSC rescue patients) a) Nystatin Suspension: 100,000 U/mL (1) Adults: to 10 mL qid or 1.3 million U/d (divided qid) Page 91 (2) Children: to mL qid (3) Tablets: 500,000) U/tablet (4) Troches/pastilles: 200,000 U/dose (5) Adult and children: 400,000 to 600,000 U qid b) Clotrimazole (1) Oral: 10 mg/troche; Adults: troche PO to times/d (2) Vaginal: 100-500-mg tablets; % vaginal cream tablet or applicator dose (5g)/24 h Systemic antifungals are generally used post-transplant to prevent serious systemic fungal infection, especially fungal septicemia and invasive aspergillosis Systemic antifungal therapy is common practice in the allogeneic BMT setting, especially throughout the first 100 days post-transplant a) Amphotericin B (Fungizone) 8, (1) Prophylaxis (low dose): Covers most every species of Candida and may help prevent aspergillosis infection Dosage: 0.1 to 0.25 mg/kg/d IV over to hours Continued until patient is no longer neutropenic and is afebrile (2) Empiric: Used in febrile patients with suspected fungal infection and those who remain febrile on broad-spectrum antibacterials Dosage: 0.5 to 1.5 mg/kg/d over to hours Continued until patient is no longer neutropenic and is afebrile with negative cultures for fungus b) Liposomal-encapsulated amphotericin B (Abelcet) may be used empirically in patients with poor renal function Generally used in the setting of documented fungal infections requiring long-term antifungal therapy Dosage: mg/kg/d over to hours Page 120 G Stem cell apheresis usually takes place over several days Each day's collection is analyzed to determine the number of CD34 progenitor cells Additionally, in the setting of autologous transplantation, CD34 cell selection may be employed to decrease the amount of tumor cell contamination of the apheresis product H As each apheresis product is obtained, it is cryopreserved as described for bone marrow, using either 10% DMSO alone or 5% DMSO in combination with 6-hydroxyethyl starch VI Umbilical Cord Blood Collection A Umbilical cord blood transplantation has been used in allogeneic transplantation for patients with a variety of disorders (e.g., malignancy, immunodeficiency disease, Fanconi's anemia) Advantages and disadvantages of umbilical cord blood transplantation are as follows: Advantages a) Immunologic naivete of cord blood may decrease potential for GVHD b) Provides rich source of progenitor cells c) Harvesting poses no risk to mother or fetus Disadvantages a) Low volume with uncertain, finite cell yield b) Potential for contamination with maternal cells c) Patients with a larger body mass may not receive the number of cells necessary to achieve engraftment B Cord blood harvesting techniques continue to be studied and refined to optimize cell yield and minimize risk of maternal contamination C Umbilical cord blood is harvested at the time of delivery The umbilical cord is drained prior to placental delivery The cord blood is collected in a tissue culture medium Page 121 containing heparin or ACD-A Following delivery of the placenta, placental vessels can be aspirated to provide additional volume An average of 100 ml of umbilical cord blood can be obtained.8 D It is essential to avoid manipulation of the umbilical cord blood product because any amount of manipulation will reduce volume and cell count Although hematopoietic engraftment has been achieved in young children, it remains unclear if umbilical cord blood will provide hematopoietic reconstitution in an adult Studies continue in an effort to improve stem cell expansion techniques to allow transplantation in an older child or adult VII Infusion of Marrow Stem Cells A Marrow or stem cell infusion is planned to occur at least 24 hours after completion of the conditioning therapy to eliminate any cytotoxic effect of the chemotherapy on the marrow/stem cells B Both bone marrow and PBSCs are infused intravenously either by infusion or IV push via syringe In either case, the patient must have secure intravenous access The patient must be prehydrated to ensure high urine output C Products that have been cryopreserved must be thawed prior to administration This is generally performed at the patient's bedside, as rapid infusion is essential after thawing Each bag of marrow/PBSC is thawed and infused individually.9 D In situations of cryopreservation with DMSO, the patient should be advised of the unpleasant odor associated with this compound Patients receiving cryopreserved product may experience a temporary red coloration of the urine secondary to red cell lysis, which occurs during the thawing process Page 122 E As with infusion of any blood product, the patient may experience infusion-related reactions These can occur both in the allogeneic and autologous transplant settings Signs of infusion-related toxicity/reaction are as follows: Headache Flushing Nausea/vomiting Abdominal cramping/diarrhea Fever Chest tightness Dyspnea Bradycardia Hypertension 10 Fluid overload 11 Pulmonary embolism 12 Adult respiratory distress syndrome 13 Anaphylaxis F Stem cells migrate to the marrow spaces following intravenous infusion Engraftment of stem cells begins within one to two weeks after infusion in most patients Page 123 References Patterson K Bone marrow harvesting In: Treleaven J, Wiernik P, eds Bone Marrow Transplantation London: Mosby-Wolfe; 1995 Whedon MB Bone Marrow Transplantation: Principles, Practice, and Nursing Insights Boston: Jones and Bartlett; 1991 Szer J Cryopreservation and functional assessment of harvested autologous bone marrow and blood stem cells In: Atkinson K, ed Clinical Bone Marrow Transplantation: A Reference Textbook Cambridge, England: Cambridge University Press; 1994 King CR Peripheral stem cell transplantation: past, present, and future In: Buschel PC, Whedon MB, eds Bone Marrow Transplantation: Administrative and Clinical Strategies Boston: Jones and Bartlett; 1995 Shpall EJ, Jones RB Mobilization and collection of peripheral blood progenitor cells for support of high-dose cancer therapy In: Forman SJ, Blume KG, Thomas ED, eds Bone Marrow Transplantation Boston: Blackwell Scientific Publications; 1994 Vose JM, Armitage JO, Kessinger A High-dose chemotherapy and autologous transplant with peripheral-blood stem cells Oncology 1993;7:23–29 Vowels MR, Lam Po Tang R Cord blood and fetal tissue transplants In: Atkinson K, ed Clinical Bone Marrow Transplantation: A Reference Textbook Cambridge, England: Cambridge University Press; 1994 Wagner JE, Broxmeyer HE, Cooper S Umbilical cord and placental blood hematopoietic stem cells: collection, cryopreservation, and storage J Hematother 1992;1:167–173 Patterson K Bone marrow processing In: Treleaven J, Wiernik P, eds Bone Marrow Transplantation London: Mosby-Wolfe; 1995 Page 124 Bibliography Buckner CD, Petersen FB, Bolonesi BA Bone marrow donors In: Froman SJ, Blume KG, Thomas ED, eds Bone Marrow Transplantation Boston: Blackwell Scientific Publications; 1994 Crouch MA, Rise C Post-induction autologous bone marrow transplantation Nurs Care Issues Adult Acute Leukemia 1995;2:6–12 Wagner JE, Kernan NA, Steinbuch M et al Allogeneic sibling umbilical cord blood transplantation in children with malignant and non-malignant disease Lancet 1995;346:214–219 Page 126 I Hematopoietic Complications 2, 3, 4, 5, A Figure 5.3 outlines hematopoietic cellular development.3 Figure 5.3 Provides a diagram of hematopoietic cellular development B Bleeding/hemorrhage1, 2, Definition: Any anticipated or unanticipated loss of blood In the BMT setting, it is most likely secondary to thrombocytopenia or abnormal coagulation factors Etiology a) Preparative regimen-induced myelosuppression resulting in profound thrombocytopenia and anemia The megakaryocyte is the last cell to arrive in the myeloid engraftment process Normal platelet counts are usually not evident until one to three months post-transplant b) Delayed platelet engraftment because of graft-versus-host disease (GVHD), cyclosporin A (CsA), infection, or marrow purging c) Poor graft function related to bone marrow suppression from medication or infection (especially viral) Page 125 Chapter 5— Management of Stem Cell/Bone Marrow Transplantation Complications Complications of bone marrow transplantation (BMT) (Figure 5.1) are frequent Astute management of these complications requires a methodical and systematic approach (Figure 5.2) Figure 5.1 Outlines the time occurrence of acute complications after blood cell/marrow transplantation Figure 5.2 Depicts the interrelatedness between the major BMT complications, etiologies, and treatments Page 127 d) Coagulation abnormalities resulting from hepatotoxicity, GVHD, disseminated intravascular coagulation (DIC), or sepsis e) Platelet autoantibodies Risk factors a) GVHD and use of CsA b) Veno-occlusive disease (VOD) with impaired production of coagulation factors c) Altered mucosal barriers d) Failed or delayed engraftment c) Viral infections f) ABO-incompatible allogeneic BMT g) Hypertension Clinical features a) Epistaxis, hematemesis, melana, hematuria, oral bleeding, guiac-positive stools b) Sudden acute drop in hematocrit (> 4% in hours) c) Acute onset of abdominal pain d) Central nervous system (CNS) bleed: acute change in mental status, headache, seizures, papilledema, focal neurologic findings Differential diagnosis a) Intra-abdominal infection, VOD b) Acute hemolysis (decreased hematocrit, hematuria) c) CNS infection or thrombosis Diagnostic studies a) Complete blood count (CBC) and platelet count at least daily during period of aplasia Increase frequency if patient is actively bleeding or requires more than daily platelet transfusions b) One-hour post-platelet transfusion count c) DIC screen: D-dimer, fibrinogen, prothrombin time (PT), partial thromboplastin time (PTT) Page 128 d) Hemolysis work-up: urinalysis, CBC with smear, haptoglobin, lactate dehydrogenase, direct and indirect Coombs' test, fractionated bilirubin e) Guiac test for each stool and emesis; dipstick urine test for heme at least q8h Management 2, a) See Table 5.1 for blood component therapy b) Avoid invasive procedures unless absolutely necessary If necessary, transfuse platelets to 50,000/µL or higher if possible c) Avoid medications that inhibit platelet function acetylsalicylic acid (ASA), nonsteroidal anti-inflammatory drugs (NSAIDs) d) Bleeding precautions if platelets are less than 20,000/µL e) Transfuse platelets if less than 10,000 to 20,000/µ, if bleeding occurs, and prior to invasive procedures All blood products must be irradiated to prevent GVHD Leukocyte-reduction filters are used for packed red blood cells (PRBCs) and platelets to reduce exposure to HLA and cytomegalovirus (CMV) Give CMVnegative products to CMV-negative patients, since the virus is carried on granulocytes and may increase the risk of CMV infection HLA-matched platelet products are indicated if the patient fails to respond to repeated transfusions of nonHLA- matched products (Table 5.2 outlines degrees of platelet HLA antigen compatibility.) Premedicate with acetaminophen, diphenhydramine, or hydrocortisone (alone or in combination) if the patient has a history of transfusion reaction Page 129 Table 5.1 Blood Component Therapy Blood component Composition Approximate volume Infusion time 2–4 hrs Red blood cells (RBCs) RBCs, reduces plasma, white blood cells (WBCs), and platelets 250–300 mL Platelets from a single donor (pheresis) Platelets, some RBCs, some WBCs, and plasma 200–300 mL per 20–60 unit (continued) Expected response Increase hemoglobin (Hgb) to g/dL per unit Indications Special considerations Symptomatic anemia because of chronic or acute blood loss; myelosuppression ABO compatibility is required; leukocyte-poor or filtered RBCs are given to patients at risk for febrile transfusion reactions Increase platelet Bleeding because count to 40,000 of per unit thrombocytopenia; presence of antiplatelet antibodies; myelosuppression Product may be human leukocyte antigen (HLA)- or random matched ABO compatibility is not required Bone marrow may be asked to donate platelets Leukocyte-poor or filtered platelets are given in patients at risk for febrile transfusion reactions Page 130 Table 5.1(continued) Blood component Composition Approximate volume Infusion time Expected response Indications Special considerations Platelests from random donors Platelets, some RBCs, some WBCs, and plasma 30–50 mL per unit 5–10 per unit Increase platelet count to 5000/µL per unit Bleeding because ABO compatibility is not of required; usually not thrombocytopenia; given to BMT recipients myelosuppression Fresh frozen plasma Plasma, all coagulation factors, and complement 220 mL 10–15 Increase coagulation factors by 5%–10% per unit Coagulation factor ABO compatibility is deficiency; required disseminated intravascular coagulation (DIC) Cryoprecipitate Plasma and stable clotting factors 200 mL 15–30 Increase factor VIII, factor XIII, and fibrinogen levels Treatment of stable clotting factors deficiencies (II, VII, IX, X, XI); DIC ABO compatibility is preferred Page 131 Table 5.2 Degrees of Platelet HLA Antigen Compatibility Match Conditions of compatibility A All four donor antigens identical to recipient B1U donor antigens identical to recipient; unknown B2U donor antigens identical to recipient; unknown B1X donor antigens identical to recipient; one cross reactive B2X donor antigens identical to recipient; cross reactive B3X One donor antigen to recipient; cross reactive B4X cross reactive C One donor antigen major mismatch to recipient D donor antigens major mismatch to recipient Reprinted with permission from Fuller, 1993 f) Replace clotting factors as indicated (see Table 5.1 on pp 130)2: (1) fresh frozen plasma (contains all clotting factors) (2) cryoprecipitate (contains factor VIII [5 to 10 U/mL], von Willebrand's factor, fibrinogen) g) Replace vitamin K for elevated PT Dosage: (1) Adults: 10 mg IV qd for days A total of 30 mg should be given; includes total IV supplemental given in total parenteral nutrition solution (2) Children: to mg/dose IV Evaluate PT prior to redosing h) Topical thrombin (see chapter for further drug information): Apply 1000 to 2000 U/mL of solution where bleeding is profuse (operative sites); apply powder directly to the site of bleeding or on oozing surfaces; use 100 U/mL for bleeding from skin or mucosal surfaces i) Aminocaproic acid (Amicar) is indicated for invasive procedures (central venous line placement, dental extraction) in the profoundly thrombocytopenic patient It is also used as Page 132 bleeding prophylaxis in the profoundly thrombocytopenic patient (chronic platelet count < 5000 µL) It may also be used in patients with chronic, profuse oral bleeding, gastrointestinal bleeding, or hemorrhagic cystitis Dosage (see chapter for further drug information): (1) Oral: g during first hour, followed by 1.0 to 1.25 g/h for about hours or until bleeding stops May swish and spit for oral oozing Total daily dose should not exceed 30 g (2) IV: to g in 250 mL of diluent during first hour, followed by continuous infusion at the rate of 1.0 to 1.25 g/h in 50 mL; continue for hours or until bleeding stops (3) Children: Loading dose is 100 to 200 mg/kg IV or PO; maintenance dose is 100 mg/kg/dose q6h C Anemia Definition: decreased hemoglobin and hematocrit levels resulting in potential alterations in body/tissue oxygenation Etiology a) The bone marrow aplasia created by the conditioning regimen creates a reduction in the production and supply of RBCs This results in a potential reduction in adequate tissue oxygenation b) About seven to 10 days after marrow ablative chemotherapy and donor or autologous marrow infusion, circulating nucleated red cells will be evident in buffy coat preparations c) Reticulocytes, however, are not evident until two to three weeks after stem cell or marrow reinfusion Page 133 Risk factors a) All patients undergoing stem cell or marrow transplantation b) Patients with active bleeding c) Acute hemolysis due to CsA, FK-506, ABO-incompatible graft, infection, or hemolyticuremic syndrome Clinical features a) Hematocrit (HCT) less than 25% or hemoglobin (Hgb) less than g/dL b) Fatigue, pallor, shortness of breath c) Hypotension (with acute drop in HCT, orthostasis Differential diagnosis a) With acute drop in HCT: active bleeding versus acute hemolysis versus dilutional laboratory draw from central venous line b) Gradual drop in HCT is normal finding early post-transplant Diagnostic studies a) Hgb/HCT at least daily throughout period of aplasia Increase frequency if patient is actively bleeding b) Platelet count and PT/PTT for sudden acute drop in HCT c) Blood cell morphology d) Hemolysis work-up: urinalysis, CBC, haptoglobin, lactate dehydrogenase, direct and indirect Coombs' test, fractionated bilirubin e) Guiac test for each stool and emesis; dipstick urine test for heme at least q8h f) Blood urea nitrogen (BUN)/creatinine g) Reticulocyte count: May be helpful in evaluating red cell function following engraftment of myeloid cell line ... allogeneic transplantation Advantages of PBSC transplantation over bone marrow transplantation are as follows: Provides more rapid engraftment Decreases risk of malignant contamination Decreases... Peripheral stem cell transplantation: past, present, and future In: Buschel PC, Whedon MB, eds Bone Marrow Transplantation: Administrative and Clinical Strategies Boston: Jones and Bartlett;... (especially viral) Page 125 Chapter 5— Management of Stem Cell/ Bone Marrow Transplantation Complications Complications of bone marrow transplantation (BMT) (Figure 5.1) are frequent Astute management