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Course: Oncology Nursing

Topic: Stem Cell Transplantation in Cancer Treatment Part 2

The Nurses International Community

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Module Goals

Learners will be able to:

Explain the impact of hematopoietic stem cell transplantation (HSCT) on various health domains.
Describe the prevention, detection, and management of common short and long term health alterations experienced by people undergoing HSCT.

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Impact of HSCT on Health Domains

Australian Government Cancer Australia, 2021

Early effects of HSCT:

Mucositis
Infection
Hemorrhagic cystitis
Veno-occlusive disease
Nausea, vomiting, diarrhoea

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Impact of HSCT on Health Domains

Australian Government Cancer Australia, 2021

Complications that may occur 30 to 100 days post allogeneic transplant include:

Acute GVHD
Interstitial pneumonia
Varicella zoster virus
Bacteremia
Herpes simplex virus
Restrictive lung disease
Disseminated fungal infection

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Impact of HSCT on Health Domains

Potential late effects: Are experienced 5 or more years after HSCT

Ophthalmologic late effects:

Sicca syndrome (dry eye)
Cataracts: Common late effect, often related to total body irradiation or steroid use.

Pulmonary late effects:

Restrictive or obstructive changes related to infections.
Chronic bronchitis, hepatopulmonary syndrome, bronchiolitis obliterans, pulmonary fibrosis, and idiopathic pneumonia syndrome.

Australian Government Cancer Australia, 2021

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Impact of HSCT on Health Domains

Australian Government Cancer Australia, 2021

Potential late effects: are those experienced 5 or more years after HSCT

Endocrine late effects:

Gonadal dysfunction
Ovarian failure
Thyroid dysfunction
Growth hormone deficiency

Gastrointestinal effects:

Dry mucous membrane

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Impact of HSCT on Health Domains

Australian Government Cancer Australia, 2021

Musculoskeletal effects

Avascular necrosis
Diminished bone mineral density
Osteochondromas

Neurocognitive effects: Cognitive dysfunction
Secondary malignant neoplasm:

Post-transplant lymphoproliferative disorders (PTLD)
Myelodysplasia (MDS)
Acute myeloid leukaemia (AML)

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Impact of HSCT on Psychological Health Domain

Isolation: (both emotional and social) as well as limitations to age appropriate activities and school attendance affects Quality of life of children.
Self-image: appeared to have been affected by certain visible physical consequences.
Social withdrawal: limitations in certain activities, such as physical exercise, driving, being around friends and having a romantic relationship.
Sense of lack of choice: Feeling restricted in their options with regards to studies, work, leisure activities or life projects.

Lahaye,, Aujoulat, , Vermylen, & Brichard, 2017

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What Would the Nurse Do?

A 42 years old male who is a case of myeloid leukemia has a bone marrow transplant before 3 months back. What are the some of the early effects of HSCT a nurse should be careful about? (Select all that apply.)

Mucositis
Infection
Veno-occlusive disease
Cataract

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Management of Health Alterations in HSCT

(HSCT) generally includes preparative regimens containing chemotherapy or radiotherapy or both in high doses immunosuppressive drugs to prevent graft versus host disease.

It affects the patient’s organs and tissues and may cause both acute and long-term complication.

Two of the most common early complications are:

Oral complications/mucositis
Sepsis

Wallhult & Quinn , 2017

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Management of Health Alterations in HSCT

Oral Mucositis:

Inflammation of the mucosal membrane.
Characterised by ulceration which may result in pain, swallowing difficulties and impairment of the ability to talk.

Principle of Treatment:

Strategies for improving mouth care are dependent on four key principles:

Accurate assessment of the oral cavity
Individualised plan of care
Initiating timely preventative measures
Correct treatment

Wallhult & Quinn , 2017

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Management of Health Alterations in HSCT

Oral Mucositis/Accurate assessment of the oral cavity:

Assess for the factors that may put them at higher risk of oral complications during treatment:

Pre-existing dental problems
Prior treatment
Older patients and females (at higher risk of oral damage)
History of alcohol and/or tobacco use
Poor nutrition and hydration
Supportive feeding (nasogastric)
Supportive therapies (opiates diuretics, sedatives, oxygen therapy – may cause dryness)

Wallhult & Quinn , 2017

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Management of Health Alterations in HSCT

Oral Mucositis/Individualized care of plan:

All patients should be encouraged to maintain good oral hygiene:

Use soft-bristled toothbrush: Prevent injury to the oral mucosa
Frequent brushing: Preferably after each meals and before going to bed.
Proper storage of the toothbrush.
Use toothpaste containing mild fluoride (1000–1500 ppm).
Lubricants, lip balm or lip cream may be used to moisten the lips.
Hydration: Drink plenty of water to maintain adequate hydration.

Wallhult & Quinn , 2017

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Management of Health Alterations in HSCT

Wallhult & Quinn 2017

Oral Mucositis/Individualized care of plan:

Good nutrition is vital in helping to

Fight infection
Maintain mucosal integrity
Enhance mucosal tissue repair and
Reduce exacerbation of existing mucositis

Certain food should be avoided to prevent damage to mucosa:

Rough, sharp and hard foods
Spicy, very salty and acidic foods

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Management of Health Alterations in HSCT

Prevention of Oral Mucositis

Educate and encourage self-reporting of any oral changes
Good and regular oral hygiene including gargling
Interdental cleaning
Fluoride toothpaste/foam/gel/tray
0.9% sodium chloride/saltwater rinse
Early nutritional intervention
Cryotherapy/sucking ice chips during melphalan infusion
Consider oral rinses (Caphosol)
Mucosal protectants/barrier rinses licenced to use as a preventative measure/reduce pain
Anti-infective prophylaxis

Wallhult & Quinn 2017

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Management of Health Alterations in HSCT

Treatment of Mild/Moderate Mucositis:

Frequency of oral rinsing may be increased to keep the oral surfaces clean and moist.
Check for oral infections, swab and treat appropriately (antifungal treatment, local or systemic).
Dexamethasone containing gels may be used for aphthous lesions.
Dietary requirements should be assessed and foods causing discomfort avoided.

Wallhult,& Quinn, 2017

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Management of Health Alterations in HSCT

Wallhult & Quinn, 2017

Treatment of Mild/Moderate Mucositis:

Adequate pain medication including:

Topical and systemic analgesia:

(such as paracetamol, codeine,morphine rinses, Benzydamine mouthwash)

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Management of Health Alterations in HSCT

Treatment of Severe Mucositis :

Increase pain medication SOS
Increase nutritional support
Increase oral rinses and care
Consider opiates with optimal application route in severe mucositis

Wallhult & Quinn, 2017

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Management of Health Alterations in HSCT

Sepsis/Infection:

Risk factors include:

Neutropenia: A longer period of neutropenia can be expected in allogeneic than in autologous transplant.
Barrier breakdown: Skin breakdown like mucositis, IV line increases the risk.
Depressed T cell and B cell function: Need for immunosuppressive treatment will increase the risk for infections.
Acute Graft vs Host Diseases
Poor general status: Diabetes

Wallhult & Quinn, 2017

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Management of Health Alterations in HSCT

Wallhult & Quinn, 2017

Sepsis Prevention

Hand hygiene
Staff should wear a uniform that is clean and short sleeved
Protective isolation during the neutropenic (patient should not be in contact with any staff or visitors with symptoms of infection)
Oral hygiene and skin care to maintain the mucosal and skin barrier
Use of prophylactic antibiotics are the most important actions

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Management of Health Alterations in HSCT

Wallhult,& Quinn, 2017

Sepsis Treatment

Early recognition and treatment is vital for a successful outcome of sepsis (vital sign frequently monitored)
The Sepsis Six has been developed as a guide to prioritise interventions in patients where sepsis is suspected:

1. Oxygen therapy

2. Blood cultures

3. I.V. antibiotics

4. Fluid resuscitation

5. Serum lactate

6. Assess urine output

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Management of Health Alterations in HSCT

Wallhult,& Quinn, 2017

Hemorrhagic cystitis (HC)

A condition in which the lining of the bladder becomes inflamed and starts to bleed.

Sign and symptoms include:

Blood in the urine/Haematuria
Dysuria
Urgency and frequency of urination
Urinary incontinence

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Management of Health Alterations in HSCT

Hemorrhagic Cystitis (HC) Diagnosis

The diagnosis of HC is confirmed by the presence of haematuria and symptoms of cystitis taking into account risk factors such as:

Age (older patients)
Chemotherapy (particularly cyclophosphamide)
Immunosuppressive drugs
Cytopenia
Thrombocytopenia
Infection
GvHD

Wallhult & Quinn, 2017

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Management of Health Alterations in HSCT

Hemorrhagic Cystitis (HC)/Prevention

Hyperhydration with forced diuresis, i.e. 3 L/m2/24 h with the goal of a diuresis of >250 mL/h, during and until the day after administration of an alkylating agent is the most important preventive action.
During the days of hyperhydration, the patient shall be closely monitored for fluid balance, including weight, at regular intervals.
The patient should be also assessed for any urinary or lower abdominal pain or discomfort.

Wallhult &, Quinn, 2017

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Management of Health Alterations in HSCT

Treatment of Hemorrhagic Cystitis (HC)

Hyperhydration with forced diuresis to prevent clot formation.
HC is usually painful and analgesia should be administered.
If the patient is thrombocytopenic, a higher threshold level for platelet transfusion and intensive platelet support should be applied.
Catheterisation and bladder irrigation with 0.9% sodium chloride may be necessary to prevent clot obstruction.
Systemic antimicrobial drugs, e.g. cidofovir, ciprofloxacin and ribavirin, can be started, if the HC is confirmed.

Wallhult & Quinn , 2017

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What Would the Nurse Do?

A 25 years old have a HSCT after the diagnosis of acute myeloid leukemia. After around 100 days he has developed inflammation of the mucous of the oral cavity. He has pain, redness, and difficulty in swallowing. What advice can a nurse gives him to relieve the signs and symptoms of oral mucositis?

Answer:

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References:

Australian Government Cancer Australia (2021). Acute Effects of HSCT. Retrieved from: https://www.edcan.org.au/edcan-learning-resources/supporting-resources/stem-cell-transplantation/acute-effects

Australian Government Cancer Australia (2021). Late Effects of HSCT. Retrieved from:https://www.edcan.org.au/edcan-learning-resources/supporting-resources/stem-cell-transplantation/late-effects

Wallhult E, Quinn B. Early and Acute Complications and the Principles of HSCT Nursing Care. 2017 Nov 22. In: Kenyon M, Babic A, editors. The European Blood and Marrow Transplantation Textbook for Nurses: Under the Auspices of EBMT [Internet]. Cham (CH): Springer; 2018. Chapter 9. Available from: https://www.ncbi.nlm.nih.gov/books/NBK543661/

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