Transplant/Infusion Day

The Hematopoietic Progenitor Cells (HPC’s) or bone marrow will be given to the child from an IV bag into his or her central line. The amount of time it takes to infuse the cells is determined by the type of transplant the child will be receiving. The infusion process is very similar to a blood transfusion. The child will receive medications or “pre-meds” (Benadryl, hydrocortisone, Tylenol) and/or extra IV fluids before or after the infusion to reduce the chance of a reaction. During the transplant, the child will be placed on a heart, breathing monitor, and an oxygen saturation monitor. Vital signs will be monitored frequently. The time of the transplant will be coordinated with the physician, transplant nurse coordinator, and nurse taking care of your child. There will be several people in and/or outside your child’s room during the transplant to assist with the process. A nurse and physician will be present in your child’s room during the infusion. The nurse will stay with your child, or just outside the room for the first two hours following the transplant. Your child will remain on the monitors, and have their vital signs monitored during this time. Your child’s intake and output will also be monitored closely.

Some possible side effects of bone marrow, umbilical cord blood or PBSC infusion include: fever, chills, rash, cough, red colored urine, or increased or decreased blood pressure.

If your child is receiving an autologous transplant the preservative (DMSO) causes a smell in the room. Some describe the smell as a “burnt creamed corn” smell. Your child’s breath and urine will have the smell for approximately 24 hours after the infusion. A special filter will be placed close to your child’s bed to decrease the odor from the DMSO. Having your child suck on hard candy, or chewing gum may help decrease the taste of the DMSO in their mouth.

Engraftment

There is a waiting phase while your healthy blood cells return to normal or the donor stem cells start growing. Engraftment is the process when the donor cells start growing. Engraftment usually takes 2-3 weeks depending on the type of transplant. Red blood cells and platelets will be administered if the red blood count or platelet count is low until your child is able to make these cells on their own. The time between when your child’s marrow cannot make cells until he or she can is the period of neutropenia.

Side Effects of Transplant

Your child will be closely monitored for any possible side effects. Listed below are the most common and expected side effects, but there may also be some unexpected side effects. The transplant team will work with you to make sure you are kept informed of your child’s progress throughout the entire process of transplant.

Infection

Your child is at risk for infection due to their weakened immune system. The most common organisms that cause infection are bacteria, fungi, and viruses. Your child will receive medications that will help guard against these infections. Your doctor or nurse can give you med cards on the medications your child will receive to prevent infections.

Your child will be in reverse isolation in the transplant unit. Anyone who comes into your child’s room must wash hands before touching your child. No one with any signs or symptoms of infections (colds, flu, fever, etc.) should visit your child. Anyone exposed to a contagious disease such as chickenpox or has had the oral polio vaccine cannot visit your child. See the section on Visitor Guidelines for further information.

If your child develops a temperature of 38.5°C or 101°F, blood cultures and cultures of urine, throat, and stool may be taken to try to find a source of the infection. Labs and vital signs will be closely monitored to watch for signs and symptoms of infection.

Bleeding/Anemia

While your child’s blood counts are recovering, platelets and red blood cells will be low, making your child at risk for bleeding and anemia. While your child’s platelet count is low, they may have blood in their urine or stool, and may have nosebleeds. Platelet and packed red blood cell transfusions will be given as needed.

GI Side Effects:

• Nausea and vomitingmay occur during the conditioning regimen due to the chemotherapy or radiation. These symptoms may continue after the conditioning regimen for a number of different reasons. Medications will be given to try and prevent or help minimize these symptoms.
• Diarrheais also a common side effect. At times this can be severe. Diarrhea occurs because chemotherapy and radiation can irritate the intestinal lining. Intestinal infection can also cause diarrhea. Talk to your nurse about things that can help ease the discomfort of diarrhea.  Changes in your child’s diet may be necessary while the diarrhea is occurring. The nutritionist will help find foods that your child can eat that will not increase the amount of diarrhea. The amount of stool output will be closely monitored.
• Mucositisis a common side effect of chemo/radiation/immune suppression. This can affect the whole GI tract and can be very painful. It may prevent your child from eating or drinking. Nutrition will be provided by TPN and lipids during this time. Pain medication will be given as needed. Once your child’s blood counts start to recover, these sores will begin to heal. Good mouth care is very important during this time to help prevent infection from getting into your child’s blood stream through these sores.

Organ Complications:

All organs can be affected by chemotherapy. Organs that are most commonly affected by transplant include the kidneys, bladder, liver, and lungs. The type of transplant your child has will affect which organ complications may be more common.

Bladder: Some chemotherapy drugs can be irritating to the bladder lining and can cause bleeding. Hemorrhagic Cystitis is bleeding of the bladder. Cytoxan is a drug that can cause this problem. Your child’s urine will be monitored frequently for any blood. IV hydration will be given during the time your child receives chemotherapy to help limit the risk of irritation to the bladder. A medication called Mesna coats the bladder wall to protect it and will be given along with the Cytoxan. Your child will be required to void every hour for 6 hours and then every two hours for 24 hours after Cytoxan infusions so that the chemotherapy does not stay in the bladder for long periods of time. If hemorrhagic cystitis occurs, your doctor/PA will discuss treatment options with you.

Kidney: High blood pressure can be common if the kidneys do not work right. Some medications your child may receive also cause high blood pressure. Your child’s blood pressure will be closely monitored. If your child develops high blood pressure, medication will be given to control it. Your child’s kidney function labs will be monitored closely during the whole transplant process.

Liver: Sinusoidal Obstuction Syndrome (Veno-occlusive disease) occurs when the blood vessels that carry blood through the liver become swollen and blocked. Without a supply of blood, the liver cannot remove waste products from the bloodstream. This causes pressure and fluids to be built up in the liver, which can cause jaundice (yellow skin), abnormal liver function, abdominal swelling and pain over the liver. If your child is at risk for VOD, medication will be given to help prevent this complication. Veno-occlusive disease usually occurs in the first month after transplant. Most patients recover from this, but it can cause death.

Lungs: If you child starts to have trouble breathing or shortness of breath, he or she may need oxygen. The transplant team will discuss treatment options with you if your child develops lung complications that require more aggressive intervention. Lung injury may require your child to be watched more closely and/or be on a respirator in the intensive care unit.

Heart: Chemotherapy, radiation, infection or Graft versus Host Disease (GvHD) can affect your child’s heart function. There may be times during the transplant process that your child will be on a heart monitor. Other tests may be necessary to evaluate how your child’s heart is working.

Graft verses Host Disease (GvHD):

If your child has received an allogeneic transplant (transplant from another person) they may be at risk for developing GvHD. No matter how well the donor matches your child, the potential for development of GvHD exists. GvHD occurs when the donor’s immune system cells see your child’s cells as different and attack your child’s body. If your child is at risk for GvHD, medication will be given to prevent this complication.

Acute GvHD:Usually happens in the first 100 days after transplant, but it can occur after a longer period of time. Acute GvHD can cause liver damage (yellowing of your child’s skin, decreased liver function), intestinal problems (decreased appetite, nausea, diarrhea, stomach pain or bleeding) and skin damage (rash, peeling, burn-like appearance on your child’s skin). The transplant team will discuss treatment options with you, if your child develops any of these symptoms.

Chronic GvHD:Usually happens more than 100 days after transplant, but may occur earlier. Chronic GvHD can affect many parts of your child’s body. The most common areas that are affected are the skin, lung, mouth, liver, GI tract and eyes. Your child may experience skin rash, skin thickening, dark color of skin, loss of color of the skin, loss of hair, thin hair, gray hair, joint pain and stiffening, dry mouth and eyes, mouth sores, nausea, vomiting, diarrhea, abdominal pain, weight loss, decreased appetite, inability to absorb medications or food, liver damage, lung damage, breakdown of red blood cells and platelets. Chronic GvHD also suppresses the immune system, making your child more at risk for infection. It can also cause damage to sweat glands and can cause lack of tolerance of heat or cold. Some uncommon symptoms are inflammation of muscles and heart damage.

The transplant team will work very hard to treat any signs and symptoms of GvHD. Your child will be on medication to prevent/treat GvHD and will remain on these medications for a few months after the transplant (or as long as the GvHD is present). Please talk to your transplant team if you have questions about GvHD.

Graft Failure

Graft failure, a serious complication, can occur when the donor stem cells do not grow in your child’s bone marrow. If this occurs, your doctor will discuss options for treatment. This may include another infusion of stem cells.