Bone Marrow Transplantation

GOAL: to rid the client of all leukemic or other malignant cells PROCEDURE: 4. Harvest 5. Conditioning 6. Transplantation 7. Engraftment

multiple aspirations from the iliac crest are done to retrieve sufficient bone marrow for transplant  VOLUME: 500 – 1000 mL of marrow  marrow is FILTERED  done before CONDITIONING is initiated 

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Immunosuppression

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Used to eradicate ALL malignant cells

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Creates a space in the bone marrow for engraftment of the new marrow

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Bone marrow is administered through a CENTRAL LINE Infused over a period of 30 minutes or administered by IV push directly into the central line

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Transfused bone marrow cells move to the marrow-forming sites of the recipient’s bones Occurs when the WBC, RBC, & platelet counts begin to rise When successful, process takes 2-5 wks

AKA: thrombocytes Normal Values: 150,000-400,000 cells/mm³ ↓ = thrombocytopenia ↑ = thrombocytosis FUNCTIONS: 8. Nurture the endothelium of the blood vessels (inactive state) 9. Form platelet plug that temporarily stops bleeding (active state) LIFESPAN: 7 – 10 days

The balance of coagulation (formation of blot clot or thrombin) and fibrinolysis (breakdown of fibrin clots) which occur simultaneously a s a result of tissue injury. It is a process that terminates bleeding through a complex mechanism that involves vasoconstriction and coagulation.

SEQUENCE OF EVENTS IN HEMOSTASIS

1. Vasoconstriction:after injury platelets come in contact with a damaged BV, their surface becomes sticky and adhere to the damaged wall.

Release of serotonin which constricts/narrows the vessel --reducing blood flow through it

2. Platelet Plug formation: adherent platelets clump to each other and release adenosine diphosphate which attract more platelet to the site to form a temporary seal to stop the bleeding. 3. Coagulation (blood clotting): this involve the use of clotting factors resulting to formation of an insoluble thread like mesh of fibrin which traps blood cells and much stronger than the rapidly formed platelet

I– II – III – IV – V– VII – VIII – IX -

Fibrinogen Prothrombin Tissue Factor (Thromboplastin) Calcium Labile Factor: Proaccelerin Stable Factor: Proconvertin Antihemophilic factor A, Antihemophilic globulin A Christmas factor, plasma thromboplastin component, antihemophilic factor B X– Stuart Prower factor XI Plasma thromboplastin antecedent (PTA), antihemophilic factor C XII – Hageman factor XIII – Fibrin stabilizing factor (there is no Factor VI) Vitamin k is essential for synthesis of Factors II, VII, IX and X

STAGES of COAGULATION Thromboplastin (initiates Platelets adhere to damage coagulation) released by BV lining damaged tissue cells enters the blood Extrinsic pathway

Intrinsic pathway Prothrombin activator

Final Common Pathway

Prothrombin(F II)

Thrombin

Fibrinogen

Loose Fibrin threads

(FI) Stabilized fibrin clot

4. Fibrinolysis : after clot was formed the process of removing it and healing the damaged BV begins

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capillary fragility test (Rumpel-Leede Test) performed to evaluate the fragility of the capillary walls, or the deficiency of blood platelets (hemorrhagic tendencies) assessed by inflating a blood pressure cuff on an arm to above venous pressure (70 mm Hg) for 5 minutes and then relieve the pressure. the ruptured capillaries will appear as petechiae the amount of petechiae present after the test are counted and are classified by a scoring system

decrease platelet level. Etiology: Decreased production – due to bone marrow deficiencies. Ex in leukemia where Platelets are being crowded out from bone marrow because of increase WBC; radiation, chemo damaging precursor cells in bone marrow Increased destruction – imbalanced between production and destruction of platelets.

> Greater than 50,000 cells/mm³:  Excessive bleeding following surgery or other trauma > Below 20,000 cells/mm³:  Appearance of petechiae  Nose & gingival bleeding  Excessive menstrual bleeding

> Less than 5,000 cells/mm³:  Spontaneous bleeding  CNS & GI bleeding

1. 2. 3. 4.

Treat underlying cause Bleeding precautions Platelet transfusion Medications: - corticosteroids - avoid the use of aspirin

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increased destruction of platelets as an autoimmune response induced by antiplatelet antibodies characterized by petechiae & ecchymosis of the skin

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exact cause: UNKNOWN

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SPLEEN: site of destruction for platelets

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petechiae: spider web appearance

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ecchymosis

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blood in any body secretions

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bleeding from mucous membranes

1. 2. 3. 4. 5.

8. 9.

Control bleeding Prevent bruising Protect from infection Bleeding precautions Medications: - steroids – platelet production - analgesics Platelet transfusion Splenectomy

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Pad crib & playpen Provide soft toys Pads in clothing Headgear Use of soft toothettes instead of bristle toothbrushes AVOID contact sports

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A group of bleeding disorders where there is a deficit of one of several factors in the clotting mechanism Sex-linked inherited disorder

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Hemophilia A: factor VIII deficiency (75% of all hemophilia) Hemophilia B (Christmas Disease): factor IX deficiency (10%-12% of all hemophilia) Hemophilia C: factor XI deficiency (autosomal recessive, affects both sexes)

Platelet plug may form at the bleeding sites Deficiency in clotting factors Impairment of formation of stable fibrin clots BLEEDING

2. 3. 4. 5.

Prolonged bleeding after minor injury Bruising & hematomas Peripheral neuropathies: pain, paresthesias, muscle atrophy Hemarthrosis (bleeding in the joints like knees, ankles, elbows, wrists)

Early signs & symptoms: 3. 4. 5. 6. 7.

At birth after cutting of cord Following circumcision Following IM immunizations Following loss of baby teeth Increased bruising as child learns to crawl & walk

Control acute bleeding episode: Ice compress Immobilize area Elevate affected extremity above heart level Manual pressure or pressure dressing Maintain calm environment AVOID: sutures, cauterization, aspirin Administer HEMOSTATIC agents: - fibrin foam - topical adrenalin/epinephrine

Provide care for hemarthrosis:  Immobilize joint  Elevate joint in a slightly flexed position  Administer ANALGESICS  AVOID use of Aspirin  Instruct pt to AVOID WEIGHT BEARING for 48 hrs after bleeding episode  Provide active or passive ROM exercises

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Administer CRYOPRECIPITATE (frozen factor VIII) - thaw slowly - gently rotate bag - infuse immediately when thawed Genetic counseling Discharge plan: prevention of trauma

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condition that results in exaggerated clotting process increases the formation of clots in the microcirculation

Uncontrolled bleeding  Bruising, purpura, petechiae, & ecchymosis  Presence of occult blood  Hematuria, hematemesis, or vaginal bleeding  Signs of shock 

Normal hemostatic mechanism are altered Massive amt of tiny clots form in microcirculation due to the release of thromboplastic substances into blood..

RBC are trapped in fibrin strands and hemolyzed

Microinfarct and tissue necrosis

Platelet & clotting factors will be consumed

When consumed --- coagulation fails

Paradoxical result of excessive clotting ---- BLEEDING

1. 2. 3. 4. 5.

Treat underlying cause Oxygen supplement Volume replacement Blood transfusion Monitor: - urine output - vital signs - complications