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ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS
which is approximately a week earlier than in BMTs.42 This is
because the stem cells procured from the peripheral blood are more
mature than in the bone marrow.
Indications for BMT include the following9.42•44,,,:
• Severe aplastic anemia
• Acute lymphocytic or myelogenous leukemia
• Chronic myelogenous leukemia
• Non-Hodgkin's lymphoma
• Relapsed Hodgkin's disease
• Multiple myeloma
• NeuroblastOma
• Testicular cancer
• Small cell lung cancer
• Breast cancer
Contraindications to BMT include the following4s:
• Inadequate cardiac function (left ventricular ejection fraction
less than 45%)
• Inadequate pulmonary function (forced expirarory capacity and
forced viral capaciry less rhan 50%)
• Inadequare renal function (creatinine greater than 2 mg/dl)
• Inadequate hepatic function (bilirubin greater than 2 mg/dl)
Patient Preparati011
Before the BMT, the recipient's body is deliberately immunosuppressed to gain the greatest acceptance of the graft. The recipient undergoes a 2- to 4-day cytoreduction protocol, consisting of ablative chemotherapy, radiation, or both, designed to destroy malignant cells and create space in the bone marrow for the engraftment of new marrow.6,9.44
ORGAN TRANSPLANTATION
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Harvesting Procedure and Illdicatioll of Post-Procedure Fr",ction
Bone marrow is harvested by multiple aspirations, most commonly
from the posterior and anterior iliac crests of the donor or, less commonly, from the sternum. Five hundred to 2,500 ml of aspirated marrow is filtered, heparinized, mixed with peripheral blood, frozen, and stored' One to three days after the last dose of chemotherapy or radiation, the marrow is then infused into the patient, much like a blood transfusion, through a central venous access device or Hickman right
atrial catheter.6.46 The most common side effects of reinfusion are
fever, chills, nausea, headache, and flushing. The stem cells from the
marrow that were infused migrate to the recipient's marrow cavities,
mature, and begin to function 10-28 days post BMT.",46 A successful
ellgraftment, which is indicated by an increase in the platelet and
WBC count, is decided 10-20 days after BMT.,·24,46
Post-Procedure Care mld Complications
All recipients undergoing BMT experience a period of bone marrow
failure, which generally begins within 10 days after the start of chemotherapy or radiation and can last up to 3 weeks after BMT.44 During this time, recipients may receive daily transfusions of platelets, lymphocytes, and granulocytes (preferably from the donor), and antimicrobial therapy to counteract the side effects of hemorrhage and infection.s.44 Daily bone marrow aspirations and complete blood
countS arc performed to monitor the progress of the grafts and to
check for recurrence of malignancy.
Clinical Tip
• BMT recipients are very susceptible to infection. When
the patient'S neutrophil count is less than 1 ,OOO/mm3, the
patient is placed on reverse protective isolation or neutropenic precautions. Patients are placed in reverse isolation in a private, sterile, laminar airflow room. In the laminar
airflow rooms, an air filtration system preserves a sterile
environment, and all items entering the room must be sterile. Before entering the patient'S room, physical therapists
and other hospital staff must thoroughly wash their hands,
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ACUTE CARE HANDBOOK FOR I'HYSICAL THERAI)ISTS
gown, and mask to maintain precautions. Live plants and
floral arrangements are not permitted in the patient's
room, because they may harbor bacteria and molds that
may be harmful to the patient during neutropenic episodes. Any exercise equipment brought into the patient's
room must be cleaned before entering the room.
• When the patient's platelet cOunt is 50,000/mm' or less,
the patient is placed on thrombocytopenic precalltiolls.
Thrombocytopenic precautions are observed (sometimes
for months) until the platelet Count returns to normal. The
physical therapist should be aware of the recipient's platelet count before any treatment is initiated. Thrombocytopenia, which occurs from chemotherapy, radiation, and the underlying disease process, can cause spontaneous
bleeding. The most common bleeding sites include the oral
and nasal mucosa, the optic sclera, and the epidermis
(petechiae) 44 Generally, patients with platelet counts of
30,000/mm' or greater are able to tolerate moderate exercise if they are asymptomatic and have no spontaneous
hemorrhage 4' A patient with platelet counts between
20,000/mm3 and 30,000/mm' should only perform light
exercise consisting of active range of motion exercises and
ambulation as tolerated. Heavy resistance work is contraindicated.42
BMT recipients are at risk for fatal infection. Patients' blood counts
drop secondary to the cytoreduction therapy. Pallcytopellia, which is a
marked reduction in red blood cells, WBCs, and platelets, persists for
at least 3-4 weeks after BMT. Normal immune function may not be
regained for 12-18 months, as it can take that long for the transplanted immune system to mature and develop normal function.9.46
Some major complications of BMT include infection, pneumonia,
hemorrhage, marrow failure, veno-occlusive disease of the liver, interstitial pneumonitis, and graft-versus-host disease (GVHD).6,9,17,J8
Vello-occlusive disease is characterized by obstruction of the hepatic
venules by deposits of collagen and fibrin. Clinical manifestations of
vena-occlusive disease include sudden weight gain, increased LFfs,
hepatomegaly, right upper quadrant pain, ascites, and jaundice." Venoocclusive disease is related ro the amOunt of chemotherapy and radiation the patient received before transplantation. Veno-occlusive disease may occur L-3 weeks after BMT and spontaneously resolves within 2-3 weeks in approximately half of those affected.'
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GVHD is a complication that occurs in approximately 20-50% of
allogeneic transplant recipients.17 It does not occur in patients with
autologous BMT or PBSC transplants.42 It is caused by the donor
marrow's production of T lymphocytes that react immunologically to
the host recipient. The peak onset is at 30-50 days after BMT. The
major organs affected by GVHD are the skin, liver, gasrrointesrinal
tract, and lymphoid system.6•44 Skin involvement manifests as an