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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

735

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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737

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