Infection, Immunity, & Inflammation: Leukemia Flashcards
type of cancer with uncontrolled production of immature WBCs (usually “blast”) cells in the bone marrow. As a result, the bone marrow becomes overcrowded with immature, nonfunctional cells and production of normal blood cells is greatly decreased.
Leukemia
What are the the two categories of leukemia with respect to cell types?
- lymphocytic or lymphoblastic (from lymphoid pathways)
- myelocytic or myelogenous (from myeloid pathways)
which cells does luekemia where does the cancer most often occur?
stem cells, causing excessive growth of specific type of immature leukocyte
What does it mean when bone marrow is full of blast phase cells?
the cells cannot provide infection prevention
Why is a client with leukemia at increased risk for bleeding?
Reduced levels of fibrinogen and other clotting factors are common in patients with acute leukemia
Clotting time and aPTT is prolonged
Lab values for a patient with acute leukemia are usually:
- decreased hemoglobin and hematocrit
- low platelet count
- abnormal WBC (high, low or normal)
- high with mostly blast = poorer prognosis
What is the definitive test for leukemia?
examination of cells obtained from bone marrow aspiration and biopsy
- phase, chromosome analysis, antigens (tell type of leukemia)
Priority intervention for patients with leukemia:
infection prevention, major cause of death in leukemia patient because the WBCs are immature and cannot function or are depleted from chemo
normal flora overgrows and penetrates the internal environment
autocontamination
organisms from another person or the environment are transmitted to the patient
cross-contamination
these systems decrease the number of airborne pathogens
high efficiency particulate air (HEPA)
diet where any uncooked foods, such as raw fruits and vegetables, are removed from the diet becuase they have large numbers of organisms
minimal bacteria diet
designed to protect a patient from infectious organisms that might be carried by the staff, other patients, or visitors or on droplets in the air or on equipment or materials.
isolation techniques per pts diagnosis
Protective (reverse) isolation
the act of spreading bacteria and viruses from one surface to another. Since bloodborne viruses can live on objects and surfaces for up to a week, germs could be spread when surfaces are not disinfected the right way or if equipment is not cleaned and sterilized between clients.
cross contamination prevention
What is the goal of bone marrow or stem cell transplantation in the treatment of Leukemia?
chemo is given to purge the marrow of leukemic cells, this is lethal to bone marrow, and without replacement of stem cells by transplantation the patient would die of infection** or **hemorrhage
the new cells go to the marrow and begin hematopoiesis**, ideally a **permanent cure
patients receive their own stem cells (which were collected before high-dose therapy)
autologous transplants
stem cells taken from patient’s identical twin
syngeneic transplants
closely HLA-matched sibling or an unrelated but matched donor provides the stem cells
allogeneic transplants
How can stem cells for transplantation be obtained?
- bone marrow harvest
- peripheral stem cell pheresis
- umbilical cord blood stem cell banking
bone marrow transplants are most ideally done following which stage of therapy
- induction, increased doses of chemo, NADIR is reached = ready for transplant
What are the five phases of transplantation?
- stem stell obtainment
- conditioning regimen
- transplantation
- engraftment
- post-transplantation therapy
How much bone marrow is taken and how long does it take to regrow?
500-1000mL of marro is aspirated (5-10%)
will regrow within a few weeks
Three phases of Peripheral blood stem cell (PBSC):
- mobilization
- collection by pheresis
- reinfusion
stem cells that have been released from the bone marrow
peripheral blood stem cell (PBSC)
involves obtaining stem cells from umbilical cord blood of newborns. After birth, before the placenta detaches, a syringe is used to withdraw 40-150mL of blood fromt he umbilical vein of the placenta.
$1500, with $200/yr to store
Cord blood harvesting
Day T-5 through T-6; this serves two purposes:
- to “wipe out” the pateints own bone marrow
- give higher than normal doses of chemo and/ radiation to rid the person of cancer cells
Conditioning Regimen
Side effects of stem cell transfusions:
- fever
- hypertension
*treated with tylenol, hydrocortisone, benadryl
Post-transplantation patient has red urine. Is this okay?
yes, usual result of red blood cell breakage in the infused stem cells
the successful “take” of the transplanted cells in the patient’s bone marrow (8-28day process)
Engraftment
How do you know engraftment has occured? and is completely successful?
the patients WBC, RBC, and platelet count will rise
only the donor’s cells are present
some GVHD
the presence of blood cells that show a genetic profile or other marker that is different from those of the patient
chimerism
the presence of both the patient’s cells and those of the donor
early mixed chimerism
increasing percentages of donor cells, indicator engraftment
progressive chimerism
wincreasing percentages of the patient’s cells; indicator of graft failure
regressive chimerism
What are severe problems that a post stem/bone cell transplant patient has in the post-transplant therapy phase? Why?
infection and bleeding; because the patient remains without any natural immunity until the transfused stem cells grow and engraft
In addition to having the aspiration sites monitored, what else do bone marrow donors need and why?
- Fluid for hydration - pts may lose alot of fluid along with marrow
- pain management - painful procedures - non-aspirin analgesics or opiods
- possible RBC transfusion - replacement of lost blood during marrow aspiration
What happens to the patient if failure to engraft occurs?
patient will die unless another transplant with stem cells is successful
when the immunocompetent cells of the donated marrow recognize the patient’s cells, tissues, and organs as foreign and start an immunologic attack against them
tissues usually damaged: skin, intestinal tract, and liver
Graft-versus-host Disease
Who is at highest risk for GVHD?
allogeneic transplants, but can also occur in autologous transplants
the blockage of liver blood vessels by clotting and inflammation (phlebitis)
occurs in 20%pts who undergo HCST; most serious
jaundice, pain URQ, ascites, weight gain, liver enlargement
no way of re-opening
Veno-occlusive disease (VOD)
drug to treat anemia and thrombocytopenia (stimulate marrow production of RBCs and platelets)
- Aranesp
- Epogen and Procrit
*increase hypertension, blood clots, strokes, and heart attacks
growth factor therapy for thrombocytopenia, increases production of platelets:
Neumega
*causes fluid retention, increased risk of heart failure and pulmonary edema
*or conjunctival bleeding, hypotension, tachycardia
What do you teach patients taking Neumega to do daily:
weigh themselves and report sudden weight gain or dyspnea
Side effects of chemo drugs:
- neutropenia
- N&V
- diarrhea
- alopecia
- stomatis (mouth sores)
- kidney/liver/cardiac toxicity
- anemia
- thrombocytopenia
- hemorrhagic cystitis, cardiac muscle damage, loss of bone density
When is the best time to give antiemetics for chemo induced N&V?
before chemo, and directly after
What do you teach your patient undergoing chemo to prevent mucositis?
gentle flossing once daily (if at all), rinse mouth hourly with plain water or saline. Clean toothbrushes weekly with dishwasher or by rinsing with bleach and running under hot water. Swish and spit local anesthetic and anti-inflammatory for current mucositis
when does hair usually start growing back in patients with chemo-induced alopecia?
one month after chemo completion. new hair may grow back differently. teach scalp care and body image change coping
NADIR
WBC = 0
Symptoms of Veno-Occlusive Disease:
after stem cell transplant
- jaundice (bili>2)
- ascite
- liver enlargement
- weight gain by 2%
malignancy of lymphoid tissues found in lymph nodes, spleen, liver, bone marrow
*lymph nodes will be enlarged if present
hodgkins disease
