BMT Adverse Reactions/Management

Question 1

Hemorrhagic cystitis

Answer 1

inflammatory condition of urinary bladder with sudden onset of hematuria, bladder pain, irritative bladder symptoms

Question 2

Hemorrhagic cystitis management with Cytoxan (4)

Answer 2

1. Hyperhydration - TO BE STARTED NIGHT BEFORE CYTOXAN IS ADMINISTERED and again 6-12h post infusion
2. Monitor UAs specific gravity (need SG to be <1.010 to start Cytoxan, if >1.010 then give 10cc/kg bolus NS)
3. MESNA- to be given with high dose Cytoxan, acts to neutralize acrolein
4. Ensure voiding q2h x 24h after Cytoxan admin (may require foley catheter or bladder irrigation)

Question 3

Hyperhydration with Cytoxan/hemorrhagic cystitis

Answer 3

125mL/m2/hr of D5NS or D5 1/2 NS

Question 4

SIADH

Answer 4

Syndrome of inappropriate anti-diuretic hormone; causes hyponatremia (though urine Na is high) and decreased bladder output (low sodium and low urine output)

Question 5

SIADH treatment

Answer 5

Lasix & fluid restrictions

Question 6

SIADH Prevention (6)

Answer 6

1. strict Is&Os
2. monitor specific gravity/UAs
3. daily weights
4. PRN lasix
5. NS boluses
6. Chem10 - monitor Na

Question 7

Cardiotoxicity with Cytoxan prophylaxis

Answer 7

Order EKG prior to each dose and look for early evidence of decreased QRS voltage or T wave changes which may indicate early cardiotoxicity

Question 8

Busulfan and hepatotoxicity (4: risk factors, management, ppx, treatment)

Answer 8

1. Risk factors: Fe overload, abnormal LFTs, previous chemo, previous abdominal radiotherapy
2. Monitor: weight, LFTs, I&Os, abd circumference, liver size
3. Prophylaxis: Ursodiol/Actigall
4. Treatment: defibrotide to treat VOD

Question 9

Busulfan seizure ppx

Answer 9

Anti-convulsant, usually Ativan, give during Bu administration and 48h after; if it is a sickle cell patient, use Keppra (30mg/kg)

Question 10

Thiotepa and skin changes management (3)

Answer 10

1. Frequent baths by RN
2. Minimal dressings and wear loose clothing
3. Protective gear

Question 11

PRES (posterior reversible encephalopathy syndrome)

Answer 11

CAUTION WITH TACROLIMUS LEVELS >15
1. Headache
2. HTN*** (give hydralazine)
3. Vision changes
4. Changes in mental status
5. Seiures 
If concerns - stop IV or PO med

Question 12

Emergency meds to have at bedside on day 0

Answer 12

1. Tylenol
2. Benadryl
3. Hydrocort - do not use with CAR-T or haplo
4. Lasix
5. Epinepherine
6. Albuterol
7. Hydralazine

Question 13

Day 0 pearls if s/e (5)

Answer 13

1. If patient has any type of reaction, stop infusion and then restart at slower rate
2. If hypertension –> pause infusion; suspect fluid overload then give Lasix. If need immediate relief or BP not lowering, give hydralazine –> restart at 1/2 rate
3. If coughing –> check for wheezing, pause, give albuterol, then once resolved restart at slower rate
4. If hives –> Benadryl –> hydrocort if not resolving
5. Complaints of itchy throat/closing –> epinepherine

Question 14

VOD

Answer 14

When the small blood vessels that lead to or are inside the liver become damaged or blocked
Increased risk with busulfan, TBI and other chemo agents b/c they damage the endothelial cells (can act on CD33 expressed by liver cells)

Question 15

VOD pathophysiology (5 steps)

Answer 15

1st: Damage to endothelium
2nd: Leakage
3rd: Clot formation (activation of coagulation cascade by leakage)
4th: Clot of bile ducts
5th: Reversal of flow, pain, ascites (fluid collected in abd)

Question 16

S/S of VOD (6)

Answer 16

Hepatosplenomegaly, ascites, weight gain, increased bilirubin, jaundice

Question 17

Labs with VOD (3)

Answer 17

1. Elevated D dimer
2. Elevated bili
3. Low platelets

Question 18

Diagnosis of VOD

Answer 18

Abdominal u/s with doppler to assess for reversal of flow

Question 19

Diagnostic criteria of VOD (Seattle criteria, 3)

Answer 19

Presentation by day 20 post HSCT of at least two of the following:

1. Bili > 2mg/dL
2. Hepatomegaly or RUQ pain
3. Weight gain >2%

Question 20

Treatment of VOD

Answer 20

DEFIBROTIDE 6.25mg/kg IV q6 (antithrombotic that breaks up clots) & give concentrated IVF

Question 21

BK Virus

Answer 21

A common virus that may become reactivated after transplant; can be in blood, bladder/kidney
May cause UTI type symptoms or hemorrhagic cystitis

Question 22

Treatment for BK virus (4)

Answer 22

1. If hemorrhagic cystitis: keep plt >50
2. If pain: Pyridium x 3 days and ditropan indefinitely (Bladder relaxant)
3. Hyperhydration to dilute RBCs and avoid clots
4. For mild or refractory illness: cidofovir IV weekly (dose higher if refractory)

Question 23

GVHD

Answer 23

When the donor’s cells attack the recipient’s body

acute: <100 days from transplant
chronic: >100 days from transplant

Question 24

GVHD Treatment

Answer 24

Methylpred 2mg/kg IV

2nd line: jakafi

Question 25

Diagnosis of PRES

Answer 25

STAT CT - will show white matter edema in both hemispheres

Question 26

Parameters to give Defibrotide for VOD treatment (3)

Answer 26

1. Plt <30 2. INR <2.5 3. Fibrinogen >150

Question 27

Gut GVHD symptoms and dx

Answer 27

Large amounts of diarrhea (may have serum protein in it), nausea, anorexia Dx: biopsy

Question 28

Skin GVHD

Answer 28

Acute erythematous rash, typically on palms of hands and soles of feet, may also present around neck, back, arms Dx via skin biopsy

Question 29

Liver GVHD

Answer 29

Increased total bili; do percutaneous or transjuglar biopsy