Jennifer G. Collins, RN Children s Hospital of Chicago

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1 Jennifer G. Collins, RN Children s Hospital of Chicago

3 Review the importance of consultation with the stem cell transplant team Review criteria to begin harvest Review ways to modify a harvest procedure Review ways to evaluate for a successful collection

4 This is the information the Apheresis nurse needs to set up for a successful collection of mononuclear cells by apheresis Some of the information is found in the patient s chart such as height, weight, laboratory results Further information is obtained through consultation with the transplant physician team

found in the patient s chart such as height, weight, laboratory results

5 Patient/donor eligibility and documentation of eligibility Mobilization regimen, clinical trial parameters, expected time frames Endpoints: goals for the product yield, total volume to be processed The oncology autologous donor: time to bone marrow recovery following the most recent chemotherapy course

for the product yield, total volume to be processed The oncology autologous

6 Height and weight (ideal body weight) Pediatric donor less or equal to 20kg will need a special prime: packed red blood cells or 5% albumin Date of birth (age) Psychosocial status Cognitive abilities Support systems: home or transportation issues Physical impairments: Contractures Chronic pain Anxiety Current medication list

Psychosocial status Cognitive abilities Support systems: home or transportation

7 Peripheral: Consider age for 17-18G apheresis needle plus return line (22-18G) Cognitive ability to cooperate Anxiety/pain from needles Central temporary: Temporary IJ (internal jugular) Can increase cooperation due to hands free Uncomfortable not usually painful An existing tunneled double lumen catheter or vortex venous port Venous access is crucial for successful harvest Important for creating interface Poorly functioning line could end a procedure prematurely

free Uncomfortable not usually painful An existing tunneled double lumen catheter or vortex venous port Venous

8 Written consultation for apheresis including all bolts Decision for peripheral access/return versus temporary central venous access Evaluation of current central venous access device for size, type, function

temporary central venous access Evaluation of

9 Written criteria to begin a harvest such as: CBC with differential: increasing WBC count Peripheral blood CD34+ count Electrolytes: no replacement necessary Patient has received all doses of granulocyte stimulating factor as part of mobilization (for mononuclear stem cell harvests)

replacement necessary Patient has received all doses of granulocyte

10 Interim Donor Assessment: feels well; maybe flu-like due to side effects from high dose granulocyte stimulating factor Donor History questionnaire reviewed for changes Central venous access: verification of line placement in chart Current lab results meet pre-determined criteria

questionnaire reviewed for changes Central venous access:

11 The donor is ready for harvest and is on the machine!

12 The procedure has begun Assess patient for side effects: citrate, hypovolemia Establish and monitor the interface Look at the contents in the bag and sample if necessary

13 Buffy coat: Platelets Lymphocytes Monocytes granulocytes

14 Typically no tweaking is necessary Consider for very high counts when harvesting cells from a healthy or non-oncology autologous donor Ensure well functioning lines Reduce external stimuli-calm relaxing environment without anxiety or medicate

autologous donor Ensure well functioning lines Reduce

15 Look at the CBC If autologous: Do you see evidence of bone marrow recovery? Do you have any abnormal cells in your differential or does the technician describe any unusual/atypical cells? Are there any abnormal values?

16 What is the CD34+ count? A marker expressed on most progenitor cells Indication of cells present in the peripheral blood stream cells/microliter is considered a minimum standard for most donors >5 cells/microliter for autologous poor mobilizers who have received several cycles of marrow toxic chemotherapy

the peripheral blood stream 10-20 cells/microliter is considered a minimum

17 Assessed by using the Colorgram against the collect line What color is your product? Too light could mean you are harvesting a platelet rich product Too dark could indicate too much red cell contamination and increased volume, decreased purity

18 Decrease the collect volume Risk: collecting too many platelets, donor platelet loss requiring transfusion Benefit: decreased red cell contamination Expand collect volume Risk: collecting more red cells Benefit: collecting white cells that have pushed into the red cell layer to scoop more white blood cells

contamination Expand collect volume Risk: collecting more red cells Benefit:

19 PB-CD34+ WBC HCT Platelet Mono% Lymph% Neut% other A A B C D nucleated RBC tox gran Howell-jolly tox gran Dohle 2+polychrom 2+oval Dohle metamyel=2% myelo=5% promyelo=1% tox gran metamyel=1% myelo=4% tox gran D NOT REPORTED

20 Goals of harvest or end points achieved Total blood volume processed achieved Desired cell dose achieved Determine the collection efficiency for subsequent collections

21 An equation that indicates how many cells should be in the collect bag based on the amount of cells circulating in the peripheral blood and the number of blood volumes processed Expressed as a percentage 20-30% is good for poor mobilizers 30-40% is adequate and anything above is great

22 Collection efficiency of the CD34+ product: Product CD34+ Yield (PB CD34+cells) x (TBVP) X100 PB= peripheral blood TBVP= total blood volume processed

23 Collection efficiency of the MNC product Useful when there are post-counts Product MNC Yield (pre-count + post count) x (TBVP) 2 X100

24 CD34+ yield CD+34 x 10 6 /kg MNC yield MNC x 10 8 /kg TBVP Minutes CD+34 CE A % A % B % C % D % D %

25 Use the collection efficiency to determine if adjustments need to be made for subsequent days of harvest Make a plan with your apheresis director Blood prime or transfuse to use donor red cells to create interface Determine how to change settings on the machine to produce a better product yield Suggest modifying the mobilization regimen to increase peripheral blood CD34+ such as a dose of Plerixafor 10 hours

26 Thank you

STEM CELL TRANSPLANTS

UAMS Information on STEM CELL TRANSPLANTS What is a Stem Cell Transplant? A stem cell transplant is an infusion of stem cells following high-dose chemotherapy. The infused cells effectively rescue the