BMT nursing questions

nurse_2365 · Apr 26, 2013

Wow I am so happy to have just found this thread! I am a new grad and I will be moving from CA to UT to begin my career in a children's hospital on the immuno-compromised unit! This gives me a starting point on what to review. Thank you! I am so excited and a little nervous!

carolinapooh, BSN, RN · May 13, 2013

Not sure what LOS is but yes, a transplant is like infusing blood

You don't use a pump for infusing stem cells or live marrow - they're pushed with a syringe. I did do one to gravity once because the syringe method, with all the stopcock tubing and flushes, wasn't needed. Other than that the rules are pretty much the same - NS only, monitor for reactions during infusion (only here it's the preservative, DMSO, that causes the reaction and not the blood product).

danceyrun · May 23, 2013

Thank you for clearing that up, Carolina. I have a few more questions for you experienced BMT nurses if you would be so kind to answer...

What are the most common meds that you give?

Do you see many codes on your unit?

Which lab values are you most concerned with? My common sense tells me WBC, electrolytes.... H&H?

Thank you in advance

carolinapooh, BSN, RN · May 25, 2013

WBC, all blood counts, really; LFTs for TPN and tacrolimus for allo recipients; K+ and Mg2+ and Phos - oh, well, you're right - all of them, really. PBSCT really screws up the system, even if it's "just" (!!!) an auto transplant. We watch post-transplant WBCs and ANCs for signs of engraftment - and sometimes for graft failure (I've seen two - it does happen and yes, it's very rare). We also test for levels of various post-transplant drugs - like methotrexate (MTX) and tacrolimus (also sometimes still called by its experimental name, FK-506), because these drugs tear up your liver like no one's business, and there are also specific therapeutic and subtherapeutic levels with FK506, a lot like vancomycin has certain levels. And urine tests - we love those, too - they give great info on the kidneys (these drugs fry them up too if you're not careful).

We're a bit lab obsessed, as you can imagine.

Most common meds aside from chemo (and I don't mean that smart): Bactrim/Septra (prophylactic pre-transplant for PCP PNA); acyclovir (kick back herpes infections - remember chickenpox is herpes!); diflucan (if LFTs permit - if not, you really have to watch them for fungals - we just lost a patient to fungicemial sepsis); allopurinol and ursidiol (I've seen two cases of venoocclusive disease of the liver, one fatal, one's now doing OK for the moment); all electrolyte replacements. Lots of painkillers - cancer sucks, btw, and it's painful. Mucositis is a HUGE problem in this population, so we use a lot of PCAs on the allo folks (it's more common in allos than autos, to the point of needing PCAs and TPN, but it can and does happen in autos). LOTS of broad spectrum abx when they pop a neutropenic fever until we narrow down sensitivity.

Allos are harder on the body because we're giving you someone else's immune system, essentially - and we fight graft-vs-host (new stem cells trying to kill the patient), the opposite of host-vs-graft (patient trying to kill, for example, the new kidney or heart or whatever) which is what you see in solid organ transplants. So those stem cells, as they develop into the different lines (lymphoid and myeloid), KNOW they're not in their usual 'home', and...well, we give drugs to control that. :)

We say you actually want a LITTLE GVHD - you want that immune system hyped up, because part of the goal of transplant is graft-v-tumor: the hope that the 'new' immune system will attack any cancer we missed and prevent relapse (yep, seen several deaths of post-transplant relapse - it happens, it sucks. A LOT). You also want it a bit hyped up so it will protect the host from opportunistic infection: we can't cover every base with a drug, it's impossible. So if a patient gets a bit of skin GVHD (the easiest to control) we're happy. Even the gut - miserable as it is - can be managed. Rampant GVHD of the liver is, as you can imagine, bad news and not good. And we can't control where you get it or to what extent. I had a pt with GVHD of the skin on her face so bad she didn't want to leave the house. And I've had one with a large patch of it on his shin - all he said was, well, guess I don't wear shorts any more. But even the bad case was happy to be alive. She adapted. (These patients are, in a word, amazing. And that's so inadequate a word.) But I lost one with it to the liver - really, really bad case to the liver. Horrible way to die.

(Sometimes to the skin it clears. Sometimes it doesn't. Transplant is a terrible, terrible crapshoot.)

A lot of codes - hmm....sometimes it seems like a code a week. Sometimes it seems like everyone we transplant dies or goes to the unit to die. We had a period a few months ago where it felt like EVERYONE was dying. But we work in the clinic too, and we have more success stories than losses - and even with the losses, a lot of times we gave them more time - more QUALITY time - with their families and loved ones than they would've had without transplant. Most of the time we don't see them when they die - we see them just before for that last infection before they say 'enough', or we'll see them one last time in the clinic.

Transplant is your last hope - it's done when either chemo 'fails' (I hate that useage of the word) or it's known that chemo won't help. These folks know the risks even if they're hard to accept. Of course we hope all of our patients are successful, but we also have known going in that there's really no hope either way - that transplant is a long, long shot. But it's still a shot, which is more than they have without it. Some opt not to do it - and that's okay. And some do. Some work - and some don't. It's the hardest, most wonderful thing I've ever done to date.

carolinapooh, BSN, RN · May 25, 2013

Hope I didn't overload you. My reputation of heavy enthusiasm for the subject is (unfortunately for those I hold captive) well known in my world... :)

danceyrun · May 28, 2013

Wow- Carolinapooh this was amazing!!! Thank you so much for taking the time to type all of that. I plan on looking up everything I didn't understand in this post once I get back from vacation and I may have some further questions but again thank you! I am so excited to start on the BMT unit with this information :)

jpw4200 · Oct 3, 2013

Wow!! I can't tell you how great it was to read your post on what it's like to be on a peds BMT unit! I a in an ABSN program at a teaching hospital, and I just found out that I was placed in my #1 choice (peds BMT) for my senior preceptorship. I was already so excited, but you just made my day! Everything you described is exactly what I am looking for. You did such an awesome job of relaying the extreme acuity along with the intense patient family interaction and psycho-social support. The best combination ever! Thank you so much for taking the time to describe it so well. It definitely sounds challenging! Can't wait!!!

PacoUSA, BSN, RN · Oct 26, 2013

I just attended a BMT continuing ed yesterday and have become very interested in this specialty lately, more than when I previously posted about my friend working on the BMT unit. It sounds so exciting and interesting enough to consider it a new move.

seasidesoul · May 12, 2015

I just accepted a new graduate position in a BMT unit, and this post has made me even more excited! I would love to get into contact with some of you!

emilygallardo · Oct 3, 2016

Though it's late but just wanna say... Wow.. LaRoseRN and Brithoover.. You guys made my day..

I am also working as a BMT nurse but our unit deals with both adult and pediatric patients..our ratio is 1:1

uhurebor · Oct 14, 2016

Love the BMT post very informative. Thanks

awoodBMT, RN · Jan 23, 2017

Hey there! Huge Congrats!
I did my senior practicum in BMT too & LOVED it. It's not for everyone, but it was definitely for me. I remember it being a steep learning curve because, as you mentioned, we really hadn't learned much about BMT during nursing school.
Now I work as a Pediatric BMT RN. We usually have no more than two patients, sometimes we share 1.5:1, 1:1 (and in really serious cases 2:1!) but on adult units it can be 3:1, and on mixed BMT/Heme/Onc it might be closer to 4:1 or 5:1 (but I think 5 is too much if blended with a BMT patient!)
Here's a taste:
Folks get super sick on BMT -- we "condition" them with very high-dose chemotherapy (Imagine the equivalent of 1 years worth of chemo given over 6 days) that ablates the bone marrow, then we infuse them with either donor stem cells (allogeneic) or their own cells (autologous, sometimes called a "rescue") -- then we manage the symptoms of the high dose chemos et al while they grow their new marrow/immune system back. Those who receive cells from a donor source take a lot longer, and require immunosuppressive drugs for life so they don't reject the transplant.
It's an incredible process, and very hard on the patients. During my senior practicum, my preceptor told me "we basically bring them to the edge of death and back again..."
With no WBC counts, they are prone to infection, their bone marrow is essentially non-existent so they need multiple platelet and blood transfusion (or FFP, Albumin...) until their counts are back up. Antibiotics/Antivirals/Antifungals are the norm. The chemo can be cardiotoxic, hepatotoxic, and can fry the kidneys, so knowing those systems are important. Knowing all the systems is important...and signs those symptoms are shutting down. Managing, pain, fevers, nausea (look up antiemetics), fatigue, mucositis, GI issues/weight loss, emotional support, the process of being in isolation for weeks to months..."those walls can close in fast"
Review general heme/onc w/ a focus on blood diseases (leukemias, sickle cell). We also transplant SCIDS babies (born without immune systems to start) and some others...what you'll see really depends on the hospital.
Review the process for transfusing blood products (probably won't be able to touch blood or chemos while your precepting, but you'll see plenty) also managing transfusion reactions. Know your antibiotics, antivirals, antifungals. Research working with severely neutropenic populations & practicing impeccable hygiene/precautions. Learn about mucositis, pain interventions, all pain narcotics. You'll learn a of critical care. We are categorized as an ICU but we don't do vents. Review signs of sepsis, infection, signs of bleeding problems (read up on hemophilia), topical skin lotions (some of the chemos burn/irritate the skin and it can peel right off), incredible wound care, working with CVCs & Ports.
I remember being intimidated by the amount of lines to manage. We frequently have kids on PN + Lipids + Heparin + Dilaudid or Morphine PCA, sometimes lasix or insulin drips...then add on their antibiotics, or blood products, and various IV meds -- and you have to double and triple check what's IV compatible with what...that can be quite a juggle! But you do get used to it.
While you are there, you will have great opportunity to practice your head-to-toe assessment and monitoring vitals signs. I'm sure you've heard throughout nursing school how important these two skills are. On BMT these two skills are SOOO important. Sometimes the slightest change in your baseline assessment can indicate a serious change in condition and these patients can crunk out fast. We've had kids who were up talking & playing and within 30 minutes were going septic! There's an art to getting reliable temps and BPs on our patients. Even changes in weights or abdominal girth can indicate big issues. Look up Veno-oclusive disease & hemorrhagic cystitis.
Some of what I love about BMT is there is a big emphasis on "team nursing" -- so much of what we do has to be double checked by other RNs at the bedside (Chemos/Blood Products/Drip Changes/Narcotic PCAs) so everyone works together a lot. You also work with patients for such an extended period of time that you really get to know them well. I love the psycho-social support aspect, personally, and with the kiddos we do so much to keep things fun and interesting and developmentally appropriate. I love the critical care aspect also (nerd alert!) and really do a lot of review and education regularly.
I also like that most of our patients can still talk and interact (no vents!) and most of them have central lines so we aren't doing a lot of poking (alas, I have zero IV skills working on BMT). I also like that there is so much teaching involved. You really have to enjoy developing relationships with people and being creative in educating them about their "new normal" post-transplant
What I don't like about it is sometimes all the interventions in the world don't seem to ease the suffering and I go home some nights feeling like I didn't provide any relief despite throwing my entire orificenal of interventions at them. Sometimes patients really break down psychologically, and if they react to medications they can hallucinate, or they don't make it through treatment...dealing with grief, and the dying process is also important to review -- and therapeutic listening/communication. Losing patients is so, so challenging and you have to learn really good coping and self-care methods to avoid burnout.
Remember to take care of yourself. Set healthy emotional boundaries. I find working with this patient population makes me recognize how magical every day is, and to not to take anything in life for granted. I really give thanks on a regular basis, and take full advantage of my days off!
That's probably more than enough...
At the end of the day, just try to soak up as much as you can! Ask questions, keep a notebook handy, and look up everything. I hope you have an enjoyable experience. It can be incredibly difficult work, but also deeply rewarding.
And I forgot the mention: BMT nurses are a super unique kind of wonderful -- often a bit type A, but extremely compassionate and fantastic colleagues.
You're going to learn so much! Enjoy the process & good luck!!!

When I received an interview on a BMT unit, I read this. And after 10 months of working on a BMT unit, this post is perfect. It's definitely a steep learning curve, and my unit also takes MICU patients so it was a pretty overwhelming learning experience at first, but I can't imagine working anywhere else. I'm always learning something new. They are sick, sick, SICK patients. Our unit ratios are 3 patients to 1 nurse for stable BMT patients (sometimes 2 to 1), and 2:1 for when we have an MICU patient with a BMT patient.