PROTOCOL OF NURSING CARE ON ZERO DAY OF THE TRANSPLANTATION OF HEMATOPOETIC STEM CELLS: COLLECTIVE CONSTRUCTION

Figueiredo, Talita Wérica Borges; Mercês, Nen Nalú Alves das; Silva, Luana Aparecida Alves da; Machado, Celina Angélica Matos

doi:10.1590/1980-265X-TCE-2018-0010

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ORIGINAL ARTICLE • Texto contexto - enferm. 28 • 2019 • https://doi.org/10.1590/1980-265X-TCE-2018-0010 copy

PROTOCOL OF NURSING CARE ON ZERO DAY OF THE TRANSPLANTATION OF HEMATOPOETIC STEM CELLS: COLLECTIVE CONSTRUCTION

PROTOCOLO DE CUIDADOS DE ENFERMERÍA EN EL DÍA CERO DEL TRANSPLANTE DE CÉLULAS MADRE HEMATOPOÉTICAS: CONSTRUCCIÓN COLECTIVA

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

to construct a protocol of nursing care to the patient on day zero of hematopoietic stem cell transplantation.

Method:

a convergent care research was developed from August to December 2016 in a Bone Marrow Transplant Service. The participants were twenty-two nurses from this service. The technique of data collection used was discussion groups. For the analysis the following steps were taken: transcription of the data, highlighting the suggestions of the participants; distribution of contributions by theme, for synthesis of the elements in a coherent whole, scientific evidence and contributions of the participants; and construction of the protocol, with refinement and approval of the final version by nurses.

Results:

the protocol, guides nursing care to be provided by the nurse on day zero of hematopoietic stem cell transplantation, according to the infusion mode: fresh and cryopreserved-thawed. These precautions aim to prevent, identify and intervene early in complications related to cell infusion.

Conclusion:

the protocol, product of the research, was elaborated in the union of scientific evidences, with the reality of the service and the experience of the participating nurses. The utilization of the methodological steps of convergent care research was a facilitator, because, as it presupposes, it provided the union of care practice with scientific research. The participation of nurses in the construction and approval of the protocol enabled the subsequent implementation and use of this tool in nursing service.

DESCRIPTORS:
Nursing; Nursing care; Hematopoietic stem cell transplantation; Hematopoietic stem cells; Nursing assessment; Protocols

Chapter of the Protocol	Version elaborated by the researcher	Contributions of nurses in the discussion groups	Version approved by nurses
Chapter 2	Homogenize the Hematopoietic stem cells bag.	When and how often will it be done? (ED1, ED2, ED4, ED13).	Homogenize the Hematopoietic stem cells bag and check the drip speed during infusion every one hour.
Chapter 3	Program the infusion of each bag (can be one or more bags) for 15 to 20 minutes.	Would not it be better to approach that this time is independent of the way the cells are thawed? (ED1, ED2, ED8, ED21). It would not be better to put the flow in ml/min, because the volume may vary (ED1). And when the cells do not infuse gravitationally? I suggest putting the option in bolus (ED2, ED6, ED7, ED18, ED21).	Program the infusion of each bag (it can be one or more bags) at a speed of 10ml/minute, regardless of the way of thawing (bedside, dilution or washing). Start the infusion slowly and schedule the end to the calculated time^* if the patient tolerates well. This infusion time should also be respected in cases of use of syringe and three-way device.

Discussion group	Objectives	Number of participants
I	Present the research in detail; Present the format intended for the protocol; Discuss the Protocol Introduction (Chapter 1).	22
II	Collectively define nursing care before, during and after infusion of fresh Hematopoietic stem cells bag (Chapter 2).	18
III	Collectively define nursing care before, during and after infusion of cryopreserved-thawed Hematopoietic stem cells bag (Chapter 3).	19
IV	Present the final version of the Protocol (complete, with the 3 chapters) and propose the approval of the Protocol by the participants.	15

Nº	Nursing Care
1	Initiate infusion of HSC immediately, when the following situations are satisfactory: - HSC bag(s) released by the Laboratory of Cellular Manipulation and Cryobiology; - Patient able to start the infusion.
2	Conduct a double checking (with a member of the nursing team) on the identification of the HSC bag with the Infusion Report from the Laboratory of Cellular Handling and Cryobiology. In ABO Incompatibility greater or bi-directional check the final volume of red blood cells.
3	Perform double checking, when entering the patient's room, with the full name on the identification bracelet and/or confirmed by the patient.
4	Check vital signs: immediately before starting infusion.
5	Keep the patient monitored (pulse oximetry) in the first hour of infusion. Monitoring should be maintained when adverse reactions occur.
6	Stay in the patient's room for the first hour of HSC infusion.
7	Stay on duty at bedside. Keep the remaining HSC bags (if there are more than one) properly identified in cooler at the Nursing Station and reinforce this information in the shift change.
8	Infuse HSC into blood transfusion set. Never use a transfusion set with a leukoreduction filter. In case there is more than one bone marrow bag, change the transfusion set each time you change the bag.
9	Infuse HSC in the most calibrated CVC pathway, after performing flushing in CVC with a syringe containing 0.9% saline solution.
10	Maintain intravenous hydration of the patient according to medical prescription.
11	Check vital signs: - every 15 minutes in the first hour of infusion; - every 30 minutes in the second hour of infusion; - every hour in the subsequent hours. The increase in the time interval should also follow the clinical status of the patient: if necessary, the vital signs should be checked more frequently.
12	Homogenize the CTH bag and check the drip speed during the infusion, every 01 hour.
13	Monitor the volume and appearance of the patient's diuresis and monitor fluid balance.
14	Program the infusion of the HSCs with the flow rate of 3ml/kg/h for cases of ABO compatibility or minor ABO incompatibility between donor and recipient.
15	Schedule the infusion of HSCs with the initial flow rate of 1ml/kg/h, which should be increased to 2ml/kg/h in the next half hour, and to 3ml/kg/h in the subsequent half hour, in cases of higher ABO incompatibility or bi-directional, between donor and recipient.
16	Decrease the speed or temporarily interrupt the infusion (depending on the severity of the reactions) if the patient experiences adverse reactions during the infusion of HSCs. Report responsible physician and perform according prescribed by him.

Nº	Nursing Care
1	Start infusion of HSC immediately after thawing.
2	Conduct a double checking (with a member of the nursing team or with biochemistry) on the identification of the HSC bag with the Infusion Report from the Laboratory of Cellular Manipulation and Cryobiology.
3	Perform double checking, when entering the patient's room, with the full name on the identification bracelet and/or confirmed by the patient.
4	Guide the patient that he can suck candy* during and after the infusion of HSCs. *Candy previously released by the Nutrition Service and/or doctor.
5	Check VS immediately before starting infusion.
6	Maintain the patient monitored (pulse oximetry and cardiac monitoring) during the infusion of HSCs.
7	Stay in the patient's room throughout the infusion of HSC.
8	Infuse HSC into blood transfusion equipment via gravitational. Never use equipment with a leukoreduction filter. In cases of difficult gravitational flow, the infusion can be done using a 60 ml syringe and a three-way device. This is connected between the transfusion set and the CVC. The contents of the bag are aspirated with the syringe and it is injected by the CVC with the syringe.
9	Infuse HSC in the most calibrated CVC pathway, after performing flushing in CVC with a syringe containing 0.9% saline solution.
10	Maintain in the other CVC path only intravenous hydration, according to medical prescription.
11	Check vital signs every 15 minutes (remembering that the patient should have continuous pulse oximetry and cardiac monitoring).
12	Notify the biochemistry for the thawing of the next bags, in the cases of thawing at the bedside.
13	Monitor the volume and appearance of the patient's diuresis and monitor fluid balance.
14	Program the infusion of each bag (it can be one or more bags) at a speed of 10ml/minute, regardless of the way of thawing (bedside, dilution or washing). Start the infusion slowly and schedule the end to the calculated time* if the patient tolerates well. *This infusion time should also be respected in cases of use of syringe and three-way device.
15	Decrease the speed or temporarily interrupt the infusion (depending on the severity of the reactions) if the patient experiences adverse reactions. Report responsible physician and perform according prescribed by him. Infuse each bag within 30 minutes in case of reaction.

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[1] CORRESPONDENCE AUTHOR: Talita Wérica Borges Figueiredo.talitawbf@gmail.com