Sunday 17 June 2007

ACUTE LYMPHOBLASTIC LEUKEMIA

QUESTION 1
Select a patient in your clinical setting and provide a brief descriptive profile outlining their age, diagnosis, disease stage and general treatment plan.
WT is a seventeen years old boy who was referred to Emergency Department by a GP with two weeks of legs petechia rash, hematuria, bilateral lower leg pain and general lethargic. It was also noted that he had a bruising and bleeding easily over last few days, tachycardic, and haematomesis. There were no epistaxis or melena presents.
From blood test showed that his blood counts were abnormal.
Haemoglobin: 110 l
White Cell Count: 268.5 c
Neotrhophills: 21.6 h
Platelets: 17 c
Circulating Blast Cells: 198.5 c
Lymp: 35.6 h
Mono: 8.9 h
RBC: 3.77 l
HCT: 0.33 l
Microscopy MSU:
WBC: >100 x 10,000,000
RBC: >100 x 6
Epi: <10
Chemistry: Positive of ketones, protein,
From blood test’s result, Tom was suspected with Acute Leukemia. Tom was then referred to haematology ward for further investigations after stayed overnight at children’s ward. These investigations include Bone Marrow Aspirate, CT Abdoment, Chest Xray, HIV V2V HSU serology and routine blood test such as FBC, EUC, CRP, LFT, Co agulation, & C3 nephritic factor.
After investigations were performed, Tom was finally diagnosed with Acute Lymphacytic Leukemia (ALL). The treatment plan for him includes:
To commence induction chemotherapy by using BFM 95 protocol.
Tissue typing of the family if allogenic stem cells transplant required in the future.
Sperm Banking.
Further Bone Marrow Biopsy and other test to view the response to induction therapy.
To understand leukemia, it is important to understand the process of blood formation. The formation of blood cells started in bone marrow which called haematopoiesis. Leukemia is a type of blood cancer affecting the bone marrow. Bone marrow is the spongy center of the bone that produces blood cells. All mature blood cells are originated from a pluripotent stem cell which is produced in bone marrow. Stem cell can be divided into two lineages, myeloid lineage and lymphoid lineage. These are a type of mature myeloid and lymphoid cells, including white cells or leukocytes (help the body fight against infection and other disease), red blood cells or erythrocytes (carry oxygen from the lungs to the body’s tissues and take carbon dioxide from the tissue back to the lungs), and Platelets (help form blood clots that control bleeding). These cells are normally produced in an orderly controlled way when the body needs them, but with leukemia that process gets out of control.

Leukemia means white blood. In leukemia the marrow produces too many immature white blood cells, which is called blasts. These immature white blood cells are abnormal shaped and cannot carry out their normal duties. These blasts are multiplying and crowding the bone marrow, as they interfere the production of other type of blood cells. Red cells, platelets and mature white cells will be affected. When they circulate in the body, they can be stayed in different places causing swelling or pain. Leukemia has a sudden onset and rapid progression of symptoms and disease.
Acute leukemia can be classified into acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL). AML develops when maturation and proliferation of myeloid stem cell are abnormal, and ALL is established when abnormalities in maturation and proliferation of the lymphoid stem cells are occurred. In other word lymphocytic leukemia that affects the white blood cells called lymphocytes, which is the overproduction of the immature lymphocytes. Lymphocytes control the body’s immune response by finding and destroying foreign substances.

ALL is common occurred in children by two third (Cremer et al. 2002, 6). As the abnormal white blood cells cannot help the body fights against infection, frequent infections and flu-like symptoms such as fever and chills will occur. As the abnormal cells keep multiplying and move out into the body, they are tend to be collected in the lymph nodes organs such as liver or spleen or joints.

QUESTION 2
Outline the role of diagnosis and staging in the evaluation of your patient’s disease and its relevance to the general treatment plan.
Untreated ALL shows the presence of abnormal white blood count, haematocrit, haemoglobin, platelets counts, bone marrow (more than 5% blast) as well as the presents of signs and symptoms of the disease. The diagnosis can be made by performing full physical examination, blood test, bone marrow aspirate/biopsy and other additional tests. The physical examination is to find out the swelling in the liver, the spleen, and the lymph nodes under the arms, groin and the neck. From Tom’s physical examination were found that he had swelling under the arms, groin and the neck. He also had an enlarged spleen.

Blood test is performed to see what the cells look like under the microscope and compare the number of abnormal cell with the normal cells. Tom’s blood test showed that he had excessive white blood cells count (268.5) and circulating blast cells (198.5). There is no blasts should be circulating in the blood.

Bone marrow aspirate is a procedure by taking a sample of bone marrow using needle inserted into large bone, usually hip. Sometimes a small cykindrical piece of bone and marrow are also needed, this procedure is called bone marrow biopsy. This procedure will confirm weather or not the leukemia is present. The ALL can be established when 25% more of nucleated cells in the marrow contain lymphoblast.
There is no clear cut staging system for ALL according to Pui and Evans (1998, 2). They also noted that the diagnosis of ALL is depending on immunophenotyping. Unlikely AML which can be identified by the presence of auer rods, myelophoblastic leukemia, or monocyte associated esterases, ALL is lack of specific morphologic or cytochemical features (Pui & Evans, 1998, 2).
World Health Organisation (WHO) classified the types of leukemia in respect to where the cell formation is disruptive and with prognosis of outcomes. Cytogenetics can confirm the diagnosis and favourable or unfavourable outcomes.
Leukemic cell characteristic such as morphological features cytocemistry, immunologic cell surface and biochemical markers and cytogenic characteristics are important when diagnosing leukemia. However cellular classification using French, American and British (FAB) classification is limited for ALL, it is still used. The FAB classification classified ALL into three morphology types including L1 T-cell and B-cell in children, L2 T-cell and B-cell in adult, and L3 B-cell (Burkitt cell types). L1 morphology occurred in 84% of children with ALL, and 80% of Adult ALL have L2 morphology.
Immunophenotyping is more relevant to ALL when makes diagnose or prognosis. Immunophenotyping can be studied by flow cytometry. Flow cytometry and the use of monoclonal antibodies allow detecting cell surface antigents. Antigens are identified by cluster differentiation (CD) number.
The treatment plan for Tom is to commence induction chemotherapy with Vincristine, Daunorubicin, and Asparaginase without methotraxate.

QUESTION 3
Considering your answer to question 2, review the current literature and rationalize the treatment regime your patient is currently receiving.
The course of therapy for ALL can be divided into three stages:
1. Induction therapy.
2. CNS propylaxis.
3. Post remission therapy.

The aim of induction chemotherapy therapy is to achieve complete remission. Complete remission is defined by restoration of normal haematopoesis including less than 5% of blast cells present on bone marrow and no circulating blast cells.
Front-line therapy for children with ALL is mostly similar in all developed countries including Australia.

Induction chemotherapy used for Tom included:
Prednison 60 grams/m2/day per oral from day 1 to day 29.
Vincristine 1.5 grams/m2 per intravenous on day 8, 15, 22, 29. Daunorubicin 30 milligrams /m2 per intravenous on day 8 & 15. Asparaginase 5000 units/m2 per intravenous on day 12, 15, 18, 21, 24, 27, 30, 33.
It is called BFM 95 protocol with modification. For his treatment, metotraxate was not used.
The side effect of Asparaginase is quite significant. For some patients, coagulopathies, pancreatitis and allergic reaction could occur. Therefore, a test dose of 100 units of asparaginase subcute is required 45 minutes prior to the therapy. APPT, PT, Fibronogen level and Pancreatic Lipase test should be taken prior to asparaginase. If fibrinogen level <1.0 g/l or Lipase level are rising, a specialist has to be contacted. When pancreatitis is present, no further dose is to be given (RNSH Hematology Department, 2001).
Gated heart pool scan cardiac echo needs to be considered to rule out ventricular dysfunction if further dose of daunorubicin required, as this chemotherapy is toxic to the heart at cumulative dose of 400 mg/m2. For high risk ALL, additional dose might be added on day 22 and 29 (RNSH Hematology Department, 2001).
After normal hematopoesis was restored post induction therapy which is called in remissio, patient will be a candidate for intensification (consolidation) therapy. The treatment will commence shortly after the induction of remission. According to RNS Haematology Protocol for Chemotherapy (2001), the treatment protocol for Tom is called BFM 95 Protocol MCA which includes Methotrexate given in high dose, 6-mercaptopurine per oral plus Cytarabine. For High risk ALL, Etoposide and Asparaginase are added without 6-Mercaptopurine. This protocol is called BFM 95 Element HR-3.
Pui et al (p. 7) also suggested that intensive multi drug therapy commenced post induction of remission will make remission lasting-longer, especially in young adults. Cyclosphomide and Cytarabine might be benefit for patient’s with T-cell ALL. It was also suggested that Cytarabine with dose will improve the outcome of patient with standard, risk, or high risk ALL (Pui et al. p. 7).
Some suggestion made by Gaynon (2002, 1) that the progress of the treatment also can be achieved by improving the post induction therapy. Pui et al (p. 7) concluded that the successful cure of ALL depends on the development of more effective multi drugs regime on well designed clinical trial. Tom has not started with intensification therapy yet as he just commenced with induction therapy.
Most of the patient with ALL can be expected to attain complete remission status following appropriate induction therapy. According to Pui et al. (p.6) the rate of complete remission for ALL in children now ranges from 97 to 99 percent and lower in adult from 75 to 90 percent. All patients with ALL are at risk of developing central nervous system involvement during the course of their disease.

QUESTION 4
Identify two actual or potential complications that may confront your patient in light of their treatment regime or disease progression.

Nausea and vomiting was perceived by patients to be the most distressing side effect of chemotherapy (Coulbourne, 1995, p. 442; Potter & Schafer, 1999, p.2). Chemotherapy drugs have been cited to often cause nausea and vomiting within 1-2 hours. However, some drugs induce these symptoms several hours after treatment. Symptoms observed ranged between a mild to severe level of severity, depending on the types of the drugs and the doses used. Usually this condition was cited to resolve within 24 hours or over several days (Held-Warmkessel, 1998, p. 43).
Chemotherapy drugs were seen to have a potential inducing nausea and vomiting in a variety of ways. Drugs associated with pronounced nausea and vomiting were noted to be that of Camustine, Cisplatin, Cyclophosphomide, Cytarabine, Dacarbazine, Dactinomycin, Doxorubicin HCl, Lomustine, Mechlorethamine HCL, and Procarbazine HCl (Glick, Griffith & Mortimer, 1998, p. 50). According to RNSH Chemotherapy Patient Information Leaflet (2001), Asparaginase and Daunorubicin have a potential nausea and vomiting side effects. It is not only on early side effects, but also on late side effects. However, mild nausea might be expected in Vincristine.
Dodd, Onishi, Dibble & Larson (1996, p. 160) determined the differences in the side effects of nausea, vomiting and retching between younger and older patients receiving chemotherapy. This research reported that younger patients’ consistently had higher nausea, vomiting, and retching than older patients. Therefore, this finding suggested that older patients could be given more aggressive chemotherapy regimes, as they were seen to be able to tolerate them better than younger patients (Dodd et al., 1996, p. 160).

Fatigue was reported as the most common and debilitating response to chemotherapy treatment (Carrol-Johnson et al, p. 116; Held-Warmkessel, 1998, p. 42; Mast, 1998; Richardson, et al. 1998). Patients receiving chemotherapy for the treatment of cancer, frequently experience severe fatigue, which was seen to be highly distruptive and distressing (Richardson & Ream, 1997, p. 35). Fatigue will be expected for patients who are receiving Asparaginase, Vincristine, and Daunorubicin (RNSH Chemotherapy Patient Information Leaflet, 2001).
Fatigue was also cited to increase over the time that the patient receives chemotherapy treatment (Berger, 1998, p. 51-62; Carrol-Johnson, et al. 1998, p 116; Richardson, et al. 1998) and after treatment (Carrol-Johnson, et al. 1998, p 116). The level of fatigue was reported to occur frequently in the afternoon and early evening, and perpetuate throughout the day (Richardson, et al. 1998). It was cited that fatigue reverted to baseline levels before the next chemotherapy cycle, and persisted for years after treatment has been completed (Carrol-Johnson, et al. 1998, p 116).
Fatigue was cited to affect the general well-being of patients, by weakness, and negative effects such as their general well-being, their specific body parts, change in self image and their daily activities. There were reported to be varying degrees and dimensions of ‘being tired’. Tiredness was not only seen as physical in nature, but also mentally exhausting (Messias, Yeager, Dibble & Dood, 1997, p. 45). Medication, nutritional status, work, and other physical conditions were seen to implicate the cause of fatigue. Patients, who were viewed to have more energy, were reported to be less tired with a lower dose of chemotherapy or on the termination of treatment (Messias et al. 1997, p.46).
When it came to patients’ awareness and expectations, some persons were reported to not have prepared for the degree or the extent of fatigue that they may experience, while others recognized the invetability and the expectations of the fatigue on the bases of their prior knowledge (Messias et al. 1997, p.46). It was also reported that "patient express frustration, worry, concern, displeasure, fear, depression, and disappointment regarding their fatigue" (Messias et al. 1997, p.46). Some patients experience frustration by the extent and the dimension of their tiredness. Others reported being annoyed or bothered by the fatigue. Fatigue was also viewed to be associated with mood and energy levels. It was seen to diminish patients’ levels of functioning and slow their pace of operation, decrease their threshold for activity, and make the person totally disabled. Patients who were tired have been seen to have difficulty with sleeping, a need for increased sleep, and also observed to lack a desire to be active. As a result of the adverse reactions from chemotherapy, patients who had fatigue were cited to be working fewer hours, taking increased time off, experiencing diminished interest and productivity, and frequently expressing their concern about the possible negative effects of not working or not going to school (Messias et al. 1997, p.46).

Dimensions of fatigue were described as the extent of fatigue, distress caused by fatigue, the influence of fatigue on the ability to engage in social activities and impact of fatigue on work related activities. By knowing these dimensions of fatigue, the nurse will be able to provide more effective help for individual who experienced fatigue (Richardson et al. 1998).

Monday 16 April 2007

PHERIPHERAL VENOUS CANNULATION AND VENEPUNCTURE WORKSHEET

Ini adalah worksheet peripheral venous cannulation and venepuncture course dari Sydney South West Area Health Service yang saya ikuti dulu. Mudah-mudahan bermanfaat bagi anda yang akan mengikuti course yang sejenis.

1. List the three layers found in Arteries and Veins?
Tunica interna
Tunica media
Tunic externa

2. Circle which vessel contains valves?
Arteries Veins

3. Describe the purpose of valves, which are found in above vessel.
The valves prevent back flow and in this way aid the flow of blood returning to the heart.

4. Please label the diagram below:
Maaf diagramnya tidak ada. Jawabannya dimulai dari

Sebelah kiri:
* Cephalic Vein

* Cephalic Vein
* Median Cubital Vein

* Median Vein
* Basilic Vein

Sebelah Kanan:
* Median Veins - Cephalic
* Cubital Vein
* Basilic Vein

* Basilic Vein

* Cephalic Vein

* Metacarpal Vein
* Dorsal Vein

5. What are the indication for performing IV cannulation?
For IV therapy and IV medication.

6. List the indication for performing venepuncture.
For various blood test.

7. What are the five legal consideration when performing venepuncture &/or cannulation procedure?
Verbal consent from patient
Medical order
Confidential documentation duty of care
Compliance with Hospital policy.
Compliance with procedural guidelines.

8. Explain the five basic rules for reducing the risk of infection when performing venepuncture &/or cannulation.
Correct hand washing technique.
Correct IV site preparation.
Maintenance of aseptic technique.
Correct choice of site.
Secure cannula firmly in place.

9. What protective equipment is used by the nurse when performing venepuncture &/or cannulation?
A protective eyewear, gloves, kidney dish, protect IV cannula/vacutaneous system and sharp bin.

10. Describe how you would identify your patient prior to the procedure of venepuncture &/or cannulation?
Ask patient her/his full name, date of birth, medical record number against both armband and clinical record such as notes, label (venepuncture)

11. List the nursing considerations when positioning a tourniquet on a patient’s limb for venepuncture &/or cannulation?
Ensure tourniquet is functional, sate and clean.
Do not have the tourniquet on too tight or for too long
Use tourniquet approx 5-10 cm above the venous access site.

12. What is the maximum tourniquet application time and state the reason?
3 minutes. Will cut the circulation to lower site.

13. Selection of a vein for IV cannulation / venepuncture depends upon.
1. Patient’s age
2. Reason for insertion
3. Size of cannula
4. Condition of vein
5. Expected duration
6. Patient co-operation
7. Position of vein
8. Solution/ fluid ordered
9. Required floe rate

14. List four sites to avoid when selecting a cannulation /venepuncture site.
1 . Bruised, tender or phlebitis areas
2. Hardened or sclerotic veins
3. Flexion areas
4 . Veins in lower limbs

15. List the most appropriate cannulation site
Cephalic vein
Metacarpal vein
Basilic vein

16. List the contraindications for performing IV cannulation.
No patient consent
No doctor order
Patient who have special medical conditions listed in hospital policy such as burns, children, infected skin.

17. What safety aspects of the cannulation / venepuncture equipment should the nurse check prior to use?
Ensure the equipments are intact and undamaged/
Ensure within the expiry date.

18. What are the four (4) complication associated with IV cannulation and venepuncture?
Haematoma.
Infiltration.
Phlebitis.
Thrombophlebitis.

19. Complete the following sentence.
The skin site is cleaned with alcohol wipe (chlorhexidine) and allowed to dry for 30 second to prevent infection and irritation when performing cannulation.

20. How many unsuccessful IV cannulation/venepuncture attempts can you have on any one patient?
Cannulation two times venepuncture two times

21. You have just inserted the IV cannula, and you notice a haematoma has formed. What action do you take?
Remove cannula, apply pressure to the site at least two minutes, monitor the site and document it.

22. When inserting the cannula, how do you ensure it will not cause a sharps injury. Give your rationale.
Ensure sharp bin inclose range, always use kidney dish when removing the sharp/ needle out. Pull back until click is heard. Always using needle lock, therefore there is no naked needle left.

23. What documentation is required when cannulation has been undertaken?
Cannulation size, site used, along with any other associated patient management provided.

24. The patient has complaint of pain and swelling around the site 36 hours after insertion of the cannula. What action do you take?
Remove cannula, note the site for pain or swelling or other sign of infection. Document the findings.

25. What safe labelling procedure should you follow when labelling the blood tubes?
Before and after taking the blood (venepuncture), patient’s name, medical report number, date of birth and test/s required must be checked with patient (family/staff mamber if it unable).

26. List the equipment you will need to prepare for a venepuncture proceure.
Alcohol swabs
Disposable gloves
Vacutainer
Tourniquet
Vacutainer needle + barrel
Needle (s)
Biohazard bag (s)
Evacuated specimen tube (s)
Gauze/wool swabs
IV pressure/ bandaid/ macropore
Pads sharp bin

27. In preparing the venepuncture needle system, what safety aspect should the RN/EN on the needle system?
Ensure equipment intact and not damage. Needle are sealed and check expiry date.

28. How many times can a vacutainer be engaged before the vacuum is lost?
Once

29. Identify the order in which blood specimens should be collected when collecting several specimens from a single venepuncture?
Number 1,2,3,4 &5 in order of collection. Type of Tube.
5 Addictive tube (green, grey, mauve, yellow, pink)
1 Blood cultures
3 Coagulation tube (blue)
2 No addictive tube
4 Serum tube with gel separator (white)

30. If drawing blood from a cannula that is newly inserted or from an arterial line… what volume of blood should you discard before collecting the first blood specimen?
Nil

31. If collecting blood via butterfly needle and there is citrate in the blood tube…how much blood do you discard first to remove the dead space in the butterfly tubing?
½ mls if 21 G needle used.

32. Circle the correct procedure for venipuncture. (A B or C)
A. Removed the vacutainer tube from needle, release the tourniquet, remove the needle and apply direct pressure to the needle site.
B. Release the tourniquet, remove the needle with the engaged vacutainer tube, apply digital pressure to the vessel above the needle site before removing the needle.
C. Release the tourniquet, remove the vacutainer tube from the needle, apply digital pressure to the vessel above the needle site before removing the needle, removing the needle and apply direct pressure to the needle site.

Sunday 25 March 2007

Therapeutik Apheresis: Overview


Prosedur Therapeutik Apheresis:
Adalah prosedur dimana komponen dari darah dikeluarkan dari tubuh dengan maksud mengurangi jumlah sel yang diinginkan atau juga menghilangkan sel mediator dari penyakit.
Rasionalnya adalah prosedur ini jauh lebih efektif mengeluarkan pathogen yang berada di dalam darah yang mana berkonstribusi terhadap penyakit daripada tubuh sendiri mampu mengeluarkannya.


Prosedur Therapeutik Apheresis terdiri dari:
1. Therapeutik Plasma Exchange (TPE)
2. Red Blood Cell Exchange (RBCE)
3. Cellular Depletion
4. Immunoadsorption
5. Photopheresis
6. LDL Apheresis


TPE
Mengeluarkan plasma dalam jumlah besar dari tubuh dan menggantikannya dengan cairan yang sesuai.
Indikasi: TTP, GBS, MG, Sindrom Good pastureSelain itu prosedur ini juga mengeluarkan mediator penyakit yang berada di dalam plasma, seperti:
Antibodi, antigen, abnormal plasma protein, cholesterol, produk-produk sampah metabolik, obat-obatan atau racun
.


RBCE
Adalah tindakan mengeluarkan atau membuang sel darah merah dan menggantikannya dengan sel darah merah dari donor yang normal.
Indikasi: Sickle cell disease, Thalassemia, Malaria, Babesiosis.


Cellular Depletion
Adalah tindakan mengeluarkan abnormal sel yang meningkat didalam darah secara pathologis. Berguna untuk menurunkan resiko sehubungan dengan vaskular statis.
Indikasi: Leukositosis (Sel darah putih >100 000/mcL)
Thrombositosis (sel trombosit/platelets >500 000
Erythrositosis (hematocrit >60%)


Immunoabsorpsi
Adalah tindakan mengeluarkan sel mediator dari penyakit yang berada didalam plasma dan mengembalikan kembali plasma yang sudah ditherapi ke pasien.
Indikasi: ITP, Rhematoid arthritis, refraktori platelets dan sindrom hemolitik uremik.


LDL Apheresis
Adalah tindakan mengeluarkan kolesterol LDL dari plasma melalui dua kali proses apheresis.
Indikasi: Hiperkolesterol (kolesterol LDL > 300 gr/dL atau > 200 gr/dL dan simtomatik).


Photopheresis
Adalah tindakan memodulasi aktifitas dari lymphosit dengan menggunakan teknologi apheresis, obat-obatan dan sinar ultraviolet.
Indikasi: Cutanous T Cell Lymphoma (CTCL), Graft Versus Host Disease (GVHD), penolakan pada transplantasi ginjal akut atau kronik serta Phemphigus vulgaris.


ELEMEN DALAM PROSEDUR APHERESIS


1. Pemisahan komponen darah
Centrifugal Force memisahkan sel berdasarkan gravity dari sel tersebut.
a> Plasma (paling atas).
b> Buffy coat (ditengah - thrombosit, lymphosit, monosit dan granulosit).
c> Sel darah merah.


2. Akses vaskularisasi
a> Antecubital
b> femoral catheter
c> Subclavian Catheter
d> Jugular Access
e> Port
f> Arteriovenous Fistula atau Graft


3. Antikoagulasi, ada 2 macam antikoagulasi yang dapat dipakai:
a> ACDA (Acid Citrate Dextrose - Formula A)
Menyatu dengan kalsium didalam darah sehingga proses pembekuan darah tidak terjadi, dari IX ke IXa, dari X ke Xa dan dari prothrombin ke Thrombin.
Akibatnya dapat menurunkan pH darah, mencegah terjadinya pembekuan darah pada thrombosit.
Sangat cepat dimetaboliskan oleh tubuh.
Dapat menyebabkan hipokalsium.


b> Heparin
Mencegah terjadinya formasi thrombus sehingga thrombin tidak dapat diproduksi yang berguna dalam pembentukan fibrin dari fibrinogen. Tidak ada fibrin, pembekuan darah tidak terjadi.
Sangat lambat dimetabolisme oleh tubuh.
Bekerja secara sistematik.
Dapat menyebabkan thrombocytopenia.

4. Cairan pengganti, setiap prosedur mempunyai cairan pengganti yang berbeda.
a> TPE, ada beberapa cairan yang bisa dipakai, tetapi yang lebih sering dipakai adalah 4% Albumin.
- Kristaloid (tidak mengandung protein).
Contoh: 0.9% Sodium Chloride.
- Koloid (mengandung protein).
Contoh: 4% Albumin, Fresh Frozen Plasma (FFP) atau Cryopersepitate.


b> RBC
Cairan penggantinya adalah sel darah merah.


c> Cellular Depletion
0.9% Sodium Chloride atau 4% Albumin.


d> Collum Prosedur (secondary plasma processing)
Tidak membutuhkan cairan pengganti.


5. Manajemen cairan yang seimbang
a> Isovolemia cairan yang diambil sama dengan cairan pengganti
b> Hipovolemia cairan yang diambil lebih besar daripada cairan pengganti
c> Hipervolemia cairan yang diambil lebih rendah daripada cairan pengganti


6. Frekuensi tindakan
a> Pada penyakit akut
Progres penyakit cepat
Membutuhkan tindakan yang sering (setiap 1 hingga 2 hari atau setiap 12 jam)


b> Pada penyakit kronik
Progres penyakit lambat
Tidak membutuhkan tindakan yang sering (setiap minggu atau bulan)

7. Potensi efek samping - preventif, gejala dan tindakan
a> Potensi terjadinya efek samping diantaranya adalah:
Hipokalsemia
Ketidak seimbangan elektrolit tubuh
Hipotensi
Syncope vasovagal
Reaksi alergi
TRALI (transfussion related acute lung injury), komplikasi yang dapat mengakibatkan kematian sesudah mendapatkan transfusi darah.


b> Pencegahan terjadinya efek samping
Sebelum memulai prosedur sebaiknya:
Mengkaji pasien secara komprehensif, diantaranya diagnosa, riwayat kesehatan, obat- obatan dan hasil laboratorium.
Mengkorekasi ketidak seimbangan elektrolit tubuh bila terjadi.


c> Gejala dan Tindakan.
Hipokalsemia
Tanda dan gejala
Perasaan baal dan kesemutan
Kedinginan
Fibrasi pada dinding dada
Tetani
Aritmia pada jantung hingga serangan jantung


Pencegahan
Cek kalsium dan elektrolit dalam darah
Berikan kalsium dan elektrolit dengan tepat sesuai dengan kebutuhan.
Pergunakan penghangat transfusi darah.


Tindakan
Hentikan/tunda prosedur hingga pasien merasa lebih baik
Turunkan kecepatan "inlet pump"
Berikan kalsium secara intravenous
Ketidak seimbangan eletrolit lain yang mempunyai tanda dan gejala yang hampir sama dengan hipokalsemia, tetapi pemberian kalsium tidak menghilangkan gejala, diantaranya Hipomagnesium, hipokalemia, alkalosis metabolik.


Hipotensive
Gejalanya:

Sakit kepala
Meningkatnya kecepatan nadi
Pernafasan pendek
Berkeringat.


Pencegahan
Naikkan persentasi albumin.
Berikan cairan tambahan
Pilih hasil cairan akhir, positive (hipervolemia), bila prosedurnya TPE


Tindakan
Tunda prosedur
Posisi kaki lebih tinggi dari kepala
Berikan cairan tambahan


Vasovagal syncope
Gejala:
Aprehensi
Pusing
Mual
Kecepatan nadi menurun.
Hipotensi
Berkeringat


Pencegahan
Komunikasi dengan pasien
Jelaskan ke pasien tentang prosedur sehingga pasien dapat mengerti apa yang terjadi
Alihkan perhatian pasien.


Tindakan:
Tunda prosedur
Posisi kaki lebih tinggu dari kepala
Berikan cairan tambahan
Tindakan hampir sama dengan hipotensi.
Reaksi Alergi


Gejalanya:
Gatal
Kemerahan pada kulit
Bengkak-bengkak
Sulit bernafas


Pencegahan
Cek apakah pasien mempunyai alergi
Berikan obat anti alergi seperti antihistamin


Tindakan
Hentikan prosedur
Kontak dokter
Berikan obat-obatan sesuai dengan yang diorder.


TRALI
Gejalanya:
Oedema pada paru-paru yang bukan diakibatkan oleh jantung
Dyspnea
Sianosis
Hipotensi.
Demam
Menggigil


Tindakan:
Seperti pada pertolongan respiratory, termasuk bantuan ventilator.


Sumber:

Successions 2: Spectra System Therapeutic Reference Book. Gambro BCT.







Saturday 3 March 2007

Little Note when harvesting stem cell

Procedure : Haemapoeitic Progenitor Cell Harvest
Machine :
Baxter CS3000+ with Long Life Kit
---------------------------------------------------------------------------------

Data:
To start Harvest, CD34 count should be 10 or over, otherwise consultant discretion.
To start checking CD34, the WCC has to be more or equal 1.
The WCC has to be on the way up, not otherwise.
Consent has to be done/referal if required.

Blood Test:
Screening, if not done yet including HIV, HTLV1&2 Hep B, Hep C, Syph EIA.
FBC, ELP+, CD34 pos and BGAB.
If Allogenic & ABMDR – screening test needs to be sent to Red Cross, including HIV, HTLV1&2, Hep B and Hep C

Plate:
Small plate for Auto or depends on WCC.
Large plate for Allogenic or AMDR.

Program: 8 Special

End point volume: 13 000 mls.

Location:
Location 68 according to patient HCT.
Location 71 according to MNC (monocyte and lymphocyte), always started with 140 for Allogenic/AMDR.

Started with Whole Blood Flow Rate (WBFR) 35mls/hr.
Anti Coagulant Ratio --- 11:1 mls, anti coagulant will be 32x/mnts.
Increase the WBFR up to 85.
Set Interface detector baseline after the 1st spill over.
Check Obs for the first 15 minutes and every hour after.
Change the Location 68 and 71 according to result ASAP.
After 10 liters processed, plasma can be collected.
- Small plate, 100 mls.
- Large plate, usually 100 mls. If to be sent overseas/ABMDR or WCC very high, collect 200 mls.
Before finish, ACD A needs to be collected and mixed with Progenitor Stem Cells.
- Small plate, 12 mls.
- Large plate, 44 mls.
The aim for CD34 Yield is between 2 to 5 x 1,000,000 L. Enough collection will be determined by Consultant.

Wednesday 21 February 2007

Paul Malau Nursing Blog

This blog is dedicated for nursing only. Mudah-mudahan blog ini berguna untuk rekan-rekan perawat dimana saja berada.