1 Bone Marrow Transplantation
Recipient
Bone marrow recipients undergo a preoperative regimen designed to achieve functional bone marrow ablation. This is done over 7-10 days, using combinations of chemotherapy and radiation. At that time, rescue with transplanted marrow infused intravenously is started. Time to engraftment is generally 10-28 days. Hematological support in the form of platelets and RBCs (leukocyte poor, irradiated) is usually necessary to keep the platelet count >20,000 and Hct >25. The bone marrow infusion does not need to be done in the OR, however, these patients often present to the OR for other reasons. Some of the specific chemotherapeutic problems associated with these patients include:
- Cisplatin – Renal insufficiency
- Daunorubicin – Congestive cardiomyopathy (exercise tolerance, MUGA)
- Bleomycin – Pulmonary insufficiency (limit fluids, limit FiO2)
- Radiation Rx – Pulmonary fibrosis
After transplant, these patients are very susceptible to graft-vs-host disease (GVHD), manifested by GI problems that may include candidiasis, esophageal or gastric ulcers, and intractable diarrhea or bleeding. Hepatic insufficiency from either GVDH or veno-occlusive disease is common. Prominent skin lesions from GVHD can also be common. Obstructive pulmonary defects may result from GVHD-induced bronchiolitis, while restrictive defects are more likely due to specific chemo or radiation therapy.
GVHD summary
Cutaneous
- Impaired thermoregulation
- Scleroderma-like syndrome
- Ulceration and infection
Eye
- Cataracts
Gastrointestinal
- Diarrhea with fluid/electrolyte/blood loss
- Esophageal infection and ulceration
- Oral ulceration and propensity for invasive candidiasis
Hepatic
- Acute and chronic hepatitis
Marrow
- Pancytopenia and immunodeficiency
Pulmonary
- Bronchiolitis obliterans
- Interstitial pneumonitis
- Pulmonary fibrosis
Renal
- Insufficiency with electrolyte abnormalities
- Renal tubular acidosis
Anesthetic Management
Use extreme measures to assure asepsis.
Avoid unnecessary nasal, rectal and urethral probes, and avoid esophageal suctioning or stethoscopes in patients with esophagitis.
Anesthetic technique otherwise based on the condition of the patient and anticipated surgery.
Donor
Children are frequently brought to the OR to be bone marrow donors for a relative.
Anesthetic Management
Patient will be prone. These patients are typically healthy and a mask or IV induction can be used. The patient is intubated with an endotracheal tube due to the prone position. Frequently, the APS service will perform a single-shot epidural for postoperative pain control which may contribute to some degree of hypotension, especially in combination with the large amount of marrow that is harvested.
Up to 1.5 liter of marrow (20 mL/kg) may be harvested from posterior iliac spines and iliac crests. These marrow spaces are in dynamic equilibrium with the extracellular fluid compartment. Therefore, sizeable volumes of fluid replacement, including colloid and/or transfusion (usually with autologous blood) may be required. For this reason, at least one large-bore IV should be placed.
Some authors suggest that, following hemodilution at the beginning of the case, blood can be withdrawn and then re-infused after the marrow has been harvested. However, this is not typically done at our institution.
Nitrous oxide inactivates vitamin B12 which can then interfere with DNA synthesis. However, recent work indicates that nitrous oxide does not interfere with bone graft viability, and therefore may be used as part of the anesthetic technique.
References
Stein RA, et al. Anaesthetic implications for bone marrow transplant recipients. Can J Anaesth. 1990;37:571-578.
Perez De Sa V, et al. Hemodilution during bone marrow harvesting in children. Anesth Analg. 1991;72:645-560.
Perez De Sa V, et al. Bone marrow harvesting in children managed without allogeneic blood. Paediatric Anaesthesia. 1994;4:375-381.
Lederhaas G, et al. Is nitrous oxide safe for bone marrow harvest? Anesth Analg. 1995;80:770-772.