Page 1709 - Hematology_ Basic Principles and Practice ( PDFDrive )

Chapter 95 Practical Aspects of Hematologic Stem Cell Harvesting and Mobilization 1519

need for general anesthesia. The health assessment must include the ethical recruitment of allogeneic and syngeneic donors, including
questioning about a history of joint disease of the cervical spine pediatric bone marrow donors and donors not related to the
and mandible, and examination of the mouth if general anesthesia recipient. 22–25 Multiple aspirations are performed with collection of
requiring intubation is chosen. Patients and donors with comorbid approximately 5 mL of marrow from each puncture site. If properly
conditions, such as aortic stenosis sensitive to changes in blood spaced, no more than two or three skin-puncture sites per side usually
volume and blood pressure, may require anesthesia consultation and are required. Other harvest sites, such as the anterior iliac crests or
plans for invasive monitoring during the surgical procedure. A history sternum, can be used, but at increased risk for complications from
of marrow fibrosis, pelvic irradiation, or pelvic tumor involvement accidental laceration or perforation of contiguous anatomic struc-
may exclude a patient from marrow harvesting, although unilateral tures. For patients with a history of radiation or tumor involvement
harvesting from the posterior and iliac crests and aspiration of the of one pelvic crest, adequate cells can be harvested from the anterior
sternum may achieve adequate quantities of cells for transplantation. and posterior crests of the other side.
The prescription for marrow collection will define the desired
Determination of Suitability for Peripheral quantity of nucleated cells per kg recipient weight to be collected.
Ideally, this quantity of cells will be collected in a minimal total
Blood Stem Cell Donation volume and procedure duration. Although transplant registries may
require physicians to be experienced in marrow harvesting, defined
The PBSC donor is exposed to the risks of cytokine (and chemokine) as the number of procedures performed, few published studies report
administration and the risks related to the apheresis procedure, a correlation between such experience and harvest yields or donor
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including the risks of central venous catheter insertion and use. No complications. The nucleated cell yield (cells per volume aspirated)
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long-term health consequences have been associated with G-CSF appears greater for needles with side aspiration ports. Smaller
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administration, and the specific toxicities with these agents are quantities aspirated per “pull” also improves cell yield. Warming of
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described later. G-CSF may lead to a flare of autoimmune disorders the donor may improve cell yield. Quality-assurance management
and may increase the risk for blood clots, particularly for donors who should review for each harvest team the nucleated cell yield per
are sedentary or who may be traveling shortly after the donation volume of marrow, total volume aspirated, use of blood replacement,
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procedures. The PBSC donor must be assessed for venous access and duration of anesthesia.
before the patient receives conditioning, and consent for use of a Marrow is collected in the day surgery suite using either general
central venous catheter must be obtained if the venous access is or regional anesthesia. With proper fluid and blood replacement,
deemed inadequate for the apheresis procedure. overnight hospitalization should not be required. Bone marrow
harvesting necessitates placing the donor into the prone position,
Suitability and Eligibility for Umbilical which has specific considerations to avoid complications directly
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resulting from this positioning. Donors must be supported, at a
Cord Blood Donation minimum, by positioning on chest rolls. For the healthy donor, the
risks for serious complications from either general or regional anes-
Evaluation of the donor for UCB donation begins with a history of thesia are minimal, although a multivariate analysis of adverse events
maternal and paternal illnesses and exposures to infectious diseases. performed by the National Marrow Donor Program for unrelated
Although linkage between the infant and the product is currently donors reported a higher risk for serious adverse events for donors
maintained, an update of infant health is not obtained at the time of receiving regional anesthesia. 37,38 Use of spinal or epidural anesthesia
transplantation, which may be several years after collection. There- avoids the nausea that may occur with general anesthesia, especially
fore, parental medical history includes specific questions addressing for younger women, but hypotension from loss of vascular tone in
the risks for transmission of hereditary or acquired blood-borne the lower extremities often occurs as the volume of marrow is col-
diseases. A comprehensive genetic and family history should be lected. General anesthesia is preferable for the donor with comorbid
obtained. Testing for infectious diseases is obtained from the mother disorders such as cardiovascular or cerebral vascular disease because
at the time of collection to minimize loss of product through such of the better control of donor airway and lower risk for hypotension
testing. during the harvest procedures. Local anesthesia is acceptable only if
Public UCB banks set criteria for the storage of units in order to a very limited harvest is being performed, because local anesthesia
avoid the collection and storage of UCB units that would not be does not achieve anesthesia of the marrow space and because large
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acceptable for transplantation. Exclusion criteria for potential quantities of lidocaine, for example, are cardiotoxic.
donors in one multicenter study, for example, included the following: Both heparin and acid-citrate-dextran-A (ACD-A) can be used for
multiple gestation; premature delivery; active chorioamnionitis or anticoagulation of bone marrow products. ACD-A decreases the
sepsis; mother being the recipient of an organ transplant; mother with accumulation of lactic acid and may be preferable, especially for
history of cancer; mother with high-risk behaviors or previously products that will be transported or stored for longer periods before
diagnosed with HIV, hepatitis, or syphilis; and mother having an infusion or cryopreservation. 39
active venereal disease such as vaginal herpes simplex and delivering
vaginally.
Toxicity of Bone Marrow Collection

COLLECTION OF BONE MARROW FOR Anesthesia complications present the major health risk to the donor;
marrow aspiration is generally well tolerated, although postharvest
TRANSPLANTATION discomfort is experienced to some extent by all donors. Complica-
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tions include hemorrhage and infections at skin-puncture sites. Severe
Bone Marrow-Collection Techniques hematomas and neuralgias rarely occur, and training regarding pelvic
anatomy is required to decrease the risk for damage to vessels and
Bone marrow is typically harvested from the posterior iliac crests nerves lying under or adjacent to the iliac crest harvest sites. Irritation
using virtually the same techniques used to obtain diagnostic samples of the sacral nerves may result from needle penetration through the
in the clinic. The primary differences between obtaining diagnostic pelvic bone or from blood tracking into the nerve roots, and requires
specimens and cell quantities adequate for transplantation are the several months of convalescence. Localized pain is common, may last
volume of blood and marrow removed, which requires attention to for several days, and may require a brief period of opioid medication.
fluid and blood component replacement during the procedure, and In a survey of over 9000 donors for unrelated bone marrow trans-
the need for appropriate anesthesia. Bone marrow harvesting from plantation, 82% reported collection site pain, with a median time to
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healthy donors presents little risk for serious morbidity, permitting recovery of 3 weeks (see Figs. 95.1 and 95.2). Pain associated with