Side effects associated with HDT and autologous SCT
Specialised nursing care is important in order to prevent, detect and manage the side effects and complications associated with HDT and SCT.
The side-effects of SCT are primarily a consequence of the high-dose melphalan. The degree and severity of side-effects vary from patient to patient and it is difficult to predict these in individual cases.
Common, usually short-term side-effects include:
- Nausea, vomiting, diarrhoea
- Oral mucositis
- Increased susceptibility to infection and bleeding due to myelosuppression
- Fatigue
- Hair loss
- Skin reactions
Potential long-term complications include:
- Infertility
- Long-term damage to the liver or kidneys
Improvements in supportive care over the years, including the use of blood cell growth factors and antibiotics, have greatly reduced the risks associated with HDT.
Prevention and management of infection
Myelosuppression following HDT-SCT increases the risk of infection and can be life-threatening and requires frequent nursing assessment of signs and symptoms of infection in patients. Read more in our Myeloma Nurse Guide: Myelosuppression and Myeloma Nurse Guide: Infection.
Key signs and symptoms to monitor:
- Vital signs including pulse, blood pressure, temperature, respiratory rate and oxygen saturation
- Chills
- Rigor
- Pain
- Redness of skin (or redness around central line site)
- Unusual discharges
- Changes in consciousness level
- Respiratory symptoms
To reduce the risk of infection, patients are prescribed prophylactic antibiotics, anti-viral and anti-fungal medications. Growth factors may sometimes be used to boost neutrophil counts. Still, patients who are neutropenic can develop bacterial infections that may, within hours, progress to septic shock and even death if untreated. NICE guidance suggests diagnosing neutropenic sepsis in patients undergoing anticancer treatment whose neutrophil count is 0.5×109 per litre or lower and who have either: a temperature >38°C or other signs and symptoms consistent with clinically significant sepsis.
If fever does occur, nurses should follow the neutropenic sepsis policy in their area and inform the medical team so the patient can be started on intravenous antibiotics as soon as possible.
Once discharged home, patients should be educated on the importance of protecting against, and being alert to the signs of, infection such that they know how to contact their team if they have concerns.
The UKONS Acute Oncology Initial Management Guidelines and UK Sepsis Trust provide guidance and clinical tools for the urgent assessment and immediate actions for patients presenting with suspected sepsis.
Blood product support
Anaemia and thrombocytopenia often occur following HDT. Nurses must closely monitor full blood counts and assess patients for signs of bleeding or bruising.
Patients usually need blood transfusions when their haemoglobin levels fall below 90g/L and platelet transfusions if their platelet levels are less than 10 x 109/L. Blood products should be irradiated (exposed to radiation) to prevent transfusion associated graft versus host disease and, if necessary, cytomegalovirus (CMV) negative.
Oral mucositis
Oral mucositis (mouth sores) is a very common and potentially distressing side effect of HDT. It usually occurs within a week or two of receiving the melphalan treatment and is caused by damage to the cells lining the mouth. This leads to inflammation that varies from mild soreness of the mouth and taste changes to painful ulceration that causes problems swallowing. Nurses are integral to the prevention, early recognition and management of oral mucositis. In clinic this includes conducting regular oral assessments, recognising and responding to early signs such as discomfort, mucosal changes or functional symptoms (e.g. pain on swallowing, changes in speech) and implementing interventions to support symptom relief and promote healing. Read more about how you can support patients with oral mucositis in our Myeloma Nurse Guide.
A key component of nursing care involves patient education and support for maintaining oral hygiene. Pain relief is commonly required and can range from local anaesthetic mouthwashes through to intravenous opiate analgesia. Intravenous fluids/tube feeding or total parenteral nutrition (TPN) may be needed if patients are unable to eat or drink.
Managing GI toxicity
Mucositis can also affect the mucosal lining of the gut and diarrhoea is a common consequence of HDT. Anti-diarrhoeal medications can help; however, prior to commencing these drugs, it is necessary to ensure that the diarrhoea is not infective. Read more about how you can support patients with gastrointestinal toxicities in our Myeloma Nurse Guide.
Further reading
UKONS Acute Oncology Initial Management Guidelines
UKONS Oncology Haematology 24-Hour Triage Rapid Assessment and Access Toolkit