Transplant patients have very low immunity to fight bacterial, viral and fungal infections and therefore need to be isolated into CLEAN ROOMS which will protect them from infections
What are clean rooms and how do they protect against infections
The air in our normal surrounding has a very high particle count. The particles in the air carry bacteria, viruses and fungi. When this air is inhaled by people with low immunity, they get infected. Therefore patients requiring BMT have to be isolated into ultraclean environment where they are not exposed to life threatening infections.
BMT CLEAN ROOMS at Dharamshila Narayana Superspeciality Hospital have been designed as per international standard “Class 1000 for clean rooms” which is equivalent to ISO class 7. In simple words, it means that particle count in the clean rooms is maintained below 1000 by fulfilling the specifications for HVAC systems, building design, building materials, treatment of water and adhering to strict protocol for maintaining a totally germ free environment as per the following guidelines.
• Air Handling Unit (AHU)
Each room of the 4 room BMT Unit, has its own dedicated Air Handling Unit (AHU) to provide 60 air changes per hour. This means the fresh air entering the patients room is first treated through special filters. Treated fresh air then passes through 0.3 Micron High Efficiency particulate Air Filter (HEPA). Hepa removes all the bacteria, viruses and fungus. This hepafiltered air passes through a laminar floor to reach the patient’s room at the desired humidity and temperature, which is comfortable for the patient.
• Automatic and Selective Control System
Automatic and selective control system provides positive air pressure in the BMT room compared to ante room and the BMT corridor. This has been done to ensure that, on opening the door of the BMT Room or the ante room, no outside air from BMT Corridor can enter the patient’s room. Air pressure in Anteroom is 10-15 pascal higher than the BMT corridor and air pressure in BMT room is 10-15 pascal higher than the ante room.
Ante room is a small room between the corridor and the BMT room for maintaining positive air pressure, special hand washing (scrubbing) and wearing a sterile gown before entering the BMT room.
• Stainless Steel Doors, Vinyl Flooring and Cladding of Walls
Stainless steel doors and vinyl surfaces are most practical to clean with disinfectants to maintain and protect patients from infections.
• Precautions before entering in the BMT Unit
- Do not carry any valuables e.g. jewellery, cash etc. to the BMT room
- Ring the bell outside the BMT unit, so that the nurse can decide, whether to let you in or not.
- If allowed, keep your cell phone, toys, games, pictures etc. in the pass box fitted with ultraviolet light to kill bacteria (germs).
- Enter the change room
- Change shoes
- Change into sterile clothes, wear cap and mask.
- Wash your hands with soap and water by following 6 step hand wash instructions, written on the wall of the sink, called scrubbing of hands.
- Use all the three disinfectants (placed above the sink) one by one. Dry your hands
- Enter the BMT corridor.
- Enter the Anteroom, scrub again as mentioned above, wear a sterile gown and then enter the BMT room.
Precautions inside the BMT Room
- Attendants– No attendants are allowed except with children and very sick patients with the doctor’s permission.
- Toilets- Attached toilet is exclusively meant for the patient. Only treated water should be used for patient. Attendants should use change room toilet at the entry to the BMT Unit only and not the patient toilet.
- No outside food is allowed inside the BMT room
- Patients will be served prescribed, pressure cooked and microwaved food inside the BMT room.
- Attendants will be served food in the BMT pantry as per their order
Note:- BMT Nurse will explain all the above in detail to the patient and the family for their full cooperation.
Equipment, Furniture and Furnishing of the BMT Unit and Room
BMT Unit is equipped with a dedicated X-ray machine, ultrasound machine, dialysis machine and a ventilator. In other words patients requiring these equipment, need not be sent to X-ray dept./ICU/Dialysis Unit etc.
- Furniture and furnishing of BMT room
- Centralised oxygen, suction system with double outlets
- State-of-art, six parameter monitors, for monitoring heart rate, breathing rate, blood pressure, oxygen saturation, Central Venous Pressure and ECG
- Infusion pumps
- Syringe pumps
- C.C. TV monitoring system for 24x7 vigilance of the patient
- Patient bed, bedside locker and desk.
- Attendant bed
- Two trolleys for medicines/ dressing etc.
- Instructions for Hospital Staff and Attendants- Step Down Isolation
Once transplanted blood / marrow starts to grow, or engraft, the white blood cell count will rise. Once the part of the white blood cell count called the NEUTROPHILS has stayed above ′500′ for 3 days, strict protective isolation measures can be somewhat relaxed. This phase of transplant is called step down isolation. In step down isolation, parents or relatives will still have to wash their hands before visiting the patient.
During bone marrow transplantation, the bone marrow is destroyed by high doses of chemotherapy. This leaves the patient at risk for developing infection, what we call Immuno suppresed.
When Patients are admitted in the isolation room, they are placed on a low bacteria diet. Most foods contain certain types and amount of bacteria. The purpose of the low bacteria diet is to reduce the total bacterial content of foods and to keep the patient away from eating potentially harmful foods. A low bacteria diet is not complicated, but it does restrict the use of some specific foods as under:-
- Home prepared foods are NOT allowed unless specified by doctors.
- Commercially packaged items are ONLY allowed after they have been approved by the dietician or nurse.
- Food should NOT be left at room temperature for longer than one hour. Eating well is very important- it keeps the body healthy and helps the new marrow grow. Patient should eat and drink, even if it in small amount. To assess the nutrient intake, we will place the patient on daily calorie counts. Please tell the nurse or the dietician what you would prefer to eat, within the choices provided.
- There may be times when Patients may not feel well enough to eat. To maintain the nutrition, TPN (Total Parenteral Nutrition) may be started. TPN is a mixture of protein, fat, sugar, vitamins and minerals that is delivered through central line into the blood stream.
Low bacteria diet guidelines
- No restaurant food, take out, cafeteria food or vendor food is allowed.
- All foods must be cooked thoroughly. Avoid uncooked, mild to moderately cooked meats and fish.
- Herbs, spices and pepper should not be added to food after it is cooked, but are allowed when cooked into the food.
- Avoid raw fruits and vegetables including salads, garnishes, stir-fried vegetables, egg rolls and any food items where vegetables are not completely cooked.
- Avoid foil- sealed plastic cups of juices because they do not have expiry date.
- Avoid food containing raw eggs, including soft cooked eggs.
- Dried fruits, nuts and seeds, are not allowed unless cooked in a food item.
Central venous lines (CVL)-HICKMAN LINE
If you do not have a double lumen central venous catheter, you need one for the transplant period. The double lumen catheter is a flexible catheter, or small tube, that is inserted through the skin and tissues in the chest into a major vein. The tube, called a central venous line or CVL, is inserted about 1-2 weeks before the patient has a blood or marrow transplant. The placement of the CVL requires minor surgery, under sedation and local anesthetic.
This CVL remains in place for the entire transplant period. It will be used to give intravenous (IV) fluids, chemotherapy, medication, blood and platelet transfusion and nutritional fluids. It will also be used for drawing blood for daily tests. Sometime the CVL will remain in place for a while after you go home. You may need to visit our clinic weekly or more frequently for blood product transfusion. Before you leave the hospital, one of the BMT nurse will teach you how to care for the central venous line at home.
When the transplant doctor decides that the line is no longer needed, it will be removed in the operating room. Usually, this is a day- surgery procedure, so no overnight stay is needed. The major risk of a CVL is that it can become infected. If this happens, the transplant physician will decide, whether the CVL needs to be removed.
Who Can Be a Donor for BMT?
Donor for BMT has to be matched with the patient in their ‘tissue type’. This is confirmed by typing their HLA antigens.
Fully HLA Matched Donor
Within a family, there is about 20% chance of finding such a match in a brother or a sister. If there is no match within the close family, the chances of finding a fully HLA matched donor in distant relatives is remote.
We inherit two sets of HLA ANTIGENS; one from each parent Thus, parents are always half matched with us. In addition, even if the brothers and sisters are not fully matched with the patient, there is 90% chance that they shall be half-matched. BMT from a half matched or HAPLOIDENTICAL donor is feasible in centres with adequate infrastructure and expertise. Dharamshila Narayana Superspeciality Hospital is the only hospital of India to have created the desired infrastructure and has the expertise for this procedure.
Unrelated Voluntary Donors
To find a match with a random person is less than one in a billion. However, if we screen million people of similar ethnic background, we might find a close match. Based on this concept, volunteer unrelated donor registries have been set up in all developed countries and they are the major source of blood stem cells in all these countries. Several such registries worldwide provide over a million donors who volunteer to donate marrow if needed. The best chances of finding a match are within the same ethnic community. Unfortunately, such registry in India are not robust at present.
What is the process of donating bone marrow, does the donor face any health problem due to donating bone marrow?
Hundred milliliter to a litre of bone marrow (depending on the age of the patient and the donor) is withdrawn under general anaesthesia, from donor’s hipbone. If the donation of more than 500 ml of bone marrow is anticipated, one unit of blood is collected from the donor and stored. This stored blood is transfused back to the donor during or after he has donated the bone marrow.
Does the donor face any health problem due to donating peripheral blood stem cell?
No. The donor receives an injection of a growth-factor for 4 days and on the fifth day the donation takes place. Similar to collection of blood, the donor′s vein is punctured with a needle whose tubings are connected to the machine called Cell Separator. The donor can sit on a motorized couch or bed and relax, while the procedure goes on. This usually takes 3-4 hours. The platelet counts might drop a little after the procedure, but this returns to normal in 2-3 days. Over 50,000 donations of peripheral blood stem cell have been collected without any harm caused to the donor.