Almost everyone will have some complications during a BMT. This is true whether you have an autologous or allogeneic transplant. However, your risk of complications is higher with an allogenic transplant. If you have an allogeneic transplant, you will probably stay in the hospital for three to six weeks. This allows the medical team to monitor your progress and watch for signs of complications.

Some complications will be minor and easy to treat. Others may be more challenging or possibly life-threatening. It’s important to recognize the signs of complications. Promptly report any of these signs to your health care team so we can provide treatment right away. At University of Minnesota Medical Center, our goal is to help you feel better as soon as possible.

Mouth sores

Nausea, vomiting and diarrhea

Loss of appetite

Bleeding

Fever

Infections

Liver complications

Graft failure

Graft-versus-host disease

Transplant related pain


Mouth Sores
Your may develop sores in your mouth or throat after chemotherapy or radiation. The medical term for this is mucositis. They typically appear three to seven days after chemotherapy or radiation. Some people have just a few sores in their mouths. Others may have sores on their lips and down into their throats. Mouth sores can be very uncomfortable and can affect your ability to eat, drink, or—in the worst cases—breathe or talk. The doctor and nurses will examine your mouth daily. You should report any pain or tenderness to your healthcare team.

Several things are done to prevent and treat mouth sores and ease your discomfort:

• Rinse your mouth with a salt (saline) solution four times a day while you have low white blood cell counts. Antiseptic mouth rinses may also be recommended to decrease the risk of infection. Avoid mouthwashes containing alcohol.
• You should use tooth sponges instead of a toothbrush to prevent your gums from bleeding.
• We can give you medicines to relieve the pain. Narcotics (opioids) such as morphine may be used for moderate to severe pain.
• You should avoid using dental floss for a few months after a BMT.  Ask your doctor when you can floss again.

Nausea, Vomiting, and Diarrhea
Chemotherapy drugs and/or radiation therapy may cause nausea, vomiting, and sometimes diarrhea. Medicines that you take after chemotherapy may also make you feel queasy. Tell your healthcare team if an additional medicine has made you feel worse or better.

Your healthcare team will prescribe anti-nausea medicines called antiemetics. These can prevent nausea and vomiting even before you get the first dose of chemotherapy or radiation. We will usually give you anti-nausea medications every four to six hours or as a continuous IV drip. Your medical team may use several different antinausea drugs to control your symptoms.

Nausea, vomiting, and diarrhea can cause problems, including:

• Decreased nutrition.You may need to take intravenous or oral nutritional supplements.
• Weight loss.
• Fluid loss (dehydration).

It can be frustrating as well as physically difficult to live with nausea, vomiting, and diarrhea. It’s hard for you to summon energy and optimism when you are feeling queasy. But remember that these symptoms should improve as you recover. Your healthcare team will help with symptom management during your recovery period.

Loss of appetite
Chemotherapy and radiation may cause other changes that affect your nutritional status. A loss of appetite may result from:

• Changes in your sense of taste. Most people describe the taste of food as bland and uninteresting after chemotherapy. Even some of your favorite foods may taste odd for a while.
• Nausea and mouth sores. For some patients it takes weeks to regain a normal appetite. We will monitor changes that affect your ability to get enough nutrition. Your dietitian and pharmacist will regularly check your calorie intake, weight, and protein status. Then they will determine what supplements you need, if any.

Bleeding
Until your bone marrow begins making blood cells on its own, you may have problems with bleeding. This can include bleeding from mouth sores or nosebleeds. If there are signs of bleeding, or your platelet counts are low, you will be given a transfusion of platelets. If your hemoglobin count is low (usually below 8.0), you may have a transfusion of red blood cells.

Fevers
Fevers are common during a BMT. A fever may be caused by an infection, a reaction to blood products, or a reaction to medicines. Sometimes the cause of a fever is difficult to determine.

We will give you antibiotics if your fever appears to be related to an infection. If the infection is related to your central venous catheter, we may need to remove or replace the catheter.

When your white blood cell count is very low, your healthcare team will give you intravenous antibiotics at the first sign of a fever over 100.5°F. We need to start antibiotics quickly because your immune system is not established enough to fight off infection right after BMT.

A fever can last from a couple of days to a couple of weeks. Fevers may come and go during your recovery. For most people, acetaminophen (Tylenol) works to reduce a fever and makes you more comfortable. It is extremely important to notify your doctors when you first develop a fever. While acetaminophen can bring the fever down, it also can mask signs that an infection is growing worse. If you have a persistent fever, you may need to have have additional tests (X-rays or scans), receive additional medicines, or be admitted to the hospital.

Infections
During the first four weeks after your transplant, you are at highest risk for infection. This is because your white blood cell count is very low. Even organisms that are normally harmless in your body can cause infections after transplant. The most common infections after a BMT are from bacteria. Mostly these are organisms that live right in your own body. When your white blood cells are suppressed, some of these bacteria can grow and become a problem. Bacterial infections typically develop in your blood, around your central venous catheter or in your mouth, lungs, or digestive tract.

We take several measures to reduce the risk of infection:

• We filter the air in your hospital room to lower the risk of airborne infections.
• You will wear a special mask when out of your room. After you leave the hospital, you will need to wear the mask when you come to the clinic or when you are in crowds. This will decrease your exposure to infections. Your nurse coordinator or physician will indicate when a mask is recommended and for how long.
• We will test you for infections frequently during the high risk period.
• We will ask you to take a bath or shower regularly and to clean your mouth several times a day when you have mouth sores.
• For some patients, we will use growth factor injections or IV infusions to speed up the production of white blood cells.
• Visitors and staff members must wash their hands before entering your room.
• Visitors and staff members may not visit if they have a fever. Visitors must also notify the nurse prior to visiting if they are experiencing other symptoms of infection, such as a cold or rash or diarrhea.
• Visitors may not bring you any plants. Molds and fungi commonly found on houseplants and flowers can be dangerous for you as you recover from BMT.

If you have symptoms of infection, we may order additional tests, cultures, or X-rays. Signs of bacterial infection include:

• Fever
• Chills, even without fever
• Redness, tenderness, or drainage around the central venous catheter site
• A general achy feeling

Bacterial infections usually respond well to antibiotics. We can use different antibiotics depending on the type of infection and your history of allergies or reactions to specific medicines. We will give you antibiotics orally or through your central venous catheter to prevent and treat certain infections.

Fungal/Yeast Infections
Fungi and yeasts normally live all around us without causing problems. But when the immune system is suppressed, a fungus or yeast can grow more than it should. For example, candida is a yeast commonly found in the mouth, intestines, and vagina. It can cause sores in the mouth (called thrush) as well as more serious widespread infections. Good oral hygiene (mouth care) and antifungal medications can help prevent and treat oral or mucous membrane candida infections.

Similarly, aspergillus is a common mold found in many places, often in dust. When it invades the body, it often affects the sinuses or lungs and causes a serious pneumonia.

Fungal infections can be treated with antifungal medicines. Patients with weakened immune systems are especially prone to Pneumocystis pneumonia, but specific antibiotic medications are very effective in preventing it. Most patients take antibiotic medicine for about a year after the transplant to prevent this infection, or even longer if they have ongoing graft-versus-host disease.

Viral Infections
You may be exposed to viruses while your immune system is suppressed, or a viral infection you had earlier may recur. Viral infections are most common during the first year after a BMT. The most common viruses that affect people after a BMT are cytomegalovirus, herpes simplex, and varicella zoster (shingles). Respiratory viruses may also occur.

• Cytomegalovirus (CMV) often occurs in healthy people without causing serious disease. You may have had it without knowing it. In a person with a healthy immune system, CMV may cause a fever, flu-like symptoms, or no symptoms at all. But after a BMT, when your immune system is suppressed, it can cause more serious illnesses such as pneumonia or hepatitis. We will give you a blood test before your transplant to see if you have been exposed to CMV. If you or your donor have been exposed to CMV, we will give you antiviral drugs to decrease the risk that CMV could become active after the transplant. You will also have regular screening (with blood tests) to see if the CMV has reactivated and needs treatment -- even if you have no symptoms.
• Herpes simplex virus is the virus that causes cold sores and genital herpes. Patients may have had the virus many years earlier, but it can be dormant for a long time. Herpes can recur with stress, illness, or a suppressed immune system. The mouth sores that are common after transplant will likely be worse if patients also have a herpes simplex infection. You will have a blood test before your transplant to see whether you have been exposed to herpes simplex. If you have, we will give you antiviral drugs to prevent the infection from coming back.
• Shingles is caused by the varicella zoster virus, the same virus that causes chickenpox. Shingles produces painful or itchy sores on the skin, usually on just one side of the body. Early symptoms include burning, itching, and pain in a localized area of the body. Usually within a few days of these symptoms, small blisters will form. Treating shingles as soon as possible is important to prevent the spread of the infection and to limit the pain. Taking antiviral drugs by mouth or intravenously can usually heal the infection quickly. Sometimes the shingles site can be painful (stinging or burning) long after the infection is healed. Prompt treatment can help prevent this long-lasting pain.

Liver complications
Occasionally, after high doses of chemotherapy or radiation, inflammation or  clotting within the liver can occur. This is called veno-occlusive disease (VOD) of the liver. Symptoms include:

• Jaundice, or yellowish eyes and skin
• Dark urine
• Weight gain/fluid retention
• Tenderness over the liver or on the right side of the abdomen
• Abnormal levels of liver enzymes in the blood

If your medical team suspects veno-occlusive disease of the liver, we may order an ultrasound. Most cases get better on their own, but severe cases can be fatal.

Graft Failure
A rare but serious complication of BMT is graft failure. This happens when the new stem cells don’t grow or your own immune system rejects the cells. Your old cells may grow back instead.

Graft failure is more common after allogeneic BMT than autologous BMT. Unrelated donor or cord blood grafts may lead to graft failure more often than related donor BMT.

Rarely, after autologous transplantation, the patient’s own cells may fail to recover completely. Some patients may need transfusions of red cells or platelets for a few weeks or months after the transplant.

If no cells grow, it is a life-threatening condition, because your body is not producing any blood cells to fight infection. Sometimes we can obtain more stem cells from the donor. The medical team will talk with you about options.

Graft-versus-host disease (a complication of allogeneic transplant)

Transplant Related Pain
During the transplant process, your health care team members will help keep you as comfortable as possible. You may experience some pain or discomfort during the BMT process. One of the more common sources of pain during the transplant is mouth sores, or mucositis. There are a number of things we can do to either alleviate the pain or make it more tolerable. The methods we use to manage pain will depend on how often and how severe the pain is. It also depends on your personal preferences for pain management.

The health care team will regularly evaluate your pain or discomfort. You can help the team by describing your pain as clearly as possible. One way to help others understand your discomfort is to use a pain scale. Adults may use a type of pain scale that ranges from 0 to 10. Zero represents no pain and 10 represents the worst pain imaginable.

Following are some methods that we may use to increase your comfort. Your health care team will work with you to find the method or methods that work best.

Medicines
A number of medicines can help to increase your comfort. For example, narcotics (opioids) such as morphine or other pain-relieving medications can be taken by mouth, through a skin patch, or given to you through an IV. Some people worry that they will become addicted to morphine or other medications. Treating pain does not cause addiction. Addiction is a psychological dependence on a narcotic and the need to use it for effects other than pain relief.

Physical dependence may occur with the use of narcotics, but we expect this. We address it by gradually reducing the amount of medication we use as your discomfort decreases. There are a variety of medicines that we can prescribe to increase your comfort. Aspirin is not given for pain because it can increase your risk of bleeding.

Relaxation techniques
Self-hypnosis and deliberate relaxation are techniques to help increase your comfort during times of pain. By using self-hypnosis or deliberate relaxation, some patients are less likely to be bothered by pain or discomfort. Social workers and other staff members are available to help patients learn these techniques. Relaxation tapes and activities are also available from other hospital staff, such as family life specialists and chaplains.

Distraction may also increase your comfort. Distration is thinking about or doing something else to take your focus off pain or discomfort. Activities that may help include listening to music, talking with family or friends, exercising, engaging in a hobby, or watching movies or television.

Imagery
Most people regularly use imagery or trances to relax without even realizing they are doing so. You may think of using imagery or trances as "daydreaming." Deliberately using imagery may be a useful way to increase comfort during BMT. Hospital staff can help teach you to effectively use this technique.

Healing Touch
Healing Touch uses purposeful touch to influence a person’s energy system. Healing Touch aims to restore physical, mental, emotional, and spiritual balance to facilitate comfort and healing.This technique can complement other medical treatments.