Discharge and followup

Criteria for discharge

Blood counts should ideally be: Hb >10.0g/dL (but may require transfusion), neutrophils >1.0 x l09/L, platelets >25 x 109/L, and patients should be able to maintain a fluid intake of 2-3L/d, tolerating diet and oral medications particularly in allografts on cyclosporin. Should be apyrexial and no longer losing weight.

Counsel patients

1. Possible need for blood/platelets.

2. Adherence to neutropenic diet.

3. Check temperature bd and report immediately if febrile.

4. Fatigue post-transplant in irradiated patients due to the late TBI effect usually 6-10 weeks post transplant.

5. Risk of HZV (explain the early symptoms).

6. To continue with mouth care.

7. To report any new symptoms.

Blood tests—initially twice weekly

340 * FBC, reticulocytes and blood film.

• Biochemistry including LFTs.

• CyA levels pre-dose (EDTA sample)—allografts only.

Initially once a week

• Coagulation screen.

• CMV screening test e.g DEAFF—allografts and seropositive autograft recipients only.

• Stool culture—allografts only unless relevant symptoms.

Drugs

1. Cyclosporin capsules—allografts only.

2. Acyclovir prophylaxis against HZV 400mg qds PO for minimum of 3 months in non-TBI patients and 6 months in TBI autografts and all allografts. Allografts may be on 800mg tds if acyclovir chosen for CMV prophylaxis. Consider low dose 200mg bd maintenance until 1-2 years post-transplant.

3. Penicillin V 250mg bd PO should be given to all patients. Erythromycin 250mg od PO if penicillin allergic.

4. Ciprofloxacin 250mg bd PO if neutrophils <1.0 x 109/L.

5. Cotrimoxazole 480mg bd PO Monday, Wednesday, Friday for 1 year minimum and until CD4 count >500. Cotrimoxazole should be started when neutrophils >1.5 x 109/L and platelets >60 x 109/L. Until then, use nebulised pentamidine 300mg every 3 weeks.

6. Itraconazole—allografts only.

7. Nystatin mouth care.

8. Folic acid 5mg bd until full engraftment.

9. Sanatogen Gold™ multivitamins 1/d may be advisable while gaining weight.

10. Antiemetics PRN.

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