Developing BMT Nurses to Care for Axicabtogene Ciloleucel (Yescarta) Chimeric Antigen Receptor T Cell Patients

Abstract

Topic Significance & Study Purpose/Background/Rationale Axicabtogene ciloleucel (Yescarta) is a chimeric antigen receptor T cell (CAR-T) therapy that carries significant acute toxicities and potential death. Yescarta is a commercial product, approved by the Food and Drug Administration (FDA) in October 2017. Yescarta is associated with a 31% risk of >grade 2 neurotoxicity and a 13% risk of >grade 2 cytokine release syndrome (CRS). Manifestations of cytokine release syndrome (CRS) can range from fevers and hypotension to severe hypotension requiring vasopressors, intubation and can result in end organ damage. The neurologic toxicities range from headache, tremors and confusion, to seizures, encephalopathy, cerebral edema and death. The care of Yescarta patients requires specialized training for inpatient BMT nurses. The purpose of this abstract is to describe how we developed inpatient BMT nurses to manage CAR T related toxicities while developing the infrastructure for safe nursing management of CAR-T therapies. Methods, Intervention, & Analysis Our center infused 30 inpatients with Yescarta through September 2018. Grade 2 neurotoxicities occurred in 29% of patients; grade 3 toxicity in 19% and 9% had grade 4 toxicity. CRS toxicity of grade 2 occurred in 71%, grade 3, 19% and 0% grade 4. The unit experienced a 32% growth of newly hired nurses during this time. Numerous educational opportunities were provided to nurses via inservices, daily huddles and a physician led symposium. In addition, 14 % of our nurses attended a Seattle symposium. CAR T resource binders were developed for reference of grading toxicities and interventions. A Clinical Nurse Specialist rounded Monday-Friday with the inpatient nurse focusing on toxicity management and clinical assessment. Relationship development including education to, and between, the crisis, ICU, ED and float nurses, and physical therapists was provided. Videos improving the neurologic assessments by nurses were provided and REMS training was completed by all staff. Findings & Interpretation Although 27% Yescarta patients went to the ICU for closer monitoring, all were successfully discharged home. Incorporating a new high-risk treatment with a significant new number of nursing staff required close monitoring of patients, ongoing education and collaborative relationship development with other disciplines. Discussion & Implications BMT nurses trained on CAR T toxicity management is critical to successful patient outcomes.