Procedures: Bone Marrow Biopsy and Aspiration

Post about Bone Marrow biopsy and aspiration in the following headings:

1. Indications and contraindications
2. Instruments and procedure in brief
3. Post-procedure care and Complications

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A bone marrow biopsy is the removal of soft tissue from inside bone. Bone marrow grows inside some of the larger bones in the body. It produces platelets and red and white blood cells.

What are the reasons to have a bone marrow biopsy and aspiration?

A bone marrow exam offers detailed information about the condition of the blood cells. Sometimes, collecting a blood sample through a vein in the arm provides enough information about the patients health. But if those results are abnormal or don't offer enough details, patient may need further evaluation with an examination of the bone marrow.
Because the bone marrow is essentially a blood cell factory, it's normally rich in young cells. Examining bone marrow gives a much more detailed picture of the types, amount and condition of these newly forming blood cells.
the doctor may want a bone marrow biopsy and aspiration done in order to:

• Diagnose certain conditions
• Assess the stage or progression of certain conditions
• Monitor treatment of certain conditions

Bone marrow biopsy and aspiration are useful for numerous conditions. They're most often used in such conditions as:

• Amyloidosis
• Anemias
• Hemochromatosis
• Infectious diseases, such as leishmaniasis or HIV
• Leukemias
• Lymphomas
• Multiple myeloma
• Myelofibrosis
• Neuroblastoma
• Polycythemia vera
• Thrombocythemia

If patient has hemophilia, blood-clotting disorders or infections at the potential biopsy site he may not be able to have a bone marrow exam. The procedure could cause excessive bleeding or worsen an infection.

how its done?

Bone marrow exams are often performed on an outpatient basis. In some cases, though, patient may already be hospitalized when he needs a bone marrow exam. Because bone marrow biopsy and aspiration can be painful, patient will need some form of anesthesia to reduce the pain.there are two options:

• Intravenous (IV) sedation. With this option, patient is either completely or partially sedated (conscious sedation) during the bone marrow procedure.
• Local anesthesia. With this option, patient is fully awake during the procedure but the area to be biopsied is numbed to reduce pain.

The bone marrow biopsy may be done in the health care provider's office or in a hospital. The sample is usually taken from the hip bone. The skin is cleansed, and a local anesthetic is injected to numb the skin.
The biopsy needle is then inserted into the bone. The core of the needle is removed by rotating the needle or inserting an instrument within the needle. This forces a tiny sample of the bone marrow into the needle. The needle is then removed. Pressure is applied to the biopsy site to stop bleeding, and a bandage is applied.
An aspirate may also be performed, usually before the biopsy is taken. After the skin is anesthetized, the aspirate needle is inserted into the bone, and a syringe is used to withdraw the liquid bone marrow. If this is performed, the needle will be removed and either repositioned, or another needle may be used for the biopsy.

complications
<LI class=doublespace>Excessive bleeding, particularly in people with a low platelet count or people taking aspirin or anticoagulants, such as warfarin <LI class=doublespace>Infection, especially in people with compromised immune systems <LI class=doublespace>Breaking of needles within the bone, which may cause infection or bleeding <LI class=doublespace>Penetration of the breastbone (sternum) during sternal aspirations, which can cause heart or lung problems <LI class=doublespace>Long-lasting pain <LI class=doublespace>Complications related to IV sedation, such as an allergic reaction, nausea or irregular heartbeats
post bone marrow aspiration care

After the bone marrow exam, a large pressure bandage is applied to help minimize bleeding.
If patient had IV sedation, he will be taken to a waiting area to recover from the effects of the sedation. Because the anesthesia may cause impaired judgment, memory lapses or slowed response times, patient may be unable to resume all of his normal activities for another 24 hours.
If patient had local anesthesia, he may have to lie on his back for 15 to 30 minutes to apply pressure to the biopsy site. he can then leave.
Whether patient had IV sedation or local anesthesia, he may feel pain or mild discomfort for a week or more after the bone marrow exam. If the pain is intolerable, pain relievers can be taken. Applying a cold compress to the biopsy site may reduce pain. Light exercise, such as walking, may also help.
Site care
Keep the pressure bandage on and dry for the next 24 hours. Don't take a shower or a tub bath and don't swim or use a hot tub. After 24 hours, it's OK to get the biopsy area wet and to replace the pressure bandage with a regular adhesive bandage.
A small amount of bleeding is normal. However, if bleeding soaks through the bandage or doesn't stop with direct pressure, contact the health care team as soon as possible.
Other situations in which to contact the health care team include:

• Developing a fever above 100.4 degrees Fahrenheit
• Unrelenting or worsening pain or discomfort
• Swelling at the biopsy site
• Increasing redness or drainage at the biopsy site

Although patient can often return to normal activities after a bone marrow exam, avoid heavy activity or exercise for the next 24 hours. This will help minimize bleeding and discomfort.

Indications:

· Fever of unknown origin to evaluate for occult mycobacterial, fungal or parasitic infections
· Unexplained anemia, leukopenia or thrombocytopenia
· Pancytopenia
· Unexplained splenomegaly
· Staging and follow-up of non-Hodgkins lymphoma and Hodgkin's disease
· Diagnosis and work up for acute leukemias (AML and ALL)
· Diagnosis and work up for myeloproliferative disease,
· Suspected metastatic disease
· Diagnosis of glycogen or lysosomal storage disease ETC

Contraindications:
1) absolute

• Hemophilia and other inherited clotting disorders
• Severe disseminated intravascular coagulopathy
• Sternal bone marrow aspiration in patients with osteoporosis or multiple myeloma

2)relative

• Infection at insertion site
• previous radiation at proposed site

Materials:
Site preparation requires:

• Large, two-ply alcohol prep pads
• Betadine (povidone iodine, 10%) swabsticks or chlorhexidine swabs
• Gauze sponges, 3 x 4 inch
• Impervious gowns
• Non-sterile latex gloves, examination
• Sterile latex gloves
• Needle, 22 gauge, 1 1/2"
• Needle, 25 gauge, 1/2"
• Sterile fenestrated drapes, small, (30" x 30" with 1 1/2" x 2" fenestration
• Sodium bicarbonate solution for injection, USP, 8.4% (1 mEq/mL), 50 mL vial
• 1% lidocaine, 10 mL
• 10 mL syringe

Marrow procurement requires:

• Blank labels
• Bone marrow aspiration needles, 15 or 16 gauge, several lengths
• Sterile disposable plastic syringes U 20 mL
• Sterile disposable plastic syringes 10 mL
• Disposable scalpel, 11 blade
• Sodium heparin vacutainers
• Frosted microscopic slides, 1" x 3"
• Zip-lock plastic bags
• Purple-top vacutainers
• Safety-flow lancet
• 20 mL Luer tip syringe

Procedures:

• Make sure the patient's bladder is empty
• When using the posterior iliac crest, have the patient lie prone or on the side with knees flexed with the head averted to one side. When using the anterior iliac crest, have the patient lie in a supine position, with hips and knees flexed with the head averted to one side.
• palpate the patient's back to identify anatomical landmarks. When using the posterior iliac crest, identify the center of the posterior superior iliac spine readily palpable as a prominence at the posterior margin of the iliac crest.
• Use three sterile, disposable swabs soaked with a 10% povidone-iodine solution Remove the povidone-iodine in the center of the cleansed area with a single swipe of sterile gauze or an alcohol swab.Place a sterile drape with a fenestrated opening over the procurement site.
• Aspirate 2 mL of 1% sterile sodium bicarbonate solution (buffered) and 8 mL of 1% lidocaine hydrochloride into a 10 mL syringeSlowly infiltrate the skin with the buffered lidocaine, raising a "dime-sized" intradermal wheal with a 25-gauge needle. Infiltrate the subcutaneous tissue and periosteum, with typically 2-5 mL of buffered lidocaine, using a 22-gauge needle (or spinal needle for obese patients). Note: Infiltrate the periosteum with approximately 1 mL of lidocaine to anesthetize the many bone pain fibers there. While removing the needle, inject 2 - 3 mL of the lidocaine 1% along the outgoing tract
• hold the needle in a horizontal position. Hold the needle with an index finger near the tip to control depth of penetration and puncture the anesthetized skin.With steady pressure and a twisting motion, advance the needle to the center of the posterior superior iliac spine, or in the case of the anterior iliac crest, to the anterior superior iliac spine .Rotate the needle clockwise and counterclockwise with steady pressure, carefully advance the needle through the cortical bone. In the anterior iliac crest, the cortical layer may be especially hard and thick.Feel for the loss of resistance, which usually indicates entry into the marrow cavity Advance needle about 1/2 cm farther into the marrow cavity .When correctly placed for aspiration, the needle will remain stationery without support.Unlock and slowly remove the obturator
• Attach a 20 mL syringe to the aspirate needle to take the specimen.
• apply gentle pressure with thumb and forefinger to halt any bleeding from the site. Use alcohol swabs to completely remove povidone-iodine from the skin. Apply a double gauze square over the site and cover the area with at least two pieces of surgical tape, approximately 2-3 inches long.

Post procedure care:

• Immediately following the procedure the patient should lie in a supine position for 15 minutes.
• no continued bleeding the patient may be discharged
• The patient should be advised that the procedure site will be tender for several days
• The patient should be instructed that any pressure dressing may be removed in 12 to 24 hours

Complications:

• Cardiac tamponade (aspiration of sternum)
• broken needle
• hemorrhage
• Infection at aspiration site
• perforation of iliac bone

Bone marrow Aspiration

Indication :

1) Look for the cause of problems with red blood cells, white blood cells, or platelets in people who have conditions such as thrombocytopenia, anemia, or an abnormal white blood cell count.

2) Find blood disorders, such as leukemia, certain anemias, or problems that affect the bone marrow, such as multiple myeloma or polycythemia vera.

3) Check to see if a known cancer, such as Hodgkin's lymphoma or non-Hodgkin's lymphoma, has spread to the bone marrow. This is part of what is called staging. It is done to find out if the cancer has spread and how much it has spread. This helps plan cancer treatment. Staging can be done for other cancers, such as prostate, breast, or lung cancer that may have spread to the bone.

4) Find infections or tumors that may start in or spread to the bone marrow. If you have an infection, a culture and sensitivity test of the bone marrow sample may be used to find out which antibiotics will work best to treat the infection.

5) Find the best treatment for a bone marrow problem. Once treatment has been started, a bone marrow aspiration and biopsy may be done to see if the leukemia cells are gone, which means the treatment is working.

6) Collect a sample of bone marrow for medical procedures, such as stem cell transplantation or chromosomal analysis

Conta- indications:

1) Severe bleeding disorders

2) Skin and soft tissue inflammation at the hip bone

Instruments :

1) Hollow aspirate needle

2) Hollow biopsy needle

3) stylet

Procedure :

1) Bone marrow is found in many different bones, but samples are usually taken from the pelvic bone, which is reached through your lower back, at a location just above the buttock. Sometimes bone marrow samples are taken from the breastbone.

2) Before the procedure, an injection of medication (anesthetic) is given to numb nearby skin and tissue down to the covering of the bone, where pain fibers are located.

3) Aspiration is the part of the procedure in which fluid or other material is suctioned out of your bone marrow. Make a small cut in the skin over your hip bone or breastbone and then insert a special needle through the cut and into the bone.

4) It might be difficult to get the needle into the bone, and some pushing and twisting may be necessary. Once the needle is inside the bone, a few teaspoonfuls of liquid bone marrow will be sucked through the needle into a tube.

5) The biopsy part of the procedure is done to obtain a sample of solid tissue from your bone marrow. This usually happens immediately after the aspiration. The needle will be pushed back into the bone and used to punch out a small cylinder of tissue (including fat cells, blood cells, and bone) from the bone marrow.

6) A bone marrow aspiration and biopsy usually doesn’t cause a great deal of pain. Many people who have had it done say they felt a sensation of pressure.

7) If in the first try, the tissues does not collect enough, a second bone marrow aspiration and biopsy may be done right away. It is usually done through the same small cut, but the needle is inserted into a different area of the bone.

8) Once the procedure is done, apply pressure to the area to stop the bleeding and will put a small bandage over the cut.

9) After the procedure patient will be monitored to make sure they do not experience any ill effects, such as lightheadedness or discomfort. After 15 to 20 minutes, the bandage will be checked, and will be allowed to go home.

10) After returning home, the biopsy site may feel sore for a few days, but they should not experience any other aftereffects from the procedure.

11) The bone marrow fluid and tissue samples will be sent to DIANON Systems, where laboratory professionals will perform a series of chemical and microscopic tests to determine the nature of any blood disorder that may be present within few days.

Complication:

1 ) Bleeding from the biopsy site. People with bleeding problems have a higher chance for this. If you have bleeding problems, pressure will be put on the biopsy site for at least 10 minutes after the biopsy. In rare cases, you may be given a blood product (clotting factor or platelets) in a vein in your arm before the biopsy to prevent bleeding after the biopsy.

2) Infection of skin or the bone (osteomyelitis) at the biopsy site.

3) injury to your heart, a lung, or a major blood vessel if the sample is taken from the breastbone (sternum). This complication is very rare. Samples are not often taken from the breastbone, so most people do not have to worry about this risk.

INDICATIONS
1) Diagnostic :
A) Bone marrow examination essential for the diagnosis :
-Aplastic anaemia
-Megaloblastic anemia
-Aleukemic leukemia
-Myelofibrosis
-Myelosclerosis
-Multiple myeloma
B) Bone marrow examinations helpful but not essential for the diagnosis:
-Anemias : a) refractory anemia
b) iron deficiency anemia (to differentiate from other hypochromic
anemia)
c)Hemolytic anemias
-Leukemias : to differentiate the types of leukemias
-Thrombocytopenia purpura
-Agranulocytosis
-Hypersplenism
-Tropical disease like malaria,kala azar
-Malignancy-secondary carcinoma
-infiltrative disorders eg. Gaucher’s disease.

2) Prognostic :
-Agranulocytosis
-Aplastic anemia
-Leukemia

3)Therapeutic :
-bone marrow aspiration


CONTRAINDICATIONS
-blood dyscrasias especially hemophilia
-clotting disorders
-infection

PRE-REQUISITES
Bleeding, clotting and prothrombin time including platelet count.

INSTRUMENTS
-Large, two-ply alcohol prep pads
-Betadine (povidone iodine, 10%) swabsticks or chlorhexidine swabs
-Gauze sponges, 3 x 4 inch
-Impervious gowns
-Non-sterile latex gloves, examination
-Sterile latex gloves
-Needle, 22 gauge, 1 1/2", Needle, 25 gauge, 1/2"
-Sterile fenestrated drapes, small, (30" x 30" with 1 1/2" x 2" feneation
-1% lidocaine, 10 mL
-10 mL syringe

PROCEDURE :

1) Sites : Sternal Puncture, spinous process of lumbar vertebrae, posterior/anterior iliac crest.
2) Position : Posterior Iliac crest- patient is prone and lie on the side with the knees flexed and head averted to one side.
3) Identify the anatomical landmark, the most palpable prominence of the posterior margin of the iliac crest.
4) Prepare the area with povidone iodine, and alcohol. Place the sterile drap over the area.
5) Local anesthesia : the skin subcutaneous tissue, periosteum over the iliac crest are infiltrated with 2% Lignocaine.
6) Aspiration : After 2-3 minutes when the local anesthetic effect is apparent, the bone marrow aspiration needle with guard half and inch from the tip is pushed vertically through the iliac crest with a boring motion. When the needle has entered the marrow, the stilette is withdrawn and 5ml of bone marrow is aspirated with 10 ml syringe. The needle is withdrawn and smears are prepared with the marrow.Hemostasis is assured by maintaining pressure over the site for 3-5 minutes. Apply bandage over it.
7) Post procedure orders :
1) temperature, pulse rate, blood pressure monitoring every hourly for 4 hours.
2)analgesics for the pain
3) make patient lie in supine position for 15-20 minutes to apply pressure over the site
4)keep the area dry for 24 hours.
5) inform if the temperature rises above 100.4 Fahrenheit, worsening of the pain, drainage from the site, redness at the site or aspiration.

COMPLICATIONS :
1)bone pains
2)hematoma
3)infection(osteomyelitis)
4)transfixation of the sternum and injury to great vessel(sternal puncture)
5)perforation of iliac bone

Indications :

• Non-Hodgkins and Hodgkins Lymphoma
• Acute leukemia
• Metastatic carcinoma
• Anemia
• Fever of Unknown Origin
• Plasma cell dyscrasia
• Myelodysplastic syndrome
• Myeloproliferative diseases
• Lymphoproliferative diseases
• Thrombocytopenia, Leukopenia, Pancytopenia
• Hepatosplenomegaly

Contraindications :

• Sternal bone marrow aspiration in patients with bone resorption, including multiple myeloma
• Acquired and congenital coagulation factor deficiencies
• Infection
• Previous radiation therapy at sample site
• Poor patient cooperation

Instruments :

• Spinal Needles 20 gauge
• Disposable scalpel, drapes
• Sodium heparin vacutainers
• Bone marrow biopsy needles 8 or 11 gauge (Jamshidi needles)
• Bone marrow aspiration needles 15 or 16 gauge
• Disposable plastic sterile syringes 20cc and 10cc

Procedure :

• Patient is kept in left lateral position with the top leg flexed and the lower leg straight.
• Sterile gloves are worn, the area is cleaned with povidone iodine and draped to expose only the biopsy area (posterior iliac crest or anterior iliac crest).
• Local anesthetic is given to the area (Lidocaine 1%) down to the periosteum.
• An incision is made using the scalpel to allow the biopsy and aspiration needles to enter.
• The bone marrow aspiration needle with a stillet in place is inserted. Once the needle contacts the bone, it is advanced by rotating clockwise and counterclockwise until the bone is penetrated and the needle enters into the marrow. A 'give' will be felt upon entering the marrow cavity.
• Once in the marrow cavity, the stillet is removed and using a 20cc syringe 2-3cc of bone marrow is aspirated for pathology slides immediately. 5cc more is aspirated and kept in a sodium heparin vacutainer if needed for cytogenetics.
• The marrow aspiration needle is removed and the bleeding is stopped using gauze and pressure application.
• Bone marrow biopsy is usually done following this.
• The bone biospy needle is held with the palm and index finger, the stilette is locked in place. Once the needle touched the bone, the stilette is removed.
• Using firm pressure, the needle is rotated clockwise and counterclockwise till entering the bone cavity till an adequate amount of marrow can be aspirated, 1.5-2cm in length.
• Rotate the needle along the axis to help cut the specimen.
• Pull back about 2-3mm and the insert the needle again slightly, at a different angle to obtain the specimen.
• Slowly pull out the needle in the clockwise-counterclockwise motion.

Post-procedure :

• After the procedure, several layers of gauze are applied and taped. The wound is then closed for 48 hours. It is checked frequently for bleeds, and the patient should keep the site dry at all times.
• Patient should initially lie flat for about 10-15 minutes to provide pressure to the site.
• If there is soreness, analgesics can be given.

Complications :

• Infection
• Hemorrhage
• Injury to vessels, heart (sternum aspiration)
• Hematoma

BONE MARROW ASPIRATION
Indications
1) diagnostic test to evaluate hematologic disorders.
2) to stage lymphoproliferative disorders and for prognostic purposes in chronic lymphoproliferative disorders such as chronic lymphatic leukemia.
3) For diagnostic workup of fever of unknown origin (FUO).
4) may reveal infections, such as tuberculosis, Mycobacterium avium-intracellulare (MAI) infections, histoplasmosis, leishmaniasis, and other disseminated fungal infections.
5) may be useful in establishing the diagnosis of storage diseases, such as Niemann-Pick disease and Gaucher disease
6) for diagnosing metastatic nonhemopoietic malignancies that have spread to the bone marrow when all other imaging and diagnostic modalities have failed or when a leucoerythroblastic peripheral blood picture is present.

Contraindications
1) hemophilia or related coagulation disorders
2) infection involving the biopsy area


Preparations
1) Obtain informed consent
2) carefully explain the procedure to the patient and/or responsible caregiver, including the risks and benefits of the procedure
3) Inform patient of possibility of complications
4) Explain the major steps of the procedure, positioning, and postpocedure care
5) assistance of a nurse and/or other medical personnel may be needed
6) Sedative medication may be required in children or in the confused or combative patient.
7) Prepare procedure kit (aseptic)

Preferred sites
1) Posterior iliac crest (both aspiration and biopsy) – center of posterior superior iliac spine
2) Sternum (aspiration only in adults) – 2nd intercostals space in midline
3) Anterior iliac crest (both aspiration and biopsy) – center of prominence of anterior superior iliac spine, just under lip of crest

Procedures
Aspiration and biopsy from the posterior iliac crest
1) Obtain consent
2) Practice aseptic precautions and hygiene – wash hands, wear gloves
3) The patient is placed in the lateral decubitus position, with the top leg flexed and the lower leg straight
4) The site is prepared, cleaned with an antiseptic (usually Betadine) scrub, and draped, exposing only the biopsy area.
5) The skin and the area down to the periosteum are infiltrated with a local anesthetic (eg, 10cc of 1% Xylocaine)
6) A skin incision is made with a small surgical blade, through which the bone marrow aspiration and biopsy needles are inserted.
7) The bone marrow aspiration needle, with a stylet in place, is inserted. Once the needle contacts the bone, it is advanced by rotating clockwise and counterclockwise slowly until the cortical bone is penetrated and the marrow cavity is entered. Usually, a sudden change in give is noted when the marrow cavity has been entered.
8) Once within the marrow cavity, the stylet is removed, and, using a 20-cc syringe, approximately 2-3 cc of bone marrow is aspirated for pathology slides.
9) The material collected for bone marrow slides usually is not mixed with any anticoagulant. It is processed immediately by a technologist; this avoids any cell morphologic artifacts. If additional marrow is needed for cytogenetics or flow cytometry, these subsequent specimens are obtained by attaching a separate syringe and aspirating approximately 5 additional cc of marrow at a time to be placed in an anticoagulant-containing tube (EDTA [ethylenediaminetetraacetic acid] or heparin, depending on the situation).
10) Once the aspiration is completed, the specimen is processed by the hematopathology technician, who selects the marrow particles to make the appropriate slides for pathology.
11) The marrow aspiration needle is removed, and pressure is applied to the site with gauze until bleeding has stopped.
12) Several layers of gauze are applied to the site with an Elastoplast on top to immobilize the gauze, and the patient is instructed to check the site frequently, to report any bleeding, and to keep it dry. The dressing is removed 48 hours later
13) Following this procedure, a bone marrow biopsy usually is performed as well

Sternal aspiration (adults only)
1) The second or third intercostal level of the sternum is selected; the area is cleaned well with an antiseptic scrub and draped.
2) Local anesthetic is used to infiltrate down to the periosteum
3) After making a small cut in the skin with a surgical blade, the aspiration needle with the stylet is inserted. Once the needle touches the bone, adjust the guard to approximately 0.5 cm to prevent pushing the needle through the sternum accidentally. With the same technique described in aspiration and biopsy from the posterior iliac crest, advance the needle into the marrow cavity, obtain the specimen, and remove the needle.
4) No core biopsy should be performed in the sternum.

Complications
1) Infection
2) Bleeding
3) cardiac injury after a sternal bone marrow aspiration
4) Chronic pain at the site of the bone marrow aspiration and biopsy

Bone marrow aspiration and biopsy

A bone marrow biopsy removes a small amount of bone and a small amount of fluid and cells from inside the bone (bone marrow).
In an aspiration, a sample of the liquid portion of your marrow is withdrawn.

1) Indications in general

• Amyloidosis
• Anemias
• Hemochromatosis
• Infectious diseases, such as leishmaniasis or HIV
• Leukemias
• Lymphomas
• Multiple myeloma
• Myelofibrosis
• Neuroblastoma
• Polycythemia vera
• Thrombocythemia

Bone marrow aspiration is used to:

• Find the cause of abnormal blood test results
• confirm a diagnosis
• check the status of severe anemia of unknown cause, or other irregularities in the way blood cells are produced or become mature.
• evaluate abnormalities in the blood's ability to store iron.
• diagnose infection

Bone marrow biopsy is used to:

• obtain intact bone marrow for laboratory analysis
• diagnose and stage some types of cancer or anemia and other blood disorders
• identify the source of an unexplained fever
• diagnose fibrosis of bone marrow or myeloma when bone marrow aspiration has failed to provide an appropriate specimen

2) Contraindications

• Allergic to any medicine, including anesthetics.
• Have any bleeding problems
• Taking aspirin, heparin, or warfarin.
• Pregnancy
• skin or soft tissue infection at the site, choose a different site

3) Instruments

• Two-ply alcohol prep pads
• Betadine
• Gaueze zponges
• Gloves
• Spinal needle 20 G
• Bone marrow biopsy needles 8 or 11 gauge
• Bone marrow aspiration needles 15 or 16 gauge
• 1% lidocaine, 10 mL
• 10 mL syringe

4) Bone marrow aspiration procedure

• Bone marrow aspiration is done before the bone marrow biopsy.
• The skin covering the biopsy site is cleansed with an antiseptic.
• The patient given a mild sedative. Local anesthetic is administered.
• For aspiration, a hollow needle is inserted through an incision and on through the bone and into the bone marrow cavity of the iliac crest. As local anesthetics aren't able to numb the interior of the bone, a deep, aching pain may be felt when the needle is fully inserted.
• A syringe is used to draw a sample of the liquid portion of the bone marrow into the hollow needle. As the liquid is drawn up, a painful stinging, sucking or pulling sensation may be felt, which may travel down the leg.
• Several samples taken.
• Needle is removed once the samples are adequate.

5) Bone marrow biopsy procedure

• A thicker, hollow needle is inserted into the bone.
• This is rotated around as it is pushed slightly forward to force a small sample of bone marrow into the hollow middle of the needle.
• This may cause some dull pain.
• The needle is then taken out.
• A pressure bandage applied to prevent bleeding.

6) Post procedure care

• After the needle is removed, the biopsy site will be covered with a clean, dry bandage.
• Pressure is applied to control bleeding.
• The patient's vitals are monitored until they return to normal.

• Lie on a bed and be observed for an hour to check for any serious bleeding.
• Take some painkillers if any discomfort.
• Be careful as patient will feel drowsy after the sedatives.
• The biopsy site should be kept covered and dry for several hours.
• Contact the doctor if severe pain, persistent bleeding, high grade temperature.

7) Complications

• Excessive bleeding.
• Infection.
• Penetration of the sternum during sternal aspirations, which can cause heart or lung problems.
• Long-lasting pain.
• Biopsy needle damage other nearby structures.

Bone Marrow Biopsy and Aspiration

Indications
1. Unexplained anemia.
2. Thrombocytopenia.
3. Pancytopenia.
4. Leukemia, lymphoma, or myeloma.
5. Lympho and myeloproliferative disorders.
6. Metastatic disease, to determine if bone marrow is involved with
cancers from other sites.
7. Chromosomal analyses.
8. Unusual infection, such as TB, Fungi and Fevers of Unknown Origin.

Contraindications
1. Hemophilia and other Clotting disorders.
2. Previous Radiation Therapy site.

Instruments
1. (1) Fenestrated Drape
2. (1) Towel
3. (3) Povidone Iodine Swabsticks
4. (1) 6cc Syringe with 20ga x 1-1/2" Blunt Tip Filter Aspiration Needle
5. (1) 20cc Syringe and Tip Cap
6. (1) 21ga x 1-1/2" Safety Needle
7. (1) 25ga x 5/8" Safety Needle
8. (1) 5ml Ampule Lidocaine Hydrochloride USP 1% (10mg/ml)
9. (1) Probe and Probe Guide
10.(1) #11 Retractable Scalpel Blade
11.(2) Specimen tubes containing Edetate (EDTA) Potassium
12.(10) Frosted Slides
13.(1) Amber Specimen Bottle with Label
14.(1) Stirring Rod
15.(3) 12ply 3" x 3" Gauze Sponges
16.(1) 1" x 3" Adhesive Bandage

Procedures
In adults, the specimen is usually taken from the posterior superior iliac crest (hip). The sternum (breastbone) may be used for aspiration, but is less desirable because it carries the risk of cardiac puncture. Other sites that are rarely used are the anterior superior iliac crest or a spinal column bone. When the patient is a child, the biopsy site is generally the anterior tibia, the larger of the two bones in the lower leg. A vertebra may also be used.

1. A bone marrow biopsy may be done in a health care provider's office or in a hospital.

2. Informed consent for the procedure is typically required.

3. The patient is asked to lie on his or her abdomen (prone position) or on his/her side (decubitus position).

4. The skin is cleansed, and a local anesthetic such as lidocaine is injected to numb the area. Patients may also be pretreated with analgesics and/or anti-anxiety medications, although this is not a routine practice.

5. An aspirate needle is inserted through the skin until it abuts the bone.

6. Then, with a twisting motion, the needle is advanced through the bony cortex (the hard outer layer of the bone) and into the marrow cavity.

7. Once the needle is in the marrow cavity, a syringe is attached and used to aspirate ("suck out") liquid bone marrow.

8. Subsequently, the biopsy is performed if indicated. A different, larger trephine needle is inserted and anchored in the bony cortex.

9. The needle is then advanced with a twisting motion and rotated to obtain a solid piece of bone marrow.

10.This piece is then removed along with the needle.

Post-procedure cares
1. The patient must remain lying down and is observed for bleeding for one hour.

2. The patient's pulse, breathing, blood pressure, and temperature are monitored until they return to normal.

3. The biopsy site should be kept covered and dry for several hours.

4. Patients who have received a sedative often feel sleepy for the rest of the day; so driving, cooking, and other activities that require clear thinking and quick reactions should be avoided.

5. Walking or prescribed pain medications usually ease any discomfort felt at the biopsy site, and ice can be used to reduce swelling.

6. The patient should go back to see the doctor if:
-feels severe pain for more than 24 hours after the procedure
-experiences persistent bleeding
-has a temperature above 38.3°C
-inflammation and pus at the biopsy site and other signs of infection

Complications
1. Bleeding from the biopsy site.
2. infections at the site of biopsy taken.
3. Injury to the nearby structures.

Indication:

• aplastic anaemia
• megaloblastic anaemia
• myelofibrosis
• myelosclerosis
• multiple myeloma
• iron defiency anaemia
• thrombocytopoenic purpura
• agranulocytosis
• Hyperspenism
• malaria
• kala azar

Contraindication:

Absolute:

• hemophilia and other clotting disorders
• DIC

Relative:

• Infection

Instruments used

• hollow aspirate needle
• hollow biopsy needle
• styllet

procedures:

• first and foremost, take the consent from the patient. In a meanwhile, explain the procedres to be done and the underlying complication that might occur.
• ask the patient to go to the toilet. emptied bladder is a pre-requisite for bone marrow aspiration.
• sites of aspiration: sternal puncture, spinous process of lumbar vertebrae and posterior/anterior iliac crest.
• position: Posterior iliac crest - Patient is prone and lie on the side with the knee flexed and head averted to one side.
• identify the anatomical landmark, it is the most palpable prominence of the posterior margin of iliac crest.
• An injection of anaesthetic (2% lignocaine) is given to the patient. This is to numb the localized nearby skin and tissues.
• Aspirate out the fluid and other material of the bone marrow.
• A small cut is introduced in the skin of the hip bone, followed by and insertion of a needle to the bone.
• Bone marrow liquid will be sucked into the tube through the needle.
• Needle is withdrawn and smears are prepared with the marker.
• Hemostasis is maintained by monitoring the pressure for 3-5 minutes.
• Apply bandage.

Post operative care:

• monitor the vital signs 4hourly
• put the patient in supine position.

Complication:

• herniation
• infection
• haemorrhage
• pain