Procedures: Bone Marrow Biopsy and Aspiration

Bone Marrow Biopsy and Aspiration

Indications:
As a diagnostic procedure when one of the following is suspected:

• Aplastic Anemia
• Acute Leukemia
• Myelodysplastic Syndrome
• Chronic Myelogenous Leukemia
• Myelofibrosis and Essential Thrombocythemia
• Multiple Myeloma
• Severe Thrombocytopenia and/or Anemia and/or Neutropenia

As a staging procedure in:

• Hodgkin’s and Non-Hodgkins lymphomas

For culturing:

• When fever is present in HIV/AIDS or other immuno-compromised patient
• In patients suspected of having Brucellosis or Typhoid Fever

Contraindications:

• Bleeding disorders
• Infection
• Uncooperative patients
• Coagulopathy

Instruments:

• Antiseptic skin cleansing agent
• Sterile dressing pack
• Selection of syringes and needles
• Local anaesthetic
• Marrow aspiration needle and guard, e.g. Salah needle
• Microscope slides and coverslips
• Specimen bottles (plain and with heparin)
• Polyurethane semi-permeable dressing or spray
• Sterile gloves
• Plaster dressing

Procedure:

• Explain the procedure to the patient and take consent
• Wash and dry hands
• Help the patient into the correct position.
  • Supine for sternal puncture
  • Prone or on side for anterior or posterior iliac crest puncture
• Skin is cleaned with antiseptic solution.
• Local anaesthetic is injected intradermally and through the various layers until the periosteum is infiltrated.
• Once the local anaesthetic has taken effect insert the marrow needle, with the guard on, into the anaesthetized area.
• The needle is advanced into the bone marrow and the required amount of marrow is withdrawn.
• The needle is removed from the puncture site
• Once the needle is removed apply pressure over the puncture site using a sterile topical swab until the bleeding stops.
• Once bleeding stops, cover the site with plaster or a plastic dressing
• Make the patient comfortable
• Remove and dispose equipment.

Post Procedure Care:

• Patient to lay supine for 10-15 minutes
• Monitor for bleeding/hematoma
• Analgesics for post procedure pain

Complications:

• Bleeding and discomfort often occur at the biopsy site
• Infection can develop
• In rare instances, the heart or a major blood vessel is pierced when marrow is extracted from the sternum during bone marrow biopsy. This can lead to severe hemorrhage and death

Indications

• 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.
• Find blood disorders, such as leukemia, certain anemias, or problems that affect the bone marrow, such as multiple myeloma or polycythemia vera.
• 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.
• 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.
• 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.
• Collect a sample of bone marrow for medical procedures, such as stem cell transplantation or chromosomal analysis.

Contraindications

• Bleeding and coagulation disorders
• Uncooperative patients
• Infections

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

Procedure

• Concent is obtained from the patient and proper explanation regarding the procedure is given to the patient.
• 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.
• The skin is then cleaned with antiseptic solution.
• 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.
• 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.
• Once the needle is in the marrow cavity, a syringe is attached and used to aspirate liquid bone marrow.
• Once the needle is removed apply pressure over the puncture site using a sterile topical swab until the bleeding stops.
• Cover the site with plaster or a plastic dressing.

Post procedure care

• Ask the patient to lye down for atleast 20-30 minutes.
• Give anelgesics for pain relief.
• Monitor patients vitals and for any hematoma formation.

Complications

• Hemorrhage
• Pain
• Infection
• Hernition
• Broken needle

INTRODUCTION

Bone marrow aspiration, also called bone marrow sampling, is the removal by suction of fluid from the soft, spongy material that lines the inside of most bones. Bone marrow biopsy, or needle biopsy, is the removal of a small piece of bone marrow.

The following are the safe and preferred sites for bone marrow aspiration and bone marrow biopsy:

1. Posterior iliac crest (both aspiration and biopsy)
2. Sternum (aspiration only in adults)
3. Anterior iliac crest (both aspiration and biopsy)

INDICATIONS

Bone marrow aspiration is used to:

• pinpoint the cause of abnormal blood test results
• confirm a diagnosis or check the status of severe anemia (abnormally low numbers of red blood cells in the bloodstream) 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 (a tumor composed of cells normally found in the bone marrow) when bone marrow aspiration has failed to provide an appropriate specimen

Bone marrow aspiration and bone marrow biopsy are also used to gauge the effectiveness of chemotherapy and other medical treatments. These procedures are often used together to ensure the availability of the best possible bone marrow specimen.

Contraindications:

• Bleeding disorders
• Infection
• Uncooperative patients
• Coagulopathy

Instruments:

• Antiseptic skin cleansing agent
• Sterile dressing pack
• Selection of syringes and needles
• Local anaesthetic
• Marrow aspiration needle and guard, e.g. Salah needle
• Microscope slides and coverslips
• Specimen bottles (plain and with heparin)
• Polyurethane semi-permeable dressing or spray
• Sterile gloves
• Plaster dressing

Preparation

> A current history and physical are obtained from the patient, along with proper consent.

> The patient is generally placed in a prone position (lying face down) for preparation, and local anesthetic, with or without sedation, is administered.


Aftercare

> 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 pulse, breathing, blood pressure, and temperature are monitored until they return to normal, and the patient may be instructed to remain in a supine position (lying face up) for half an hour before getting dressed.

> The patient should be able to leave the clinic and resume normal activities immediately.

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

> The biopsy site should be kept covered and dry for several hours. Walking or taking prescribed pain medications usually ease any discomfort felt at the biopsy site, and ice can be used to reduce swelling.

A doctor should be notified if the patient:

• feels severe pain more than 24 hours after the procedure.
• experiences persistent bleeding or notices more than a few drops of blood on the wound dressing.
• has a temperature above 101°F (38.3°C). Inflammation and pus at the biopsy site and other signs of infection should also be reported to a doctor without delay.

Risks

> Bleeding and discomfort often occur at the biopsy site.

> Infection and hematoma may also develop.

> In rare instances, the heart or a major blood vessel is pierced when marrow is extracted from the sternum during bone marrow biopsy. This can lead to severe hemorrhage.

Normal results

Healthy adult bone marrow contains yellow fat cells, connective tissue, and red marrow that produces blood. The bone marrow of a healthy infant is primarily red due to active production of red cells necessary for growth.

Abnormal results

> Culture of bone marrow aspirate may yield information about an infectious agent.

> Microscopic examination of bone marrow can reveal granulomas, myelofibrosis, lymphomas, leukemias, or other cancers.

> Analyzing specimens can help doctors diagnose iron deficiency, vitamin B12 deficiency, and folate deficiency, as well as anemia.

> Obesity can affect the ease with which a bone marrow biopsy can be done, and the results of either procedure can be affected if the patient has had radiation therapy at the biopsy site.

Indications:

• To evaluate hematologic disorders
• To stage lymphoproliferative disorders
• Diagnostic work-up of fever of unknown origin
• Diagnosing metastatic non-hemopoietic malignancies that have spread to bone marrow.

Contraindications:

• hemophillia
• coagulation disorders
• infection at site of biopsy
• uncoorperative patients

Instruments:

• Bone marrow biopsy tray
• Dressing tray, cleaning solution, sterile gloves, gauze
• Local anesthetic agents
• Occasionally a longer needle is needed to reach the bone
• Bone marrow aspiration needle, biopsy (Jamshidi) needle, stylet
• Scalpel
• Containers for specimen collection

Procedure:

1. Patient is placed in supine position or prone position.
2. identify site for aspiration.
3. wash hands, wear mask and sterile gloves.
4. Clean the area with iodine and apply sterile drapes.
5. inject local anesthesia at site for aspiration.
6. bone marrow aspiration needle with guard half an inch from the tip is pushed vertically through the bone with boring motion. When the needle has entered the marrow, the stilette is withdrawn and 0.2-0.5ml of bone marrow is aspirated with a 1ml syringe.
7. needle is withdrawn and smears prepared with the marrow.
8. pressure applied at the site for 3-5minutes for hemostasis.

Complications:

• bone pain
• hematoma
• infection
• transfixation of sternum and injury to great vessels.

Post procedue care:

• Patient to lay on supine position for about 15 - 20 minutes
• Monitor site for bleeding or hematoma
• prescribe analgesics for post procedure pain
• always keep the biopsy area clean and dry

Bone biopsy

Indications
-Anemia
-Leucopenia
-Thrombocytopenia
-Pancytopenia
-Non- Hodgkin Lymphona
-Hodgkin’s disease
-Metastatic carcinoma
-Acute leukemia
-Myeloproliferative disease
-Fever of uknown origin
-Hepatosplenomegaly
-Other indications

Contraindications

-Acquired or congenital coagulation factor deficiency
-Infection or previous radiation therapy at the sample site
-Poor patient cooperation
-Sternal bone marrow aspiration is completely contraindicated in patients with disease associated with bone resorption including multiple myeloma

Instruments
-Alcohol prep pads
-Betadine( povidone iodine, swab sticks
-Ear speculum plastic tips
-Gauge sponges
-Impervious gowns
-Isopropyl alcohol swabsticks
-Latex gloves, examination, non sterile
-Latex gloves sterile
-Lidocaine hydrochloride, injection
-Needles 22 gauge needle
-Fenestrated drapes, sterile small
-Sodium bicarbonate solution
-Sodium heparin injection
-Spinal needle 20 gauge 3.5 inch
-Blank labels
-Bone marrow aspiration needles, 15 and 16 gauge
-Disposable plastic syringes
-Disposable scalpel
-Green- top ( sodium heparin) vacutainers
-Microscopic slides
-Plastic bags, zip lock
-Safety flow lancet.

Procedures
- Locate of the right posterior iliac crest

- Subcutaneous infiltration of 1% buffered lidocaine, using a 26-gauge needle.

- Infiltration of 1% lidocaine into the periosteum of the posterior iliac spine, using a 10 mL syringe with a 3 1/2 in. spinal needle.

- Bone marrow aspiration. A 16 gauge Illinois sternal/Iliac aspiration needle will be placed into the marrow cavity. The obturator is removed.

- Bone marrow aspiration. The obturator of the Illinois sternal/Iliac aspiration needle will be removed and a 10 mL syringe attach to the hub.

- Suction is applied to the syringe, with successful aspiration of marrow.

- Prepare aspiration smears.

- Determine length of biopsy core in needle by carefully reinserting obturator. Ideally, the core length should be 2 cm or greater

- Deliver of biopsy core on to a glass microscope slide. The core will be forced through the hub of the needle using a small blunt obturator.

- Prepare touch preparations from the biopsy core.

- Cells on the surface of the core stick to the clean slide, which is later stained by the Wright-Giemsa technique.

- Cytologic detail of the cells can be visualized and complements the aspirate and biopsy.


Post procedure care
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 your health care team as soon as possible.
Other situations in which to contact your 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 you 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.
Complications.
- Excessive bleeding, particularly in people with a low platelet count or people taking aspirin or anticoagulants, such as warfarin
- Infection, especially in people with compromised immune systems
- Breaking of needles within the bone, which may cause infection or bleeding
- Penetration of the breastbone (sternum) during sternal aspirations, which can cause heart or lung problems
- Long-lasting pain
- Complications related to IV sedation, such as an allergic reaction, nausea or irregular heartbeats

Bone marrow aspiration/biopsy

Indications

• Diagnostic

Essential for diagnosis;
- Aplastic anemia
- Megaloblastic anemia
- Leukemia – to differentiate types
- Myelofibrosis
- Multiple myeloma
Helpful in diagnosis;
- Anemias : refractory, hemolytic, iron deficiency
- Thrombocytopenic purpura
- Agranulocytosis
- Hypersplenism
- Tropical diseases : Malaria, kala azar
- Secondary carcinomas
- Infiltrative disorders : Gaucher’s disease

• Prognostic

- Agranulocytosis
- Aplastic anemia
- Leukemia

• Therapeutic : bone marrow typing and transplant

Contraindications :

- Infection at aspiration/insertion site
- Previous irradiation at insertion site
- Blood dyscrasias; hemophilia, inherited clotting disorders
- Severe Disseminated Intravascular Coagulation
- Sternal aspiration in osteoporotics/multiple myeloma patients

Instruments :

· Alcohol prep pads
· Betadine (povidone iodine, 10%) swabs
· Gauze sponges
· Impervious gowns
· Sterile & non-sterile latex gloves
· Sterile fenestrated drapes
· 2% lignocaine, 10 mL
· Bone marrow aspiration needles; 15 or 16 gauge,
· Sterile disposable plastic syringes 2 mL & 10 mL
· Sodium heparin vacutainers
· Safety-flow lancet

Procedure :

1) Obtain informed consent ; explain procedure thoroughly & reassure patient.
2) Site : Sternal puncture – mid manubrium(commonest)
Spinous process of lumbar vertebrae
Illiac crest in children
3) Position : supine, chest shaved and prepared with alcohol swabs and Betadine.
4) Local anesthetic, Lignocaine infiltrated at site of choice. Eg. In the skin, subcutaneous tissue and periostium over manubrium
5) After 2- 3 minutes, the bone marrow aspiration needle is taken; with guard half an inch from the tip , is pushed vertically through sternal plate with boring motion.
6) When needle enters the marrow, the stillette is withdrawn, and 0.2 - 0.5 ml of bone marrow is aspirated via syringe.
7) The needle is withdrawn, smears are prepared with marrow.
8) Hemostasis secured by maintaining pressure over site for 5 – 10 mins.
9) Seal the site of aspiration tightly with gauze and surgical tape.

Post procedure care :

- patient should be in supine position and motionless for at least 15 minutes
- BP and vitals monitoring for 4 hours
- Nil by mouth for 4 hours
- Analgesics given for pain; advised that procedure site will be tender for several days
- Discharge on the same day if no continued bleeding

Complications :

- Bone pains
- Hematoma at aspiration site
- Infection ( osteomyelitis )
- Transfixation of sternum and injury to great vessels
- Cardiac tamponade (aspiration of sternum)
- Perforation of iliac bone

BONE MARROW BIOPSY AND ASPIRATION

Bone marrow biopsy: is the removal tissue of the marrow also known as trephine biopsy.

Bone marrow aspiration: is the removal of the fluid in the marrow.

These are pathological analysis of bone marrow.

Indications of Bone marrow biopsy and aspiration

• Anemia
• Leukemia
• Trombocytopenia
• Pancytopenia
• Multiple myeloma
• Lymphoma
• Myelofibrosis
• Polycythemia vera
• Pyrexia of unknown origin
• HIV
• Hemochromatosis
• Amyloidosis

Contraindications of Bone marrow biopsy and aspiration

Bleeding disorders such as: hemophilia.
Infection at the site of injection.


Materials for Bone marrow biopsy and aspiration

Material for sterile technique
Bone marrow aspirate needle
Trephine needle/ bone marrow biopsy needle
Sterile drapes
1% lidocaine without epinephrine in a 5-cc syringe with a 22 and 25-gauge needles
Material for skin sterilization (iodine and swabs)
Adhesive dressing
Slides for staining and microscopy

Procedure of Bone marrow biopsy and aspiration

Pre procedure:

• Get the patients consent and explain the procedure, the need for the procedure and complications that may occur.
• Usually it is advised not to have food and fluid before the procedure.
• The patient should tell about any allergies, previous reactions to medications, any bleeding problems in the past, if pregnant and if currently on any medications.
• Patients may have their vitals checked.
• Patients can ask to be given some medicine to relax (analgesics or anti-anxiety medication).

Procedure:

• Patient is asked to lie on left decubitus position (usually iliac bone is choosen).
• The skin over the bone to be sampled is cleaned with antiseptic.
• Drapes are placed and local anaesthetic is injected, Lignocaine 1% is used.
• After 1 minute the needle is pushed until the bone is reached then it twisted until it reaches the marrow.
• The stylet is removed and a 1ml syringe is placed and fluid from the marrow is aspirated (0.2 to 0.5 ml).
• For the biopsy another needle is used (trephine needle), the same way it is bored in to the bone and once the marrow is reached through rotational movements a part of marrow tissue is forced into needle.
• The needle is removed, the smears are prepared and hemostasis is achieved by maintaining pressure at the site for 3 to 5 minutes.
• The site dressed with bandage.

Post Procedure care

The patient is asked to lie flat for 10 to 15 minutes and apply pressure to the site.
Some amount paracetamol or analgesics can be given to relieve the pain.
Blood pressure and vitals can be monitored

Complications of Bone marrow aspiration and biopsy

Hematoma
Bone pain
Infections like osteomyelitis
Injury to the nerves or vessel (rarely)

INDICATIONS:

1)amyloidosis
2)anemias
3)hemochromatosis
4)infectious diseases, such as leishmaniasis or HIV
5)leukemias
6)lymphomas
7)multiple myeloma
8)myelofibrosis
9)neuroblastoma
10)polycythemia vera
11)thrombocythemia
CONTRAINDICATIONS:

1)coagulation factor deficiencies
2)infection or irradiation at the site of procedure
3)poor patient compliance





INSTRUMENTS:

Purpose

Supplies and Equipment

Obtaining written consent
Ballpoint pen
Clipboard
Patient consent forms
Site preparation
Alcohol prep pads, 2 ply, large
Betadine (povidone iodine, 10%) swabsticks
Ear speculum plastic tips
Gauge sponges, 3 x 4 in.
Impervious gowns
Isopropyl alcohol swabsticks
Latex gloves, examination, non-sterile
Latex gloves, sterile
Lidocaine hydrochloride, Injection, 1%, 20 mL vials
Needles, 22 gauge, 1 1/2”
Fenestrated drapes, sterile, small (30” x 30” with 1 1/2” x 2” fenestration)
Sodium bicarbonate solution, Injection, USP, 8.4% (1 mEq/mL), 50 mL vials
Sodium heparin, Injection, 1000 USP Units/mL, 2 mL vials
Spinal needles, 20 Guage, 3.5 in.
Spinal needles, 20 Guage, 5 in.Sub-Q needles, 26 gauge, 5/8 in.
Marrow procurement
AZF fixative, 10 mL sealed, labeled containers
Blank labels
Bone marrow aspiration needles, 15 or 16 gauge, several lengths
Bone marrow biopsy needles, several lengths, 8 and 11 gauge
Disposable plastic syringes, sterile U 20 cc.
Disposable plastic syringes, sterile, 10 cc.
Disposable scalpel, 25 kGy (2.5 mrad)
Green-top (sodium heparin) vacutainers
Microscope slides, 1” x 3”, frosted
Plastic bags, zip-lock
Purple-top vacutainers
Safety flow lancet
Wound care
Bandage scissors
Elastic tape (Elastikon, J&J)
Transpore tape (3M)
Other supplies
Safety flow lancet


PROCEDURE:

Administering Local Anesthesia

Once a sterile site has been achieved, a local anesthetic is utilized to “numb” the skin and periosteum over the chosen area of the posterior iliac crest. Lidocaine or a similar local anesthetic can be used, providing the patient has no history of an allergic reaction to this medication . During this process, local anesthetic is first infiltrated into the skin and subcutaneous tissue to anesthetize an area approximately 1 cm. in diameter.

Medications for pain and anxiety reduction

Agent

Route

Adult Dosage*

Ativan (Lorazepam)
IM, IV, PO
0.044 mg/kg IM, IV
2-5 mg PO
Demerol (Merperidine)
IM
50-100 mg
Versed (Midazolam)
IM, IV
**
Vistaril (Hydroxyzene)
IM, PO
25-100 mg IM
50-100 mg PO
Valium (Diazepam)
IV, PO


After the skin is numb, lidocaine is infiltrated directly over the periosteum to numb an area approximately 2-3 cm in diameter. Discomfort can be avoided during the remainder of the procedure if adequate time is taken to assure good anesthesia

Marrow Aspiration: AIC, PIC

Marrow aspiration from the posterior or anterior iliac crest is performed as follows:
Fill the necessary number of 10 mL syringes with heparin solution or other anticoagulant as required. Regardless of the suspected diagnosis or purpose of the study, it is best to obtain at least one heparin-anticoagulated tube of marrow aspirate, “just in case” it is needed for special studies (i.e., microbiologic culture, immunophenotypic analysis, cytogenetic analysis, molecular biology studies, etc.).
Obtain the desired marrow aspirate needle from the assistant and inspect for signs of manufacturing defects. Remove the plastic guard from the needle (if one is present). Loosen and remove the obturator to make certain that it can be removed with ease. Insert obturator and relock. Hold the needle with index finger near needle tip to control the depth of penetration.
Hold needle horizontally (for a patient lying on their side) or vertically (if supine) to puncture the anesthetized skin. If the skin is tough, make a small incision with a sterile scalpel.
Advance the needle with steady pressure and a slight twisting motion to the center of the posterior iliac prominence (PIC) or to the bone (AIC). Angle the needle 15 degrees caudad (PIC) or cephalad (AIC).
Rotate the needle back and forth (90o-180o) and carefully apply pressure to advance the needle through the cortical bone. The consistency of the bone varies considerably from patient to patient, but may have significance as follows: Soft (“Swiss cheese”) consistency = osteoporotic bone (elderly patient, multiple myeloma, renal failure, some post-chemotherapy patients), firm (“pine board”) consistency = Normal for young athletic individuals, very hard (“oak board”) consistency = possible hyperostosis.
Decreased resistance (Usually!) indicates penetration of cortex and entry into the marrow cavity.
Advance needle about 1 cm into the marrow cavity. Unlock and slowly remove the obturator. Some patients may notice pain if the obturator is not removed carefully
Attach a 10 ml syringe to the aspirate needle. Quickly (< 5 seconds) aspirate 1.0 mL marrow into the 10 mL syringe (more than this dilutes the specimen with peripheral blood). BEWARE! The sudden sharp pain may cause the patient to shout, move suddenly, or even try the strike you! Remain alert, try to maintain sterility, and calm the patient quickly if this happens.
Quickly give the syringe to the technical assistant to prepare specimen slides. Hold a finger over needle opening to prevent blood flow while the technician prepares slides and evaluates for the presence of spicules.
If spicules are present, extra marrow specimen(s) for special studies can be obtained. Aspirate approximately 2 mL of marrow into a syringe containing 1 mL of heparin solution.
If a “dry tap” (no fluid, no sharp pain) occurs, then reposition needle (depth, angle or location) and try again. As a “last resort” touch preparations can be prepared from the core biopsy. Try the opposite side if necessary.
Remove aspiration needle and apply pressure with a sterile sponge until bleeding ceases.
Perform a bone marrow biopsy or place a folded piece of gauze over the site, apply pressure bandage, and have patient lie supine for at least 30 minutes.

POST PROCEDURE CARE:

After procurement of the marrow specimens, bleeding must be stopped, the procedure site must be cleaned up, needles properly disposed of in a Sharps container, and the site bandaged. A procedure note must be placed on the patient’s chart. Apply pressure with thumb or fingers to procedure site until bleeding has completely ceased. Gently remove and dispose of the fenestrated drape.
Completely remove povidone-iodine from the skin with alcohol swabs. Residual povidone-iodine may cause itching and lead to a future allergic response.
Double gauze square an place over the procedure site. Cover the area with at least two pieces of surgical tape approximately 2-3 inches in length. Pressure tape should be used if unusual oozing was encountered during the procedure, and in patients with thrombocytopenia or a history of a hemostatic disorder.
Advise the patient to remove the dressing the following day, after first wetting the tape to make removal easier. Have the patient lie supine, putting pressure on the procedure site for at least 30 minutes. Advise the patient to contact their physician if tenderness or bleeding is noted at the procedure site during the next few days. Thank the patient for their cooperation.
Carefully dispose of the syringes and needles in a sharps container. Advise the patient’s nurse or physician that you have completed the procedure and remind them to keep the patient supine for 30 minutes
Place a note on the patient’s chart. This is required for medicolegal and billing purposes, as well as to alert the patient care team to the performance of the procedure and any complications that were encountered.

COMPLICATIONS:

1) excessive bleeding particularly in pts. with low platelet count or taking anti-coagulants/aspirin
2) infections especially in pts that are immunocompromised.
3) breakin of needles within the bone which may cause bleeding or infection.
4) long term pain.
5) complications of IV sedation such as allergic reactions, nausea, arrhythmias.

BONE MARROW ASPIRATION and BIOPSY

A bone marrow aspiration is a type biopsy which involves the removal of a small amount of bone and a small amount of fluid and cells from inside the bone (bone marrow).Its called aspiration as the fluid is aspirated out unlike biopsies where tissue is obtained surgically.However, bone marrow biopsy is also done,the steps are stated below

1) Indications

• 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

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 required

• Two-ply alcohol prep pads
• Betadine
• Gauze sponges
• 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.