PROCEDURE 117 The acquisition of a bone marrow aspirate from the core of the bone is used in the diagnosis of hematopoietic disorders. It is also used to follow the effectiveness of treatment in patients undergoing conventional chemotherapy, to assess response in the post autologous blood and marrow transplant period as well as treatment response and engraftment in the post allogeneic stem cell transplant. The preferred site for a bone marrow aspirate and biopsy is the posterior iliac crest.1 The sternum may be used in aspiration of marrow; however, a core biopsy cannot be obtained from the sternum because of the risk of damage to underlying internal organs, most significantly the heart.6,8 • A thorough understanding is needed of the anatomy and physiology of the posterior and anterior iliac crest and the sternum. • Clinical and technical competence in performing a bone marrow aspirate and biopsy is necessary. • Essential knowledge of sterile technique is needed. • An understanding is needed of institutional policies and procedures for administration of intravenous (IV) pharmacologic agents, including conscious sedation (if indicated) and intradermal and epicortical local anesthesia (lidocaine in most cases; procaine may be used in cases of lidocaine allergy) and procedural care of the patient receiving conscious sedation (if used). • Knowledge is needed of information to be gained from a bone marrow aspirate sample (i.e., identification of normal and abnormal hematopoietic elements, identification of malignant clones with flow cytometry, identification of chromosomal abnormalities that occur in hematologic malignant diseases, identification of molecular diagnostic studies that show gene rearrangements and translocations, and the performance of chimerism studies in patients after allogeneic transplant). • A bone marrow biopsy is used for morphologic analysis of hematopoietic cells and for assessment of the architecture of the bone marrow that may be abnormal in certain disease states. • Indications for bone marrow aspiration and biopsy include the following: • Contraindications to bone marrow biopsy and aspirate are the presence of hemophilia, severe disseminated intravascular coagulopathy, or other related severe bleeding disorders. Thrombocytopenia alone is not a contraindication to bone marrow examination.3,5 The use of anticoagulant medications may pose serious bleeding risk; therefore, coagulation studies should be obtained in these patients. The decision on whether anticoagulation can be safely withheld prior to and restarted after the procedure is patient dependent. • Bone marrow aspiration and biopsy kit, which includes the following: • Fluid shield face mask or goggles • Required tubes for specimen processing: two edetate disodium (EDTA; lavender top) and two sodium heparin (green top) tubes (follow institution standard) • Glass slides and cover plate • 2½- to 6-inch spinal needle (may be required for anesthetizing periosteum in the obese patient) • Extra-long Jamshidi needle (may be needed to acquire core specimen in obese patient) • Container for bone core biopsy specimen, including appropriate fixative (10% formalin or 2 ×2 cotton gauze soaked with sterile saline solution to keep specimen from drying out) • 1 vial of 100 units/mL heparin (follow institution standard) Additional equipment for patients receiving conscious sedation:
Bone Marrow Biopsy and Aspiration (Perform)
PREREQUISITE NURSING KNOWLEDGE
To diagnosis a hematologic abnormality
To monitor a hematologic disease state after initial diagnosis or therapy
To assess the status of disease after autologous bone marrow or hematopoietic stem cell transplant
To evaluate immunodeficiency syndromes or to confirm an infectious disease process in the marrow
EQUIPMENT
Povidone-iodine or chlorhexidine-alcohol antiseptic preparation
1 vial lidocaine (1% or 2%; 5-10mLs)
5 or 10-mL syringe for drawing up lidocaine
Filter needle (if lidocaine drawn from glass vial)
Needles of appropriate lengths to anesthetize both skin and periosteum
Sterile 4 × 4 and 2 x 2 gauze pads
Illinois needle (for bone marrow aspirate)
Jamshidi bone biopsy needle (for core biopsy)
20-mL syringe for bone marrow aspirate
Multiple 10-ml syringes with slip tips or adaptor for leur lock
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117: Bone Marrow Biopsy and Aspiration (Perform)
