Bone marrow aspiration

Definition

Bone marrow aspiration, which is also called bone marrow sampling, is the removal by suction of the soft, spongy

semisolid tissue (marrow) that fills the inside of the long and flat bones. Bone marrow biopsy, or needle core biopsy,

is the removal of a small piece (about 0.75 by 0.06 inch, or 2 by 0.16 cm) of intact bone marrow. The bone marrow is

where bloodcells are made.

Purpose

Examination of the bone marrow may be the next step that follows an abnormal clinical finding, abnormal complete

blood count (CBC), and/or an abnormal peripheral blood smear. It may be performed following an abnormal bone

image such as the finding of a mass lesion on x ray.

A biopsy of bone marrow shows the intact tissue, so that the fat cells, lymphocytes, plasma cells, fibrous connective

tissue cells, and other cells can be seen in their overall structure, and in their relationships to each other. Bone

marrow biopsy is used to:

Aid in the diagnosis and management of any form of leukemia or other myeloproliferative condition such as

multiple myeloma.

Rule out or identify bone marrow infiltration of other malignancies such as Hodgkin's disease, non-Hodgkin's

lymphoma, and metastatic carcinoma.

Monitor the effects of chemotherapy and the response or lack of response to treatment of blood disease.

Evaluate the success of bone marrow transplantation.

Diagnose certain genetic diseases (e.g., lipid storage disease).

Investigate pancytopenia (a decrease of all blood cells in peripheral blood), neutropenia (decreased phagocytic

white blood cells), or thrombocytopenia (decreased platelets).

Diagnose an infection of unknown origin.

Investigate rare anemias for which a cause cannot be found or which does not respond to treatment as

anticipated.

Obtain intact bone marrow for laboratory analysis.

Diagnose some types of cancer or anemia and other blood disorders.

Identify the source of an unexplained fever (e.g. granulomatous lesions).

Diagnose fibrosis of bone marrow and myeloma when bone marrow aspiration has failed to provide an

appropriate specimen.

The combination of aspiration and biopsy procedures are commonly used together to ensure the availability of the

best possible bone marrow specimen. The aspirate is collected at the same time as the bone core biopsy by

attaching a syringe to the bone marrow needle and withdrawing the sample before the cutting blades are inserted and

the bone core is removed. The aspirate is the sample of choice for studying and classifying the nucleated blood cells

of the bone marrow (e.g., determining the ratio of immature white blood cells to red blood cells, the M:E ratio). The

biopsy is the only sample that shows the blood forming cells in relation to the structural and connective tissue

elements (i.e., the microarchitecture) of the bone marrow. It is the best sample to evaluate the cellularity of the bone

marrow (the percentage of blood forming tissue versus fat).

Precautions

The bone marrow procedure is performed with strict attention to aseptic technique and universal precautions for

the prevention of transmission of bloodborne pathogens. Fixation fluids, slides, and tubes with proper anticoagulant

should be at the bedside so that the specimen can be preserved immediately and slides prepared that are of suitable

quality. Obesity can affect the ease with which a bone marrow biopsy can be done, and the results can be affected if

the patient has had radiation therapy at the biopsy site.

Description

Bone marrow aspiration and biopsy are performed by a pathologist, hematologist, or oncologist with special training

in this procedure. The procedure may be performed on an outpatient basis. In adults, the specimen is usually taken

from the posterior superior iliac crest (hip). The sternum 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 spinous

process of a vertebra, 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.

The skin covering the biopsy site is cleansed with an antiseptic, and the patient may be given a mild sedative. The

patient is positioned, and a local anesthetic such as lidocaine is administered first under the skin with a fin needle and

then around the bone at the intended puncture site with a somewhat larger gauge needle. After the area is numb a

small incision is made in the skin and the biopsy needle is inserted. Pressure is applied to force the needle through

the outer bone and a decrease in resistance signals entry into the marrow cavity. The needle most often used for

bone marrow biopsy is a Jamshidi trephine needle or a Westerman-Jensen trephine needle. A syringe is placed on

the hup of the needle and 1-2 mL of the bone marrow is aspirated into the syringe. In some instances, the marrow

cannot be aspirated because it is fibrosed or packed with neoplastic cells. The syringe is removed and the medical

technologist uses this sample to prepare several smears containing small bone spicules. Another syringe is fitted

onto the needle hub and another sample of 3 mL is removed and transferred to a tube containing EDTA for analysis

by flow cytometry, cytogenetic testing or other special laboratory procedure. Following aspiration, the cutting blades

are inserted into the hollow of the needle until they protrude into the marrow. The needle is then forced over the tips

of the cutting blades and the needle is rotated as it is withdrawn from the bone. This process captures the core

sample inside the needle. A wire probe is inserted at the cutting end and the bone marrow sample is pushed through

the hub of the needle onto sterile gauze. The specimen is used to make several touch preparations on glass slides or

coverglasses and is transferred to a fixative solution.

In the laboratory the aspirate slides are stained with Wright stain or Wright-Giemsa stain. The biopsy material is

sectioned onto glass slides and stained with hematoxylin-eosin, Giemsa, and Prussian blue stains. Prussian blue

stain is used to evaluate the amount of bone marrow ironand the other stains are used to evaluate cell morphology.

In addition, special stains may be used that aid in the classification of malignant white blood cells.

Preparation

The physician should be told of any medication the patient is using and any heart surgery that the patient has

undergone.

Aftercare

After the needle is removed, the biopsy site will be covered with a clean, dry pressure bandage. The patient must

remain lying down and is observed for bleeding for one hour. The patient's pulse, breathing,blood pressure, and

temperature are monitored until they return to

Medical workers filter the bone marrow following aspiration. (Custom Medical Stock Photo. Reproduced by permission.)

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

The patient should be able to leave the clinic and resume most normal activities immediately. 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. Walking or 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.

Complications

A small amount of bleeding and moderate discomfort often occur at the biopsy site. Rarely, reactions to anesthetic

agents, infection, and hematoma (blood clot) or hemorrhage (excessive bleeding) 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.

Results

Healthy adult bone marrow contains yellow fat cells, connective tissue, and red marrow that produces blood. Bone

marrow is evaluated for cellularity, megakaryocyte production, M:E ratio, differential (classification of blood forming

cells), iron content, lymphoid, bone, and connective tissue cells, and bone and blood vessel abnormalities. The bone

marrow of a healthy infant is primarily red (75-100% cellularity), but the distribution of blood forming cells is very

different than adult marrow. Consequently, age related normal values must be used.

Microscopic examination of bone marrow can reveal leukemia, granulomas, myelofibrosis, myeloma, lymphoma, or

metastatic cancers, bone marrow infection, and bone disease. Bone marrow evaluation is usually not needed to

diagnose anemia, but may be useful in cases that cannot be classified by other means.

Health care team roles

A physician requests or orders the procedure. The aspirate and biopsy are most often performed by a hematologist or

pathologist that has been trained in the procedure. The analysis of the bone marrow is done by a pathologist, and a

written report is added to the patients medical record. A histologic technician performs special stains for bone

marrow. Clinical laboratory scientists/medical technologists perform smear reviews and analysis of bone marrow cells

by flow cytometry. Cytogenetic technologists may perform chromosomal analysis of bone marrow white blood cells.

PROCEDURE Lumbar puncture

BEFORE THE PROCEDURE

Explain the procedure to the client and support persons. The primary care provider will be taking a small sample of spinal fluid from the lower spine. A local anesthetic will be given to minimize discomfort. Explain when and where the procedure will occur (e.g. the bedside or in a treatment room) and who will be present (e.g., the primary care provider and the nurse). Explain that it will be necessary to lie in a certain position without moving for about 15 minutes. A slight pinprick will be felt when the local anesthetic is injected and a Sensation of pressure as the spinal needle is inserted. • Have the client empty the bladde and bowels prior to the procedure to prevent unnecessary discomfort Position ned diup tile Uen tire turilbur puncture cut

DURING THE PROCEDURE Support and monitor the client throughout: Stand in front of the client and support the back of the neck and knees if the client needs help remaining still. Reassure the client throughout the procedure by explaining what is happening. Encourage normal hreatlrxrg and relaxation. Observe the client’s color, respirations, and pulse during the procedure. Ask the client to report headache or persistent pain at the insertion site. Handle specimen tubes appropriately: • Wear gloves when handling test tubes. • Label the specimen tubes in sequence. • Send the CSF specimens to the lab immediately.

Pincc’ a serull sterile drcrs’riny over the . .

AFTER THE PROCEDURE Ensure the client’s comfort and safety: i • Assist the client to a dorsal recumbent position with only one head pillow. The client remains in this position for 1 to 12 hours, depending on the primary care provider orders. Determine whether analgesics are ordered and can be given for headaches. • Offer oral fluids frequently, unless contraindicated, to help restore the volume of CSF. Monitor the client: • Observe for swelling or bleeding at the puncture site. • Monitor changes in neurologic status. • Determine whether the client is experiencing any numbness, tingling, or pain radiating down the legs. Document the procedure ui I bc ]ierrIs churt: tnicli,cfc., date ned mi’n:’rlur, tIre ci:ilcrr, character, neil CSE, and the number of speciirrcns obtained Also document CSP pressure nd the nurse’s assessments and interventions.

Abdominal paracentesis

BEFORE THE PROCEDURE

Prepare the client: Explain the procedure: obtaining the specimen usually takes about 15 minutes. Emphasize the importance of remaining still during the procedure. Tell the client when and where the procedure will occur and who will be present. Have the client void just before the paracentesis to reduce the possibility of puncturing the urinary bladder. I Help the client assume a sitting position in bed, in a chair, or on the edge of the bed supported by pillows. Maintain the client’s privacy and provide blankets for warmth.

DURING THE PROCEDURE-

Assist and monitor the client: Support the client verbally and describe the steps of the procedure as needed. Observe the client closely for signs of distress (e.g., abnormal pulse rate, skin coloç and blood pressure). Observe for signs of hypovolemic shock induced by the loss of fluid: pallor, dyspne diaphoresis, drop in B and restlessness or increased anxiety. • Place a small sterile dressing over the site of the incision after the cannula or aspirating needle is withdrawn

AFTER THE PROCEDURE

Monitor the client closely: • Observe for hypovolemic shock. • Observe for scrotal edema with male clients. I Monitor VS, urine output, and drainage from the puncture site every 15 minutes for at least 2 hours and every hour for 4 hours or as the client’s condition indicates.

• Measure the abdominal girth at the level of the umbilicus. Document all relevant information: • Include date and time performed; the primary care provider’s name; abdominal girth before and after; the color, clarity, and amount of drained fluid; and the nurse’s assessments and interventions. Transport the correctly labeled specimens to the laboratory:

Thoracentesis

BEFORE THE PROCEDURE

Prepare the client: I Explain the procedure to the client. Normally, the client may experience some discomfort and a feeling of pressure when the needle is inserted. The procedure may bring considerable relief if breathing has been difficult. The procedure takes only a few minutes, depending primarily on the time it takes for the fluid to drain from the pleural cavity.

To avoid puncturing the lungs, it is important for the client not to cough while the needle is inserted. Explain when and where the procedure will occur and who will be present. i Help position the client and cover the client as needed with a bath blanket.

DURING THE PROCEDURE-

Support and monitor the client throughout: • Support the client verbally and describe the steps of the procedure as needed. • Observe the client for signs of distress, such as dyspnea, pallor, and coughing. Collect drainage and laboratory specimens. Place a small sterile dressing over the site of the puncture

AFTER THE PROCEDURE

. Monitor the client

I Assess pulse rate and respiratory rate and skin color. Don’t remove more than 1,000 mL of fluid from the pleural cavity within the first 30 minutes. • Observe changes in the client’s cough, sputum, respiratory depth, and breath sounds, and note complaints of chest pain.

Position the client appropriately: • Some agency protocols recommend that the client lie on the unaffected side with the head of the bed elevated 30 degrees for at least 30 minutes because this position facilitates expansion of the affected lung and eases respirations. Document all relevant information: Include date and time performed; the primary care provider’s nanre; the amount, color, and clarib’ of fluid drained; and nursing assessments and interventions provided. Transport the specimens to the laboratory.

BONE MARROW BIOPPSY

BEFORE THE PROCEDURE

Prepare the client: • Explain the procedure. The client may experience pain when the marrow is aspirated and hear a crunching sound as the needle is pushed through the cortex of tIre bone. The procedure si rally or kes P to 30 or in ales. L.pl r ;.irnr aricl i1 LiL tlr

5 c ‘, ,,r’.rc’, P Jeri acs Hrcf I ipso posit on (xvi hr one p I Ioei I desired) fur a b ups, of lIce sternuir (sternal puncture) or a prone position for a biopsy of either iliac crest. rold the bedclothes back or drape the client to expose the area. • Administer a sedative as ordered.

DURING THE PROCEDURE-

Monitor and support the client throughout: • Describe the steps of the procedure as needed and provide verbal support. • Observe the client for pallor, diaphoresis, and faintness clue to bbs cling icr pa S vcrc a cgcrr’ iv I’’ Oil direct pressure vjer the site for P to U nniiiuteS to prevent bluebing Assist with preparing specimens as needed.

AFTER THE PROCEDURE

Monitor the client: • Assess for discomfort and bleeding frocithe site. The client may experience some tenderness in the area. Bleeding and hematoma formation need to be acsessecl for several days. Report bleeding or ),ilfl to ti LJr in . S i(YLJmc’nt 1 ore . in at uli. ii In cl Lide cIa te and t] me of the procedure, the n n ar’ care provider’s narriu; ae1 any nursing assessments and interventions. Document airy specimens obtained. Transport the specimens to the laboratory.

LIVER BIOPSY-

BEFORE THE PROCEDURE

Prepare the client: Give preprocedural medications as ordered. Vitamin K may be given for several days before the biopsy to reduce the risk of hemorrhage. • Explain the procedure and tell the client that the primary care provider will take a small sample of liver tissue by putting a needle into the client’s side or

abdomen. Explain that a sedative and local anesthetic will be given, so the client will feel no pain. Explain when and where the procedure will occu who will be present, the time required, and what to expect as the procedure is being performed (e.g., the client may experience mild discomfort when the local anesthetic is injected and slight pressure when the biopsy needle is inserted). • Ensure that the client fasts for at least 2 hours before the procedure. Administer the appropriate sedative about 30 minutes beforehand or at the specified time. Help the client assume a supine position with the upper right quadrant of the abdomen exposed. Cover the client with the bedclothes so that only the abdominal area is exposed

DURING THE PROCEDURE-

Monitor and support the client throughout: • Support the client in a supine position. • Instruct the client to take a few deep inhalations and exhalations and to hold the breath after the final exhalation for up to 10 seconds as the needle is inserted, the biopsy obtained, and the needle withdrawn. Holding the breath after exhalation immobilizes the chest wall and liver and keeps the diaphragm in its highest position, dvuiding injury to the lung and laceration of the liver. • Instruct the client to resume breathing when the needle is withdrawn. • Apply pressure to the site of the puncture to help stop any bleeding. Apply a small dressing to the site of the punctLcre.

AFTER THE PROCEDURE

Position the client appiopriately: Assist the client to a right side-lying position with a small pillow or folded towel under the biopsy site. Instruct the client to remain in this position for several hours.

Monitor the client: • Assess the client’s VS every 15 minutes for the first hour following the test or until the signs are stable. Then monitor vital signs every hour for 24 hours or as needed. Determine whether the client is experiencing abdominal pain. Severe abdominal pain may indicate bile peritonitis.

• Check the biopsy site for localized bleeding. Pressure dressings may be required if bleeding does occur. Document all relevant information: • Include date and time performed; the primary care provider’s name; and all nursing assessments and interventions. Transport the specimens to the laboratory.

LIFESPAN CONSIDERATIONS

CHILDREN

a Children may be frightened of even non invasive procedures to collect specimens if they are not sure what is going to happen. Cooperation can be maximized by:

Demonstrating on dolls or teddy bears. Allowing the child to examine and explore the collection materials being used. Explaining in age-appropriate language what will be done. Having parents actively involved in gently holding and comforting the child during and after the procedure. Being well prepared to conduct the procedure. Performing the procedure quickly. competently, and as gently as possible.

ELDERS

In elders homeostatic are not as efficient as in the younger person. When undewrgoing diagnostic tests that challenge these functions care must be taken to accurately monitor functions and note any challenges.emanples:

Dehydration and electrolyte imbalance can occur from laxative preps given before bowel diagnostic tests, such as a colonoscopy.

-‘ Fluid restrictions and NPO status for a length of time carl lead to hypovolemia and electrolyte imbalances.

• Many dye contrasts used for x-rays and scans can cause renal damage (especially in clients with diabetes).

• Sedatinn used for certain procedures may require a longer recovery time for older clients.

• Having several tests at a time or for several days compounds these potential problems and increases fatigue.

Interventions should focus on ensuring that the client is hydrated Fir np and after tl vse diagnostic tests, monitoring intake and output and signs frequently and accurately, and noting any mentalk status changes that might suggest electrolyte imbalance. Identification of clients at risk (person with kidney disease, or on certain medication)will help initiate measures to prevent injuries or complications from diagnostic tests.

KEY TERMS

Aspiration procedure to withdraw fluid and cells from the body.

Connective tissueells such as fibroblasts, and material such as collagen and reticulin, that unites one part of the

body with another.

Fibrosis condition characterized by the presence of scar tissue, or reticulin and collagen proliferation in tissues to the

extent that it replaces normal tissues.

Hematologist specialist who treats diseases and disorders of the blood and blood-forming organs.

Hematomalood that collects under the skin, forms a blood clot, and causes swelling.

Hemorrhageeavy bleeding.

Lymphocytesertain white blood cells that have an immune function. The lymphocytes are composed of three main

cell lines; B lymphocytes, T lymphocytes, and natural killer (NK) cells.

Myeloma (multiple myeloma) tumor of plasma cells that originates in bone marrow and usually spreads to more

than one bone.

Needle biopsyhe procedure of using a large hollow needle to obtain a sample of intact tissue.

Pathologist medical doctor that specializes in the study of diseases and laboratory tests.

Plasma cellsells in the blood and bone marrow that are formed from B lymphocytes, and that produce antibodies.

White blood cells (leukocytes)ells of the blood that are composed of neutrophils, monocytes, lymphocytes,

eosinophils, and basophils.

- Explain the procedure to patient or parents, the purpose to allay fear and nervousness.- Inform the patient or parents that more than one bone marrow specimen may be required to assess the proration of the disease and blood sample will be collected before the procedure for laboratory testing to determine the level of the immunity.- Inform the pt or the parent that a local anesthetic will be administered to maintain the physical and mental comfort for the pt.- Get a surgical consent form signed by the pt or parent to have legal documentation permission for the procedureconfirm time for procedure.- Start pt nil 4 hr before the procedure to avoid any vomiting and discomfort of pt.- In preparing a child more than 3 years old till him it is alright to cry if he want to but the pain will go away quickly to gain his co operation and confidence.- Position pt according to biopsy site and instruct him to remain as still as possible .Hold the child if necessary securely.- Assist doctor with mask gown and gloves and set up the sterile field to expedite procedure by being thoroughly prepared.

Source: http://www.nursing-lectures.com/2011/01/nursing-intervention-for-bone-marrow.html

Prepare dressing trolley:- 

- Doctor will clean chosen area ,administer local anesthetic ,insert the aspiration needle and withdraw bone marrow with 20 cc

syringe.

- After aspiration the nurse should apply firm pressure for 5-10 minutes to point of entry .spray and apply pressure bandage to

prevent complications after the procedure and reduce infection.

- Doctor will spread the specimen on slides to transfer properly labeled specimen to the laboratory promptly.

- Check that specimen is labeled correctly by doctor.

Source: http://www.nursing-lectures.com/2011/01/nursing-intervention-for-bone-marrow.html