Bone Marrow Biopsy and Aspiration (Perform)
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
PREREQUISITE NURSING KNOWLEDGE
• 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:
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
• 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.
EQUIPMENT
• Bone marrow aspiration and biopsy kit, which includes the following:
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
• 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:
PATIENT AND FAMILY EDUCATION
• Assess patient and family understanding of the bone marrow aspiration and biopsy procedure and the reason for it. 
Rationale: Clarification of the procedure and reinforcement of information are expressed patient and family needs in times of stress and anxiety.
• Inform the patient and family (if permitted by patient) that the results will be shared with them as soon as they are available. 
Rationale: The patient and family are usually anxious about the results.
• Explain the actual procedure to the patient and family. 
Rationale: The patient and family are prepared for what to expect; anxiety may be decreased.
• Review safety requirements for patients who will receive pharmacologic agents for sedation (i.e., must have transportation and escort home and may not drive until the following day). 
Rationale: This review ensures patient safety and healthcare provider’s accountability for patients receiving sedation.
• Encourage the patient to verbalize any pain experienced during the procedure. 
Rationale: Additional lidocaine, pain medication, or sedation medication can be administered. Poor relaxation can cause the large gluteal muscles to spasm, making the procedure more difficult for all involved.
• Instruct patient and family to keep pressure dressing clean, dry, and in place for 24 hours after the procedure. 
Rationale: Proper dressing care reduces chance of bleeding and minimizes chance of infection at the site.
• Advise patient and family that a wrapped ice bag applied to the site over clothing may add comfort. The ice should never be applied directly to the skin. 
Rationale: Ice reduces swelling, decreases chance of hematoma, and adds comfort.
• Avoid applying heat to the procedure site. 
Rationale: Heat could exacerbate bleeding.
• Advise against non-steroidal anti-inflammatory drugs or aspirin for 24 hours after biopsy. 
Rationale: This measure reduces the chance of bleeding or hematoma at site.
• Advise use of acetaminophen for pain relief, if not contraindicated. 
Rationale: Acetaminophen relieves pain and does not promote bleeding.
PATIENT ASSESSMENT AND PREPARATION
Patient Assessment
• Assess patient’s home medications, including over-the-counter medications that can increase clotting time. 
Rationale: Assessment can decrease risk of bleeding and hematoma.
• Assess the need for antianxiety or analgesic medication or conscious sedation. 
Rationale: If the patient is very anxious before the procedure or has had severe pain with previous bone marrow procedures, small doses of analgesia or sedation promote patient comfort. Tense muscles can create a technically difficult procedure and add to pain and anxiety.
• Assess coagulation studies in patients who are taking anticoagulant medications. 
Rationale: Patients at risk for bleeding complications are identified.
• Assess the ability of the patient to lie on his or her stomach or side, with the head of the bed at no greater than a 25-degree elevation. 
Rationale: Access to and control of the posterior iliac crest is best obtained with the patient lying flat, or with the head of the bed only slightly raised, in a side-lying or prone position.
• Assess vital signs and oxygenation status. 
Rationale: Baseline data are provided. Assessment ensures that the blood pressure and oxygenation status can be maintained if the patient is placed on his or her side or prone.
• Assess the posterior iliac crest with palpation. In select cases, the anterior iliac crest may be used as a result of positioning limitations or excessive tissue surrounding the posterior iliac crest. However, an increased risk of injury to the surrounding nerves and blood vessels makes this procedure more complicated. The sternum is used for aspiration only in very select cases because of potential fatal complications with this procedure. It should be performed with cardiac monitoring by a physician. 
Rationale: Assessment identifies the most suitable area for obtaining optimal samples with a minimum of risk of discomfort and danger to the patient.
• Assess for recent bone marrow aspiration and biopsy sites. 
Rationale: The patient may have a painful experience if an additional biopsy is performed at a site that has not yet healed from a previous procedure. Penetration of scar tissue from previous bone marrow biopsy sites may also be difficult.
Patient Preparation
• Ensure that the patient and family understand pre- and postprocedural teachings and discharge instructions. Answer questions as they arise, and reinforce information as needed. 
Rationale: Understanding of previously taught information is evaluated and reinforced. The patient and family understand postprocedure care.
• Verify correct patient with two identifiers. 
Rationale: Prior to performing a procedure, the nurse should ensure the correct identification of the patient for the intended intervention.
• Obtain informed consent for bone marrow aspiration and biopsy and, if indicated, conscious sedation. 
Rationale: Informed consent protects the rights of the patient and makes a competent decision possible for the patient.
• Perform a pre-procedure verification and time out, if non-emergent. 
Rationale: Ensures patient safety.
• Prescribe analgesia or sedation, if needed. 
Rationale: Patient may need analgesia or sedation to ensure adequate cooperation and minimize discomfort during the procedure.
• Follow institution standard for a patient receving conscious sedation. 
Rationale: Preparation ensures that appropriate emergency equipment and medical staff are available.
• Obtain IV access for patients receiving sedation. 
Rationale: A secure patent IV line is necessary for administration of IV pharmacologic agents and, if necessary, emergency antagonist agents.
• Obtain a complete blood count and differential via venipuncture. 
Rationale: Many pathologists prefer to review a peripheral blood sample in conjunction with the marrow to make a complete and accurate diagnostic evaluation.
• Confirm availability of personnel who will assist with the procedure. If the procedure is to be performed without assistance, prepare all equipment and walk through the procedure for concise and accurate specimen acquisition. 
Rationale: Slide preparation, specimen processing, and additional supplies require an appropriately trained assistant for the procedure if available.
• Assist the patient to an appropriate position depending on the patient’s comfort and the practitioner’s preference. 
Rationale: Positioning ensures good visualization and control of the posterior iliac crest.
• Ensure site markings have been made where appropriate. Site may be marked with sterile marking pen. 
Rationale: Procedure site is identified.
References
1. Bain, BJ. Bone marrow aspiration. J Clin Pathol. 2001; 54:657–663.
2. Burkle, CM, et al. Morbidity and mortality of deep sedation in outpatient bone marrow biopsy. Am J Hematol. 2004; 77:250–256.
3. Ellis, LD, Jensen, WN, Westerman, MP. Needle biopsy of bone and marrow; an experience with 1,445 biopsies. Arch Intern Med. 1964; 114:213–221.
4. Gudgin, EJ, Besser, MW, Craig, JIO. Entonox as a sedative for bone marrow aspiration and biopsy. Int J Lab Hematol. 2008; 30:65–67.
5. Hyun, BH, Gulati, GL, Ashton, JK, Bone marrow examination. techniques and interpretation. Hematol Oncol Clin North Am 1988; 2:513–523.
6. Riley, RS, et al, A pathologist’s perspective on bone -marrow aspiration and biopsy. 1performing a bone -marrow examination. J Clin Lab Anal 2004; 18:70–90.
7. Vanhelleputte, P, et al, Pain during bone marrow aspiration. prevalence and prevention. J Pain Symptom Manage 2003; 26:860–866.
8. Van Marum RJ, Te Velde L. Cardiac tamponade following sternal puncture in two patients. Netherlands J Med. 2001; 59:39–40.
