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PROCEDURE
124 Bone Marrow Biopsy and
Aspiration (Perform)
Glen Peterson and Carrie Marvill
PURPOSE: The bone marrow aspiration and biopsy is performed to obtain
information on initial diagnosis, staging, or treatment response for hematology/
oncology patients.
PREREQUISITE NURSING disease testing may be requested, including culture and
gram stain, fungal culture, viral culture, polymerase chain
KNOWLEDGE reaction (PCR), acid-fast bacillus (AFB), or gomori methe-
namine silver (GMS) stain.
• The bone marrow aspiration and biopsy is a common ❖ A thorough understanding is needed of the anatomy
procedure performed on patients with a hematologic dis- and physiology of the posterior and anterior iliac crest
order or a suspected or previously diagnosed hematologi- and the sternum. The preferred site for a bone marrow
1
cal malignancy. It is performed during the initial diagnosis aspirate and biopsy is the posterior iliac crest. The
and/or staging and used to determine treatment response sternum may be used to aspirate marrow; however,
in patients with leukemia, lymphoma, multiple myeloma, a core biopsy cannot be obtained from the sternum
and other hematologic disorders. because of risk of damage to underlying organs, most
7,9
• The procedure is performed by physicians, advanced signifi cantly the heart.
practice nurses, physician assistants, and other healthcare ❖ Clinical and technical competence in performing a
professionals with special training and experience. It is bone marrow aspirate and biopsy is necessary.
typically completed at the bedside with local anesthetic ❖ Essential knowledge of sterile technique is necessary.
and minimal requirement for sedation, however moderate ❖ An understanding is needed of institutional policies
sedation may be performed in patients intolerant to the and procedures for administration of intravenous (IV)
procedure. pharmacological agents, including moderate sedation
• The procedure is performed at the preferred location of (if indicated) and intradermal and epicortical local
the superior, posterior iliac crest, usually while the patient anesthesia (lidocaine in most cases; procaine may be
is positioned in the prone or lateral (side-lying) position. used in cases of lidocaine allergy) and procedural care
Routinely, an aspirate is obtained from the cancellous of the patient receiving moderate sedation (if used).
(soft, spongy) portion of the bone after a needle is used ❖ Procedural care of the patient receiving IV moderate
to penetrate through the outer, fi rm cortical bone. Simi- sedation or oral antianxiolytics or pain medication
larly, a core biopsy is obtained with the use of a trephine should be understood.
coring needle either manually or with a power drill device. ❖ Knowledge is needed of information to be gained from
The sternum and anterior iliac crest may also be used in a bone marrow aspirate sample (i.e., identifi cation of
rare situations; however, this is discouraged because of normal and abnormal hematopoietic elements, identi-
the excessive risk of trauma to underlying tissues includ- fi cation of malignant clones with fl ow cytometry,
ing the heart. immunohistochemistry and other pathological analysis
• The bone marrow biopsy is generally a safe procedure; techniques, identifi cation of chromosomal abnormali-
however, infection, bleeding, and nerve damage (usually ties that occur in hematologic malignant diseases, iden-
due to nerve compressive hematoma) may occur. Care tifi cation of molecular diagnostic studies that show
should be taken to prevent such complications by maintain- gene rearrangements and translocations, and the per-
ing strict sterile technique, assuring coagulation laboratory formance of chimerism studies in patients after alloge-
parameters are met, anticoagulation therapy is managed neic transplant).
appropriately, and local hemostasis is maintained. ❖ A bone marrow biopsy is used for morphological anal-
• Multiple tests are required depending on the diagnosis. ysis of hematopoietic cells and for assessment of the
Common diagnostic tests include morphology, fl ow cytom- architecture of the bone marrow that may be abnormal
etry, cytogenetics, fl uorescence in situ hybridization (FISH), in certain disease states.
and molecular studies. Much less commonly, infectious ❖ Indications for bone marrow aspiration and biopsy
include the following:
This procedure should be performed only by physicians, advanced To diagnose a hematologic abnormality or malig-
practice nurses, and other healthcare professionals (including critical care nancy
nurses) with additional knowledge, skills, and demonstrated competence per To monitor a hematologic disease state after initial
professional licensure or institutional standard. diagnosis or therapy
1110
124 Bone Marrow Biopsy and Aspiration (Perform) 1111
To diagnose bone marrow involvement before stem • Nonadhering dressing (for core biopsy placement and
cell collection and for staging of various malignant touch preps)
states • One-roll paper micropore or Medipore tape
To assess the status of disease after autologous bone • Sterile gloves
marrow or hematopoietic stem cell transplant • Sterile gowns
To assess chimerism disease status and immune • Fluid shield, face mask, or goggles
reconstitution after an allogeneic bone marrow or • Specimen bags and labels
hematopoietic stem cell transplant • Required tubes for specimen processing (variable based
To evaluate immunodefi ciency syndromes or to on required tests; follow institutional standards): two
confi rm an infectious disease process in the marrow edetate disodium (liquid EDTA and/or EDTA lavender
❖ Contraindications to bone marrow biopsy and aspirate top) and two sodium heparin (green top) tubes, edetate
are the presence of hemophilia, severe disseminated disodium (EDTA) sterile solution (15 mg/mL; 2 mL total)
intravascular coagulopathy, or other related severe or prefi lled EDTA tube
bleeding disorders. Thrombocytopenia alone is not • Eight glass slides and cover plate
4,5 31
a contraindication to bone marrow examination, • 2 - to 6-inch spinal needle (may be required for anesthe-
although a platelet transfusion may be indicated if the tizing periosteum in the obese patient)
patient is severely thrombocytopenic or if bleeding • Container for bone core biopsy specimen, including
2
develops or persists after the procedure. The use of appropriate fi xative (10% formalin)
anticoagulant medications may pose a serious bleeding Additional equipment, to have available as needed, includes
risk; therefore, coagulation studies should be obtained the following:
in these patients. The decision on whether anticoagula- • Power drill
tion can be safely withheld before and restarted after • One vial of 100 units/mL heparin (follow institutional
the procedure is patient dependent and may require standards)
specialty consultation. • One vial of buffered lidocaine (optional: The addition of
sodium bicarbonate may minimize pain during lidocaine
7
EQUIPMENT administration. )
• Equipment for patients receiving moderate sedation:
• Bone marrow aspiration and biopsy kit, which includes ❖ Pulse oximeter with telemetry
the following: ❖ Automated blood pressure monitor
❖ Antiseptic solution (e.g., 2% chlorhexidine based ❖ Oxygen
preparation) ❖ Suction
❖ Two sterile fenestrated drapes ❖ Ambu bag
❖ One to two vial(s) of lidocaine (1% or 2%; 5 to 10 mL. ❖ IV pharmacological agents for sedation (i.e., midazolam,
Follow institutional standards; administration should 1 to 4 mg; lorazepam, 1 to 2 mg; fentanyl, 25 to 100 μ g;
12
not exceed 4.5 mg/kg or 300 mg ) morphine 2 to 4 mg; hydromorphone 0.5 to 2 mg)
❖ 5- or 10-mL syringe for drawing up lidocaine ❖ IV opiate and benzodiazepine antagonist agents (i.e.,
❖ Filter needle (if lidocaine drawn from glass vial) naloxone and fl umazenil)
❖ Needles of appropriate lengths to anesthetize both skin ❖ Emergency equipment
and periosteum
❖ Sterile 4 × 4 and 2 × 2 gauze pads PATIENT AND FAMILY EDUCATION
❖ Small scalpel blade
❖ Bacitracin or Bactroban ointment (optional; for inci- • Assess patient and family understanding of the bone
sion site post procedure) marrow aspiration and biopsy procedure and the reason
• Biopsy needle options: for it. Rationale: Clarifi cation of the procedure and rein-
❖ Illinois needle (16 gauge for bone marrow aspirate forcement of information may reduce patient and family
only) anxiety and stress.
❖ Jamshidi bone biopsy needle (for aspirate and core • Inform the patient and family (if permitted by patient) that
biopsy, 8 or 11 gauge, 4 inches or longer) the results will be shared with them as soon as they are
❖ TrapLok bone marrow biopsy needle (for aspirate and available. Rationale: The patient and family are usually
core biopsy, 8 or 11 gauge, 4 inches or longer) anxious about the results.
❖ SNARECOIL bone marrow biopsy needle (for aspi- • Explain the actual procedure to the patient and family.
rate and core biopsy, 8 or 11 gauge, 4 inches or longer) Rationale: The patient and family are prepared for what
❖ Powered bone marrow biopsy system (for aspirate and to expect and anxiety may be decreased.
core biopsy, 8 or 11 gauge, 4 inches or longer) • Review safety requirements for patients who will receive
❖ Extra long bone marrow biopsy needle may be required pharmacological agents for sedation (i.e., must have trans-
for obese patients portation and escort home and may not drive until the
• Two or three 20-mL syringes for bone marrow aspirate next day). Rationale: Review ensures patient safety and
• Blunt tip needles for drawing up ethylenediaminetetraace- accountability of the physician, advanced practice nurse,
tic acid (EDTA), heparin or other healthcare professional for patients receiving
• Adhesive bandage sedation.
1112 Unit VI Hematologic System
• Encourage the patient to verbalize any pain experienced positioning limitations or excessive tissue surrounding the
during the procedure. Rationale: Additional lidocaine, posterior iliac crest. However, an increased risk of injury
pain medication, or sedation medication can be adminis- to the surrounding nerves and blood vessels makes this
tered. The patient becomes a participant in care. Poor procedure more complicated. The sternum is used for
relaxation can cause the large gluteal muscles to spasm, aspiration only in very select cases because of potential
making the procedure more diffi cult for all involved. fatal complications with this procedure. It should only be
performed in the absence of lower-risk techniques and
PATIENT ASSESSMENT AND with special equipment and close cardiac monitoring by
PREPARATION an experienced physician. Rationale: Assessment identi-
Patient Assessment fi es the most suitable area for obtaining optimal samples
with a minimum of risk of discomfort and danger to the
• Assess the patient ’ s allergies and home medications, patient.
including over-the-counter medications that can increase • Assess for recent bone marrow aspiration and biopsy sites.
the risk of bleeding. Anticoagulant medications may need Rationale: The patient may have a painful experience if
to be held. Specialty consultation may be required to an additional biopsy is performed at a site that has not
clarify risks and benefi ts related to anticoagulation. Ratio- yet healed from a previous procedure. Penetration of scar
nale : Assessment can decrease the risk of bleeding, hema- tissue from previous bone marrow biopsy sites may also
toma, and allergic reaction. be diffi cult and yield inadequate results
• Assess the need for antianxiety or analgesic medication
or moderate sedation. Rationale: If the patient is very Patient Preparation
anxious before the procedure or has had severe pain with
previous bone marrow procedures, small doses of analge- • Ensure that the patient and family understand information
sia or sedation promote patient comfort. Tense muscles taught. Answer questions as they arise, and reinforce infor-
can create a technically diffi cult procedure and add to pain mation as needed. Rationale: Understanding of previously
and anxiety. taught information is evaluated and reinforced.
• Assess coagulation studies (PT/INR, PTT) in patients who • Verify that the patient is the correct patient using two
are taking anticoagulant medications. No recommenda- identifi ers. Rationale: Before performing a procedure, the
tions exist regarding minimal requirements for coagula- nurse should ensure the correct identifi cation of the patient
tion studies before bone marrow biopsy; however, based for the intended intervention.
on clinical guidelines for similar procedures and expert • Obtain informed consent for bone marrow aspiration and
opinion, a PTT goal of less than 1.5 times the control and biopsy and, if indicated, conscious sedation. Rationale:
INR less than 2 ( 1.5 if platelet count < 20) are recom- Informed consent protects the rights of the patient and
mended. 10 Rationale: Patients at risk for bleeding compli- makes a competent decision possible for the patient.
cations are identifi ed and anticoagulant medications may • Perform a preprocedure verifi cation and timeout. Ratio-
need to be held. nale: This ensures patient safety.
• Assess current cell blood count (CBC) for severe throm- • Prescribe analgesia or sedation, if needed. Rationale:
bocytopenia requiring pre- or intraprocedure transfusion. Patient may need analgesia or sedation to ensure ade-
No recommendations exist regarding minimal require- quate cooperation and minimize discomfort during the
ments for coagulation studies before the bone marrow procedure.
biopsy; however, based on clinical guidelines for similar • Follow institutional standards for a patient receiving
procedures and expert opinion, a platelet count of greater moderate sedation. Rationale: Preparation ensures that
than or equal to 20 is recommended. If the procedure appropriate emergency equipment and medical staff are
needs to be performed emergently and the platelet count available.
is greater than or equal to 10 but not greater than or equal • Obtain IV access for patients receiving sedation. Ratio-
to 20, platelet transfusion during and possibly after the nale: A secure patent IV line is necessary for administra-
10
procedure is recommended. Rationale: Patients at risk tion of IV pharmacological agents and, if necessary,
for bleeding complications are identifi ed and interventions emergency antagonist agents.
for bleeding prevention are completed. • Obtain a complete blood count and differential. Ratio-
• Assess the ability of the patient to lie in the prone or lateral nale: Many pathologists prefer to review a peripheral
position, with the head of the bed at no greater than a blood sample in conjunction with the marrow to make a
25-degree elevation. Rationale: Access to and control of complete and accurate diagnostic evaluation.
the posterior iliac crest are best obtained with the patient • Place the patient on a cardiac monitor. Rationale: This
lying fl at, or with the head of the bed only slightly raised, allows for assessment of patient status during procedure.
in a side-lying or prone position. • Assist the patient to an appropriate position depending
• Assess vital signs and oxygenation status. Rationale: on the patient ’ s comfort and the preference of the physi-
Baseline data are provided. Assessment ensures that the cian, advanced practice nurse, or other healthcare profes-
blood pressure and oxygenation status can be maintained sional. Rationale: Positioning ensures good visualization
if the patient is placed on his or her side or prone. and control of the posterior iliac crest.
• Assess the posterior iliac crest with palpation. In select • Ensure site markings have been made where appropriate.
cases, the anterior iliac crest may be used as a result of Rationale: Procedure site is identifi ed.
124 Bone Marrow Biopsy and Aspiration (Perform) 1113
Procedure for Performing Bone Marrow Aspiration and Biopsy
Steps Rationale Special Considerations
Bone Marrow Aspiration
1. Confi rm availability of personnel Slide preparation, specimen If the procedure is to be performed
who will assist with the processing, and additional supplies without assistance, prepare all
procedure. require an appropriately trained equipment and walk through the
assistant for the procedure if procedure for concise and accurate
available. specimen acquisition.
2 . HH
3 . PE Minimizes possible contamination of Apply mask.
procedure site.
4. Open the bone marrow procedure Maintains sterility of the procedure. An extra overbed table works well as
tray; add any additional supplies a procedure table. Clean before and
in a manner that preserves after each use.
sterility.
5 . HH
6. Apply sterile gown and gloves. Maintains sterility of the procedure.
7. Prepare all necessary syringes, Ensures adequate preparation for the
including lidocaine syringe and procedure and reduces distraction
those requiring anticoagulant. once the procedure is started.
8. Prepare the intended site with the Minimizes risk for infection.
antiseptic swabs (e.g.,
chlorhexidine-based preparation),
and place sterile drape.
9. With a 25–30-gauge needle, A small-gauge needle lessens the The use of buffered lidocaine may
inject the skin with lidocaine, discomfort associated with minimize the pain associated with
6
creating a wheal. administration of local anesthesia. administration compared with
7
lidocaine alone.
11 If the periosteum is not anesthetized If additional lidocaine is needed, ask
10. With a 21-gauge 2 -inch needle
(or spinal needle if necessary), the patient may have extreme the critical care nurse or person
infi ltrate the periosteum with discomfort. Also, assessing the area assisting to invert the extra vial. If
11
lidocaine in a “peppering” of the posterior iliac crest in an the 2 -inch needle does not reach
31
obese patient is often diffi cult. Use the bone, use the -inch spinal
fashion with 5–15 mL of 2
lidocaine (1–2%) with 1–2 mL of the spinal needle helps the needle to reach it. The spinal needle
bicarbonate buffer solution, if practitioner locate an appropriate can also be used to assess the
available. Downward pressure on site. geography of the posterior iliac
7
the tissue and stabilization of the Buffered lidocaine reduces pain. crest and allows the practitioner to
needle with the thumb and assess the depth of the bone.
forefi nger of the opposite hand It is helpful to anesthetize an area of
are helpful. about a quarter to half dollar size so
that adjustments can be made in
needle placement.
11. Make an incision over the biopsy Slight rotation of the needle allows If the patient experiences pain, it is
site with a small scalpel. Advance for smooth entry into the marrow recommended that the needle be
the aspirate needle (may also use cavity. placed in another section of bone or
biopsy needle or power drill Attempting to stabilize drill needle by additional lidocaine be applied to
device needle for aspirate) holding will tear sterile gloves. the outer surface of the bone.
through the incision (with Repositioning the needle even
stabilization of the needle with 2–3 mm from the site of pain may
the thumb and forefi nger of the reduce or eliminate the pain
opposite hand) to the periosteum sensation.
with fi rm pressure and slight Follow institutional training
rotation; penetrate the cortex. If a guidelines for use of the power drill
power drill device is used, DO device.
NOT hold the needle. A slight
sensation of “giving” is often
noticed as the marrow cavity or
medulla is reached.
Procedure continues on following page
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