n engl j med 361; october
8, 2009
e 28T h e ne w engl a nd jour na l o
f medicine
Bone Marrow Aspiration and Biopsy
Suman Malempati, M.D., Sarita Joshi, M.D., Susanna Lai, M.P.H.,
Dana A.V. Braner, M.D., and Ken Tegtmeyer, M.D.
From the Division of Hematology and
Oncology (S.M.) and the Division of Criti-
cal Care Medicine (S.L., D.A.V.B.), De-
partment of Pediatrics, Doernbecher
Children’s Hospital, Oregon Health and
Science University, Portland; and the Di-
vision of Hematology and Oncology (S.J.)
and the Division of Critical Care Medicine
(K.T.), Cincinnati Children’s Hospital Medi-
cal Center, Cincinnati.
N Engl J Med 2009;361:e28.
Copyright 2009 Massachutts Medical Society.Indications
Bone marrow aspiration is performed to obtain specimens ud to asss cellular morphology and to conduct specialized tests on the bone marrow, such as flow cytometry for immunophenotypic analysis, cytogenetic studies, or molecular stud-ies. It is a time-tested, reproducible procedure ud f
or the evaluation of hemato-logic conditions, cancers, metastatic dia, and storage disorders as well as some chronic systemic conditions. Bone marrow biopsy is often performed as part of the aspiration procedure and can provide more specific information about the cellular-ity of the marrow and the extent of dia.1 As with any invasive procedure, bone marrow aspiration and biopsy are best performed by trained clinicians who are aware of the indications and contraindications and knowledgeable about the man-agement of potential complications.
Contraindications
Bone marrow aspiration and biopsy have no absolute contraindications, but there may be relative contraindications related to the general condition of the pati剑的结构
ent or the risk of anesthesia or deep dation. An active infection at the propod site of aspiration, such as the posterior iliac crest, would preclude the u of the site. How-ever, the procedure can be performed at an alternative site if the indication for the procedure warrants it. Other sites that have been ud successfully to perform as-pirations include the anterior iliac crest, the manubrium of the sternum, the tibia (in infants), and, in extremely rare instances, the vertebral body. Thrombocytopenia and other coagulopathies are not contraindications for the procedure if it is execut-ed by a skilled clinician. The sternum is not recommended as a site for biopsy.
Equipment
To perform the procedure you will need sterile solution (preferably chlorhexidine,低碳环保作文
unless it is contraindicated, in which ca povidone–iodine may be ud), sterile drapes, sterile gloves, local anesthesia (1% plain lidocaine or 0.25% or 0.5% bupi-vacaine), a 25-gauge needle with two 5-ml syringes for administration of local an-esthetic, an 11-blade scalp虫儿飞舞蹈
el for stab incision, two larger syringes (10 ml or 35 ml), a bone 依繁钢管舞
marrow aspiration needle (preferably disposable), a bone marrow biopsy needle (Jamshidi, Islam, or disposable snare-coil biopsy needle), slides, prerva-tive-free heparin sulfate, and, if a trephine-biopsy specimen is to be obtained, for-malin or another fixative. Local anesthetic can be buffered with sterile sodium bi-carbonate to minimize irritation from the injection.
Sedation
Bone marrow aspiration and biopsy are painful procedures. At a minimum, the patient should receive a judicious amount of local anesthetic. For pediatric patients, the administration of deep dation by an anesthesiologist or other qualified pro-
bone marrow aspiration and biopsy
n engl j med 361; october 8, 2009vider of dation has become the standard of care — it should also be considered for patients of any age who may be anxious about pain during the procedure.
Procedure
Obtain connt from the patient 我的偶像作文600字
or from a parent or guardian. Review patient iden-tifiers to make sure you will perform the procedure on the intended patient. Be sure that the site you plan to u is the correct one. If the posterior iliac crest is the chon site, patients are generally placed in the lateral decubitus position or the prone position; the video demonstrates aspiration and biopsy with the patient in the decubitus position. Sterilize the site with the sterile solution, place a sterile drape over the site, and administer local anesthesia, letting it infiltrate the skin, soft tis-sues, and periosteum.
Bone Marrow Aspiration
After local anesthesia has taken effect, make an incision through which you can introduce the bone marrow aspiration needle. Some needles ud for intraosous access have a guard in place to keep the needle from passing all the way through the bone. If a guard is prent, you should remove it before starting bone marrow aspiration, to ensure adequate depth of penetration. Since the ileum is a large bone, the marrow space should be easy to locate, but the angle of entry is also important. In general, the needle should be advanced at an angle completely perpendicular to the bony prominence of the iliac crest (Fig. 1). Once the needle pass through the cortex and enters the marrow cavity, it should stay in place without being held.Once the periosteum has been penetrated, u pressure to advance the needle through the cortex and rotate the needle in a micircular motion, alternating clockwi and counterclockwi movements. If the patient is in the lateral posi-tio
n, you may stabilize the hip with your other hand so that you can get a better feel for the position and depth of the needle. You may u the thumb of this hand to mark the desired site and to prevent accidental repositioning of the needle. You will feel a slight give, after which you will feel that the needle is fixed solidly within the bone. Remove the stylet and aspirate approximately 1 ml of unadulter-ated bone marrow into a syringe (Fig. 2). An assistant should take the specimen from you and asss it for the prence of bony spicules; sometimes this can be done by merely looking at the flow of the blood in the syringe, but it is more eas-ily achieved by spreading a drop of blood on a slide or dish and allowing it to spread. Bony spicules will appear as irregularities in the otherwi smooth surface of the drop (Fig. 3). If the specimen shows spicules, the assistant should u it to make smear slides immediately. If spicules are spar or are not prent, a new sample should be obtained from a slightly different site.At this point, speed is important. Leave the needle in place and fill quential syringes that have been prepared with heparin or other anticoagulants or prerva-tives, depending on the requirements for specific studies to withdraw samples for additional analysis. Then remove the needle, either after reinrting the stylet or with the syringe attached.
Bone Marrow Biopsy You may u the same skin incision to perform a subquent core biops童谣怎么写
y, but adjust the needle for inrtion at a different angle into the bone itlf. With a clockwi motion, introduce the needle with the stylet in place to puncture the periosteum. Then withdraw the stylet and advance the needle with a micircular or circular motion to a depth of approximately 2 cm. You may u the stylet to asss the depth
of the specimen by gently inrting it into the needle until resistance is met. The
Figure 1. Bone marrow aspiration n eedle inrted into the iliac crest at an angle perpendicular to the bony
prominence.Figure 2. Aspiration of bone marrow
into a syringe.
Figure 3. Bony spicules in the aspirate confirm the prence of bone marrow.
n engl j med 361; october 8, 2009
distance from the hub of the needle to the screw-top of the stylet approximates the length of the biopsy specimen within the needle. In an adult, an adequate specimen is approximately 2 cm long. To make sure the biopsy specimen is not left behind when you remove the needle, twist the needle clockwi and counterclockwi v-eral times and rock it gently back and forth in multiple directions, then slowly ex-tract it from the bone. Once the needle is removed, extract the core by using an-other, thinner sterile stylet or a probe to push the specimen from the needle tip out the proximal end of the needle onto a sterile gauze or slide. The biopsy specimen can be ud to make touch-preparation slides at the bedside, but it should then be placed in a labeled sterile container.Apply pressure to obtain adequate hemostasis (this may take a few minutes, or longer in a patient with coagulopathy), then clean the area with alcohol or another disinfectant. Place clean or antibiotic-soaked gauze at the incision site, using a compression bandage. The bandage may be removed after 24 hours; once the ban-dage is removed, the area should be monitored for infection o
r delayed bleeding.Complications A bone marrow aspiration is a potentially hazardous procedure. Complications have been documented but are rare (incidence, 0.12 to 0.30%).2 All trainees must be super-vid until competence is ensured. Tho trained to carry out this procedure may include not only medical practitioners but also midlevel care providers.Complications may include trauma to neighboring structures (e.g., lacerations of a branch of the gluteal artery) and soft tissues, infection, and hemorrhage. The most commonly reported complication is hemorrhage.3 Risk factors for hemor-rhage include thrombocytopenia, concurrent u of anticoagulants, and the pres-ence of an underlying myeloproliferative disorder. Retroperitoneal hematomas re-sulting from trephine biopsies 4,5 have been reported, as have (on rare occasions) fractures of the underlying bone, especially in patients with osteoporosis. Patients and their family members should be instructed to watch for signs of bleeding or swelling at the procedure site and to ek immediate attention for anything out of the ordinary, particularly light-headedness or altered mental status that could reprent early signs of shock.
No potential conflict of interest relevant to this article was reported.
bone marrow aspiration and biopsy
References
Bain BJ. Bone marrow trephine biopsy. 1. J Clin Pathol 2001;54:737-42.
Idem.2. Bone marrow biopsy morbidity
and mortality. Br J Haematol 2003;121: 949-51.
Idem.3. Morbidity associated with bone
marrow aspiration and trephine biopsy — a review of UK data for 2004. Haema-tologica 2006;91:1293-4.
Arellano-Rodrigo E, Real MI, Munta-4. ola A, et al. Successful treatment by -lective arterial embolization of vere retroperitoneal hemorrhage condary to bone marrow biopsy in post-polycythemic myelofibrosis. Ann Hematol 2004;83:67-70.
Wahid SF, Md-Anshar F, Mukari SA, 5. Rahmat R. Massive retroperitoneal hema-toma with condary hemothorax com-plicating bone marrow trephine biopsy in polycythemia vera. Am J Hematol 2007;82: 943-4.
Copyright 2009 Massachutts Medical Society.
