Bone marrow biopsy procedure instructions and information

This content is anecdotal and is provided only as an example of what certain medical professionals providers have done.

Bone marrow biopsy protocol

Paperwork

1. Speak to the patient about the indication for the procedure, and the potentials risks and benefits. Obtain informed consent, mentioning risks of: risk of infection, bleeding, pain, scar formation, and failure to obtain adequate specimen.
2. Label requisitions and complete paperwork with patient's identifying information, clinical history, and studies requested for bone marrow prior to the procedure to avoid delay in delivering the samples to the lab. If one plans to send markers/flow or special stains, it is recommended to notify the Hematology Pathology Lab.

Schedule

1. When possible, please inform the patient's nurse of the appropriate time of the procedure to ensure patient availability.
2. Collect materials (see below)
3. All patients should have a CBC/diff drawn on or about the day of the bone marrow examination. This will help for clinical correlation with the findings of the bone marrow aspirate and biopsy.

Safety

1. Gloves and goggles should be worn during all procedures.
2. To minimize the risk of injuries while transferring blood from syringes to vacutainers, one can use a "multi-sample transfer set luer adapter/holder" or similar item.

Materials

1. Depending on specific needs, one can set up an unsterile tray with:
   • preservative for biopsy
   • requisition paperwork for the specimen
   • vacutainer tubes (EDTA, heparin, yellow tube for extra studies)
   • extra aspirate and Jamshidi needles (if not in the bone marrow biopsy kit, or if one wishes to use different needles than what is provided)
   • unopened bottle of EDTA
2. Sterile bone marrow biopsy kit
3. Sterile gloves
4. Chux

Preparation

1. Place patient in prone or lateral decubitus position.
2. Locate the posterior iliac spine and mark with thumbnail pressure or a ballpoint pen.
3. Place Chux under patient and work area.
4. Prepare the skin with 3 Povidone-iodine (PVP-I, Betadine) swabs, cleaning from the intended biopsy area outward in increasingly large concentric circles. The area can optionally be additionally be swabbed with acetone/alcohol to clean the iodine off the skin.
5. If samples are to be collected for culture, chromosomes or marker studies, set up unsterile yellow, green, or purple tubes for easy accessibility.
6. Open sterile tray.
7. Open Jamshidi package and aspirate needles and drop onto sterile field.
8. Put on sterile gloves. Depending on the glove, one may wish to wipe excess powder with a sterile alcohol wipe to prevent talc from getting in the sample.
9. Position a sterile towel under patient and drape the biopsy site.
10. Fill a 12 mL syringe with lidocaine using a 21 gauge needle.
11. Raise a skin wheal with lidocaine using a 25 gauge needle.
12. Replace the 25 gauge needle with the 21 gauge needle. Infiltrate the subcutaneous and intramuscular areas and--most importantly--periosteum. At the periosteum, try to administer the lidocaine in a circular fashion to numb an area at least the size of a dime (1 cm diameter). Adequate administration of lidocaine to the periosteum is one of the most important factors for patient comfort. Usually 5 to 10 mL lidocaine is sufficient.
13. Allow about 5 minutes for the lidocaine to take effect. During this time:
    • Unscrew cap of sterile EDTA tube (if one plans to use this to prime the aspirate syringe).
    • Pull the plungers back on the syringes you will be using to break their seal, then return the plungers to the down position.
    • Set up slides for the touch prep (if planned). If smears will be made at the bedside, place two slides on a gauze at a slight (30 degree) angle and stack other slides nearby. (Alternatively, you may use a watchglass over a cup of ice as outlined below in the "Watchglass technique" section).
14. To test whether the periosteum has been adequately anesthetized, you can use the 21 gauge needle to lightly tap the intended biopsy location and ask if the patient feels any pain.

Bone marrow aspirate

1. If EDTA is being used to prime the aspirate syringe, prime the 6 mL syringe with EDTA using the 18 gauge needle. Push out all excess EDTA; only a little is needed to wet the inside of the syringe.
2. Make a 3 mm incision at puncture site with scalpel blade (optional).
3. Remove the shaft guard that comes with most aspirate needles unless a sternal aspirate is being performed.
4. Hold the aspirate needle with the proximal end in the palm and index finger against the side of the needle's metal shaft near the tip. This position stabilizes the needle and allows better control.
5. Introduce the needle through the incision pointing toward the anterior superior iliac spine and bring the needle into contact with the posterior iliac spine.
   • If you have introduced the needle to the anesthetized area of the periosteum, the patient should feel only pressure; no pain. If the patient feels pain, either reposition the needle, gently inch along the periosteum with the needle to find the anesthetized spot, or administer more lidocaine.
6. Using gentle but firm pressure, advance the needle while rotating it in an alternating clockwise-counterclockwise motion. Entrance into the marrow cavity is generally detected by decreased resistance.
7. Twist off the cap at the proximal end of the aspirate needle. Pull the stylet out of the needle.
8. Attach the 6 mL syringe to the hub of the aspirated needle.
9. Warn the patient that they may feel a cramping sensation and pain when marrow is being aspirated.
10. Apply negative pressure by withdrawing the syringe plunger with one quick pull. The majority of the spicules will be in the first 0.5 mL obtained from the initial pull. Do not dilute the sample by aspirating more than 1 mL.
11. Remove the syringe and replace the stylet into the aspirate needle, informing the patient not to move since the needle is still in place.

Aspirate sample preparation

1. Examine the aspirate sample for adequacy as demonstrated by the presence of spicules. If spicules are not obtained, it may be necessary to draw from a new site.
2. Place at least 0.4 mL of marrow aspirate in the EDTA tube. Invert the tube immediately several times to ensure anticoagulation of the sample. The Hematology Pathology lab will make the aspirate slides for you.
3. If adequate spicules were not obtained or if this was a dry tap, return to the bone marrow aspirate section above, and using a new aspirate needle, repeat the procedure as outlined. Using a 12 mL syringe may create greater suction and increase the chances of a successful marrow aspiration. Please note that using the same aspirate needle increases the chance of a clotted sample because of tissue factor contamination of the needle at the time of the initial pull.
4. If you prefer to break sterility and then reglove, you may make slides using the watchglass technique as described below.

Additional samples

1. Reattach the 6 mL syringe and aspirate the remainder of the marrow needed:
   • Please note that you should always invert each tube immediately after placing the marrow aspirate into the specimen tube to ensure adequate anticoagulation of the sample.
2. Since these tubes cannot be sterilized for inclusion into the marrow kit, one can either:
   • Obtain assistance from an assistant who is unsterile and can handle the specimen tubes.
   • Handle the unsterile tubes with a sterile gauze.
   • After breaking sterility by handling the tubes themselves, people performing the bone marrow biopsy will need to unglove and reglove with sterile gloves.
   • Marker studies are performed on 2 mL of marrow aspirate in a purple top tube (EDTA).
   • Chromosome studies are performed on 2 to 3 mL marrow in a green top tube (heparin).
   • Cultures (bacterial, fungal, AFB) are performed on 1.5 mL of marrow in a small dark yellow top isolator tube. Please note that the large light yellow top tubes contain ACD and should not be used. Oftentimes, HIV/AIDS patients should have a yellow isolator tube--labelled "isolator microbial tube"--sent.
   • Viral cultures are performed on 1 mL marrow in an EDTA tube and placed immediately on ice.
3. If additional samples are taken, a clot section may be done by leaving 0.1 mL of marrow aspirate to clot in the syringe. This clot is then placed in the preservative with the biopsy at the end of the procedure.

Bone Marrow Biopsy

1. Remove the aspirate needle from the biopsy site. One may apply pressure briefly with sterile gauze if there is excess bleeding.
2. Introduce the Jamshidi needle through the same incision, but aim the needle in a direction slightly different from that used for the aspirate.
3. Using a gentle but firm pressure, advance the needle, rotating the needle in an alternating clockwise-counterclockwise motion (for better cutting) until the bone cavity has been entered. One can tell that the cavity has been entered if the needle stays firmly planted in the patient even after the person performing the procedure lets go of the needle.
4. Remove the cap at the top of the needle, and remove the obturator/stylet in the middle of the needle.
5. Advance the empty needle 10 to 20 mm into the marrow using the same motion. The obturator may optionally be gently dropped back into the Jamshidi to assess the size/adequacy of the core (optional). Some kits also contain specialized probes for this purpose.
6. Some kits contain "trap" cutting blades (also known as trapsystem) which can be inserted at this time into the Jamshidi at this time to increase chances of retaining the bone marrow biopsy specimen when the needle is withdrawn.
7. Rotate the needle with quick, full twists several times to the right and to the left to separate the bone marrow biopsy specimen. Some people like to slightly withdraw the Jamshidi needle, change the angle, and advance the needle a bit to try to cut off the bone marrow biopsy specimen.
8. Slowly remove the needle.
9. After withdrawing the needle, place a gauze over the incision site, and turn your attention to the biopsy.

Handling of the biopsy specimen

1. If touch preps are desired, remove the specimen by gently inserting the probe through the distal cutting end and allow the sample to fall on a gauze pad.
2. Take a glass slide and gently touch the slide to the biopsy (touch preps) at three to four sites on the slide. Make two such slides.
3. After preparing the touch preps, or if they are not desired, drop the biopsy specimen into the container of formalin preservative. Ideally, the bone marrow biopsy specimen is 2 cm in length, but at least 1 cm to faciliate adequate review by pathology.
4. Remove the syringe's plunger which has the residual clot from the aspirate. Invert the syringe so that the clot section drops into the formalin as well. If the clot does not readily fall out, use the Jamshidi probe to loosen the edges of the clot and allow it to drop out.
5. If biopsies are obtained from two separate sites, place the samples in two separate, labeled formalin containers.

Final patient care

1. Clean all the Povidone-iodine (PVP-I, Betadine) off the patient with alcohol or warm water.
2. Place gauze pads over the incision and cover with a bandaid. If possible, have the patient lie with their weight on the incision to enhance hemostasis.
3. Post-procedure discomfort can be managed with Tylenol.

Cleanup and processing

1. Dispose of needles and scalpel in appropriate sharps containers.
2. Remove and discard all remaining marrow-related materials from the patient's bedside.
3. Stack slides and tubes safely for transport to lab.
4. Write a procedure note in the patient's chart briefly documenting the time, the site of the procedure and how the patient tolerated the procedure. If special samples were obtained (cultures, etc.), this can be documented here as well.
5. Bring samples to the Hematology Lab as quickly as possible if collected at the hospital or notify the phlebotomist if done in the clinic.

Watchglass technique

Aspirate smears may also be made by the following technique which might require gloving/ungloving or assistance or another person.

1. Ahead of time, place a watchglass on a cup of ice.
2. After 0.5 mL of marrow is aspirated, eject some of the marrow into a watchglass near the rim. Some should be put in an EDTA tube as well.
3. Using a Pasteur pipette, pick out spicules from the aspirate in the watchglass and place them on a coverslip.
4. Gently place another coverslip over two-thirds of the coverslip with marrow and gently slide apart, pulling each coverslip in an opposite direction.
5. Repeat the procedure by putting other spicules on other coverslips and making as many coverslips as possible.
6. At the completion of marrow, place the residual clotted marrow in the watchglass into the preservative preparation as a clot section.

Bone marrow biopsy and aspirate procedure note

Procedure: Bone marrow biopsy and aspirate
Indication: ___________
Performed by: ___________
Assistant: _(if any)__

Written and verbal informed consent were obtained by the patient and placed in the chart. The indication and risks of bone marrow biopsy and aspiration were discussed, including risk of infection, bleeding, pain, scar formation, and failure to obtain adequate specimen.

Time out was performed to confirm patient identification with two identifiers. The area to be biopsied was located using anatomic landmarks. The left/right posterior superior iliac crest was sterilely prepped and draped in the usual manner with Povidone-iodine (Betadine) swabs. Using sterile technique, 2% lidocaine was generously administered to the tissue and periosteum, with confirmation by the patient that we had achieved adequate analgesia. Aspirate needle was inserted, and bone marrow aspirate was obtained with confirmation of adequate spicules. The aspirate needle was withdrawn. Bone marrow biopsy was performed with adequate marrow specimen obtained. Biopsy needle was removed, and there was no significant post-procedural bleeding or immediate complications. The area was covered with gauze and an adhesive bandage. The patient was given post-procedural instructions, including not to shower until tomorrow and, if possible, to lie down with pressure on the biopsy location. The patient tolerated the procedure well. Specimens were sent for pathology examination, flow cytometry, and cytogenetics.

Risks

Risks of bone marrow biopsy and aspiration include risk of infection, bleeding, pain, scar formation, and failure to obtain adequate specimen.

Patient information

• Bone marrow aspiration and biopsy patient information sheet (excellent handout by Rush.edu)
• Bone marrow aspiration and biopsy patient information sheet (Kidshealth.org)
• Bone marrow aspiration and biopsy patient information sheet (MedlinePlus)
• Bone marrow aspiration and biopsy patient information sheet (Drugs.com)

Contents of a sterile bone marrow biopsy kit

Individual kits may vary; this is provided just as an example.

Packaged separately and attached outside the sterile cover

• 3 Providone Iodine Swab Sticks (1% Iodine)
• 1 Disposable Illinois aspiration needle
• 1 Disposable Jamshidi biopsy needle
• 3 Acetone/alcohol swab sticks
• 2 Band-aids

Packaged within the sterile cover

• 1 Towel
• 1 Fenestrated Drape
• 1 12 mL syringe (non-Luer lock)
• 1 3 mL syringe (non-Luer lock)
• 2 6 mL syringe (non-Luer lock)
• 3 Needles: 18 gauge, 21 gauge, and 25 gauge
• 1 30 mL bottle of lidocaine HCI (10 mg/mL)
• 1 Scalpel blade
• 10 Frosted slides
• 1 1 mL screw top Potassium EDTA tube
• 10 Gauze pads
• 1 Kelly clamp
• 2 Pasteur pipette bulbs

References

• Bone marrow biopsy protocol, Watchglass technique, and contents of bone marrow biopsy kit were adapted with permission from the Fellows' Handbook of the Division of Hematology/Oncology at Beth Israel Deaconess Medical Center, Boston, MA.