THIS IS A VIDEO IN CLINICAL MEDICINE FROM THE NEW ENGLAND CLINICAL JOURNAL.

This video will demonstrate the procedure for bone marrow aspiration and bone marrow biopsy from the posterior iliac crest. Obtaining a bone marrow aspirate and core biopsy is often necessary when evaluating a patient who has a hematologic abnormality. Examining bone marrow is also useful in the diagnosis of metastatic spread of nonhematologic malignancies and to diagnose metabolic disorders. Gather the necessary equipment prior to performing the procedure. You will require equipment for sterile skin preparation and a sterile field:

1% lidocaine buffered with sterile sodium bicarbonate, a 25-gauge needle and 5-ml syringe, a bone marrow aspiration needle 2 30 mililitres syringes steril heparin sulfate steril gauze and bandage

several types of bone marrow biopsy needles are commercially available. This video will demonstrate the use of the gem sheedy needle for obtaining a cord biopsy.

There should be an aditional team member present responsible for inmediate preparation of specimens.

As you prepare to perform these procedures insure that there are no contraindications, that consent has been obtained after explaining the procedure and that you have gathered

the necessary equipment. Bone marrow aspiration and biopsy should not be performed if an infection of the bone is suspected. As the risk of bleeding with this procedure is low, XXXXXXXX is generally not a contraindication. The posterior iliac crest is the most common side used to obtain bone marrow. This side can be reached with the patient in either the prone or decubitus position. This video will demonstrate the decubitus position.

The patient should be positioned in the right or left lateral decubitus position with knees flexed. The posterior iliac crest is located at the center of the superior iliac spine. With the patient lying on his or her side, palpate the posterior iliac crest. If there is a reason not to use the posterior iliac crest, bone marrow aspiration from the posterior iliac crest may be performed. Though this turn can be used to obtain a bone marrow aspiration under exceptional circumstances, it is not suitable for a bone marrow biopsy.

Once the patient is positioned, the sid eshould be prepped with a clerk exiting scrubb and draped with steril tiles. As with all invasive procedures, meticulous care should be taken to minimise the risk of infection. While the invasiveness of the procedure may not necessitate a steril goune and mask, the operator should don sterile gloves and adhere to strict standard precautions.

At a minimum, the patient will need medication for procedural pain. The needs of each patient should be considered and discused in advance. Local or systemic analgesia or both may be indicated. Some patients may need medication to induce conscious sedation. Deep sedation is generally recommended for all pediatric patients. A separate clinician should be responsible for monitoring the patient's sedation and physiological status during the bone marrow procedure. After sterile preparation, 1% xxxxx cane should be slowly injected to raise a xxxxxxx over

the biopsy site. Then infiltrate the periostium with two to five mililiters of buffer liadicaine. In the awake patient, insure the adecuacy of local anesthesia by gently tapping the periostium with the tip of the needle used to deliver the anesthetic. Be sure that you have prepared the appropiate number of 30 milimetres syringes with and without heparine prior to starting the bone marrow aspiration. Inspect the bone marrow aspiration needle and remove the plaSTIC GUARD IF ONE IS PRESENT. Hold the needle horizontally and insert it in the skin over the posterior eliac crust. Advance the needle until it contacts bone. To engage the bone, the needle should be rotated alternately clockwise and counterclockwise while applying steady pressure. When the marrow cavity is entered, is certain decrease in resistance is usually felt. The ileum is a large bone and the marrow space should be located easily, however the angle of entry is important. In general the needle should be advanced at an angle completely perpendicular to the bony prominence of the eliac crest. Once the needle is through cortex and the marrow cavity is entered the needle should stay in place without being held, next remove the stilet, attach a 30 milimeters syringe without XXXXX and aspirate one mililiter of marrow with affirmed pull. Since the aspiration itself can be particularly painful, it is prudent to warn the conscious patient before you aspirate. Note that you may hand the syringe to an assistant or pathologist taking care to maintain sterility. The nine hypernise aspirate should be used to prepare specimen slides. Adecuacy of the specimen can be verified by the presence of bony specuels in the sample. Next aspirate marrow into syringes containing one milimiter heparin as needed for diagnostic test, remove the aspiration needle and apply pressure with sterile gause until you are ready to perform the biopsy. A bone marrow biopsy is often done following a bone marrow aspiration. Maintaining sterility obtaining a bone marrow aspiration needle, holding the needle between your palm and index finger, insert the needle into the patient's skin, and advance until it touches bone. If an aspirate has been performed, the same entry site through the skin may be used for the biopsy, however, a

skin incision may be indicated if only a bone marrow biopsy is being done or after an aspirant to allow for entry of the larger biopsy needle. While applying steady pressure, advance the needle with the stilet in place into the cortex by rotating back and forth. The biopsy needle should be inserted into bone at a slightly different angle than a previously performed aspiration. Once the needle is anchored in bone, remove the stylet, continue to advance the needle one to two centimeters into the marrow cavity with a back and forth rotating motion. The stylet may be reinstated to determine the lenght of the biopsy specimen in the needle. In order to remove the biopsy specimen, it must be detached from the surrounding meryl and bone. Do not pull the needle straight out as doing so may allow the specimen to remain attached to surrounding marrow and prevent it from being removed in the needle. Rotate the needle 360 degrees several times in both clockwise and counter-clockwise directions prior to removal. The needle should then be rocked back and forth to ensure detachment of the specimen from surrounding marrow. Slowly pull the needle out while continuing to rotate remove a specimen from the needle by inserting a sterile probe into the distal end of the needle and push the specimen through the hub onto sterile gauze or a slide. Inspect the specimen for adequacy of marrow. Apply pressure to the biopsy side with gauze until any bleeding stops and cover with a bandage or pressure dressing. Instruct the patient that the dressing can be removed the next day and that they should protect the wound from contact with water until a firm scab is formed. Any substantial bleeding from the side should be reported to the physician. The patient may experience soarness at the biopsy side for one to two days, it is best controlled with oral analgesics. The patient should be instructed that anything out of the ordinary should prop physician evaluation.

Occasionally, bone marrow cannot be aspirated. A dry aspiration may be due to inadequate angle of the needle insertion. In this case, repeat needle placement should be

performed. A dry tab can also be due to underlying bone marrow disease such as milofibrosis or certain hematologic malignancies. Removal of the biopsy needle without breaking off the course specimen is a common problem. In this case reinsert the biopsy needle, ensure that the specimen has been detached from the surrounding marrow before removing the needle and be sure to remove the biopsy needle slowly while continuing to rotate the needle. If the core specimen is too small or contains too much cortex, and too little marrow, consider obtaining an additional biopsy specimen.

A technician is often available to assist with preparation of the bone marrow aspirate and bone marrow biopsy. Aspirate smears may be prepared at the bedside from unheparinized bone marrow aspirate. This should be done quickly to avoid clotting of the specimen.

Bone marrow aspirate may also be sent to the lab for further analysis in heparinized syringes. The core biopsy specimen should be collected onto a sterile gauze or slide and inspected for adequacy of marrow. The biopsy specimen should be at least two centimeters in lenght in an adult patient. If desired, attached prep of the biopsy core can be made. Attach prep can allow for morphologic analysis similar to that obtained with an aspirate. After the tach prep the bone marrow biopsy specimens should be placed in a proper sterile specimen container.

A bone marrow aspirate and biopsy are useful tools in assessing a variety of hematologic oncologic and other disease processes that may involve the marrow space. Attention to detail and care for the patient can yield valuable information that is not available by routine blood studies.