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Introduction ⬇

Bone marrow is the major site of blood cell formation. Obtaining a specimen enables evaluation of overall blood composition, blood elements, precursor cells, and abnormal or malignant cells. A practitioner may obtain a bone marrow specimen by aspiration or needle biopsy. (See Obtaining a bone marrow specimen.)

Aspiration and biopsy help diagnose leukemia, multiple myeloma, anemias, and other blood disorders. They can also help assess bone marrow cellularity, cellular morphology, and maturation.1 During aspiration, the practitioner removes cells through a needle inserted into the marrow cavity of the bone. During a biopsy, the practitioner removes a small, solid core of marrow tissue through the needle. A physician, an advanced practice nurse, or another specially trained practitioner performs both procedures, usually at the same time, to stage the disease and monitor the patient’s response to treatment. Note that bone marrow biopsy is contraindicated in patients with severe bleeding disorders.1

Bone marrow aspiration and biopsy require a sedative, pain medication, or moderate sedation, depending on the patient’s condition.2,3,4

Equipment ⬆ ⬇

Equipment

Bone marrow tray (which generally includes sterile gauze or cotton balls; sterile forceps; sterile scalpel; sterile bowl; sterile marker; antiseptic solution [chlorhexidine-based preparation]2; two sterile fenestrated drapes; 4" × 4" [10-cm × 10-cm] gauze pads; 2" × 2" [5-cm × 5-cm] gauze pads; 10-mL or 20-mL syringes; 21G or 22G 1" [2.5-cm] or 2" [5-cm] needle; specimen container with appropriate fixative; bone marrow needle; biopsy needle; specimen tubes; glass slides and cover glass; sterile labels; adhesive tape; and sterile gloves) • gloves • sterile gown • mask with face shield or masks and goggles • vital signs monitoring equipment • pulse oximeter and probe • alcohol pads • 1% or 2% lidocaine with syringe and needle • labels • laboratory biohazard transport bag • Optional: prescribed antibiotic ointment, prescribed sedative, prescribed pain medication, emergency equipment (code cart with emergency medications, defibrillator, handheld resuscitation bag with mask, intubation equipment), moderate sedation medication, IV catheter insertion equipment, cardiac monitoring equipment.

Most of the equipment above is available in a sterile, prepackaged tray. Familiarize yourself with your facility’s tray and obtain any additional equipment needed.

Preparation of Equipment ⬆ ⬇

Preparation of equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility. If the patient is receiving moderate sedation, make sure that emergency equipment is functioning properly and readily available.

Implementation ⬆ ⬇

Implementation
  • Verify the practitioner’s order.
  • Gather and prepare the necessary equipment and supplies.
  • Confirm that informed consent has been obtained and that the signed consent form is in the patient’s medical record.5,6,7,8
  • Check the patient’s medical record for a history of allergies to the local anesthetic and pain and sedation medications.
  • Assess the patient for an increased risk of bleeding, and assess coagulation studies and complete blood count, as ordered.2
  • Conduct a preprocedure verification to make sure that all relevant documentation, information, and equipment are available and correctly identified to the patient’s identifiers.9,10
  • Perform hand hygiene.11,12,13,14,15,16
  • Confirm the patient’s identity by using at least two patient identifiers.17
  • Provide privacy.18,19,20,21
  • Reinforce the practitioner’s explanation of the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation. Answer any questions they may have.5,6,7,8
  • Tell the patient which bone the practitioner will aspirate. Inform the patient that the practitioner will administer a local anesthetic and that the patient will feel a heavy pressure during insertion of the biopsy or aspiration needle, as well as a brief pulling sensation. Tell the patient that the practitioner may make a small incision to avoid tearing the skin.
  • Encourage the patient to verbalize any discomfort or anxiety during the procedure.
  • Explain to the patient with osteoporosis that the needle pressure may be minimal and that a drill may be necessary.
  • Inform the patient that the procedure normally takes about 20 minutes, and that the practitioner may need more than one marrow specimen.
  • If appropriate, make sure that the aspiration site has been marked as directed by your facility.22
  • If the patient will be receiving moderate sedation, ensure patent IV access. (See the "IV catheter insertion and removal" procedure.)
  • Attach the patient to a cardiac monitor if moderate sedation will be used and the monitor isn’t already attached.2 Make sure that alarm limits are set appropriately for the patient’s current condition, and that alarms are turned on, functioning properly, and audible to staff.23,24,25
  • Assess the patient’s vital signs and oxygen saturation level by pulse oximetry to provide baselines to monitor for changes during and after the procedure.2,26
  • Screen for and assess the patient’s pain using facility-defined criteria that are consistent with the patient’s age, condition, and ability to understand.27
  • Perform hand hygiene.11,12,13,14,15,16
  • The practitioner puts on a cap and mask, performs hand hygiene, and puts on a sterile gown and sterile gloves.11,12,13,14,15,16
  • Prepare the sterile field, open the prepackaged tray, and prepare the supplies.
  • Assist with labeling all medications, medication containers, and other solutions on and off the sterile field.28,29
  • As ordered, administer a sedative, pain medication, or moderate sedation following safe medication administration practices.2,30,31,32,33,34
  • Raise the bed to waist level before providing care, to prevent caregiver back strain.35
  • Perform hand hygiene.11,12,13,14,15,16
  • Put on gloves.36,37,38
  • Position the patient according to the selected puncture site and instruct the patient to remain as still as possible. (See Preferred site for bone marrow aspiration and biopsy.)
  • Conduct a time-out immediately before starting the procedure to ensure identification of the correct patient, site, positioning, and procedure and that, as applicable, all relevant information and necessary equipment are available during and after the procedure.39
  • Using sterile forceps and sterile gauze or cotton balls, the practitioner cleans the puncture site with antiseptic solution and lets it dry. Then, the practitioner covers the area with sterile drapes.
  • Assist the practitioner, as needed, during the procedure.
  • To anesthetize the site, the practitioner infiltrates it with 1% or 2% lidocaine, using an appropriately sized needle to inject a small amount intradermally and then a larger 21G or 22G 1" to 2" (2.5-cm to 5-cm) needle to anesthetize the tissue down to the bone.1,2
  • When the needle tip reaches the bone, the practitioner anesthetizes the periosteum by injecting a small amount of lidocaine in a circular area about ¾" (2 cm) in diameter.1 The practitioner should withdraw the needle from the periosteum after each injection.
  • After allowing about 1 minute for the lidocaine to take effect, the practitioner may use a scalpel to make a small stab incision in the patient’s skin to accommodate the bone marrow needle. This technique facilitates entry and also helps avoid unnecessary skin tearing to help reduce the risk of infection and promote healing.1
  • Monitor vital signs, oxygen saturation, and pain levels throughout the procedure. For the patient receiving moderate sedation, see the "Moderate sedation" procedure. 2,26

Bone Marrow Aspiration

  • The practitioner inserts the bone marrow needle and lodges it firmly in the bone cortex. If the patient feels sharp pain instead of pressure when the needle first touches bone, the practitioner most likely inserted the needle outside the anesthetized area. If this is the case, the practitioner should withdraw the needle slightly and moved to the anesthetized area.2
  • The practitioner advances the needle by applying an even, downward force with the heel of the hand or the palm, while twisting the needle back and forth slightly. A "giving" sensation means that the needle has entered the marrow cavity.1,2
  • The practitioner removes the inner cannula, attaches a syringe to the needle, aspirates the required specimen (usually 3 to 5 mL), and removes the syringe.2
  • The practitioner or assistant places a small portion of the specimen on a glass slide to verify the presence of spicules. The remainder of the specimen is placed in the appropriate tubes for clot sections or molecular studies.2
  • The practitioner attaches a second syringe and aspirates additional samples, which are placed in the appropriate tubes.2
  • Assist by inverting all the tubes several times to thoroughly mix and prevent clotting.2
  • Label the specimen in the presence of the patient to prevent mislabeling.17
  • After needle removal, if a bone marrow biopsy isn’t being performed, the practitioner applies pressure to the aspiration site with a gauze pad for 5 minutes to control bleeding.2
  • Clean the area with an antiseptic solution and apply an antibiotic ointment, if prescribed.2
  • Apply a sterile pressure dressing.
  • Have the patient remain in a supine position for 10 to 15 minutes to maintain pressure at the aspiration site.2

Bone Marrow Biopsy

  • The practitioner inserts a biopsy needle into the periosteum through the same incision but at a slightly different site, and advances it steadily until the outer needle passes into the marrow cavity. The practitioner directs the biopsy needle into the marrow cavity by alternately rotating the inner needle clockwise and counterclockwise.1
  • The practitioner removes a plug of tissue, withdraws the needle assembly, and expels the bone core specimen on a glass slide or nonadherent dressing.2
  • After needle removal, the practitioner firmly presses a sterile 2" × 2" (5 cm × 5 cm) gauze pad against the incision for 5 minutes or until bleeding ceases.1
  • Clean the area around the biopsy with an antiseptic solution and apply an antibiotic ointment, if prescribed.2
  • Apply a sterile pressure dressing.
  • Assist the practitioner with touching the glass slides gently against the bone core biopsy sample to make imprints. Then help place the bone core sample in a specimen container with the appropriate solution (10% formalin fixative or sterile saline solution–soaked gauze) for processing.
  • Label the specimen in the presence of the patient to prevent mislabeling.17
  • Have the patient lie in the supine position for 10 to 15 minutes to maintain pressure at the biopsy site.2

Completing the Procedure

  • Discard used supplies in appropriate receptacles.36
  • Assist the patient into a comfortable position.
  • Return the bed to the lowest position to prevent falls and maintain the patient’s safety.40
  • Place the specimen in a biohazard transport bag and send it to the laboratory immediately.36
  • Remove and discard your gloves36 and perform hand hygiene.11,12,13,14,15,16
  • Continue to assess the patient until fully awake.2 Note that the duration of medications administered for sedation may extend the length of time needed to complete the procedure.
  • Reassess and respond to pain by evaluating the patient’s response to treatment and progress toward pain management goals. Assess for adverse reactions and risk factors for adverse events that may result from treatment.27
  • Perform hand hygiene.11,12,13,14,15,16
  • Document the procedure.43,44,45,46

Special Considerations ⬆ ⬇

Special considerations
  • Faulty needle placement may yield too little aspirate. If aspiration doesn’t produce a specimen, the practitioner must withdraw the needle from the bone (but not from the overlying soft tissue), replace the stylet, and insert the needle into a second site within the anesthetized field.2
  • The Joint Commission has issued a sentinel event alert concerning medical device alarm safety because alarm-related events have been associated with permanent loss of function and death. Among the major contributing factors were improper alarm settings, alarms turned off inappropriately, and alarm signals that are inaudible to staff members. Make sure that alarm limits are set appropriately, and that alarms are turned on, functioning properly, and audible to staff. Follow facility guidelines for preventing alarm fatigue.47
  • If the patient has received sedation, provide instruction about safety concerns and driving restrictions. Monitor the patient closely.
  • Bone marrow specimen collection shouldn’t occur from irradiated areas, because radiation may have altered or destroyed the marrow.1
  • Apply ice to the site, as needed and ordered, to reduce discomfort and the risk of bleeding.2

Patient Teaching ⬆ ⬇

Patient teaching

Instruct the patient and family (if applicable) to leave the sterile pressure dressing in place for 24 hours, according to the practitioner’s orders.2 Advise the patient to avoid strenuous activity, tub baths, hot tubs, swimming pools, and whirlpool baths for 48 hours after the procedure to allow the biopsy site adequate time to heal. Tell the patient to expect mild to moderate discomfort at the site for 24 to 48 hours. Instruct the patient to take analgesics as needed, but to avoid aspirin and nonsteroidal anti-inflammatory drugs for 24 hours to minimize the risk of bleeding from the site.2 Tell the patient to call the practitioner for bleeding or fever after discharge.

Complications ⬆ ⬇

Complications

Bleeding and infection are potentially life-threatening complications of aspiration and biopsy at any site. Rarely, tumor seeding or needle breakage may occur. Complications of sternal needle puncture are uncommon but include puncture of the heart and major vessels, causing severe hemorrhage; puncture of the mediastinum, causing mediastinitis or pneumomediastinum; and pulmonary emboli, sternal fracture, and puncture of the lung, causing pneumothorax.1

Documentation ⬆ ⬇

Documentation

Document the time and date of the procedure, the location of the aspiration and biopsy site, and the patient’s tolerance of the procedure. Note the amount and color of aspirated marrow, ordered laboratory tests, and the time you sent the specimen to the laboratory. Record the patient’s vital signs, oxygen saturation level, pain level, level of consciousness, and cardiac arrhythmias or other complications that occurred during the procedure, any prescribed interventions, and the patient’s response to those interventions. Document the type of dressing applied. Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

References ⬆

  1. ZehnderJ. L. (2020). Bone marrow aspiration and biopsy:

    Indications and technique

    . In: UpToDate, LarsonR. A. (Ed.).
  2. WiegandD. L. (Ed.). (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.). St. Louis, MO: Elsevier.
  3. McGrathP., et al. (2013). Procedural care for adult bone marrow aspiration and biopsy:

    Qualitative research findings from Australia

    . Cancer Nursing, 36, 309–316. (Level VI)
  4. TanasaleB., et al. (2013). Pain and anxiety during bone marrow biopsy. Pain Management Nursing, 14, 310–317. (Level VI)
  5. The Joint Commission. (2021). Standard RI.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  6. Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.11. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  7. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Patient’s rights. 42 C.F.R. § 482.13(b)(2)

    .
  8. DNV GL-Healthcare USA, Inc. (2020). PR.2.SR.3. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  9. The Joint Commission. (2021). Standard UP.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  10. Accreditation Association for Hospitals and Health Systems. (2020). Standard 30.00.14. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  11. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings:

    Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

    . MMWR Recommendations and Reports, 51(RR-16), 1–45. http://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)
  12. The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  13. World Health Organization. (2009). WHO guidelines on hand hygiene in health care:

    First global patient safety challenge, clean care is safer care

    . https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequence=1 (Level IV)
  14. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Infection control. 42 C.F.R. § 482.42

    .
  15. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.21. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  16. DNV GL-Healthcare USA, Inc. (2020). IC.1.SR.1. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  17. The Joint Commission. (2021). Standard NPSG.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  18. The Joint Commission. (2021). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  19. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Patient’s rights. 42 C.F.R. § 482.13(c)(1)

    .
  20. Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.16. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  21. DNV GL-Healthcare USA, Inc. (2020). PR.2.SR.5. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  22. The Joint Commission. (2021). Standard UP.01.02.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  23. GrahamK. C., & CvachM. (2010). Monitor alarm fatigue:

    Standardizing use of physiological monitors and decreasing nuisance alarms

    . American Journal of Critical Care, 19, 28–37.
  24. American Association of Critical-Care Nurses. (2018). AACN practice alert:

    Managing alarms in acute care across the life span-Electrocardiography and pulse oximetry

    . https://www.aacn.org/clinical-resources/practice-alerts/managing-alarms-in-acute-care-across-the-life-span (Level VII)
  25. The Joint Commission. (2021). Standard NPSG.06.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  26. The Joint Commission. (2021). Standard PC.01.02.03. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  27. The Joint Commission. (2021). Standard PC.01.02.07. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  28. The Joint Commission. (2021). Standard NPSG.03.04.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  29. Accreditation Association for Hospitals and Health Systems. (2020). Standard 25.01.27. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  30. TalamoG., et al. (2010). Oral administration of analgesia and anxiolysis for pain associated with bone marrow biopsy. Supportive Care in Cancer, 18, 301–305.
  31. The Joint Commission. (2021). Standard MM.06.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  32. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Nursing services. 42 C.F.R. § 482.23(c)

    .
  33. Accreditation Association for Hospitals and Health Systems. (2020). Standard 16.01.03. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  34. DNV GL-Healthcare USA, Inc. (2020). MM.1.SR.3. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  35. WatersT. R., et al. (2009). Safe patient handling training for schools of nursing. https://www.cdc.gov/niosh/docs/2009-127/pdfs/2009-127.pdf (Level VII)
  36. Occupational Safety and Health Administration. (2012). Bloodborne pathogens, standard number 1910.1030. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS (Level VII)
  37. SiegelJ. D., et al. (2007, revised 2019). 2007 guideline for isolation precautions:

    Preventing transmission of infectious agents in healthcare settings

    . https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level II)
  38. Accreditation Association for Hospitals and Health Systems. (202-). Standard 07.01.10. Healthcare Facilities Accreditation Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  39. The Joint Commission. (2021). Standard UP.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  40. GanzD. A., et al. (2013-reviewed 2021). Preventing falls in hospitals:

    A toolkit for improving quality of care

    (AHRQ Publication No. 13-0015-EF). Rockville, MD: Agency for Healthcare Research and Quality. https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html (Level VII)
  41. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.02.03. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  42. RutalaW. A., et al. (2008, revised 2019). Guideline for disinfection and sterilization in healthcare facilities, 2008. https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines-H.pdf (Level I)
  43. The Joint Commission. (2021). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  44. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Medical record services. 42 C.F.R. § 482.24(b)

    .
  45. Accreditation Association for Hospitals and Health Systems. (2020). Standard 10.00.03. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  46. DNV GL-Healthcare USA, Inc. (2020). MR.2.SR.1. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  47. The Joint Commission. (2013). Sentinel event alert 50:

    Medical device alarm safety in hospitals

    . https://www.jointcommission.org/assets/1/6/SEA_50_alarms_4_26_16.pdf (Level VII)