Bone Marrow Aspiration and Biopsy

A Case Study Presented to College of Nursing Adventist University of the Philippines Putting Kahoy, Silang, Cavite

Submitted to Mrs. Jacqueline G. Polancos Submitted by Jeraldine A. Arguelles

December 05, 2012

I. INTRODUCTION

Bone marrow the soft tissue contained in the medullary canals of the long bone and in the interstices of cancellous bone, may be removed by aspiration and biopsy under local anesthesia . The bone marrow biopsy and aspiration procedure provides information about the status of and capability for blood cell production. It is not routinely ordered and in fact the majority of people will never have one done. A bone marrow aspiration and/or biopsy may be ordered to help evaluate blood cell production, to help diagnose leukemia, to help diagnose a bone marrow disorder, to help diagnose and stage a variety of other types of cancer that may have spread into the marrow, and to help determine whether a severe anemia is due to decreased RBC production, increased loss, abnormal RBC production, and/or to a vitamin or mineral deficiency or excess. Conditions that affect the marrow can affect the number, mixture, and maturity of the cells, and can affect its fibrous structure. (Pagana, 2009) A bone marrow sample may also be evaluated and cultured for the presence of microorganisms such as fungi, bacteria, or mycobacteria (such as that which causes tuberculosis) when the patient has a fever of unknown origin. Additional marrow testing may be ordered when it is suspected that the patient has a chromosomal abnormality and/or a disorder associated with iron storage that may cause iron to accumulate in the marrow. When a person is being treated for a cancer, a bone marrow aspiration and/or biopsy may be ordered to evaluate the response to therapy to determine whether suppressed marrow function is beginning to return to normal. A CBC and reticulocyte count are frequently ordered along with the bone marrow aspiration/biopsy. The results are used to help evaluate cell production in the marrow and compare it to current cell populations in the blood. Bleeding and infection may result from bone marrow biops at any site ,but the most serious complications occur at the sternum .Such complications occur at the sternum .Such complications are rare but include puncture of the mediastinum and causing mediastinitis or pneumoniditis. (Smeltzer, Suzanne C., Bare, Brenda G., Hinkle, Janice L., Cheever, Kerry H., 2010)

II.INDICATIONS

Examination of the bone marrow may be the next step that follows an abnormal clinical finding, such as an abnormal complete blood count (CBC), and/or an abnormal peripheral blood smear. It may also be performed following an abnormal bone image such as the finding of a lesion on x rays. Aspiration and biopsy of bone marrow shows the intact tissue, so that the structure of the fat cells, lymphocytes, plasma cells, fibrous connective tissue cells, and other cells, and their relationships to each other, can be seen. A bone marrow aspiration and biopsy biopsy is used to: (Fischbach, 2008)

diagnose and manage any form of leukemia or other myeloproliferative condition such as multiple myeloma

rule out or confirm bone marrow infiltration by malignancies such as Hodgkin's disease, non-Hodgkin's lymphoma, and metastatic carcinoma

monitor the effects of chemotherapy and the response or lack of response to treatment of blood disease

evaluate the success of bone marrow transplantation diagnose certain genetic diseases (e.g., lipid storage disease) investigate pancytopenia (a decrease of all blood cells in peripheral blood), neutropenia (decreased phagocytic white blood cells), or thrombocytopenia (decreased platelets)

diagnose an infection of unknown origin

investigate rare anemias for which a cause cannot be found or which does not respond to treatment as anticipated

obtain intact bone marrow for laboratory analysis diagnose some types of cancer or anemia and other blood disorders identify the source of an unexplained fever (e.g., granulomatous lesions) diagnose fibrosis of bone marrow and myeloma when bone marrow aspiration has failed to provide an appropriate specimen

The combination of aspiration and biopsy procedures are commonly used to ensure the availability of the best possible bone marrow specimen. The aspirate is collected at the same time as the bone core biopsy by attaching a syringe to the bone marrow needle and withdrawing the sample before the cutting blades are inserted and the bone core is removed. The aspirate is the sample of choice for studying and classifying the nucleated blood cells of the bone marrow (e.g., determining the ratio of immature white blood cells to red blood cells (M:E ratio). The biopsy is the only sample that shows the blood forming cells in relation to the structural and connective tissue elements (i.e., the microarchitecture) of the bone marrow. It provides the best sample for evaluating the cellularity of the bone marrow (the percentage of blood-forming tissue versus fat). (Malarkey and McMorrow, 2010)

III. CONTRAINDICATIONS There are few contraindications to bone marrow examination. The only absolute reason to avoid performing a bone marrow examination is the presence of a severe bleeding disorder which may lead to serious bleeding after the procedure. If there is a skin or soft tissue infection over the hip, a different site should be chosen for bone marrow examination. Bone marrow aspiration and biopsy can be safely performed even in the setting of extreme thrombocytopenia (low platelet count). (Leeuwen, Kranpitz & Smith, 2009)

IV. NORMAL VALUES / SIGNIFICANT FINDINGS

CELL TYPES

ADULTS

CHILD REN

INFANTS CLINICAL IMPLICATIONS 8% 0.1% 0.34% 6.9% 0.54% Elevated vera values:polycythemia

Normoblast,tot al

25.6% 0.2%-1.3%

23.1% 0.5% 1.7% 18.2% 2.7%

Depressed values: vitamin B12 or folic acid

Pronormoblast 0.5% - 2.4% Basophilic 17.9%Polychromatic Orthochromatic Neutrophils total Myeloblasts Promyelocytes Myelocytes Metamyelocytes Bands Segmented 29.2% 0.4% - 4.6% 56.5% 0.2% - 1.5% 2.1% - 4.1% 8.2% 15.7% 9.6% 24.6% 9.5% 15.3% 6% - 12% Eosinophils 3.1% 3.6% 2.6% 57.1% 1.2% 1.4% 32.4% 0.62% 0.76% 2.5% 11.3% 14.1% 3.6%

deficiency;hypoplastic oraplastic anemia

Elevated

values:

acute

myeloblastic or chronic myeloid leukemia Depressed lymphoblastic,lymphatic monocytic anemia values: or

- 18.3% 23.3% - 0 12.9%

leukemia;aplastic

Elevated values bone marrow carcinoma,lympadenoma myeloid leukemia,eosinophilic

leukemia ,pernicious anemia (in relapse)

Plasma cells

1.3%

0.4%

0.02%

Elevated values:myeloma,collagen disease,infection,antigen sensitivity,malignancy

Basophils

0.01%

0.06%

0.07%

Elevated values: no relation between basophil count and symptoms Depressed values: no relation between symptoms. basophil count and

Lymphocytes

16.2%

16.2%

49%

Elevated values: B and T cell chronic lymphocytic leukemia , other lymphatic leukemias

,lymphoma,mononucleosis,apla stic anemia,macroglobulinemia Megakaryocyte s 0.1% 0.1% 0.05% Elevated values: advanced age ,chronic myeloid vera

leukemia,ppolycythemia ,megakaryocytic

myelosis,infection,idiopathic thrombocytopenic purpura,thrombocytopenia Depressed values: pernicious anemia Myeloiderthyroi d ratio 2:1 to 4:1 2.9:1 4.4:1 Elevated values:myeloid

leukemia,infection,leukemoid reactions,depressed hematopoiesis Depressed values:agranulocytosis hematopoesis after

hemorrhage or hemolysis iron deficiency anemia polcythemia vera

III. PROCEDURE A bone marrow biopsy may be done in a health care provider's office or in a hospital. Informed consent for the procedure is typically required. The patient is asked to lie on his or her abdomen (prone position) or on his/her side (lateral decubitus position). The skin is cleansed, and a local anesthetic such as lidocaine or procaine is injected to numb the area. Patients may also be pretreated with analgesics and/or anti-anxiety medications, although this is not a routine practice. Typically, the aspirate is performed first. An aspirate needle is inserted through the skin using manual pressure and force until it abuts the bone. Then, with a twisting motion of clinician's hand and wrist, the needle is advanced through the bony cortex (the hard outer layer of the bone) and into the marrow cavity. Once the needle is in the marrow cavity, a syringe is attached and used to aspirate ("suck out") liquid bone marrow. A twisting motion is performed during the aspiration to avoid excess content of blood in the sample, which might be the case if an excessively large sample from one single point is taken. (Nettina, 2006) Subsequently, the biopsy is performed if indicated. A different, larger trephine needle is inserted and anchored in the bony cortex. The needle is then advanced with a twisting motion and rotated to obtain a solid piece of bone marrow. This piece is then removed along with the needle. The entire procedure, once preparation is complete, typically takes 1015 minutes.

IV. NURSING CARE BEFORE THE PROCEDURE (Beers, 2008) Explain the procedure to the patient Obtain a written and informed consent for this procedure Encourage the patient to verbalize fears because many patients are anxious concerning this study.

Assess the coagulation studies .Report any evidence of cougulopathy to the physician. Check the patients history for hypersensitivity to the local anesthetic Obtain an order for sedatives if the patient appears extremely apprehensive Remind the patient to remain very still throughout the procedure Inform the patient that he need not to restrict food or fluids Tell the patient who will perform the biopsy and when and where it will be done Inform the patient that more than one bone marrow specimen may be required and that a blood sample will be collected before biopsy for laboratory testing DURING THE PROCEDURE(Leeuwen, Kranpitz & Smith, 2009)

Note the following procedural steps for bone marrow aspiration,which is performed on the sternum ,iliac crest,anterior or posterior iliac spines,and proximal tibia (in children )

The nurse positioned the patient to the site that will be biopsied. for sternal or tibial biopsy,the supine position is used .Biopsy of the iliac crest requires lateral recumbent prone position .vertebral biopsy is performed with the patient in a seated position. prepare the skin by cleansing it with antiseptic solution

The nurse provides support and reassurance as the physician is till the local anesthesia. Caution the patient to remain immobile as the biopsy needle is inserted into the marrow .Some pain is felt as the marrow is aspirated

The nurse assists with the preparation and labeling of the slides. The clot and biopsy tissue are placed in a sterile specimen jar that contains fixative . POST TEST (Pagana, 2009)

Arrange for prompt transfer of specimens and slides to the laboratory Reassure the patient that a few days ,mild discomfort at the biopsy site is expected .Any signs of persistent bleeding or infection should be reported to the physician.

Bibliography Books: Beers, M. H. (2008). The Merck Manual of Medical Information 2nd Ed. Merck Fischbach, F. (2008). Manual of Laboratory and Diagnostic Test. Lippincott William and Wilkins. Leeuwen, Anne M., Kranpitz, Todd R., Smith, Lynette. (2009). Davis's Comprehensive Laboratory and Diagnostic Handbook. Saunders. Lichtman,, Marshall A. , et al. 6th Edition Williams Manual of Hematology. McGraw-Hill, 2003. Malarkey and McMorrow. (n.d.). Saunder's Nursing Gude to Laboratory and Diagnostic Tests. Nettina, S. M. (2006). The Lippincott Manual of Nursing Practice. Lippincott William and Wilkins. Pagana. (2009). Mosby's Diagnostic and Laboratory Test Reference. Smeltzer, Suzanne C., Bare, Brenda G., Hinkle, Janice L., Cheever, Kerry H. (2010). Brunner's and Suddarth's Medical-Surgical Nursing. Lippincott William and Wilkins.