Bone marrow biopsy

The purpose of this guideline is to provide guidance about bone marrow biopsies at Great Ormond Street Hospital (GOSH). 

Note: While this guideline refers to the ‘child’ throughout, all activities are applicable to young people.

A bone marrow biopsy is performed to examine the bone marrow and identify any abnormality in the developing blood cells to confirm a diagnosis and to allow additional tests. (Bailey and Skinner 2010)  (Rationale 1). 

Children who may have a biopsy include those with haematological, oncological, metabolic, immunological conditions and infections.

Background

The blood cells in the marrow are examined for their shape, size, number and characteristics, for example immune phenotype and cytogenetics (Rationale 2).

The bone marrow biopsy can be an aspirate or a trephine. An aspirate involves obtaining a small volume of bone marrow from inside the bone using a bone marrow needle. A trephine is the removal of a small 'core' of bone marrow to show the structure of the bone marrow cavity – this procedure must be carefully discussed and be at the discretion of the Haematology Consultant (Bailey and Skinner 2010: Macqueen, Bruce and Gibson 2012) (Rationale 3).

Bone marrow can be aspirated from the following sites (Rationale 4):

  •  posterior iliac crest (most commonly used) 
  •  upper portion of tibia (babies only)
  •  sternum (rarely used). 

This procedure is usually performed once the child has received a general anaesthetic in theatre or in specified clinical areas, for example Safari Day-care (Rationale 5). Occasionally older children may have a biopsy performed using local anaesthetic whilst sedated.

When the procedure is performed, a doctor and the anaesthetist must be present. A nurse with relevant experience (preferably registered children's nurse) must be present throughout the procedure (Rationale 6).

Inform child and family

Inform child and family of the following (Rationale 7 and Rationale 8):

  • that a marrow aspirate and/or biopsy is necessary
  • the reason for the aspirate/biopsy
  • what it entails
  • the potential risks of an aspirate/biopsy
  • the duration of the procedure.

If the biopsy is to be performed using a general anaesthetic the child's doctor or nurse, who has received the necessary training and is authorised to take consent, must obtain written consent (Rationale 9). If necessary, contact an appropriate play specialist or nurse to work with the child (Rationale 10).

Supply the child and their parents with the appropriate information leaflet, obtainable online, or from speciality teams or the Family Information Centre (Rationale 11).

Preparation

If an anaesthetic is to be used, the child must be nil orally according to hospital policy (Rationale 12). Blood test results, for example full blood count (Rationale 13), should be available prior to performing the biopsy.  

Guidelines for platelets:

  • A bone marrow aspirate - there is no minimum platelet level (bone marrow aspirates can be performed even if the result is in single figures). 
  • A bone marrow trephine must only be performed if the platelet levels are >30 x 109/l. 

Advice may be sought from the Theatre Coordinator for Haematology/Oncology on bleep 0419 or from the general anaesthetic guidelines for ICI-LM Clinical Division.

The following equipment will be required:

  • dressing pack
  • sterile gloves
  • alcohol-based antiseptic ChloraPrep®, 2% chlorhexidine in 70% isopropyl alcohol (see below for alternative solutions for infants under 35 weeks and where there is any skin reaction to the solution)*
  • 20ml syringes
  • local anaesthetic if required
  • needles and syringes for local anaesthetic
  • bone marrow aspiration needle
  • trephine needle if required
  • glass slides
  • slide container
  • specimen bottles i.e. lithium heparin 5ml x1 (cytogentics), minimal residual disease (MRD and immunophenotyping) bottles x 2 from haematology
  • plain sterile pot, 0.9% saline solution and sterile gauze/formalin pot for trephine sample
  • pencil
  • Micropore/Transpore tape. 

*Infants under 35 weeks: 2% chlorhexidine gluconate in 70% isopropyl alcohol should not be used on the skin of pre-term infants under 35 weeks gestational age.

Skin reactions: 2% chlorhexidine gluconate in 70% isopropyl alcohol can be used with caution in children under two months of age. However, if there is any evidence of skin reaction in this age group, discontinue its use and consult the following for further advice:

Alternative antiseptic solutions:

  • Povidone-iodine 10%
  • 0.5% chlorhexidine gluconate in 70% isopropyl alcohol.

Staff should perform a surgical hand wash prior to commencing the procedure. Standard (universal) precautions must be adopted. The medical staff should prepare the equipment for use adopting an aseptic technique. (Macqueen, Bruce and Gibson 2012) (Rationale 14).

Perform procedure

As soon as the child is anaesthetised they should be monitored with an oxygen saturation monitor (Rationale 15).

If the procedure is being performed on the ward the child’s parents may remain with their child if they wish to do so.

If a local anaesthetic is used the drug should be checked according to the Medicine Administration Policy (Rationale 6). The child’s doctor administers the local anaesthetic into the proposed puncture site and should wait for it to take effect (Rationale 16).

Whilst the child is anaesthetised the following should be observed:

To perform the procedure:

  • Once anaesthetised, position child on their side with the proposed puncture site uppermost, whilst maintaining their dignity (Rationale 19). 
  • The child's position should be maintained throughout the procedure whilst ensuring an adequate airway (Rationale 20). 
  • The doctor performing the procedure must put on protective clothing and perform a surgical hand wash (Rationale 14). 
  • Clean the proposed puncture site using ChloraPrep®, 2% chlorhexidine in 70% isopropyl alcohol and allow site to dry (Rationale 14) (Killeen et al 2012).
  • Insert the aspiration needle and attach a 20ml syringe (Rationale 21). 
  • Aspirate the bone marrow. 
  • Place aspirate on the microscopic slides and in the specimen pots (Rationale 22). 
  • Label as appropriate. The slides should be placed in the slide container when dry. 
  • Withdraw the aspiration needle whilst exerting pressure on the puncture site. 
  • Apply continuous pressure until bleeding stops (Rationale 23). 
  • Apply a dressing, for example gauze and tape. 
  • Dispose of used equipment according to the Waste Management Policy (Rationale 6). 
  • Record procedure in the child's health care records (Rationale 24). 

To perform the bone marrow trephine insert the trephine needle into the same puncture site from the bone marrow aspirate. 

  • Move the needle up and down and side to side to obtain a small piece of bone tissue. 
  • Remove the needle and pass the introducer through the end of the needle in order to remove bone tissue and place in plain sterile pot with gauze and few drops of saline 0.9% (if this is diagnostic sample for Haematology diagnosis) or place sample in formalin pot.
  • Apply continuous pressure until bleeding stops (Rationale 23).
  • Apply a dressing, for example gauze and tape. 
  • Dispose of used equipment according to the Waste Management Policy (Rationale 6). 
  • Record procedure in the child's health care records (Rationale 24). 

If inadequate samples have been obtained both the procedures may need to be repeated from another site (Rationale 25).

The bone marrow aspirate samples and trephine sample in saline 0.9% should be sent to the haematology laboratory. The bone marrow trephine sample in formalin should be sent to histopathology.

Post procedural care

The child should continue to have their vital signs monitored and documented on the CEWS chart until they are fully awake (Rationale 26).

Whilst waiting for the child to regain consciousness, the noise levels in the room should be kept to a minimum (Rationale 27).

Once the child is rousable, the child's parents should be invited to return (Rationale 28).

The child should be taken back to their bed and if they wish to sleep they should be placed in a semi-prone position. If awake the child can be nursed however they are comfortable (Rationale 29 and Rationale 30). Oxygen and suction should be available by the child's bed (Rationale 31).

Prescribed analgesia may be required if the child is in pain. It should be repeated as necessary (Rationale 32).

The child should be permitted to eat and drink whenever they are fully awake and wish to do so.

The puncture site should be observed for signs of bleeding or oozing of serous fluid. This must be documented in the child’s health care record. The child's doctor should be informed if any of these occur (Rationale 33).

The child's parents should be advised that their child may have a bath/shower whenever they wish and that they should remove the dressings within 24 hours (Rationale 14, Rationale 34).

The results, when known, must be recorded in the child's health care records (Rationale 24).

The child and family should be informed of the results of the procedure as soon as possible. The subsequent discussion must also be recorded in the child's health care records (Rationale 35).

Rationale

Rationale 1: It aids diagnosis.
Rationale 2: It provides more accurate information in some disorders, e.g. aplastic anaemia and metastatic cancer.
Rationale 3: Careful discussion is required to decide if both procedures are necessary to obtain an accurate diagnosis.
Rationale 4: These are the recommended sites to obtain a good sample of bone marrow aspirate and trephine samples.
Rationale 5: To minimise anxiety.
Rationale 6: To adhere to hospital policy. 
Rationale 7: To help prepare the child 
Rationale 8: To address any information requirements.
Rationale 9: To obtain informed consent.
Rationale 10: To prepare child for the procedure.
Rationale 11: To ensure child and family fully informed.
Rationale 12: To minimise the risk of aspiration of stomach contents whilst under anaesthetic.
Rationale 13: To reduce risk of haemorrhage.
Rationale 14: To minimise risk of infection.
Rationale 15: To monitor effects on cardio-respiratory systems.
Rationale 16: To ensure effectiveness of the local anaesthetic.
Rationale 17: To determine need for suction.
Rationale 18: To determine need for further anaesthetic.
Rationale 19: To facilitate accurate aspiration.
Rationale 20: To maintain safety of the child.
Rationale 21: To obtain sample.
Rationale 22: To prepare for laboratory analysis.
Rationale 23: To minimise haematoma formation.
Rationale 24: To maintain an accurate record.
Rationale 25: Sufficient aspiration is not always obtained from one site.
Rationale 26: To ensure safe recovery from anaesthetic.
Rationale 27: To minimise distress.
Rationale 28: To minimise distress for their child.
Rationale 29: To facilitate comfort.
Rationale 30: To maintain a clear airway.
Rationale 31: To enable emergency airway support.
Rationale 32: To relieve pain.
Rationale 33: To detect puncture site complications.
Rationale 34: To continue normal hygiene practices.
Rationale 35: To keep family informed.

References

Reference 1: 
Bailey S and Skinner R. (Eds.) (2010) Paediatric Haematology and Oncology.  Oxford University Press. 

Reference 2: 
GOSH (2015) Central Venous Access Devices – Long term Clinical Guideline.

Reference 3
Killeen, T.  Kamat, A. Walsh, D.  Parker, A. and Aliashkevich A.(2012) Severe adhesive arachnoiditis resulting in progressive paraplegia following obstetric spinal anaesthesia: a case report and review. Anaesthesia Journal of the Association of Great Britain and Ireland. 67(12): 1386-1394 [accessed 17.12.2015].

Reference 4:  
Macqueen S, Bruce E and Gibson F. (Eds) (2012) Great Ormond Street Hospital Manuel of Children Nursing Practices. John Wiley and Sons. West Sussex.

Document control information

Lead Author(s)

Carol Walsh, Theatre Co-ordinator/Senior Staff Nurse, Unit 13 & 14

Document owner(s)

Carol Walsh, Theatre Co-ordinator/Senior Staff Nurse, Unit 13 & 14

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
30 September 2001
Date approved: 
03 December 2015
Review schedule: 
Three years
Next review: 
03 December 2018
Document version: 
4.0
Previous version: 
3.1