Pre‐procedure

ActionRationale

1. 1.Show
   Explain and provide written information about the bone marrow examination.
   To ensure the patient is properly informed about the procedure (DH [28], C; NMC [86], C).
2. 2.Show
   Obtain written informed consent.
   To enable patients to actively participate in and comply with their treatment (NMC [86], C).
3. 3.Show
   Check that blood parameters are within safe limits.
   To decrease the risk of haemorrhage, which has been identified as the most common and serious adverse event associated with bone marrow examination (Bain [9], E).
4. 4.Show
   Consider oral (e.g. lorazepam), Entonox or intravenous (e.g. midazolam) sedation for very anxious patients (Giannoutsos et al. [45]).
   To ensure that the procedure is performed safely and with minimal distress to the patient. E
5. 5.Show
   Prepare the procedure trolley and ensure that all the necessary equipment and specimen containers are readily available.
   To ensure the procedure is performed efficiently and that all the necessary specimens are collected and handled correctly (Smock and Perkins [105], E).
6. 6.Show
   Ensure patient privacy by drawing the curtains and making use of a sheet or blanket.
   An environment that facilitates the patient's need for privacy and dignity is essential for bone marrow biopsy procedures (NMC [86], C).
7. 7.Show
   Assist the patient into the correct position, which is usually the left or right lateral position with the knees drawn up to the chest.
   To access the posterior iliac crest, the most common biopsy site in adults. E

Procedure

1. 8.Show
   Open pack and then open all the equipment onto sterile field.
   To maintain asepsis throughout the procedure to minimize the risk of infection (Fraise and Bradley [41], E).
2. 9.Show
   Wash hands and apply sterile gloves.
   To maintain asepsis throughout the procedure to minimize the risk of infection (Fraise and Bradley [41], E).
3. 10.Show
   Reassure and observe the patient throughout the procedure.
   To allay anxiety and facilitate the patient's maximum co‐operation. P
4. 11.Show
   Clean the skin thoroughly at the biopsy site with an antiseptic solution (Perkins [92]), for example chlorhexidine 0.5%, and alcohol solution and allow to dry.
   To maintain asepsis throughout the procedure to minimize the risk of infection (Fraise and Bradley [41], E).
5. 12.Show
   Administer local anaesthetic (e.g. lidocaine 2%) intradermally and subcutaneously at the site of the biopsy. Warn the patient that the drug can result in a ‘stinging’ sensation during administration.
   To minimize pain during the procedure (Ruegg et al. [100], R1).
6. 13.Show
   Make a small cut in the skin overlying the biopsy site with a scalpel.
   To allow for better insertion of the biopsy needle through the skin and to avoid a skin ‘plug’. E
7. 14.Show
   Insert the aspiration needle through the skin and subcutaneous tissues. Penetrate the marrow cortex 3–10 mm, with a slight rotating motion (Provan et al. [95]). Entry of the needle into the bone marrow cavity may be sensed as a slight give.
   To access the bone marrow for aspiration. E
8. 15.Show
   Remove the introducer, attach a 5 mL syringe to the needle and aspirate a volume of 0.2–2 mL marrow (bloody fluid) (Smock et al. [105]). Aspiration may cause a very brief, sharp, dragging sensation.
   To aspirate liquid bone marrow in order to prepare specimens for further investigation (Hoffbrand and Moss [51], C).
9. 16.Show
   Disconnect the syringe and smear the marrow quickly onto the cytology slides.
   To avoid clotting. E
10. 17.Show
    Perform additional aspirations if necessary.
    To provide material for flow cytometry, cytogenetics, culture or other special studies as required (Provan et al. [95], C).
11. 18.Show
    Perform the trephine biopsy using the same skin incision if the aspirate has been performed in the iliac crest area. Use a separate biopsy needle, slightly larger than the aspirate needle (Smock et al. [105]).
    In order to minimize the number of skin entry sites. E
12. 19.Show
    Advance the trephine needle to penetrate the bone cortex (Provan et al. [95]). The biopsy needle may require more pressure to enter the bone because of the larger bore size.
    To access the bone for biopsy. E
13. 20.Show
    Position the trephine needle away from the area where the aspiration was performed.
    To avoid collection of a specimen with extensive artefact induced by the aspiration procedure (Smock et al. [105], E).
14. 21.Show
    Remove the introducer and use firm hand pressure to advance the needle another 2 cm
    To provide a solid core of bone (Provan et al. [95], E).
15. 22.Show
    Insert a stylet into the back of the needle.
    To give an approximation of the size of the bone core within the needle (Smock et al. [105], E).
16. 23.Show
    Ensure the length of the trephine specimen is in the range of 1.6–2 cm (Bain [6], Bishop et al. [13], Campbell et al. [19]).
    The analysis of the relation between length of trephine and the rate of positivity for neoplasia yielded a minimum adequate length of 1.6 cm before processing (Bishop et al. [13], C).
17. 24.Show
    Remove the needle from the bone and use the stylet to express the specimen into the appropriate container (Smock et al. [105]).
    To collect the solid core of bone and marrow to examine as a histological specimen after fixation in formalin, decalcification and sectioning (Hoffbrand and Moss [51], C).
18. 25.Show
    Apply manual pressure to the site for several minutes until the bleeding stops.
    To achieve haemostasis (Smock et al. [105], E).
19. 26.Show
    Apply a sterile pressure dressing.
    To achieve haemostasis and decrease the risk of infection at the biopsy site (Provan et al. [95], E).

Post‐procedure

1. 27.Show
   Apply pressure bandages and check the site for prolonged bleeding if a patient is thrombocytopenic (Smock et al. [105]).
   To minimize bruising, prevent haematoma and decrease the risk of haemorrhage (Bain [9], C).
2. 28.Show
   Dispose of sharps as per local policy.
   To ensure the safe handling and disposal of needles and other sharp instruments and to protect staff, patients and visitors from exposure to bloodborne pathogens (Loveday et al. [73] C).
3. 29.Show
   Label specimens as per trust policy and send them to the appropriate laboratory department.
   To prevent incorrect diagnosis and disease management through incorrectly labelled specimens (BCSH [11], C).
4. 30.Show
   Record the necessary information in the appropriate documents as per local policy.
   To maintain accurate records (NMC [86], C).
5. 31.Show
   Ensure the patient has returned to pre‐procedure functional status before discharge.
   To ensure the safe management and recovery of patients receiving sedation. E
6. 32.Show
   Give the patient appropriate aftercare instructions (see ‘Education of patient and relevant others’).
   To ensure the safe management of patients and to enable them to actively participate in and comply with their treatment (NMC [86], C).