Pre‐procedure

ActionRationale

1. 1.Show
   Explain and provide written information about the bone marrow harvest.
   To ensure the donor is properly informed about the procedure (DH [30], C; NMC [86], C).
2. 2.Show
   Obtain written informed consent.
   To enable donors to actively participate in and comply with their treatment (FACT‐JACIE [40], C; Human Tissue Authority [56], C; NMC [86], C).
3. 3.Show
   Ensure that two units of cross‐matched, allogeneic packed red cells are available on the day of harvest. These should only be used in exceptional circumstances, for example massive haemorrhage.
   To reduce the risks associated with allogeneic blood transfusion (Confer et al. [23], E).
4. 4.Show
   Prepare the sterile procedure trolley and ensure that all the necessary equipment is available.
   To ensure the procedure is performed efficiently and that the cells are collected and handled correctly. E
5. 5.Show
   Bring the donor into the operating room when anaesthetized and position correctly on the operating table. In adults, this is usually the prone position with hands placed above the head.
   To allow marrow to be collected simultaneously from both the left and right posterior iliac crest by two practitioners (Confer et al. [23], E).
6. 6.Show
   Ensure the harvest is performed as a sterile procedure.

   • 1. Don facemasks.
     2. Scrub hands meticulously.
     3. Don sterile gowns.
     4. Don sterile gloves.
   To maintain asepsis throughout the procedure to minimize the risk of infection (Fraise and Bradley [41], E).

Procedure

1. 7.Show
   Clean the skin over the posterior iliac crests thoroughly with an antiseptic solution and allow to dry.
   To maintain asepsis throughout the procedure to minimize the risk of infection (Fraise and Bradley [41], E).
2. 8.Show
   Place four sterile drapes over the patient to maintain a sterile field.

   1. One drape placed above the posterior iliac crests and spread towards the donor's head.
   2. One drape placed below the posterior iliac crests and spread towards the donor's feet.
   3. Two drapes spread left and right of the harvest site respectively.
   To create a sterile field around the harvest site and to maintain asepsis throughout the procedure to minimize the risk of infection (Fraise and Bradley [41], E).
3. 9.Show
   Place two receivers on the sterile towels.

   1. One should contain two 11 G harvest needles (flushed with heparinized saline).
   2. One should contain six 20 mL syringes (flushed with heparinized saline and drawn up to 1 mL with heparinized saline).
   To ensure the harvest equipment is easily accessible. The heparinized saline prevents the marrow from clotting in the syringe. E
4. 10.Show
   Locate the posterior iliac spine through palpation (Confer et al. [23]).
   To ensure the preferred site for harvest is located. E
5. 11.Show
   Insert the harvest needle through the skin and subcutaneous tissues, and penetrate the marrow cortex 3–10 mm, with a slight rotating motion. Entry of the needle into the bone marrow cavity may be sensed as a slight give.
   To access the marrow within the bony cortex (Confer et al. [23], E).
6. 12.Show
   Remove the introducer and attach the harvest needle to a 20 mL syringe. Aspirate a volume of 10–20 mL of marrow (bloody fluid) by applying vigorous suction.
   To aspirate marrow from the donor. Short, vigorous aspirations are generally thought to produce a higher concentration of marrow cells relative to peripheral blood (Confer et al. [23], E).
7. 13.Show
   Place filled syringes in the receiver.
   To allow the nurse responsible for transferring the marrow into the sterile collection set to access them. E
8. 14.Show
   If using ACDA, the nurse should add 70 mL of ACDA to the main collection bag prior to each harvest of 420 mL.
   To prevent any clotting. E
9. 15.Show
   Remove the filled syringe from the receiver and dispel any air from the syringe.
   To ensure that the correct amount of marrow is aspirated. E
10. 16.Show
    Ensure the marrow volume is recorded by a member of the theatre staff.
    To keep a running total to ensure that the correct amount of marrow is aspirated. E
11. 17.Show
    The nurse should gently add the marrow to the collection bag and gently agitate the collection bag to mix the marrow with the anticoagulant.
    To prevent any clotting. E
12. 18.Show
    Flush the syringe with heparinized saline (leaving 1 mL in the syringe).
    To prevent any clotting. E
13. 19.Show
    Return it to the receiver ready for subsequent aspirations.
    To ensure the practitioners performing the harvest have a supply of appropriately prepared syringes to perform the aspirations. E
14. 20.Show
    Advance the harvest needle several millimetres and repeat the process.
    To allow for several aspirations from a single bone puncture as the needle is repeatedly advanced (Confer et al. [23], E).
15. 21.Show
    After a number of aspirations from the same site, replace the introducer and move the position of the harvest needle to another place in the bone approximately 2 cm from the first entry site.
    To allow the bone to be entered multiple times through a single skin entry site. A typical collection may involve 70 marrow aspirations obtained through only a few skin punctures. E
16. 22.Show
    1. Once a total of 420 mL of marrow has been collected, open the clips to allow the marrow to pass through the in‐line filters (the 500 µm filter and then the 200 µm filter) from the collection bag to the first transfer pack. Then close the two clips prior to adding a second volume of 70 mL of ACDA to the collection bag and beginning bone marrow aspirations for a second transfer pack.
    2. The total volume in each bag should approximate 420 mL of marrow and 70 mL of ACDA. If less than 420 mL of marrow is required for subsequent bags, the ACDA should be reduced accordingly to maintain a ratio of 1:7 ACDA:marrow.
    To ensure that transfer packs are not overfilled and that the correct amount of anticoagulant is added to prevent clotting (E) and to remove particulate matter (FACT‐JACIE [40], C).

    To prevent any clotting. E
17. 23.Show
    Aspirate a small sample from the first transfer pack when this has been filled.
    To allow the adequacy of the collection to be determined by a nucleated cell count (Confer et al. [23], E).
18. 24.Show
    Place the sample in an EDTA specimen container.
    This is the preferred medium for nucleated cell count analysis (Confer et al. [23], E).
19. 25.Show
    Label specimen container.
    To ensure safe and correct processing of sample (BCSH [11], C).
20. 26.Show
    Send sample to the laboratory for a white cell count.
    To allow the adequacy of the collection to be determined by a nucleated cell count (Confer et al. [23], E).
21. 27.Show
    This process should be repeated for each transfer pack filled.
    To allow the adequacy of the entire collection to be determined by a nucleated cell count (Confer et al. [23], E).
22. 28.Show
    Document in the hospital notes the number of puncture holes made.
    To facilitate post‐operative wound care and to maintain accurate records (NMC [86], C).
23. 29.Show
    The nurse should seal the transfer packs as per local policy, using an approved heat sealer.
    To maintain asepsis, minimize the risk of infection and facilitate the safe transport of the cells (Fraise and Bradley [41], E).
24. 30.Show
    The nurse should record the respective volume of bone marrow on the outside of the transfer pack in millilitres, using FACT‐JACIE approved labels.
    To establish total amount of bone marrow in each bag. E
25. 31.Show
    Withdraw the harvest needles from the posterior iliac crest, pack sterile gauze over the left and right harvest sites respectively and maintain digital pressure until the bleeding has stopped.
    To achieve haemostasis, minimize leakage and prevent the formation of a haematoma. E
26. 32.Show
    Instil lidocaine 2% intradermally into the harvest sites up to the maximum recommended dose.
    To help with pain control immediately post‐operatively. E

Post‐procedure

1. 33.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 (DH [29], C; Loveday et al. [73], C).
2. 34.Show
   Inspect the puncture sites for bleeding. Mepore and a pressure dressing may be applied over the sterile gauze.
   To achieve haemostasis and decrease the risk of infection at the harvest sites. E
3. 35.Show
   Take the donor to the recovery room.
   To ensure appropriate post‐operative care. E
4. 36.Show
   Label each transfer pack as per local policy with FACT‐JACIE compliant labels.
   To ensure correct management of the product (FACT‐JACIE [40], C).
5. 37.Show
   Place the transfer packs in a secondary container (e.g. a zip‐type resealable bag) prior to transfer to the appropriate processing facility.
   To prevent the loss of a portion of the collection, to minimize the potential of post‐collection contamination of the component and to prevent potential spillage of biohazard material in areas where it may pose a risk to employees, visitors or patients (FACT‐JACIE [40], C).
6. 38.Show
   Transport the marrow to the appropriate processing facility with the necessary forms and in a FACT‐JACIE compliant container.
   To allow for cell measurement, storage and/or issue of the marrow. E
7. 39.Show
   Record the necessary information in the appropriate documents as per local policy.
   To maintain accurate records (NMC [86], C).
8. 40.Show
   Ensure post‐donation care is appropriately managed (see ‘Post‐procedural considerations’).
   To ensure the safe management of patients and to enable them to actively participate in and comply with their treatment (NMC [86], C).