Before a bone marrow examination is carried out, clear diagnostic goals about the information to be obtained from the procedure should be defined. It should be decided whether any special studies are needed so that all the necessary specimens may be collected and handled correctly (Hoffbrand and Moss [51]). Table 21.2 outlines this in more detail.

Several sites may be used for bone marrow aspiration and biopsy (Figure 21.2). Normally, only aspirations and not biopsies are done on the sternum because of its small size and proximity to vital organs. The site selected may reflect the normal distribution of bone marrow in relation to the age of the patient. Younger children may have marrow taken from the anterior medial tibial area, whereas adult marrow is best sampled from the sternum at the second intercostal space or from either the anterior or posterior iliac crest area (Hoffbrand and Moss [51], Koeppen et al. [66]). Sternal marrows do not allow a trephine biopsy to be performed, and several possible complications, including haemorrhage and pericardial tamponade, may occur if the inner table of the sternum is penetrated by the needle at areas other than the second intercostal space (Hoffbrand and Moss [51], Koeppen et al. [66]). In contrast, little morbidity is associated with iliac crest aspiration and biopsy, and the posterior iliac crest is the most common site for bone marrow examinations (Figure 21.3). The anterior iliac crest may be used if previous radiation, surgery or patient discomfort does not allow a posterior approach (Hoffbrand and Moss [51], Koeppen et al. [66]).

The procedure should be performed in an aseptic manner with meticulous handwashing to reduce any risk of infection. Any equipment that may cause a needlestick injury must be safely disposed of. Local anaesthetic/general anaesthetic and fasting procedure policies should be followed.

A suitable training package should be available for new practitioners. All practitioners should be assessed by a competent practice facilitator prior to performing procedures on their own. Nurses must always operate within their scope of practice as set out by their profession (NMC [86]). Learning tools may include competency‐based workbooks.

The practitioner performing the procedure is responsible for providing information prior to the biopsy and obtaining written consent. In the case of paediatric patients, parental consent is required unless the child is over the age of 16 years (NMC [86]).

Needles with a range of gauges may be used. Most have a removable introducer (which prevents plugging of the needle before aspiration) and a stylet that may be used to express the bone marrow biopsy sample. Some models, primarily used for sternal bone marrow aspiration procedures, have adjustable guards that limit the extent of needle penetration; there are currently no safety devices available for this procedure (Smock & Perkins [105]). Figure 21.7 shows the more specialist equipment needed to perform a bone marrow biopsy. Procedure guideline 21.1 provides a full list of essential equipment.

In most adult cases, bone marrow biopsies may be carried out with little risk of patient discomfort, provided adequate local anaesthesia is administered. Lidocaine 2% (maximum dose 200 mg) is frequently used (Joint Formulary Committee [62]). Patients may describe a ‘dragging sensation’ during the actual aspiration procedure, even when the site is numb. The duration of the local anaesthetic action is about 90 minutes (Joint Formulary Committee [62]).

Apprehensive patients may be given an oral sedative, Entonox® or intravenous conscious sedation before the procedure, but this is usually not necessary (Hjortholm et al. [50], McGrath [74]). When intravenous sedation is used, a second practitioner should be present to administer the conscious sedation and to monitor the patient. A local standard operating practice should be in place to support practitioners in practice, for example ensuring that cardiac monitoring, pulse oximetry, oxygen administration, the reversal agent and resuscitation equipment are available in order to adhere to guidance from the Academy of Royal Medical Colleges (Academy of Royal Medical Colleges [1], Provan et al. [95]).

Bone marrow biopsy may be more upsetting for paediatric patients and measures to reduce distress include:

Special consideration may also be needed for those who are extremely anxious. Measures include ensuring that the patient has a family member or friend present and complementary therapies such as relaxation, massage and music (Bufalini [17]).

Thrombocytopenia is not a contraindication and bone marrow examination seems to be safe even when thrombocytopenic purpura is present (Lewis et al. [69]). However, the nurse must take a history to assess for risk of bleeding (BCSH [10]). This should include details of family history, previous excessive post‐traumatic or post‐surgical bleeding, liver disease and the use of antithrombotic drugs. If the bleeding history is negative, no further coagulation testing is indicated. If the bleeding history is positive or there is a clear clinical indication (e.g. liver disease), a haematologist should be consulted as to what screening tests are needed and what actions should be taken. Some of these are outlined in the pharmacological support section. If haemorrhage occurs post bone marrow biopsy, the main reasons (in order of frequency) are (Bain [8]):

Questions to determine if the patient's posterior iliac crests have undergone previous radiation or surgery or are affected by soft tissue damage or infection will aid appropriate site selection.

Further assessment should determine if the patient has an allergy to any of the medication, cleaning agents, dressings or equipment to be used.

The need to stop taking antithrombotic drugs prior to the procedure should be discussed with the referring medical team. It is usual practice to stop warfarin 3 days and low molecular weight heparin 24 hours before the procedure. If a patient is on warfarin, a blood test to check the international normalized ratio (INR) should be requested. The result of this should be within the range stipulated by local policy prior to performing the procedure, for example ≤ 1.5.

Some patients, such as those with multiple myeloma, will require careful positioning due to the infiltration of disease in their bones. These patients may also find bone marrow biopsies more uncomfortable as maintaining the correct position may be difficult. An environment that facilitates the patient's need for privacy and dignity is essential for bone marrow biopsy procedures (NMC [86]).

The patient's co‐operation is essential to ensure the procedure is undertaken safely. All patients should be given access to information and support in a manner that they understand (DH [28], NMC [86]). Written information should be available and patients often access information via the internet at sites such as www.macmillan.org.uk. Consideration must be given to those patients with learning disabilities, language barriers or sensory deficit (DH [30]).

The patient should be advised to lie on their back, exerting pressure downwards on the biopsy site to assist in achieving haemostasis (Bain [9]). The biopsy site should be checked before the patient leaves the department to ensure that there is no bleeding. The patient should not experience any discomfort at the biopsy site immediately after the procedure due to the ongoing action of the local anaesthetic (Joint Formulary Committee [62]). The patient should return to pre‐procedure functional status immediately after the procedure if no sedation has been used. A medical review should be requested if the patient has any unexpected pain or loss of mobility.

This comprises wound care, pain control and monitoring for signs of infection. This is discussed further in ‘Education of patient and relevant others’, as a bone marrow examination is usually an outpatient procedure (Lewis et al. [69]).

The operator is responsible for documenting the procedure details to ensure accurate records are kept (NMC [86]). These should include:

The patient should be encouraged to contact the hospital if there are any concerns about post‐procedural care. Contact telephone numbers and the following advice should be given to patients.