• 
  

  • Pancytopenia.

  
  

  • Unexplained anemia, leukopenia, or thrombocytopenia (aspiration only).

  
  

  • Acute or chronic leukemia (aspiration only).

  
  

  • Myelodysplasia.

  
  

  • Myeloproliferative disease.

  
  

  • Non-Hodgkin or Hodgkin lymphoma.

  
  

  • Childhood solid tumors (including sarcoma, Wilms tumor, neuroblastoma, germ cell tumor).

  
  

  • Bone marrow failure (including acquired aplastic anemia, Fanconi anemia, Diamond-Blackfan syndrome).

  
  

  • Fever of unknown origin.

  
  

  • Storage disease.

  
  

  • Monitoring during chemotherapy or following stem cell transplantation (aspiration only).

Relative

• 
  

  • Congenital factor deficiency or acquired coagulation defect.

  
  

  • Anticoagulation with warfarin or heparin.

  
  

  • Severe thrombocytopenia.

  
  

  • Infection or prior radiation at sample site.

Site Preparation

• 
  

  • 10% povidone-iodine.

  
  

  • Alcohol preparation pads or swabs.

  
  

  • Sterile gloves, gown, and drape.

  
  

  • Spinal and subcutaneous needles, 20 to 26 gauge.

  
  

  • 1% lidocaine hydrochloride, injection.

  
  

  • 8.4% sodium bicarbonate, injection, USP.

Marrow Aspiration and Biopsy

• 
  

  • Sodium heparin, injection, 1000 USP units/mL, preservative free.

  
  

  • Bone marrow aspiration needles (15 and 18 gauge, adjustable lengths).

  
  

  • Bone marrow biopsy needles (11 and 13 gauge, 4 or 2 inches in length).

  
  

  • Sterile syringes, 10 to 20 mL.

  
  

  • Container with fixative for trephine biopsy specimen.

  
  

  • Vacutainers; one for sodium heparin and one for ethylenediaminetetraacetic acid (EDTA).

  
  

  • Gauze sponges.

  
  

  • Bandages.

• 
  

  • Risk of bleeding is low if adequate pressure is provided over site to achieve primary hemostasis.

  
  
  
  
  • 
    

    • Platelet transfusion is indicated when technical difficulties are anticipated in patients, especially those who are obese, with severe thrombocytopenia.

    
    

    • Defects in coagulation should be corrected before the procedure.

  
  

  • Risk of infection and osteomyelitis is extremely low when procedure is performed in sterile fashion.

  
  

  • Pain and discomfort are alleviated with adequate sedation and analgesics.

• 
  

  • Adolescents may require only local anesthesia for the procedure.

  
  

  • Conscious sedation or general anesthesia is generally necessary in young children, particularly if repeated procedures are required.

  
  

  • Adding local anesthesia in young patients also decreases postprocedural discomfort at the site.

  
  

  • Lidocaine used for local anesthesia should be buffered with sodium bicarbonate (sodium bicarbonate mixed with lidocaine in a 1:4 ratio) to reduce burning during injection.

  
  

  • Obtaining spicules (bone marrow particles rich in hematopoietic elements) on the first pull of the aspiration may be easier using a larger syringe (30 or 60 mL).

  
  

  • Aspirating more than 0.25 mL of marrow initially dilutes the sample with sinusoidal blood and interferes with morphologic studies.

  
  

  • If an aspirate is “dry” and an adequate specimen cannot be obtained, a touch imprint of the biopsy core may be helpful for cytologic examination.

  
  

  • A dry tap usually indicates myelofibrosis or a marrow cavity packed with malignant cells.

  
  

  • All equipment, tubes, and syringes should be ready and available before preparing the patient.

  
  
  
  
  • 
    

    • Lidocaine should be drawn.

    
    

    • Syringes that will be used to collect any additional marrow after the first pull should be heparinized to prevent clotting.

    
    

    • A laboratory assistant should be ready to help in the immediate preparation of bone marrow smears and handling of the core biopsy.