• Sedation

  • Some of these patients did not tolerate a bone marrow biopsy in the office due to anxiety. These patients will need conscious sedation. Remember if patients need conscious sedation they need to be NPO (8 hours).

  • An alternative is to get IV Versed only - nursing is willing to do that without the patient being NPO, but they still need a ride home.

  • Otherwise the standard is to perform the procedure without conscious sedation.

  • Inpatients can also get some anxiety (Ativan) and/or pain (Fentanyl, etc) medication prior to coming down for the procedure, since they will be monitored on the floor after they go back upstairs.

• Orders – Preferably, the referring physician puts the orders in for the marrow biopsy prior to the procedure, because some of them have their own special tests that they would like to order. If there are no special tests, then you can do it on Epic (see page 11 of Figure 1), although it is VERY RARE that you should have to do this and it's best if the ordering physician does it!

  • PLEASE NOTE THAT if the ordering physician has put in the order, you need to follow some special steps to print out the order so that it has the correct date and time (Figure 1). PLEASE do this immediately before the procedure so that the date and time are as close to the actual procedure time as possible.

    • As a last resort, you can hand write-in the date and time on the printout (just cross it off and write in the correct date and time), but it is only a LAST RESORT.

• Lab tests:

o   CBC (Platelets > 10)

o   INR (< 2.0)

ALL BIOPSIES 

****IF SUPPLIES ARE NOT AVAILABLE FOR SOME REASON IN ELLISON 2, SEE THE BOTTOM OF THIS PAGE FOR HOW TO FIND THE SUPPLIES ON YAWKEY 7B****

o   OnControl either 4 inches or 6 inches, depending upon patient size (Figure 3)

o   Specimen tubes

• • See below

  • All tubes for standard aspirate and biopsy are available in CT.  Any others that are required the ordering clinicians will drop off in the blue bin on the bookshelf in the reading room (Figure 4), including any required for clinical trials (RARE).

o   Heparin syringe (Figure 5).  

• • WE RARELY DO THIS. It's only recommended if you're doing these procedures alone. The advantage is that it buys you more time before the sample clots to get the aspirates into the correct tubes and to get the smears done. The disadvantage is that too much heparin can lead to artifact on the smears. You can safely assume that you won't be doing this, but just know that it is a possibility.

  • Note there are different strengths of heparin with different color schemes. Please use the yellow syringe which is 100 USP units/ml. Make sure  you use SODIUM heparin, not LITHIUM heparin, which is toxic to the cells

o   2 x 10 mL luer lock syringes – one which you will coat with heparin, and the other you will leave as is.

STANDARD HEMATOLOGY ASPIRATE (Figure 6)

o   Purple*  (2), Green (1) and Yellow (1) tubes, filled in the order Purple, Green, Yellow, Purple (*There are 2 versions of the purple top tube. See Figure 6B)

o   One core biopsy 1-3 cm in fixative (blue formalin solution)

o   2 sets (4) slides – marrow smear made with 1st aspirate, 1 set with first drop, 1 set with last drop*

o   1 slide – core touch prep**

STANDARD MYELOMA ASPIRATE (Figure 7)

UPDATED OCTOBER 2022: UNTIL FURTHER NOTICE, CYTOGENETICS ARE DONE ON THE YELLOW TOP TUBE. THEREFORE, SEND TWO PURPLE AND TWO YELLOW FOR MYELOMA PATIENTS (no more tiger top tube)

THIS TEXT BELOW IS JUST SAVED IN CASE IT IS NEEDED IN THE FUTURE.

o   Purple* (2), Purple Tiger (1), and Yellow (1) tubes filled in the order Purple, Purple Tiger, Yellow, Purple (*There are 2 versions of the purple top tube. See Figure 6B)

o   One core biopsy 1-3 cm in fixative (blue formalin solution)

o   (optional - see the order) 2 sets (4) slides – marrow smear made with 1st aspirate, 1 set with first drop, 1 set with last drop*

o   1 slide – core touch prep**

*Please note that at NWH they want 4 sets (8) slides, 2 set with first drops, 2 set with last drops. They save the slides for a month in case any additional tests need to be done.

**Please note that at NWH they want 4 core touch prep slides.

RESEARCH SAMPLES

o   May require additional tubes (research coordinators should stop by Ellison before the procedure and leave the additional tubes with instructions - please check the comments from the Marrow Biopsy order in Epic to see if there is a pager number for the research coordinator)

o   Conventional samples always take priority over research samples

TECHNIQUE

1.             Target one of the iliac crests. If there is a focal lesion, best to try to avoid it

2.             Local anesthesia (lidocaine 1%, 2 mL) down to periosteum. Wait 5 minutes

3.             IF ALONE: Prepare the HEPARIN-COATED syringe. The heparin syringe is sterile on the inside, but the package is not sterile. Ask someone who is not sterile to expel the contents of the syringe onto the sterile tray. Draw 2 mL of heparin into a 10 mL syringe, then aspirate 8 mL of air into the syringe so that you can coat the entire inside of the syringe. Then expel the extra heparin

4.             Prepare the tubes by taking the top off, so you can directly place aspirate into the tubes (Figure 8)

5.             Place OnControl biopsy device with stylet about 5 mm into the bone to assure that the outer sheath is anchored in the bone.

6.            Aspirates:

1st Pull (10 mL syringe, NO heparin): Remove the stylet and immediately do a fast pull aspirate of ~2-3 mL. into dry (no heparin) tube. For HEMATOLOGY patients, make a set of slides with the first drop, Slide is air dried and placed in slide box (Figure 9). For ALL patients place the rest of the aspirate into one of the purple top tubes. Recap the tube and label it “Buffy coat”

2nd Pull: using the HEPARIN-COATED syringe, aspirate another 2-3 mL per tube (calculate total before aspirate). Fill the remaining tubes. For HEMATOLOGY patients, use the last drop to make another set of slides (air dry, slide box)

7. Biopsy: 

• • • • Put the stylet back in, advance the needle another 5 mm. 

      • Remove stylet and take a 1-3 cm core and expel it onto a piece of gauze

        • NOTE: The OnControl sample for the marrow kit is expelled RETROGRADE (enter through tip and expel through hub) using the assistance of the bowtie-shaped adaptor (Figure 10). Make sure you do not expel the sample ANTEGRADE for this kit or you will get crush artifact!

      • Take a slide and touch it to the sample several times to make a touch prep (Figure 11). This is most important if there is a dry tap and of lesser importance if there are smears.

      • Scrape the core into the fixative (Figure 12) using the 16 gauge, 1.5 inch needle.

        • The fixative cap has TWO CLICKS when it closes. Please be sure to shut it tightly and feel for both clicks, or the formalin may leak out!

10.         Hold pressure for 5 minutes and close the incision with Dermabond.

11.         If the patient is pancytopenic, give them an ice pack for the incision site and have them sit on the site (to apply pressure) for 20-30 minutes. Then discharge the patient.

SAMPLE DELIVERY - All samples (tubes, slides, biopsy) should be placed in a single pathology bag and brought to the Core Lab on Gray 5. DO NOT bring the specimen to Surgical Pathology on Blake 3.

· Special Considerations 

Research specimens may be specified by requesting clinician.  If so, they must provide any required tubes and orders (check the Epic order for a research coordinator pager or contact number)

Always fill the tubes in the order above, which prioritizes the most important tubes. If there is a dry or scant tap, prioritize standard tubes over research tubes.

If you do not have enough aspirate to fill one or more of the tubes,  cross off the tubes you are NOT sending on the order requisition. If you do not do this the lab may think that a specimen is missing.

If there is any doubt of which tubes should be prioritized, page the referring physician or p21867 (hematopathology)

·        What is each aspirate tube for?

o   Purple = Buffy coat, smear, molecular testing, tissue banking

o   Green = Cytogenetics

o   Yellow = Flow cytometry

o   Purple tiger = Flow cytometry. Myeloma cells are "fragile", and the purple tiger top has a preservative in it that optimizes them for flow (NOT BEING USED AT THE MOMENT - *updated 2023)

Figure 1 - Epic orders for marrow biopsy

Figure 2 - Reprinting the Marrow Requisition with the Correct Date and Time

Figure 4 - blue bin with special tubes from ordering clinicians

Figure 5 - Heparin syringe (100 USP units/ml )

Figure 6A - Typical hematology tubes; Figure 6B - Alternate purple top tube - either one is fine

Figure 7 - Typical myeloma tubes

Figure 8 - Take the tops of the tubes to fill

Figure 9 - Slide Box

Figure 10 - Adapter for removing marrow biopsy core from OnControl

Figure 11 - Making the Touch Prep

Figure 12 - Fixative for core biopsy - feel for TWO clicks to tightly close the fixative cap!

Bone Marrow Cheat Sheet

From the snap board to print up the Bone Marrow Order:

*Right click on patient’s name

*Click on labs

*Find the order for the “Bone Marrow” (not CT Bone Marrow)

*Click on the order so it shows up on the right side of the screen

*Scroll done on the order and click on the link for “Reprint Order Requisition”

*Print the order for the pathology bag

From the snap board to print up ATD Labels:

*Right click on patient’s name

*Go to “Appt. Desk”

*Right click on the patient’s “CT Bone Marrow Biopsy”

*High light “Appointment Options”

*Click on “Label” 

*Click on “Print” (Ellison 2 CT 1’s printer is L715335TRAY1)

*This is set will say 1 label, but 5 will print up

From the snap board to print Slide Labels:

Right click on patient’s name

Go to “Print Forms”

Under the form box enter “Rad” and “Radiology Slide Label (MGH)” should appear

Under the printer box enter “MGH_BCELL228TRAY1”  (Ellison 2 CT 1’s Label printer)