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Sternal puncture. Sternal puncture (bone marrow puncture from the sternum): indications, performance, interpretation, consequences When to remove the bandage after sternal puncture

All materials on the site were prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative in nature and are not applicable without consulting a doctor.

Blood tests, no matter how extensive they are, are not always able to provide a complete amount of information about the state of the bone marrow and its functioning, because mature cells are usually present in the bloodstream. A sternal puncture allows a specialist to trace the nature of hematopoiesis and the morphological characteristics of blood cells, through which a specialist obtains a bone marrow sample for examination.

Red bone marrow is the most important tissue of the body, ensuring the maturation of all blood cells without exception. It contains stem elements and cells of all stages of maturation, which, after full formation, enter the peripheral blood to ensure immunity, gas exchange, thrombus formation, etc.

In newborn children, red bone marrow fills all the bones, but as they grow, its volume decreases and by the age of five it begins to be replaced by fatty (yellow) bone marrow. In adults, hematopoietic tissue is concentrated in the sternum, pelvic bones, vertebral bodies, long tubular bones, and ribs, where it is available for aspiration for the purpose of diagnosing various pathological conditions.

The term "sternal" implies that the bone marrow will be taken from the sternum, although it can also be obtained from the ilium or calcaneus (in young children). Puncture of the sternum seems to be a fairly simple and safe diagnostic method, provided that all precautions and manipulation techniques are followed.

Indications and contraindications for sternal puncture

The reason for examining bone marrow aspirate obtained from the sternum is suspicion of hematological diseases, a planned bone marrow transplant, or some infectious processes when other routine examinations do not provide sufficient information. Sternal puncture is performed when:

Anemia - severe iron deficiency, megaloblastic, aplastic.
Tumors of hematopoietic tissue - leukemia, paraproteinemic hemoblastosis.
Myelodysplastic syndrome.
Leukemoid reactions, when the peripheral blood picture does not exclude tumor growth.
Storage diseases of hereditary nature, metabolic disorders (Gaucher disease, Niemann-Pick disease).
Visceral leishmaniasis.
Suspicion of the presence of metastases of other malignant neoplasms in the bones (prostate cancer, for example).
Assessing the effectiveness of treatment and monitoring the condition of hematological patients.
Research and procurement of the resulting stem cells for transplantation to a donor or the punctured patient himself after courses of chemotherapy or radiation.
Intraosseous administration of drugs.

An established diagnosis of chronic leukemia in the acute stage, as well as iron deficiency anemia, diagnosed through routine examinations, serve as relative indications for bone marrow puncture, that is, in these cases, the procedure can be abandoned.

Contraindications for sternal puncture there are also:

Severe bleeding disorders.
Old age in cases where sternal puncture is not the only possible diagnostic method.
Acute inflammatory and infectious lesions at the site of the intended skin puncture.
Patient refusal to study.
Severe concomitant diseases in the stage of decompensation (the question of the advisability of a puncture is decided individually).

Preparation and technique for performing sternal puncture

Sternal puncture is not a complex procedure; it is safe, does not require anesthesia and is performed both in a hospital and on an outpatient basis. Preparation for sternal bone marrow aspiration is extremely simple:

The patient undergoes a blood clotting test and a general analysis no more than 5 days before the planned procedure;
Two hours before the puncture, the last meal and water is possible;
Before the procedure, the bladder and intestines are emptied;
All medications are canceled, except those that are vital;
On the day of the puncture, no other procedures are prescribed.

Before the manipulation, the patient must inform the doctor about all the medications he is taking, especially for anticoagulants and other blood-thinning agents, which should be discontinued due to the greatly increasing risk of bleeding while taking them.

The specialist who will perform the sternal puncture will find out information about the presence of allergies to medications, since the administration of anesthetics will be required. The patient is told in detail about the essence of the puncture, its purpose and the meaning of the upcoming operation. The doctor warns about the possible pain of the puncture and subsequent precautions. It is mandatory to obtain the written consent of the person being examined (or the parents during a puncture of the child) to carry out the procedure.

The technique of performing sternal puncture includes several stages:

Special precautions should be taken when puncturing the sternum in children. Their bone is softer and more elastic, so careless actions can pierce it through. If possible, the child should be immobilized so that his movements do not disrupt the process of puncture of the sternum.

Features of sternum puncture in children:

Sternal puncture is possible only from two years of age;
Special needles of smaller diameter than for adults are used;
General anesthesia is possible.

Elderly people, patients receiving long-term corticosteroid drugs may suffer from osteoporosis, so precautions for through puncture, which is possible due to a decrease in bone tissue density, also apply to them.

The sternum puncture procedure is rarely performed without anesthesia - if it is unavoidable, and the patient has absolute contraindications to the administration of anesthetics. In such a situation, the patient is warned about the painfulness of the manipulation; it is possible to use tranquilizers before the procedure and analgesics.

The bone marrow obtained through a puncture of the sternum is placed on a glass slide, then a cytological preparation is prepared, which is assessed by a cytologist. When diagnosing hematological pathology, the latter pays attention to the structure of blood cells, their number, degree of maturity, and the ratio of various elements in the total volume of punctate.

Bone marrow extracted from the sternum can also be subjected to cytochemical, immunological, and histological examination. Histological assessment of punctate provides more opportunities to assess the ratio of fatty and active bone marrow, the state of the vascular component and cellular elements of varying degrees of maturity.

The results of a sternal puncture can be obtained on the same day if a cytological examination of a bone marrow smear is expected. With histological analysis and other more technically complex studies, the diagnosis is extended for a period of 7-10 days.

The above method of sternal puncture was proposed in 1927 by Arinkin M.I. and is still practiced to this day. The Kassirsky needle has been successfully used by hematologists for decades. It is durable, wide, has a removable handle that is convenient for insertion, and is also equipped with a limiter that prevents the needle from moving too deeply.

Video: sternal puncture technique

Complications and features of the postoperative period

The bone marrow collection procedure lasts approximately 20 minutes. After it, the patient is observed for about an hour, general health, pulse and blood pressure are monitored. You can leave the hospital the same day, but it is highly undesirable to drive, as there is a risk of fainting.

The puncture site does not require any treatment at home, however, for the first three days it is recommended to exclude water procedures so as not to introduce an infection into the puncture hole. Sternal puncture does not imply any restrictions on diet and nutrition. If there is severe pain at the puncture site, the patient can take a painkiller.

Following the precise technique of sternal puncture, using a Kassirsky needle with a limiter, and treating the puncture site with antiseptics virtually eliminates the likelihood of complications. In rare cases, adverse consequences are possible in the form of:

Through puncture (in a child or patient with osteoporosis);
Bleeding from the puncture site;
Infection of the puncture site (extremely rare);
Fainting states in emotionally labile persons, hypotensive persons, with insufficiently thorough psychological preparation of the patient for manipulation;
Shock in case of severe pathology of the cardiovascular system in elderly people.

In general, the sternal puncture procedure is easily tolerated and is extremely rarely accompanied by complications. Feedback from patients is mostly positive, and well-being and attitude towards the manipulation largely depend on the quality of preparation and competent conversation between the doctor and the patient. Some people note severe pain at the time of puncture and removal of material from the sternum, and in the next 2-3 days, others feel only slight discomfort.

Interpretation of sternal puncture results

Analysis of bone marrow obtained through sternal puncture shows the number of cellular elements in it, their ratio and degree of maturity. The myelogram characterizes the qualitative and quantitative indicators of the white germ of hematopoiesis:

Myelokaryocytes (the total number of blood cells containing nuclei) are 50-250x10 9 per liter of blood;
Megakaryocytes (precursors of platelets) - 0.054-0.074x10 6 per liter;
Reticulocytes (precursors of red blood cells) make up 20-30% and increase with blood loss and hemolytic anemia;
Blast cells - 0.1-1.1%, myeloblasts - 0.2-1.7%, promyelocytes - 0.5-8.0% of all elements of the white sprout of the bone marrow, lymphocytes - 1.2-1.5 %, monocytes - 0.25-2.0%, plasma cells - no more than 1%.

A decrease in the number of myelokaryo- and megakaryocytes is possible due to errors in the puncture, when the bone marrow is diluted with liquid blood.

The specialist studying the bone marrow punctate reflects in the conclusion the type of hematopoiesis, cellularity, bone marrow indices, the presence and number of uncharacteristic cells (for example, Hodgkin's in lymphogranulomatosis). Each of the sprouts is analyzed separately.

Bone marrow indices

To assess the quantitative content of each type of bone marrow cells, their ratio in 500 cells is calculated. An important indicator is bone marrow neutrophil maturation index, which is calculated by dividing the total number of white lineage precursor cells by the total number of band and segmented neutrophils. Normally, the indicator is 0.6-0.8.

Along with the assessment of the white sprout, the characteristics of erythropoiesis are also important. Erythroid element maturation index calculated by the content of erythroblasts and normocytes and is 0.8-0.9. This indicator characterizes iron metabolism, the degree of saturation of red cells with hemoglobin, and increased erythropoiesis in anemia.

After calculating the number of granulocytes and the total number of red germ cells containing nuclei, their ratio is calculated, which is normally 3-4: 1 - leuko-erythroblastic ratio.

Bone marrow indices make it possible to objectify data on absolute numbers and percentages of specific cell populations. So, increase in leuko-erythroblastic index characteristic of hyperplasia of the white germ of hematopoiesis, which is observed in chronic lympho- and myeloblastic leukemia, infectious diseases, intoxications, and it can also indicate hypoplastic anemia with a general depletion of bone marrow tissue.

Decrease in leuko-erythroblastic index is indicative of hemolytic, posthemorrhagic and megaloblastic anemia (with normal bone marrow cellularity), and in the case of bone marrow depletion, it indicates agranulocytosis (decreased leukocyte count).

The normal value of this ratio can indicate either complete health, or aplasia and hypoplasia of bone marrow tissue, when a more or less uniform decrease in the number of cells of both white and red sprouts is observed, which is why it is so important not to conduct isolated assessments of only the myelogram in order to avoid diagnostic errors.

Neutrophil Maturation Index with sufficient cellularity of the punctate, it increases in case of tumors of the hematopoietic tissue (leukemia), drug poisoning, and its decrease is usually characterized by bone marrow dilution due to errors during puncture.

The described myelogram criteria make it possible to assess hematopoiesis as a whole, but the specialist’s conclusion should not be categorical. It is important to correlate the results of the study of sternal puncture with the characteristics of the clinical picture and the data of peripheral blood analysis.

Patients and their relatives should especially be cautioned against independently assessing the results that may come into their hands. Such amateur activities usually lead to erroneous conclusions that can only harm the patient. Analysis of bone marrow puncture indicators is a complex process that requires utmost attention exclusively from a specialist in this field, who can accurately indicate whether there are changes and whether it is worth worrying about.

Target: diagnostic.

Indications: diseases of the blood and hematopoietic organs,

Equipment: sterile gloves, Kassirsky needle, iodine, 0.5% novocaine solution, sterile needles, 70% alcohol solution, dressing material, adhesive plaster or cleol, containers with initiating solution, ammonia, sterile diapers, referral forms,

Contraindications: determined by the doctor

Note:

Preparation for the procedure Collect information about the patient before meeting him. Explain the purpose and sequence of the upcoming procedure. Obtain consent for the procedure (if the patient is conscious) (Ward nurse) Psychological preparation of the patient for the procedure.

2. Wash and dry your hands. Wear gloves Ensuring infection safety

Procedural nurse

3. Set the sterile table and prepare the necessary equipment

4. Help the doctor prepare for the procedure (washing hands, putting on sterile clothing)

P. Performing the procedure 1. Carry out premedication as prescribed by the doctor.

Charge nurse

2. Deliver the patient to the treatment room on a gurney

3. Place the patient on the couch (operating table) on his back without a pillow

4. Assist the doctor during puncture (processing the surgical field, administering anesthesia, supplying instruments)

Procedural nurse

5. Monitor the patient’s condition during the procedure

All participants

6. Apply a sterile bandage after the procedure

Procedural honey

7. Make a bone marrow smear on a glass as quickly as possible

8. Transport the patient to the room on a gurney. Monitor the patient's condition for 2-3 hours after puncture

III. Completion of the procedure 1. Disinfect used instruments followed by disposal of disposable medical supplies. Wash and dry your hands

Procedural nurse

2. Deliver the smears with a direction to the laboratory.

NURSE'S PARTICIPATION IN ABDOMINAL PUNCTURE

Target: therapeutic and diagnostic.

Indications: ascites.

Equipment: sterile gloves, iodine, 0.5% novocaine solution, 70% alcohol solution, sterile syringes and needles, scissors, tweezers, 2 clamps, trocar, rubber catheter, needle holder, flapping needle, silk, dressing material, adhesive plaster or cleol, 1- 2 test tubes, an oilcloth apron, a towel or sheet, a container for collecting ascitic fluid, containers with a disinfectant solution, ammonia, referral forms.

Contraindications: determined by the doctor.

Note: As a rule, procedure and ward nurses participate in the manipulation.

Preparation for the procedure on the day before the manipulation Collect information about the patient before meeting him.

Obtain consent for the procedure (if the patient is conscious) Psychological preparation of the patient for the procedure. Respect for the patient's rights to information Ward nurse

In the evening, give the patient a cleansing enema

Preparation for the procedure on the day of manipulation Wash and dry your hands. Put on gloves

Procedural nurse

Set the sterile table and prepare the necessary equipment

Help the doctor prepare for the procedure (washing hands, putting on sterile clothing)

Ensure that the patient's bladder is emptied before the procedure

Charge nurse

Performing the procedure Deliver the patient to the treatment room on a gurney Ensure the physical safety of the patient Help the patient sit on a chair so that his back is pressed tightly against the wall of the chair (if the patient cannot sit, the puncture is performed in a lying position on the right side). Place a container between the patient's legs to collect ascitic fluid.

Premedication(1 ml of 2% solution of promedol and 0.1% solution of atropine subcutaneously).

Cover the patient's legs with an oilcloth cover, the end of which is lowered into the pelvis

5. Assist the doctor during puncture (processing the surgical field, administering anesthesia, puncture of the abdominal cavity, collecting material for research, applying sutures and aseptic dressings)

Procedural nurse

6. Monitor the patient’s condition during the procedure

7. After the fluid begins to be removed, place a folded sheet (large towel) on the patient’s stomach above the puncture site and tie it behind the patient’s back. As the fluid is removed, gradually tighten the sheet around the patient's abdomen

Prevention of the development of a collaptoid state

Charge nurse

8. Apply a sterile bandage after the procedure

Procedural nurse

9. Transport the patient to the room on a gurney in a supine position with a fixed sheet or towel. Ensure that the patient adheres to strict bed rest during the day. Monitor the condition of the bandage

Prevention of complications Ward nurse

IV. Completion of the procedure 1. Disinfect used instruments followed by disposal of disposable medical supplies. Wash and dry your hands

Procedural nurse

2. Deliver the test tube with the material and directions to the laboratory

Charge nurse

3. Make a note in medical documents about the procedure and the patient’s reaction.

"Preparation of the patient for ultrasound examinations."

Sequence of actions	Rationale
in stationary conditions
1. Register the patient for the prescribed study, if necessary, complete the referral form.	Provides quick results.
2. Explain to the patient the purpose of the study, the nature of the study, the need for it, and obtain the patient’s consent.
3. Explain to the patient who will conduct the examination, approximately how long it will take, the patient’s possible subjective feelings during and after the examination, and the nature of the preparation.	The reliability of the result and the conscious participation of the patient in the procedure are ensured.
4. Pay attention to the most important aspects of preparation. Ask the patient to repeat the main points and all information received.
5. Prepare the patient for the study.
6. On the day of the examination, make sure that the patient has completed everything correctly and accompany (transport) with the medical history to the endoscopy room.
7. Transport the patient after the study to the department. Monitor the patient's condition.	Patient safety.
on an outpatient basis
1. Explain the purpose of the study and obtain the patient’s consent.	Ensuring the patient's right to information.
2. Complete the referral form.	Ensures accurate patient information and reduces searches for both laboratory and patient records.
3. Explain to the patient who will conduct the research and approximately how long it will take.	The reliability of the result and the conscious participation of the patient in the procedure are ensured.
4. Teach the patient and/or his relatives how to prepare for the study and the correct technique. Give a reminder if necessary.
5. Explain to the patient and/or his relatives where and at what time to come with a referral.
6. Ask the patient to repeat all the information received from you.	Condition for learning effectiveness.

Note : it is necessary to warn the patient that each type of examination is carried out in a certain position and it is important to take this position correctly, and also try to orient the patient to the fact that during the examination he must lie calmly and patiently.

Sternal puncture– study of a human bone marrow sample. During the procedure, the sternum wall is pierced with a syringe. Bone marrow is the soft mass that fills the cavities in the bones. In some cases, its study is extremely important and necessary. Today we will look at what this procedure is and for what purpose it is carried out.

Main indications

Puncture is most often used for diagnostic purposes for diseases of the circulatory system. The main indications are as follows:

Anemia;
Leukemia;
Myelodysplastic syndrome;
Christian-Schuller disease;
Gaucher disease;
Visceral leishmaniasis. With its help, you can accurately determine the state of the bone marrow, its functioning, and also study changes in hematopoiesis. Before performing a puncture, you need to prepare.

Preparation rules

Before sternal puncture No special diet is required, but 2 hours before it is better not to eat or drink. The bladder and intestines should be empty. Before the puncture, you should not take any medications other than those prescribed by the doctor performing the puncture. Before the procedure, the doctor will explain its purpose, tell you about the method of implementation, and complications. The patient must give written consent, only after which a sternal bone marrow puncture will be performed.

How is the puncture performed?

It can be performed on an outpatient basis under local anesthesia. The patient is placed face up on the couch. The sampling is made with a Kassirsky needle. This is a hollow, short needle with a nut that limits the depth of penetration. This prevents damage to the mediastinal organs. The doctor carefully selects the puncture site; it is treated with iodine solution and alcohol. After this, novocaine anesthesia is performed. Although the patient may feel a slight tingling and pain during the injection, it does not cause much discomfort and is more similar to the feeling of a regular vaccination. A quick rotational movement makes a puncture and removes the liquid. Only 0.3 ml of bone marrow is taken, this amount is quite enough for study.

Then the needle is slowly removed from the sternum, and a bandage is fixed at the puncture site with an adhesive plaster. The bone marrow sample is placed in a Petri dish, after which smears are prepared on a glass slide and carefully examined in the laboratory. Laboratory assistants count the number of bone marrow cells and study their morphology. When the laboratory test is completed, further procedures are developed based on its results. But do not forget that after a bone marrow puncture, some complications are possible. Let's look at them.

Possible complications

Negative consequences of sternal puncture include a through puncture of the sternum, and bleeding from the puncture site is also possible. A through puncture is possible when the operation is performed on a child, because in children the sternum has a high degree of elasticity. This is also quite likely if the child moved during the puncture. Therefore, the procedure must be carried out extremely carefully. Osteoporosis is possible in patients taking corticosteroids. In most cases, complications occur if the procedure is performed by an inexperienced doctor. Therefore, we recommend that it be carried out in our center. We employ only experienced and highly qualified specialists who will do everything quickly and efficiently.

Rehabilitation period

After the puncture, the patient must remain in the clinic under the supervision of doctors. Typically, such control does not last more than an hour, unless complications arise. After the procedure, no special recovery period is required; it is important to follow all doctor’s recommendations.

A sternal puncture allows a specialist to trace the nature of hematopoiesis and the morphological characteristics of blood cells, through which a specialist obtains a bone marrow sample for examination.

The term "sternal" implies that the bone marrow will be taken from the sternum, although it can also be obtained from the ilium or calcaneus (in young children). Puncture of the sternum seems to be a fairly simple and safe diagnostic method, provided that all precautions and manipulation techniques are followed.

Indications and contraindications for sternal puncture

Anemia - severe iron deficiency, megaloblastic, aplastic.
Tumors of hematopoietic tissue - leukemia, paraproteinemic hemoblastosis.
Myelodysplastic syndrome.
Leukemoid reactions, when the peripheral blood picture does not exclude tumor growth.
Storage diseases of hereditary nature, metabolic disorders (Gaucher disease, Niemann-Pick disease).
Visceral leishmaniasis.
Suspicion of the presence of metastases of other malignant neoplasms in the bones (prostate cancer, for example).
Assessing the effectiveness of treatment and monitoring the condition of hematological patients.
Research and procurement of the resulting stem cells for transplantation to a donor or the punctured patient himself after courses of chemotherapy or radiation.
Intraosseous administration of drugs.

There are also contraindications to sternal puncture:

Severe bleeding disorders.
Old age in cases where sternal puncture is not the only possible diagnostic method.
Acute inflammatory and infectious lesions at the site of the intended skin puncture.
Patient refusal to study.
Severe concomitant diseases in the stage of decompensation (the question of the advisability of a puncture is decided individually).

Preparation and technique for performing sternal puncture

The patient undergoes a blood clotting test and a general analysis no more than 5 days before the planned procedure;
Two hours before the puncture, the last meal and water is possible;
Before the procedure, the bladder and intestines are emptied;
All medications are canceled, except those that are vital;
On the day of the puncture, no other procedures are prescribed.

Before the manipulation, the patient must inform the doctor about all the medications he is taking, especially for anticoagulants and other blood-thinning agents, which should be discontinued due to the greatly increasing risk of bleeding while taking them.

The technique of performing sternal puncture includes several stages:

Lay the patient on his back and place a cushion under his shoulder blades.
Treatment of the puncture site with antiseptic solutions (iodine, ethanol); in men, the hair is shaved.
For pain relief, local anesthetics (lidocaine, novocaine) are injected into the skin, subcutaneous tissue and periosteal space, since a puncture is a rather painful event, especially when the needle passes through the periosteum.
The puncture is performed at the level of attachment to the sternum of the third or fourth rib, along the midline, using a Kassirsky needle, which is inserted into the bone with a quick twisting motion. When the bone marrow enters the receptacle, the doctor will feel a dip, which indicates that the needle is passing through the surface of the bone. When the needle is immersed through the compact bone layer and the bone marrow is aspirated, the patient will feel a short-term pain.
When the needle is in the medullary canal of the sternum, a syringe is connected to it, through which the doctor aspirates 0.3 ml of bone contents.
After obtaining the required volume of hematopoietic tissue, the needle is removed, and a sterile napkin or patch is applied to the puncture site.

Features of sternum puncture in children:

The results of a sternal puncture can be obtained on the same day if a cytological examination of a bone marrow smear is expected. With histological analysis and other more technically complex studies, the diagnosis is extended for a period of 7-10 days.

Video: sternal puncture technique

Complications and features of the postoperative period

The bone marrow collection procedure lasts approximately 20 minutes, after which the patient is monitored for about an hour, and their general well-being, pulse and blood pressure are monitored. You can leave the hospital the same day, but it is highly undesirable to drive, as there is a risk of fainting.

The puncture site does not require any treatment at home, however, for the first three days it is recommended to exclude water procedures so as not to introduce an infection into the puncture hole. Sternal puncture does not imply any restrictions on diet and nutrition. If there is severe pain at the puncture site, the patient can take a painkiller.

Through puncture (in a child or patient with osteoporosis);
Bleeding from the puncture site;
Infection of the puncture site (extremely rare);
Fainting states in emotionally labile persons, hypotensive persons, with insufficiently thorough psychological preparation of the patient for manipulation;
Shock in case of severe pathology of the cardiovascular system in elderly people.

Interpretation of sternal puncture results

Analysis of bone marrow obtained through sternal puncture shows the number of cellular elements in it, their ratio and degree of maturity. The myelogram characterizes the qualitative and quantitative indicators of the white germ of hematopoiesis:

Myelokaryocytes (the total number of blood cells containing nuclei) are 10 9 per liter of blood;
Megakaryocytes (precursors of platelets) - 0.054-0.074x10 6 per liter;
Reticulocytes (precursors of red blood cells) make up 20-30% and increase with blood loss and hemolytic anemia;
Blast cells - 0.1-1.1%, myeloblasts - 0.2-1.7%, promyelocytes - 0.5-8.0% of all elements of the white sprout of the bone marrow, lymphocytes - 1.2-1.5 %, monocytes - 0.25-2.0%, plasma cells - no more than 1%.

A decrease in the number of myelokaryo- and megakaryocytes is possible due to errors in the puncture, when the bone marrow is diluted with liquid blood.

Bone marrow indices

To assess the quantitative content of each type of bone marrow cells, their ratio in 500 cells is calculated. An important indicator is the bone marrow neutrophil maturation index, which is calculated by dividing the total number of white lineage precursor cells by the total number of band and segmented neutrophils. Normally, the indicator is 0.6-0.8.

Along with the assessment of the white sprout, the characteristics of erythropoiesis are also important. The maturation index of erythroid elements is calculated from the content of erythroblasts and normocytes and is 0.8-0.9. This indicator characterizes iron metabolism, the degree of saturation of red cells with hemoglobin, and increased erythropoiesis in anemia.

After calculating the number of granulocytes and the total number of red germ cells containing nuclei, their ratio is calculated, which is normally 3-4:1 - the leuko-erythroblastic ratio.

Bone marrow indices make it possible to objectify data on absolute numbers and percentages of specific cell populations. Thus, an increase in the leuko-erythroblastic index is characteristic of hyperplasia of the white germ of hematopoiesis, which is observed in chronic lympho- and myeloblastic leukemias, infectious diseases, intoxications, and it can also indicate hypoplastic anemia with a general depletion of bone marrow tissue.

A decrease in the leuko-erythroblastic index is indicative of hemolytic, post-hemorrhagic and megaloblastic anemia (with normal bone marrow cellularity), and in the case of bone marrow depletion, it indicates agranulocytosis (decreased leukocyte number).

The neutrophil maturation index, with sufficient cellularity of the punctate, increases with tumors of the hematopoietic tissue (leukemia), drug poisoning, and its decrease is usually characterized by bone marrow dilution due to errors during puncture.

The described myelogram criteria make it possible to assess hematopoiesis as a whole, but the specialist’s conclusion should not be categorical. It is important to correlate the results of the study of sternal puncture with the characteristics of the clinical picture and the data of peripheral blood analysis.

101. The concept of sternal puncture, lymph node and trepanobiopsy, interpretation of the results of bone marrow puncture examination.

Sternal puncture is one of the methods of intravital bone marrow examination; is a bone marrow puncture performed through the anterior wall of the sternum. Bone marrow examination is necessary for the diagnosis of anemia, leukemia, myelodysplastic syndromes, tumor metastases, etc. Sternal puncture can be performed on an outpatient basis.

The puncture site is treated with ethyl alcohol and an alcohol solution of iodine. For anesthesia, a 2% novocaine solution is usually used; You can do a puncture without pain relief. The sternum is pierced with a Kassirsky needle at the level of the attachment of the III-IV rib along the midline or the manubrium of the sternum is punctured. The needle is inserted with a quick rotational movement. When it passes through the layer of the cortical (compact) substance of the anterior surface of the sternum and enters the spongy (marrow space), a sensation of failure is noted. An indirect sign of a successful puncture is short-term pain. After removing the mandrin, a syringe (10 or 20 ml capacity) is attached to the needle, with which the bone marrow is aspirated. Gradually, creating a vacuum in the syringe, suck in no more than 0.2-0.3 ml of bone marrow suspension. The needle is then removed from the sternum. A sterile sticker is applied to the puncture site. The contents of the needle and syringe are squeezed onto a glass slide and smears are prepared.

Trephine biopsy provides more accurate information about the composition of the bone marrow. Special

a trocar needle is inserted into the iliac crest and its column is cut out from

bone marrow tissue from which histological preparations are made. In them

the structure of the bone marrow is preserved, and the absence of blood admixture makes it possible to evaluate it

cellular composition and identify focal and diffuse changes in it.

Often they resort to puncture of enlarged lymph nodes, which gives

the ability to determine the nature of changes in their cellular composition and clarify the diagnosis

a number of systemic diseases of the lymphatic system: lymphocytic leukemia,

lymphogranulomatosis, lymphosarcomatosis, detect tumor metastases, etc. More

accurate data can be obtained using a lymph node biopsy. puncture

performed without anesthesia with a simple injection needle,

Trepanate (spongy bone tissue) in healthy people and in patients with hyperplastic processes is rich in bone marrow. In severe aplastic processes, the trepanate has a yellow color, which is caused by the almost complete disappearance of bone marrow elements and their replacement with adipose tissue.

Bone marrow puncture: indications, preparation for the study, methodology

Bone marrow puncture (or sternal puncture, aspiration, bone marrow biopsy) is a diagnostic method that allows you to obtain a sample of red bone marrow tissue from the sternum or other bone by puncture with a special needle. After this, the obtained biopsy tissue is examined. This test is usually performed to detect blood disorders, but is sometimes performed to diagnose cancer or metastasis.

The collection of material for its implementation can be carried out both in outpatient and inpatient settings. The tissue obtained after puncture is sent to the laboratory to perform a myelogram, histochemical, immunophenotyping and cytogenetic analysis.

This article will provide information on the principle of execution, indications, contraindications, possible complications, advantages and method of performing bone marrow puncture. It will help you get an idea of this diagnostic procedure, and you can ask your doctor any questions you have.

A little anatomy

Bone marrow is located in the cavities of different bones - vertebrae, tubular and pelvic bones, sternum, etc. This body tissue produces new blood cells - leukocytes, red blood cells and platelets. It consists of stem cells, which are in a state of rest or division, and stroma - supporting cells.

Up to 5 years of age, bone marrow is present in all bones of the skeleton. With age, it moves to tubular bones (tibia, humerus, radius, femur), flat bones (pelvic bones, sternum, ribs, skull bones) and vertebrae. As the body ages, red bone marrow is gradually replaced by yellow bone marrow, a special fatty tissue that is no longer capable of producing blood cells.

Principle of bone marrow puncture

The most convenient bone for collecting bone marrow tissue in adults is the sternum, namely the area on its body located at the level of the II or III intercostal space. In addition, the arches or crest of the iliac bone and the spinous processes of the lumbar vertebrae can be used to perform the manipulation. In children under 2 years of age, the puncture can be performed on the calcaneus or tibial plateau, and in older adults - on the ilium.

To extract biopsy tissue, special needles and ordinary syringes (5, 10 or 20 ml) are used, which allow tissue to be aspirated (suctioned) from the sternum cavity. As a rule, bone marrow altered by pathology has a semi-liquid consistency and its collection is not difficult. After obtaining samples of the material, smears are made on glass slides, which are examined under a microscope.

What does a puncture needle look like?

To perform bone marrow puncture, non-oxidizing steel needles of various modifications are used. The diameter of their lumen is from 1 to 2 mm, and the length is from 3 to 5 cm. Inside these needles there is a mandrin - a special rod that prevents blockage of the needle lumen. Some models have a blocker that limits too deep penetration. At one end of the bone marrow puncture needle there is a scrolling element that allows you to comfortably hold the device while performing the puncture.

Before the procedure, the doctor adjusts the needle to the expected puncture depth. In adults it can be about 3-4 cm, and in children - from 1 to 2 cm (depending on age).

Indications

Puncture and analysis of bone marrow tissue may be prescribed in the following cases:

disorders of the leukocyte formula or clinical blood test: severe forms of anemia that are not amenable to standard therapy, increased amounts of hemoglobin or red blood cells, increased or decreased levels of leukocytes or platelets, inability to identify the causes of a high level of ESR;
diagnosis of diseases of the hematopoietic organs against the background of the appearance of symptoms: fever, swollen lymph nodes, weight loss, rash in the mouth, sweating, a tendency to frequent infectious diseases, etc.;
identification of storage diseases caused by a deficiency of one of the enzymes and accompanied by the accumulation of a certain substance in tissues;
histiocytosis (pathology of the macrophage system);
prolonged fever if lymphoma is suspected and another cause of fever cannot be identified;
determining the suitability of transplant tissue obtained from a donor before surgery;
assessment of the effectiveness of bone marrow transplantation;
detection of metastases in the bone marrow;
intraosseous administration of drugs;
preparation for chemotherapy for blood cancers and for assessing treatment results.

Contraindications

Contraindications to bone marrow puncture can be absolute or relative.

acute myocardial infarction;
decompensated form of heart failure;
acute cerebrovascular accident;
decompensated form of diabetes mellitus;
inflammatory or purulent skin diseases at the puncture site;
the result of the puncture will not have a significant impact on improving the effectiveness of treatment.

In some cases, doctors may have to refuse to perform a bone marrow tap because the patient (or their designee) refuses the procedure.

Preparation for the procedure

Before performing a bone marrow puncture, the doctor must familiarize the patient with the principle of its implementation. Before the examination, the patient is recommended to take a blood test (general and clotting tests). In addition, the patient is asked questions about the presence of allergic reactions to medications, medications taken, the presence of osteoporosis, or previous surgical interventions on the sternum.

If the patient is taking blood thinning medications (Heparin, Warfarin, Aspirin, Ibuprofen, etc.), then he is advised to stop using them several days before the intended procedure. If necessary, a test is performed to determine the absence of an allergic reaction to the local anesthetic that will be used to numb the puncture.

On the morning of the bone marrow puncture, the patient should take a shower. The man must shave the hair from the piercing site. The patient can eat a light breakfast 2-3 hours before the test. Before performing the procedure, he should empty his bladder and bowels. In addition, it is not recommended to carry out other diagnostic tests or surgical procedures on the day of puncture.

How is the procedure performed?

The collection of red bone marrow tissue is carried out in a hospital or diagnostic center (outpatient) in a specially equipped room in compliance with all the rules of asepsis and antiseptics.

The sternal puncture procedure is carried out as follows:

30 minutes before the start of the procedure, the patient takes a painkiller and a mild sedative.
The patient undresses to the waist and lies on his back.
The doctor treats the puncture site with an antiseptic and performs local anesthesia. A local anesthetic is injected not only under the skin, but also into the periosteum of the sternum.
After the painkiller begins to take effect, the doctor marks the puncture site (the space between the 2nd and 3rd rib) and selects the necessary needle.
To perform a puncture, the specialist makes gentle rotational movements and applies moderate pressure. The depth of the puncture may vary. When the end of the needle enters the sternum cavity, the doctor feels a decrease in tissue resistance. During the puncture, the patient may feel pressure, but not pain. After insertion, the needle itself is held in the bone.
After puncturing the sternum, the doctor removes the mandrel from the needle, attaches a syringe to it and performs a bone marrow aspiration. From 0.5 to 2 ml of biopsy material can be taken for analysis (depending on age and clinical case). At this point, the patient may feel slight pain.
After collecting material for research, the doctor removes the needle, disinfects the puncture site and applies a sterile bandage for 6-12 hours.

The duration of a sternal puncture is usually about minutes.

To obtain bone marrow tissue from the iliac bones, the doctor uses a special surgical instrument. When performing punctures on other bones, needles and appropriate techniques are used.

After the procedure

30 minutes after completion of the bone marrow puncture, the patient can go home (if the study was performed on an outpatient basis) accompanied by a relative or friend. On this day, he is not recommended to drive a car or operate other traumatic mechanisms. Over the next 3 days, you must refrain from bathing and showering (the puncture site must remain dry). The puncture area should be treated with a solution of an antiseptic prescribed by a doctor.

Examination of the material obtained after puncture

After obtaining red bone marrow tissue, they immediately begin to perform a smear for a myelogram, since the resulting material resembles blood in its structure and quickly clots. The biopsy sample is poured from a syringe at an angle of 45° onto a fat-free glass slide so that the contents flow freely from it. After this, thin strokes are made with the sanded end of the other glass. If the material for research contains a lot of blood, then before performing a smear, its excess is removed using filter paper.

To perform a cytological examination, 5 to 10 smears (sometimes up to 30) are prepared. And part of the material is placed in special tubes for histochemical, immunophenotyping and cytogenetic analysis.

The test results can be ready 2-4 hours after receiving the smears. If the material for research is sent to another medical institution, it may take up to 1 month to obtain a conclusion. The interpretation of the analysis result, which is a table or diagram, is carried out by the patient’s attending physician - hematologist, oncologist, surgeon, etc.

Possible complications

Complications almost never arise after a bone marrow puncture is performed by an experienced doctor. Sometimes the patient may feel slight pain at the puncture site, which disappears over time.

If the procedure is performed by an inexperienced specialist or the patient has been improperly prepared, the following undesirable consequences are possible:

In some cases, infection may occur at the puncture site. It is possible to avoid this complication of the bone marrow puncture procedure by using disposable instruments and following the rules of care for the puncture site.

Particular attention should be paid to patients suffering from osteoporosis. In such cases, the bone loses its strength, and its puncture can provoke a traumatic fracture of the sternum.

Benefits of bone marrow puncture

Carrying out a bone marrow puncture is an accessible, highly informative procedure that is easy to perform and prepare. Such a study does not put a serious burden on the patient, rarely causes complications, allows for an accurate diagnosis and assessment of the effectiveness of the treatment.

Bone marrow puncture plays an important role in the diagnosis of blood pathologies and oncological processes. Its implementation makes it possible to quickly and accurately make a diagnosis. After treatment, such a diagnostic technique can be carried out to assess its effectiveness.

Which doctor should I contact?

Typically, a bone marrow puncture is prescribed by a hematologist or oncologist. The reason for such a procedure may be various severe blood diseases, malignant tumors, suspicion of metastases, preparing the patient for bone marrow transplantation or chemotherapy, storage diseases, etc.

A specialist from the Moscow Doctor clinic talks about bone marrow puncture:

Myelogram - interpretation of bone marrow smear

For patients with severe anemia, if certain types of tumors and blood diseases are suspected, a myelogram is often prescribed during the diagnosis of the pathology.

This study helps to identify abnormalities in the bone marrow and hematopoietic processes. Based on the results of the myelogram, treatment is selected and the therapy is evaluated.

What is a myelogram?

A myelogram is actually not a diagnostic method itself, but the result of a microscopic analysis of a smear obtained from the bone marrow.

A puncture or biopsy of red bone marrow is also called a sternal puncture and is a standard diagnostic method in hematology. This study must be carried out simultaneously with a detailed analysis of peripheral blood.

The material is taken from the sternum or ilium from adults.

Indications and contraindications

A myelogram allows us to establish the nature of erythropoiesis and identifies cells that appear in various pathologies of the hematopoietic system.

Changes in the bone marrow are detected in Nimman-Pick and Gaucher diseases, and with the development of metastases.

An assessment of bone marrow hematopoiesis together with indicators of a general and complete blood count is required to clarify the cause of a decrease in hemoglobin, that is, anemia.

Absolute indications for which a bone marrow biopsy is required include:

All types of anemia, except typical iron deficiency anemia.
Cytopenia.
Acute leukemia and the chronic form of this disease at the initial stage of development.
A significant increase in ESR, in which it is not possible to find out the main cause of this pathology. An increase in ESR may occur in people with Waldenström's macroglobulinemia or multiple myeloma.
Increased risk of developing bone marrow metastases in patients with various malignancies.

In some cases, a myelogram is necessary to determine the cause of iron deficiency anemia and to determine changes in chronic long-term leukemia. These indications for obtaining bone marrow punctate are considered relative.

Sternal puncture is not performed on patients:

With acute myocardial infarction.
In acute cerebrovascular accident.
At the time of an attack of suffocation, angina pectoris and during a hypertensive crisis.

Preparing for analysis

Sternal puncture is a fairly common procedure and does not require special preparation of the patient.

There is no need to change your diet; you just need to eat two to three hours before the test.

The doctor must know about all the medications used; only those that are necessary for health reasons are left for several days. Be sure to stop heparin, as it thins the blood and can cause bleeding.

How is the procedure done?

Sternal puncture takes only a few minutes and is performed under local anesthesia.

The research consists of several stages:

The patient lies on his back on the couch.
The skin of the sternum is treated with an antiseptic.
Local anesthetic is injected under the skin and into the periosteum.
The sternum is punctured with a special needle with a hollow channel. Localization of the puncture site is the level of the sternum opposite the third rib and in the middle.
The depth of the puncture is controlled by a special disk located on the needle.
Approximately 0.3 ml of bone marrow is aspirated with a syringe.
After removing the needle, apply a sterile bandage to the puncture site.

If it is necessary to obtain punctate from the iliac crest, it is taken using a special surgical instrument. In young children, the sternum is usually not pierced, and the material is obtained from the calcaneus or tibia.

There is a high risk of sternum puncture in those patients taking corticosteroids. Under the influence of these drugs, osteoporosis often develops, leading to bone loss.

Interpretation of myelogram results

Not only hematologists, but also therapists, oncologists, and neurologists are involved in deciphering bone marrow smear parameters. Before making a definite diagnosis, the data of all other examinations and, necessarily, blood test results are taken into account.

Normal indicators

Myelogram in the table:

For what diseases is the rate increased?

An increase in the number of cellular elements of the bone marrow is possible with a variety of diseases of the blood system:

The growth of megakaryocytes indicates metastases in the bone marrow and myeloproliferative processes.
An increase in the ratio between erythrocytes and leukocytes indicates leukemoid reactions, chronic myeloid leukemia, subleukemic myelosis.
An increase in blasts by more than 20% of normal occurs in acute leukemia. Blasts also increase up to 20% in acute leukemia, but also in myeloid forms of chronic leukemia and in people with myelodysplastic syndrome.
The neutrophil maturation index increases in patients with blast crisis and chronic myeloid leukemia.
Myeloblasts increase by more than 20% during blast crisis, in patients with chronic myeloid leukemia. An increase in myeloblasts of less than 20% is also observed in myelodysplastic syndrome.
An increase in promyelocytes occurs in leukemoid reactions, promyelocytic leukemia, and in patients with chronic myeloid leukemia.
Neutrophilic myelocytes and metamyelocytes increase in chronic myeloid leukemia, subleukemic myelosis, and leukemoid reactions of the body.
The growth of band neutrophils indicates leukemoid reactions, subleukemic myelosis, chronic myeloid leukemia and the syndrome of “lazy” leukocytes.
Segmented neutrophils grow in patients with chronic myeloid leukemia and subleukemic myelosis. A change towards an increase in these elements can occur with the syndrome of “lazy” leukocytes and with leukemoid reactions.
Growing eosinophils are detected in allergic reactions, malignant tumors, helminthiasis, acute leukemia, chronic myeloid leukemia and lymphogranulomatosis.
Basophils increase in the chronic form of myeloid leukemia, erythremia, and basophilic leukemia.
An increase in lymphocytes indicates aplastic anemia or chronic lymphocytic leukemia.
A large number of monocytes can be present in leukemia, tuberculosis, sepsis, and chronic myeloid leukemia.
Bone marrow plasma cells increase in number during multiple myeloma, infections, aplastic anemia, and immune agranulocytosis.
Erythroblasts deviate from the norm towards an increase in different forms of anemia and in patients with acute erythromyelosis.

The norm has been lowered, what does this mean?

A decrease in megakaryocytes indicates hypoplastic and aplastic autoimmune and immune processes in the body. A decrease in megakaryocytes is determined in patients after radiation exposure and taking cytostatics.
A decrease in the ratio between leukocytes and erythrocytes can occur due to blood loss, hemolysis, erythremia and acute erythromyelosis.
A decrease in promyelocytes occurs with aplastic anemia, under the influence of ionizing radiation, and cytostatics.
A decrease in the erythroblast maturation index is observed in patients with B 12 deficiency anemia, with blood loss and reflects ineffective erythropoiesis during hemodialysis.
A decrease in the number of neutrophil myelocytes and metamyelocytes, band and segmented, indicates aplastic anemia, immune aphanulocytosis, which often develops under the influence of cytostatics and ionizing radiation.
A decrease in the number of erythroblasts occurs with aplastic anemia, partial red cell aplasia and develops when taking cytostatics and when the body is exposed to ionizing radiation.

Complications

Sternal puncture, when performed by an experienced doctor, practically does not cause complications.

Cost of analysis

The cost of a sternal puncture and myelogram in Moscow clinics starts from about 800 rubles. The average cost of the procedure is about three thousand.

Indications– blood diseases, tumor processes.

Kit:

– gloves, alcohol, balls, syringes and needles for anesthesia, novocaine 0.5%, Kassirsky needle (Fig. 5) with a syringe for punctate, aseptic dressing material.

Rice. 5. Kassirsky needle attached to the syringe: 1 – needle; 2 – safety shield; 3 – coupling; 4 – screw thread; 5 – cannula; 6 – syringe.

Technique:

· after disinfection of the body in the sternum area, the skin and periosteum are anesthetized;

· upon the onset of anesthesia, a Kassirsky needle is used to puncture the sternum along the midline approximately at the level of the III-IV rib. The needle stop safety flap is pre-installed according to the guidelines (see table).

· punctate in an amount of up to 0.5 ml is obtained using a syringe placed on a needle so that air does not penetrate into it. After taking the bone marrow, the needle, without disconnecting the syringe, is removed from the sternum, and the puncture site is covered with a sterile sticker. From the resulting punctate, smears are prepared, which are fixed and stained in the same way as peripheral blood smears;

· In young children, the puncture of the sternum should be done carefully due to its lower density. Therefore, in newborns and infants, it is preferable to puncture the upper third of the tibia (on the inner side of the proximal epiphysis), calcaneus, and ilium (1-2 cm posterior to the anterior superior crest spine).

LUMBAL PUNCTURE

Indications - diagnosis of diseases of the central nervous system (meningitis, encephalitis, tumors, traumatic brain injuries, etc.). Removal of cerebrospinal fluid for communicating hydrocephalus.

Kit:

3 sterile test tubes, sterile diapers, gauze, gloves, alcohol, iodine solution, aseptic dressing. The needle for puncture is selected depending on the age of the child (special needles with a short cut and with a mandrel). For puncture of newborns, a 22-gauge needle 2.5 cm long is used.

Technique:

· An assistant holds the child in a sitting position or lying on his side. When lying on your side, your head and legs should be bent (knee-thoracic position). Palpate the iliac crest and slide your fingers down to the spine (usually at the L 4 -L 5 level). The puncture is usually performed between the L 2 -L 3 or L 3 -L 4 lumbar vertebrae. In newborns and young children, the puncture is carried out between L 4 -L 5;

· put on gloves, open the sterile containers, pour the antiseptic solution into the container included in the lumbar puncture kit;

· wipe the puncture site with an antiseptic solution, starting from the selected intervertebral space and then along an ever-widening circle to the iliac crest;

· cover the puncture area with sterile diapers: place one under the child, the second cover everything except the intervertebral space selected for puncture;

· Palpate the selected intervertebral space again;

· insert the needle strictly along the midline in the direction: for newborns - to the umbilical ring; in young children - perpendicular to the line of the spine; in children over 10-12 years old - with a slight tilt towards the head, i.e. from bottom to top, slowly advance the needle, first breaking through the skin, then the intervertebral ligaments and dura mater until a feeling of “failure” occurs. Then remove the mandrin and check whether cerebrospinal fluid appears in the needle;

· draw about 1 ml of cerebrospinal fluid into each of the three test tubes as it flows out in drops from the needle;

· reinsert the mandrin into the needle and remove it. The puncture site is pressed with a sterile swab and sealed with an adhesive plaster. The patient must observe strict bed rest for at least 24 hours (Fig. 6);

When examining cerebrospinal fluid, the following tests are performed:

Tube 1: Gram stain, culture, and antibiotic sensitivity testing.

Test tube 2: determination of sugar and protein levels.

Tube 3: cell counting and differentiation.

If there is an admixture of blood in the first test tube, make sure that the cerebrospinal fluid in the second and third test tubes is cleared:

a) if the blood admixture has disappeared, this means that the puncture was performed traumatically;

b) if the blood admixture does not disappear, but clots form, the vessel is apparently punctured;

c) if the blood does not disappear and a clot does not form, the newborn obviously has intraventricular hemorrhage.

GASTRIC WASHING

Indications- gastric lavage is used for therapeutic or diagnostic purposes in case of poisoning.

Contraindications - for gastric lavage are organic narrowing of the esophagus, acute esophageal and gastric bleeding, severe chemical burns of the mucous membrane of the larynx, esophagus and stomach with strong acids and alkalis (several hours after poisoning), cerebrovascular accidents.

Remember! - gastric lavage for an unconscious patient in the absence of cough and laryngeal reflexes to prevent aspiration of fluid is carried out only after preliminary intubation of the trachea.

If, when the probe is inserted, the patient begins to cough, choke, or his face becomes cyanotic, the probe should be removed immediately - it has entered the larynx or trachea, and not the esophagus.

Kit:

- sterile gastric tubes with two holes on the side walls; funnel; towel; napkins; sterile container for rinsing water; container with water at room temperature (10 l); mug; container for draining wash water; gloves; 2 waterproof aprons; glycerol; spatula; bandage.

Technique:

· The position of children during washing depends on their age. Young (infant) children are most often placed on their side with their face slightly turned down. The nurse picks up a preschool child, wraps him in a sheet (diaper), clamps the child’s legs tightly between her legs, and presses his head to his shoulder. Older children are seated on a chair, their chest is covered with an oilcloth apron;

· put on a waterproof apron. Wash your hands and put on gloves. Lubricate the blind end of the probe with glycerin;

· To hold the patient's mouth open, use a spatula or mouth retractor. A gastric tube is inserted behind the root of the tongue and advanced to the established mark. An older child is asked to make several swallowing movements. Confirmation that the tube is in the stomach is the cessation of gagging;

· attach a funnel to the probe and lower it to the level of the stomach. Holding the funnel slightly inclined at the level of the stomach, pour water into it (see table);