Other

Preparation for sternal puncture algorithm. Sternal puncture

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 safety shield of the needle limiter 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, monitor the purification of the cerebrospinal fluid in the second and third test tubes:

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-age 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);

Purpose: diagnostic.

Indications: diseases of the blood and hematopoietic organs. Contraindications: determined by the doctor.

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

Stages	Rationale	Providing
I. Preparation for the procedure: 1. Collect information about the patient before meeting him. Introduce yourself kindly and respectfully to him. Find out how to contact him. Explain the essence and course of the upcoming procedure if he is unfamiliar with it. Obtain consent for the procedure (if the patient is conscious).		Charge nurse
2. Wash your hands (hygienic method). Wear gloves.		Procedural nurse
3. Set the sterile table and prepare the necessary equipment.
4. Help the doctor prepare for the procedure: cleaning hands, putting on sterile clothing.	Ensuring infection safety.
II. Performing the procedure: 5. Carry out premedication as prescribed by the doctor.		Charge nurse
6. Deliver the patient to the treatment room on a gurney.
7. Place the patient on the couch (operating table) on his back without a pillow.	Ensuring that the procedure is carried out effectively.
8. Assist the doctor during puncture (processing the surgical field, administering anesthesia, supplying instruments).	Ensuring that the procedure is carried out effectively.	Procedural nurse
9. Monitor the patient’s condition during the procedure.		All participants
10. Apply a sterile bandage after the procedure.	Ensuring infection safety.	Procedural nurse
11. Make a bone marrow smear on a slide as quickly as possible.	Ensuring reliable results.
12. Transport the patient to the ward on a gurney. 13. Monitor the patient’s condition for 2-3 hours after the puncture.	Prevention of complications.	Charge nurse
III. Completion of the procedure: 14. Disinfect used instruments followed by disposal of disposable medical supplies. 15. Wash your hands (hygienic level).	Ensuring infection safety.	Procedural nurse
16. Deliver the smears and send them to the laboratory.		Charge nurse
17. Make a record of the procedure and the patient’s response in the medical record.

NURSE'S PARTICIPATION IN ABDOMINAL PUNCTURE

Purpose: therapeutic and diagnostic.

Indications: ascites.

Contraindications: determined by the doctor.

Equipment: sterile gloves, iodine, 0.5% novocaine solution, 70% alcohol solution, sterile syringes and needles, scissors, tweezers, scalpel, 2 clamps, trocar, rubber catheter, needle holder, rail needle, silk, dressing material, adhesive plaster or cleol, 1-2 test tubes, oilcloth apron, towel or sheet, container for collecting ascites O1 fluid, containers with disinfectant solution, ammonia, referral forms.

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

Stages	Rationale	Providing
I. Preparation for the procedure (on the day before the procedure): 1. Collect information about the patient before meeting him. Introduce yourself kindly and respectfully to him. Find out how to contact him. Explain the essence and course of the upcoming procedure if he is unfamiliar with it. Obtain consent for the procedure (if the patient is conscious).	Psychological preparation of the patient for the procedure. Patient motivation to cooperate. Respect for the patient's right to information.	Charge nurse
2. In the evening, give the patient a cleansing enema.	Ensuring that the procedure is carried out effectively.
Preparation for the procedure (on the day of manipulation): 3. Wash your hands (hygienic method). Wear gloves.	Ensuring infection safety.	Procedural nurse
Stages	Rationale	Providing
4. Set the sterile table and prepare the necessary equipment.	Ensuring that the procedure is carried out effectively.
5. Help the doctor prepare for the procedure: cleaning hands, putting on sterile clothing.	Ensuring infection safety.
6. Ensure that the bladder is emptied before the procedure.	Ensuring that the procedure is carried out effectively.
II. Performing the procedure: 7. Carry out premedication as prescribed by the doctor.	Ensuring psychological safety.
8. Deliver the patient to the treatment room on a gurney.	Ensuring the physical safety of the patient.	Ward
9. 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.	Ensuring that the procedure is carried out effectively.	nurse
10. Cover the patient’s legs with an oilcloth apron, the end of which is lowered into the basin.	Ensuring infection safety.
11. Assist the doctor during puncture (processing the surgical field, administering anesthesia, puncture of the abdominal cavity, collecting material for examination, applying sutures and aseptic dressing).	Ensuring that the procedure is carried out effectively.	Procedural nurse
12. Monitor the patient’s condition during the procedure.	Ensuring the physical and mental safety of the patient.	All participants
13. 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
14. Apply a sterile bandage after the procedure.	Ensuring infection safety.	Procedural nurse
15. Transport the patient to the room on a gurney in a supine position with a fixed sheet or towel. 16. Ensure that the patient adheres to strict bed rest during the day. Monitor the condition of the bandage.	Prevention of complications.	Charge nurse
III. Completion of the procedure: 17. Disinfect used instruments followed by disposal of disposable medical supplies. 18. Wash your hands (hygienic level).	Ensuring infection safety.	Procedural nurse
19. Deliver the test tube with the material and directions to the laboratory.	Conditions for obtaining a reliable result.	Ward
20. Make a record of the procedure and the patient’s response in the medical record.	Ensuring continuity of nursing care.	nurse

LABORATORY AND INSTRUMENTAL STUDIES

METHODOLOGICAL INSTRUCTIONS "RULES AND TECHNIQUES FOR OBTAINING SAMPLES OF CLINICAL MATERIAL FOR STUDY IN THE LABORATORY OF CLINICAL MICROBIOLOGY"

MONIKI, Moscow, 1997

For microbiological examination of all types of clinical material it is necessary:

· collect the material in sterile containers with stoppers obtained in the laboratory;

· have an alcohol lamp in the clinical department;

· follow the rules of asepsis when taking samples;

· take material for culture before the start of specific antibacterial therapy, or at least 6-12 hours after the last administration of the antibiotic;

· deliver the material to the laboratory no later than two hours from the moment the sample is taken;

· in emergency cases, if it is impossible to deliver the material immediately to the laboratory (evenings, weekends), samples of clinical material (except for cerebrospinal fluid and blood samples) are stored in a refrigerator at a temperature of 8-10°C, then transferred to the laboratory.

Errors in the rules for obtaining material for microbiological research lead to errors in diagnosing the pathogen and determining its antibiotic sensitivity.

Sternal puncture– a technique for obtaining bone marrow from the breast bone for diagnosing blood diseases. A procedure for removing a small amount of red bone marrow sample for testing. The name comes from the Latin name for the sternum - sternum(sternum), puncture means puncture. Synonyms are no less often used: bone marrow puncture, bone marrow aspiration, taking bone marrow from the chest bone.

During a sternal puncture, the doctor uses a special needle to penetrate the cavity of the sternum containing the red bone marrow. A small volume of bone marrow is aspirated (sucked out) with a syringe, from which preparations are prepared - smears on glass slides for examination under a microscope.

What is red bone marrow?

Red bone marrow- this is the soft tissue in which blood cells are formed -, and. Located in the cavity of the bones.

Bone marrow is made up of stroma, a network of supporting cells and stem cells that lie dormant or divide to give rise to new cells.

In children under 5 years of age, red bone marrow fills the cavities of all bones of the body, but with age it moves to large tubular bones (femur, tibia), flat bones (skull, sternum, ribs, pelvic bones) and some small bones (vertebrae) . During the aging process, bone marrow is increasingly replaced by yellow bone marrow - adipose tissue in which there is no hematopoiesis.

Indications

changes in general blood count or

diagnosis of diseases of the hematopoietic system in the presence of symptoms - sweating, fever, weight loss, frequent infectious diseases, rash in the mouth, and others
before starting chemotherapy (for leukemia, lymphoma, neuroblastoma), after its completion to assess the success of treatment
diagnosis of thesaurismosis - storage diseases, when enzyme deficiency leads to the accumulation of a particular substance in the body
diseases of the macrophage system - histiocytosis
enlargement of the lymph node if it is impossible to study it and lymphoma is suspected
long-term elevated body temperature with reduced immunity

Advantages

simple
available
informative
does not require special training
does not bear much burden on the patient

Flaws

Bone marrow cells are examined, since during aspiration the tissue structure is destroyed and it is impossible to assess the ratio between stromal and stem cells. For this purpose, it is carried out from the posterior crest of the iliac bone.

Contraindications

There are no absolute contraindications (completely prohibiting indications) for sternal puncture.

Among the relative contraindications:

older age – the procedure will cause suffering, and the benefit from the diagnosis is minimal (for example, in a patient over 80 years old)
the result of the puncture will not have an impact on treatment and will not improve the quality of life
inflammatory skin diseases at the site of a potential puncture
severe concomitant diseases (severe heart failure, uncompensated diabetes mellitus and others)
refusal by the patient (or authorized person)

Preparation

A few days before the sternal puncture, a general blood test with a leukocyte formula and an analysis are done. It is necessary to inform your doctor about allergies to medications (especially local painkillers), medications taken (warfarin, acetylsalicylic acid, etc.) and diseases with disorders of the blood clotting system.

It is necessary to indicate the presence, recall the surgical interventions performed in the sternum area.

On the morning of the procedure, you can eat a light breakfast.

Needle for sternal puncture

The needle for sternal puncture has a rod for closing the lumen, a scrolling element and a limiter. The doctor first adjusts the needle to an approximate length of about 3-4 cm in adults, 2 cm in older children and 1 cm in younger children. The blocker prevents unwanted deep penetration into the bone cavity. There are different sizes of sternal puncture needles.

Complications

Complications of sternum puncture are rare and depend on compliance with the rules of preparation and care of the puncture site.

local bleeding
wound infection
pain at the puncture site

Execution

Puncture of the sternum lasts 15-20 minutes. 30 minutes before the procedure begins, the patient takes a painkiller and a sedative.

The patient undresses to half his body and lies with his back on the couch. For men, the puncture area is first shaved.

The doctor disinfects the puncture site in the upper third of the sternum at the level of 2-3 intercostal space, and injects an anesthetic into the subcutaneous tissue. After 3-4 minutes, checks skin sensitivity. Using a sternal puncture needle, using rotational, gentle movements and moderate pressure, the needle penetrates into the sternum cavity. The resistance of the bone decreases after entering the cavity. The needle itself is held in the bone. The patient feels pressure, but not pain.

The doctor removes the rod and aspirates the bone marrow (2 ml) into a syringe (volume 20 ml), which may be accompanied by unpleasant mild pain. Bone marrow is no different in appearance from blood. The needle is removed, the puncture site is disinfected and covered with a sterile bandage.

Immediately after aspiration, the resulting bone marrow is applied to a prepared fat-free glass slide and smears are made on 5-10 slides (up to 30). For immunological and cytogenetic studies, more bone marrow needs to be aspirated and placed in tubes with anticoagulants.

Sternal puncture is performed both on an outpatient basis and during hospitalization. 30 minutes after the procedure, the patient can go home. You cannot drive a car, so it is better to come to the hospital accompanied by a relative or friend. It is forbidden to take a bath or wet the puncture site for 3 days.

The result is obtained within 2 hours in case of extreme need or up to 1 month if the test tubes or smears are examined in another medical institution.

Material analysis

The resulting bone marrow aspirate is examined under a microscope (morphological examination, cytology) to evaluate different lines of blood cell elements and for differential cell counting after special staining.

Part of the material is placed in test tubes for a special study - histochemical analysis to determine enzyme activity or PAS for glycogen content, immunophenotyping (the presence of CD antigens on the surface of white blood cells), cytogenetic research.

Sternal puncture in children

Sternal puncture was last modified: March 28th, 2018 by Maria Bodyan

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 this 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.

It is also supplemented by puncture of the bone marrow itself.

Technique(according to Heilmeyer). After cleansing and disinfecting the skin in the area of the body of the sternum with iodine, the skin and especially the periosteum are numbed with several milliliters of anesthetic liquid. After the onset of anesthesia, a special needle for bone marrow puncture with an inserted mandrel is used to puncture the sternum along the midline at approximately the height of the II - III costal cartilage.

The safety shield (arrest) is installed at a level of 4 - 5 mm and then the cortical layer is pierced. In this case, the passage of the needle is felt quite clearly. With a thick and dense bone layer, this requires the use of quite significant force. If there is doubt whether the needle has penetrated the bone marrow, they resort to testing with aspiration test. About 0.5 - 1 ml of bone marrow is sucked in with a record syringe mounted on a needle so that air does not penetrate into it, which causes a pronounced pain reaction, which, however, soon subsides.

If it is not possible to obtain bone contents, then inject a little physiological solution of table salt and perform aspiration again. If necessary, you can penetrate the needle a little deeper. With careful and correct technique, this intervention is safe.

Erythropoiesis is found to be increased in most anemias. In the bone marrow with pernicious anemia, pronounced disturbances in cell maturation are detected, such as megaloblastic hematopoiesis. In contrast, with a decrease in erythropoietic function, the number of cells is significantly reduced, puncture reveals “empty” bone marrow: aplastic anemia is evident.

Leukopoiesis always occurs simultaneously with erythropoiesis. A significant increase in the leukopoietic function of the bone marrow occurs in myeloid leukemia, and complete depletion occurs in agranulocytosis.

Thrombocytopoiesis has its source in giant cells of the bone marrow - megakaryocytes, about a third of which, as it turns out, form plates (functioning forms), while 2/3 are at rest.

Complete extinction of all hematopoietic functions leads to a severe, almost always fatal disease - panmyelophthisis (pancytopenia).

In this regard, when studying bone marrow smears, it is necessary to distinguish between:

Hypoplasia due to a variety of lesions of the hematopoietic organs and

Hyperplasias arising due to increased demands from the periphery, impaired maturation or leaching of cells and as a result of neoplastic processes.

Normal Heilmeyer myelogram

Per 100 leukocytes:

Proerythroblasts
Macroblasts
Normoblasts
Myeloblasts
Promyelocytes
Neutrophils	Myelocytes	23,9 (15,3-29,6)
Eosinophils
Basophils
Neutrophils	Metamyelocytes
Eosinophils
Basophils
Neutrophils	Rod
Eosinophils		23,4 (17,8-30,2)
Basophils
Neutrophils	Segmented leukocytes
Eosinophils
Basophils
Lymphocytes
Monocytes
Megakaryocytes
Lymphoid reticular cells		5.0 (0.6-12.2) according to Rohr
Plasma reticular cells		2.0 (1-3.6) according to Rohr

Moreover, each individual myelogram characterizes the constantly changing structure of the bone marrow at the moment, and repeated studies provide a kind of movie that, more clearly than any other test, allows us to judge the functional state of the bone marrow.

Quite similarly, with the help of a puncture, extramedullary foci of hematopoiesis in the spleen and lymph glands can also become available for research, however, the evaluation of the obtained preparations requires a lot of special experience in this area.