How to improve the success rate of bone marrow aspiration

Over the years, it has been common for patients to undergo a bone marrow aspiration diagnosis from laboratory reports and clinical symptoms, but very few patients who have undergone bone marrow puncture. Bone marrow aspiration [Doctors are not clear about the indications for bone marrow cytology. Bone marrow cytology is mainly used for the diagnosis of hematopoietic system diseases, but it also has certain significance in other diseases. The indications are the following clinical manifestations that cannot be explained by other systemic diseases of the body, such as: anemia, bleeding, infection symptoms [lymph nodes, liver, splenomegaly, sternal tenderness [red blood cells, white blood cells and platelets (three lines or among them) One to two lines) increase or decrease in the number [reticulocytes increase or decrease [the appearance of giant red blood cells, large red blood cells, spherical red blood cells, oval red blood cells, small red blood cells, abnormal and fragmented red blood cells [with immature red blood cells and (or) myelocytes, etc. . Combined with the above abnormal signs and blood picture, it is highly suspected of various leukemia, malignant histiocytosis and leukemia-like reactions [leukopenia and agranulocytosis [megaloblastic anemia, aplastic anemia, microangiopathic hemolytic anemia, and other causes Unknown anemia [multiple myeloma, 1]. However, hemophilia and sodium poisoning by the mouse can cause local bleeding after puncture, which is an indication for bone marrow cytology. However, it is necessary to communicate with the patient before the bone marrow puncture operation, so that the patient understands the purpose of the puncture, reduces the patient's psychological fear, and obtains the patient's understanding and support to the greatest extent. However, bone marrow cytology must be guaranteed by successful bone marrow puncture. 1 How to successfully complete each case of bone marrow puncture 1.1 The criteria for successful bone marrow puncture Generally speaking, if there are obvious small bone marrow granules in the bone marrow fluid, a certain amount of megakaryocytes, plasma cells, tissue cells, and immature red cells can be seen during microscopic examination. When the bone marrow-specific cells such as myeloblasts, etc., it can be considered satisfactory [3]. Bone marrow puncture is a traumatic diagnostic technique. In order to reduce the pain caused to patients, we should strive to successfully complete every bone marrow puncture at one time (except for aplastic anemia). Clinicians should be proficient in this technique, because bone marrow fluid is generally collected by clinicians, and bone marrow aspiration in some hospitals is done by technicians in blood laboratories. However, now the implementation of the "Practicing Physician Law" requires laboratory technicians to complete bone marrow collection. Deemed illegal. It is very important to fully grasp the basic knowledge and essentials of bone marrow puncture before operation. The inspiration gained from bone marrow aspiration over the years is summarized as follows. 1.1.1 Selection of the puncture environment In clinical practice, only about 1% of patients can only choose to complete the bone marrow puncture on the hospital bed. Most patients can choose to complete the bone marrow puncture in a relatively quiet environment with a dedicated puncture workbench. The quiet environment can reduce the psychological pressure for both the patient and the operator, and many operators panic because of too many onlookers around. A highly suitable operating table can greatly reduce the difficulty of the puncture operation. It is very painful for the operator to complete the puncture on the hospital bed in a bent posture, and it also increases the chance of failure in the puncture. 1.1.2 The selection of bone marrow puncture site Generally take the sternum, spinous process, anterior or posterior crest of the iliac bone. Tibia puncture is recommended for children under two years of age. The puncture site is different, there may be significant differences in the selection of materials [2]. However, if necessary, aplastic anemia should be taken from multiple sites, because the degree of cell proliferation is the best in the sternum, the spinous process is the second, and the ilium is the worst. However, sternal puncture is sometimes not safe enough, and patients are easy to fear, and the posterior superior iliac spine cortex is thin, the bone marrow volume is large, the puncture is easy and safer, so it is mostly used [3]. 1.1.3 Mastery of the anatomical structure To do each case of bone marrow puncture, it is necessary to thoroughly understand the anatomical structure of each puncture site and the difficulty of puncture. If there is a complete whole body skeletal specimen, it can be found that the size of the bone marrow cavity at each puncture point is very different. If this point is ignored, it is easy to advance into the bone marrow cavity during the puncture process and then penetrate the bone marrow cavity, and eventually appear Thin blood or fake "dry pumping". 1.1.4 The positioning of the puncture point allows the patient to lie on his side, with the upper leg bent to the chest, and the lower leg straightening is a common posture for puncture of the posterior superior iliac spine. It is easier to find the puncture site in thin patients because of its The posterior superior iliac spine is significantly higher [and how to find the puncture site in a fat patient? After a long period of observation, it is found that the fat patient is in the above posture state and observed from the patient's head at a 10 degree horizontal direction. The posterior superior iliac spine is the lowest area. Find the lowest point in this area, touch the shape of the posterior superior iliac spine with your hand, and then mark the skin with your nail. 1.1.5 Anesthesia at the puncture point After the skin is disinfected, perform the anesthesia at the puncture point. Do not underestimate the anesthesia, because the size, position, and depth of the posterior superior iliac spine can be further determined by the touch of the needle during the anesthesia process. Because the general syringe is relatively sharp, you can feel a layer of about one to two millimeters thick before touching the periosteum. The resistance lies between muscle and bone. It is a layer of cartilage. If this layer is not touched, it is very likely that the real puncture site has not been found. 1.1.6 Selection of the puncture needle If the puncture needle has been used for many years, most of the puncture needles are not matched, the positioning depth nut cannot be positioned (this kind of needle must not be used for sternal puncture), and the resistance during puncture is relatively large [the puncture bag is not standardized, and often The gauze in the bag is too small or too small, or the adult puncture bag contains a pediatric puncture needle. Because the diameter of the pediatric puncture needle is too small, it can often cause false "dry pumping" in the bone marrow puncture of patients with extremely active hyperplasia. 1.1.7 Skills during puncture Many operators always use all the force on the tail of the puncture needle during puncture, without rotating but directly forward or downward with a strong force, once through the medullary cavity into the boneless cavity. In the bone, there may only be a sense of frustration and no bony sensation during the puncture process, but peripheral blood is drawn out after exhausting the strength. Or the needle was retracted and punctured many times, and as a result, several small holes were punched in a small posterior superior iliac spine, forming multiple connected "tunnels". After several tossings, the bone marrow was drawn while retreating. The fluid is both coagulated and blood thin. Correct puncture: When opening the puncture bag, you must check whether the contents are complete, whether the puncture needle positioning nut is normal, whether the hole is blocked, whether it is matched, whether the model is correct, and the best gauze is 4 to 5 sheets. Adjust the length of the needle according to the thickness of the skin fat. Wrap a larger piece of gauze around the tail of the puncture needle. After the puncture needle enters the skin, lightly touch all directions of the posterior superior iliac spine with the needle tip to further determine the puncture The ideal point for needle insertion is when the puncture is in contact with the periosteum, it should be rotated at an angle of 45 degrees counterclockwise and pushed forward with a little force. With these two sensations, the depth of entry cannot exceed 8 mm (the thickness of the medullary cavity of the posterior superior iliac spine in adults is about 6 mm to 8 mm), otherwise it will pass through the medullary cavity. 1.1.8 The glass syringe used for the extraction of bone marrow fluid must pay attention to whether there is any water left on the piston due to cleaning or disinfection (which can cause cell destruction). If there is water, it must be wiped clean, but basically only 30 ml~ 50 ml disposable syringe. Before aspirating bone marrow, it is best to pull out a small part of the plunger of the syringe and connect it with the puncture needle. When there is a sufficient amount of bone marrow fluid, gently open the plunger so that the plunger does not touch the bone marrow fluid, and it is removed from the puncture needle. Remove the syringe, aim at the slide and push it out quickly, but it is better not to let the piston touch the bone marrow fluid, because many operators failed to push out the first time, and the bone marrow fluid adhered to the inner wall of the syringe and could not be pushed out. The puncture can fail because of this. In general bone marrow cell examination, it is sufficient to extract 0.2 ml of bone marrow fluid. If the amount of suction is too much, it is easy to be diluted by blood [3]. Many operators do not have a clear concept about the amount of 0.2 ml in the book (it is recommended that the operator go to the laboratory to carefully check what is 0.2 ml? Or pay attention to the two compartments of a one-ml syringe?) [Or think that the bone marrow in the bone marrow cavity The fluid is very rich, the more you pump, the better [or because the operation is out of control, you pump too much with too much force. However, an experienced operator usually starts with a small amount of force and then a large amount, and at the same time asks the patient's feeling. When the suction pressure reaches a certain level, the patient often tells the operator that he feels swollen because of the pain. At this time, you must control the strength and speed of the suction, because the bone marrow fluid is about to be pumped out. Only one successful puncture can be done at one site, otherwise there is no guarantee that it will not be bloody or coagulated. 1.1.9 Treatment of blood thinness and coagulation Unsmooth puncture often results in blood thinness or coagulation. Once coagulated, it should not be used as a smear. The bone puncture has failed. If the bone marrow fluid is drawn too much, a syringe can be used to suck part of the blood, or the glass slide with a large amount of bone marrow fluid can be tilted to make the excessive blood flow away, and then try to use the part with more small bone marrow particles to make the slide [3]. However, when the blood is thin due to repeated formation of "tunnels" during the puncture process, no matter whether the bone puncture is blood thin or not, it must be smeared. Whether the blood is thin should be finally confirmed by the laboratory, because the bone marrow fluid of patients with severe anemia is often Like peripheral blood. 1.1.10 Smear and staining The success or failure of bone marrow aspiration is closely related to smear and staining. The slides used for smearing should be clean, it is best to use clean new slides. Some scratched slides can seriously affect the observation of cells under the microscope. The smear action should be fast, the thickness should be moderate, and the bone marrow granules should not be wiped off. It is best to have more than 5 smears for selection and histochemical staining during inspection. 2 Analysis of the reasons for the failure of bone marrow aspiration. In the first half of 1997, more than 1,200 bone marrow aspirations were successfully completed in the blood laboratory of Chongqing Southwest Hospital. Only 1 case had blood thinning and 4 cases had dry aspiration. The dry aspiration patients were confirmed by biopsy. Dry aspiration is more common in patients with bone marrow fibrosis or bone marrow hyperplasia. If multiple punctures are dry aspiration but feel that the puncture needle is indeed in the bone marrow cavity, you can use the needle core to remove the tip of the needle after the puncture needle is pulled out. A small amount of bone marrow is introduced, smear examination, and sometimes a diagnosis can be made [3]. Looking back at the high success rate of more than a thousand cases of bone marrow puncture that year, the story of selling oil can explain that the root of success is only familiar. Indeed, because clinicians rarely do bone marrow puncture within a year, they will become very rusty if they do not do it for a long time. The teachers who have stayed in the blood laboratory for many years need to complete more than ten bone marrow punctures every day. It's natural. However, it is difficult to make progress in a short period of time because of lack of basic knowledge and not good at summarizing and analyzing the reasons for failure. In the past ten years, the percentage of hundreds of clinical bone marrow punctures that are successful in one-time observation and statistics is very low. Careful analysis found that such results are related to many reasons. Mainly: some clinicians are too short-qualified and inexperienced [lack of puncture opportunities, long periods of non-operation and unfamiliar [wrong technique, excessive force [unclear anatomical structure, inaccurate positioning [patient position is not ideal, patient is not cooperative [] Needle mismatch or quality problems [the puncture environment is too poor, the height of the puncture table is not appropriate, the puncture is performed on the hospital bed, and the operator is in a forced posture of bending over for a long time. Various reasons such as measures caused the failure.

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