Study of bone marrow function. Participation of a nurse in performing a sternal puncture Sterile puncture

Sternal puncture- a technique for obtaining bone marrow from the sternum for the diagnosis of blood diseases. The procedure for taking a small amount of a sample of red bone marrow for examination. 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, bone marrow sampling from the sternum.

With a sternal puncture, the doctor penetrates the sternum cavity containing red bone marrow with a special needle. A small amount of bone marrow is aspirated (sucked off) 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 a soft tissue in which blood cells are formed -, and. Located in the cavity of the bones.

The bone marrow is made up of stroma, a network of support cells and stem cells that either dormant or divide to give rise to new cells.

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

Indications

  • changes in the complete 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 oral cavity, and others
  • before the start of chemotherapy (for leukemia, lymphoma, neuroblastoma), after its completion to assess the success of treatment
  • diagnosis of thesaurismoses - accumulation diseases, when an enzyme deficiency leads to the accumulation of a particular substance in the body
  • diseases of the macrophage system - histiocytosis
  • enlargement of the lymph node when it is impossible to study it and suspicion of lymphoma
  • long-term elevated body temperature with reduced immunity

Advantages

  • simple
  • accessible
  • informative
  • does not require special training
  • does not carry a large burden for 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 iliac crest.

Contraindications

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

Among the relative contraindications:

  • older age - the procedure will bring suffering, and the benefit of the diagnosis is minimal (for example, in a patient over 80 years old)
  • the result of the puncture will not affect the treatment and will not improve the quality of life
  • inflammatory diseases of the skin 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)

Training

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

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

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. Beforehand, the doctor 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 needles for sternal puncture.

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


Performance

Puncture of the sternum lasts 15-20 minutes. For 30 minutes to start the procedure, the patient takes an anesthetic and a sedative.

The patient undresses to half of the body, lies back on the couch. In men, the puncture area is shaved beforehand.

The doctor disinfects the puncture site in the upper third of the sternum at the level of 2-3 intercostal space, injects an anesthetic into the subcutaneous tissue. After 3-4 minutes, check the sensitivity of the skin. The needle for sternal puncture with rotational, soft movements with moderate pressure, the needle penetrates into the cavity of the sternum. The resistance of the bone after entering the cavity decreases. 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 (20 ml), which may be accompanied by unpleasant mild pain. Bone marrow does not look different from blood. The needle is removed, the puncture site is disinfected and covered with a sterile dressing.

Immediately after aspiration, the resulting bone marrow is applied to a prepared defatted slide and smears are made on 5-10 slides (up to 30). For immunological and cytogenetic studies, more bone marrow must 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 can not 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 for 3 days and wet the puncture site.

The result is obtained after 2 hours with extreme need or up to 1 month if the 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 various blood cell lines and for differential cell count after special staining.

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

Sternal puncture in children


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

The bone marrow is the most important organ in the hematopoietic system. It produces new blood cells. It is located inside the bodies of the vertebrae, ribs, in the pelvic and tubular bones. One of the methods for diagnosing diseases of the hematopoietic system is a bone marrow puncture.

Sternal puncture is a puncture with a special needle in the chest area. It allows you to take a punctate for research (this method is called a biopsy).

Indications for manipulation

  • Intraosseous administration of drugs;
  • Determining the quality of donor punctate for transplantation;
  • Diagnosis of diseases (anemia, acute leukemia, radiation sickness, leukemia).

Intraosseous administration of drugs is used when it is not possible to inject into a vein (the venous network is poorly expressed, there are massive burns). It is allowed to administer the same drugs as intravenously (this can be NaCl, plasma substitutes, alcohol and aqueous solutions, etc.).

Video

Attention! The information on the site is presented by specialists, but is for informational purposes only and cannot be used for self-treatment. Be sure to consult a doctor!

In the practice of a hematologist, it is very important to get a complete, reliable and clear idea of ​​the state of the circulatory system. A regular blood test will not help with this. To obtain this information, you need to study the state of the bone marrow, the place where hematopoiesis or the development of blood cells occurs. To obtain the bone marrow substance, it is necessary to perform a sternal puncture, a special procedure or manipulation used by hematologists in their practice, otherwise called bone marrow sampling.

STERNAL PUNCTION IS AVAILABLE AT THE BRANCHES:

Address: St. Petersburg, Primorsky district, st. Repishcheva, 13

Address: St. Petersburg, Petrogradsky district, st. Lenina, 5

Address: Vsevolozhsk, Oktyabrsky pr-t, 96 A



Sternal puncture or, if translated from Latin, “sternum piercing” was first proposed in the USSR by Academician M.I. Arkin and is currently widely used by hematologists all over the world.

When should a sternal puncture be done?

Blood is one of the most important components of our body. You can't live without blood. Without blood, the heart will not work, oxygen will not flow to the cells, nutrients will not be carried, there will be no immunity, there will be no .- in general, even one of these will not be enough to understand how important blood is.

Like any other system of the human body, cardiovascular or respiratory, the blood system is also subject to a number of diseases, many of which, unfortunately, are serious and difficult to treat. Sternal puncture is used in hematological practice to assess the state of the bone marrow and the diagnosis and course of diseases of the blood system, the impact of the treatment of blood diseases (for example, anemia, leukemia, myelodysplastic syndromes, tumor metastases and other diseases).

Sternal puncture belongs to the category of medical manipulations and should be performed only by an experienced hematologist who is able to identify contraindications to the procedure and correctly interpret the results.

At Dynasty Medical Center, a sternal puncture is performed by Dr. Romanenko Nikolai Alexandrovich, a doctor of the highest qualification category, candidate of medical sciences, a member of the St.

Sternal puncture technique

Manipulation is performed under local anesthesia, in the supine position. The skin in the projection of the puncture is treated with an antiseptic solution. The puncture is carried out with a special needle. After treatment of the skin and usual local anesthesia of the skin, subcutaneous tissue and periosteum, the hematologist makes a puncture along the midline of the sternum at the level of the 3rd-4th intercostal space perpendicular to the sternum until a “dip” sensation occurs when the anterior plate of the sternum is punctured. After inserting the needle, a 10-20-gram syringe is attached to it, with which a small amount of bone marrow substance is “pulled out”. It is necessary up to 0.5 ml. After removing the needle, the puncture site is sealed with a sterile napkin. The patient remains under observation for half an hour after the procedure in a day hospital. The contents of the needle and syringe are applied to a glass slide and smears are prepared.

The resulting bone marrow substance or punctate is sent for research. This study is called a myelogram, which allows you to evaluate the ratio of different cells and forms of bone marrow cells. In addition, it is possible to perform a number of other, more specific studies that allow you to set a precision, i.e. absolutely accurate diagnosis.

Indications for sternal puncture

  • anemia
  • leukemia;
  • myelodysplastic syndromes;
  • Gaucher disease;
  • Christian-Schuller disease;
  • visceral leishmaniasis;
  • tumor metastases in the bone marrow, etc.

Preparing the patient for a sternal puncture

On the day of the sternal puncture, the usual regimen can not be changed, but the puncture is performed at least two hours after a meal with an empty bladder and intestines. The patient must have the result of a detailed blood test with a prescription of no more than 5 days.!

Before carrying out a sternal puncture, it is necessary to refuse to take all medications, with the exception of vital ones. Also on this day, any other medical and diagnostic events are canceled.

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

Main indications

Puncture is used most often for diagnostic purposes in 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, as well as 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 bowels must be empty. Before the puncture, you can not take any medications, except for those prescribed by the doctor performing the puncture. Before the procedure, the doctor will explain its purpose, talk about the method of carrying out, about the complications. The patient must give written consent, only after that a sternal puncture of the bone marrow will be performed.

How is a puncture performed?

It can be performed on an outpatient basis under local anesthesia. The patient is placed face up on the couch. The fence 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 organs of the mediastinum. The doctor carefully chooses the puncture site, it is treated with a solution of iodine and alcohol. After that, 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 like the feeling of a regular vaccination. With a quick rotational movement, a puncture is made and fluid is taken. 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, a bandage is fixed at the puncture site with adhesive tape. A bone marrow sample is placed in a Petri dish, after which smears are prepared on a glass slide, which are carefully studied in the laboratory. Laboratory assistants count the number of bone marrow cells, study their morphology. When the laboratory study 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 take a look at them.

Possible Complications

The 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 likely if the child moved during the puncture. Therefore, the procedure must be carried out with extreme caution. Osteoporosis is possible in patients taking corticosteroids. In most cases, complications arise if the procedure is performed by an inexperienced doctor. Therefore, we recommend its implementation 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. Usually such control does not last more than an hour, if complications do not appear. After the procedure, a special recovery period is not required, it is important to follow all the recommendations of the doctor.

A sternal puncture is performed to obtain red bone marrow for examination. The puncture is performed in the area of ​​the handle or body of the sternum at the level of 3-4 ribs along the midline. Trepanobiopsy is performed 1-2 cm posterior to the anterior superior spine of the iliac crest.

Indications: 1) diagnosis of diseases of the hematopoietic system.

Workplace equipment: 1) manipulation table; 2) 5.0 ml syringes; 3) Kassirsky's needle; 4) glass slides; 5) sterile cotton balls, sterile wipes; 6) antiseptic; 7) iodine-containing antiseptic; 8) adhesive plaster; 9) 1-2% novocaine solution; 10) containers with disinfectant.

Preparatory stage of the manipulation.

1. The day before, conduct a conversation with the patient about the need and essence of the manipulation, obtain his written consent.

2. Carry out surgical hand antisepsis, put on personal protective equipment.

3. Prepare the manipulation table.

4. Deliver the patient to the manipulation room.

5. Offer to undress to the waist and lie on your back, on the couch.

The main stage of the manipulation.

6. Treat the puncture site with an iodine-containing antiseptic.

7. For surgical hand antisepsis, give the hematologist an antiseptic, and then a syringe with 5.0 ml of 1% novocaine solution for local anesthesia (puncture can be performed without anesthesia).

8. Give the doctor a Kassirsky needle (previously set the fuse-limiter to the required puncture depth and insert the mandrin).

9. After the puncture, give the doctor a 1.0 ml syringe.

10. Give the doctor two glass slides.

11. Close the puncture site with a sterile cloth, secure with a plaster.

The final stage of the manipulation.

12. Inquire about the patient's well-being and take him to the ward.



13. Issue a referral.

14. Deliver the prepared swabs to the clinical laboratory.

Note: pre-sterilization cleaning of syringes, injection needles, Kassirsky needles and used balls is carried out, as with any injection.

For general analysis

This type of study allows you to determine the organoleptic properties of urine (smell, color), physicochemical (transparency, reaction, specific gravity) qualitative reactions to sugar, protein and microscopic examination of the sediment (erythrocytes, leukocytes, cylinders, bacteria, salts).

Indications: 1) survey.

Contraindications: no.

Equipment: 1) disinfected glass container 250 ml, with a lid 2) referral for research for outpatients, or a label indicating the department, ward, full name patient, type of examination, date and signature of the nurse (for inpatients).

Action algorithm:

2. In the morning, before collecting urine, wash the external genitalia

3. When urinating, allocate a small portion of urine into the toilet (to avoid getting secretions from the genital tract). Collect the rest of the urine in a container, close the lid.

4. Leave in a sanitary room in a special box (on an outpatient basis, deliver urine to the laboratory).

5. The duty nurse to ensure the delivery of the material for examination to the laboratory before 8 00 hours.

6. Glue the test results obtained from the laboratory into the medical history (outpatient card).

Note:

Preparation of the patient and collection of urine according to Nechiporenko

Urinalysis according to the Nechiporenko method is used for the quantitative determination of formed elements in the urine: leukocytes, erythrocytes, cylinders.

Normally, microscopy can detect: erythrocytes 2x106/l, leukocytes up to 4x106/l

Indications: 1) survey.

Contraindications: no.

Equipment: 1) disinfected glass container 100 - 200 ml, with a lid 2) referral for research for outpatients, or a label indicating the department, ward, full name patient, type of examination, date and signature of the nurse (for inpatients).

Action algorithm:

1. On the eve (in the evening) inform the patient about the upcoming study, issue a referral or a prepared container with a label attached and teach the technique of collecting urine for the study:

In the morning, before collecting urine, wash the external genitalia

2. Collect an average portion of urine: first, allocate a small portion of urine into the toilet, hold urination, then collect 50-100 ml of urine in a container and release the rest into the toilet.

3. Leave in a sanitary room in a special box (on an outpatient basis, deliver urine to the laboratory).

4. The duty nurse to ensure the delivery of the material for examination to the laboratory before 8 00 hours.

5. Glue the test results received from the laboratory into the medical history (outpatient card).

Note:

1. If the patient is in serious condition or is on bed rest, the patient is washed away and urine is collected for examination by a nurse.

2. If the patient is menstruating at this moment, then the urine test is postponed to another day. In emergency cases, urine is taken with a catheter.

Patient preparation and urine collection

According to Zimnitsky

Urinalysis according to the Zimnitsky method is carried out under the conditions of the patient's usual food and drink regimen.

Urine is collected during the day in the form of eight three-hour portions:

Daytime diuresis Nighttime diuresis

№1 6 00 - 9 00 № 5 18 00 - 21 00

№2 9 00 - 12 00 № 6 21 00 - 24 00

№3 12 00 - 15 00 № 7 24 00 - 3 00

№ 4 15 00 - 18 00 № 8 3 00 - 6 00

In each portion of urine, its quantity and density are determined. Normally, daytime diuresis predominates over nighttime. The relative density of urine varies from 1.010 to 1.025, and the difference between the highest and lowest specific gravity must be at least 10.

Indications: determination of the concentration and excretory ability of the kidneys.

Contraindications: No

Equipment: 1) 8 labeled disinfected containers of 250 ml and two additional

Action algorithm:

1. On the eve (in the evening) inform the patient about the upcoming study, the procedure for its conduct.

2. Prepare containers, stick labels on them indicating the department, ward, full name. patient, type of study, portion number, time, date of urine collection and signature of a nurse.

3. Give the patient labeled containers.

4. Urine collection for research will be carried out during the day:

At 6 00, the patient must pass urine into the toilet, as this urine, accumulated during the night

Wash and collect urine in separate jars with the number and time indicated on them, respectively, every 3 hours for the next 24 hours.

5. Warn the patient that he will be awakened at night to collect the appropriate portion of urine.

6. In case of inconsistency of the container with the amount of urine excreted, use an additional one with the indication on the label “Additional urine to portion No. ...”.

7. In the absence of urine for a time period, the corresponding container remains empty, a note is made on the label: “No portion”, this container is delivered to the laboratory along with the rest.

8. The duty nurse to ensure the delivery of the material for examination to the laboratory before 8 00 hours.

9. Glue the research results received from the laboratory into the medical history.

Note:

1. If the patient is in serious condition or is on bed rest, the patient is washed away and urine is collected for examination by a nurse.

2. If the patient is menstruating at this moment, then the urine test is postponed to another day. In emergency cases, urine is taken with a catheter.

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