Steps

Rationale/Points of Emphasis

1 Apply anesthetic cream to site of aspiration at least 1 hour before procedure.

Anesthetic cream will help to decrease pain at the injection site.

Various medications, distraction techniques, and comfort measures may be used to enhance the child’s comfort during the procedure. For example, one study using an adult population demonstrated that preprocedural injection of buffered lidocaine at the bone aspiration site improved patient comfort during the procedure.

2 Gather the necessary supplies.

Ensure age-appropriate resuscitation equipment is accessible to the treatment room, because children under sedation are at an increased risk for adverse events. Age-appropriate resuscitative equipment and personnel trained in pediatric resuscitation techniques should be available in the event of cardiovascular or respiratory complications.

Promotes efficient time management and provides an organized approach to the procedure.

Preparation before the child is in the room can help to decrease the child’s anxiety by limiting the length of time the child is in the treatment room.

3 Perform hand hygiene.

Reduces transmission of microorganisms.

4 Set up sterile bone marrow tray.

Maintains sterility while setting up the supplies.

5a Bring the child and the family member (if available and willing to accompany child) into the treatment room. Place the infant or young child on the procedure table, keeping one hand on the child at all times to ensure safety. Permit the older child to climb on to the procedure table with minimal assistance (if not sedated).

Painful procedures are never completed in the child’s own room; that area should remain a “safe haven.” The child should not be left unattended on the procedure table because there is the potential to roll off or fall off the table.

5b Show the family member where he or she can stand to be of most support and benefit to the child during the procedure.

Family presence during invasive procedures has been demonstrated to be beneficial to the child and the participating family members. Families perceive themselves as active participants, caring for the child with the staff. Families generally view their presence as a right, an obligation, and a natural event. Family presence is optional, and their choice in this matter should be respected.

6 Assess the child’s vital signs and comfort level.

Changes in vital signs may indicate bleeding or infection.

Provides baseline for monitoring changes during and after the procedure.

7 Perform hand hygiene and don gloves.

Standard precaution to reduce transmission of microorganisms. Note: The healthcare prescriber performing the procedure will be wearing sterile gloves. The nurses assisting in the procedure do not need sterile gloves unless their activities enter the sterile field.

8 Perform the universal protocol and time-out for verification of correct patient identification, correct procedure and correct site.

Ensures patient safety and compliance with accreditation standards.

9a Administer pain management/procedural sedation medications as ordered.

Bone marrow aspiration is a painful procedure.

9b If ordered, administer sedation. Monitor the child according to sedation guidelines (see Chapter 98 ).

Pulse and oxygen saturation monitoring should be used to assess the child’s status because of the potential for decreased responsiveness and altered respiratory status during sedation.

KidKare Effective pain management reduces deleterious effects of pain and enhances the child’s coping with current and subsequent procedures.

10 Position the child according to the aspiration site selected by the healthcare prescriber:

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  Posterior iliac crest: prone with a small roll under the child’s hips

  
  
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  Sternum or anterior iliac crest: supine

  
  
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  Vertebral: on one side, with knees and head tucked tightly together

  
  
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  Tibia: supine with knee bent and supported by pillow or towel roll (Figure 22-1)

Assists the healthcare prescriber in locating the correct landmark for the aspiration procedure.

Decreases risk of complication by misplacement of needle.

If the child is overweight, a pillow, folded towel, or blanket can be placed under the abdomen to elevate the hips and facilitate access to the posterior iliac crest.

caREminder

The most common sites in children are the anterior and posterior iliac crests. The tibia is sometimes used in infants. Spinous processes may be used when both bone marrow aspiration and lumbar puncture must be performed.

11 Wipe the site with a clean cloth or gauze to remove the anesthetic cream.

Removes white cream for clear visualization of land-marks.

12a The healthcare prescriber will perform the aspiration procedure using sterile technique. Several sites and attempts may be necessary to gather the needed amount of specimen.

The initial aspirate on a newly diagnosed leukemic child may be difficult to withdraw because the bone marrow is very hypercellular and packed with leukemic cells.

12b The healthcare prescriber will drape the selected area with sterile towels and cleanse the site with an antiseptic solution.

Cleaning the site reduces transmission of bacteria.

12c A surface anesthetic is injected at this time.

Surface analgesia aids in pain relief during the procedure.

Figure 22-1 Aspiration sites for bone marrow include (A) posterior iliac crest, (B) sternum, (C) anterior iliac crest, and (D) tibia.

13 Hold the child in place during the procedure.

Decrease in movement allows for the procedure to be completed with ease and prevents misplacement of the needle. Older children may be able to hold still with little need for physical restraint. Young children will require more physical restraint to maintain correct positioning during the procedure.

caREminder

Family members should not be placed in a position to assist in restraining the child. Families do not have training in proper restraint techniques and their role should be to offer comfort and support.

14 During the procedure, use age-appropriate diversion and breathing techniques to distract the child. For instance, the older child may prefer to listen to music on headphones during the procedure.

May help distract and reduce child’s perception of pain and help enhance the child’s coping skills.

15 After the procedure is completed, remove the drapes and cleanse the antiseptic from the area.

Decreases the risk for skin irritation from the antiseptic.

16 Assess the bone marrow aspirate site for signs of bleeding and apply a dressing (using a gauze pad secured with tape) or an adhesive bandage.

Detects complication promptly. Reduces risk of bleeding.

Apply a pressure dressing to prevent bleeding if the child’s platelet count is 50,000 or less.

17 Label the specimens and send to the appropriate laboratory for examination.

The child should never be left unattended while on the procedure table. Attention to specimens and disposal of equipment may need to be delayed until the child is safely secured in the crib/bed with safety measures used (e.g., side rails up).

Decreases the risk for error and loss.

18 Dispose of equipment and waste in appropriate receptacle. Remove gloves and perform hand hygiene.

Standard precautions. Reduces transmission of microorganisms.

19 Assist the child to return to a comfortable position and maintain diversion.

Promotes comfort and reduction of anxiety.

20 If sedation was used, assess the child until he or she is fully awake (which can take about 60 minutes from the time the medication was administered), because duration of medications administered for sedation may extend beyond length of time needed to complete the procedure.

Ensures early detection of cardiorespiratory compromise. Monitoring must be maintained until child reaches baseline premedicated cognitive state to ensure child’s safety.

21 Assess the child for discomfort and medicate as ordered.

The child may have pain at the injection site for 1 to 2 days after the procedure.

22 Return the child to his or her room or discharge child home when stable.

Moving the child to a more comfortable and safe location will help alleviate the child’s anxiety.