Sternal punction (pediatry)

Indications

 * Disorders of the hematopoietic system,
 * oncological diseases: leukemia, lymphoma, neuroblastoma,
 * thesaurisms,
 * diseases of the macrophage system: histiocytosis.

Contraindications

 * There are no contraindications to bone marrow harvesting (in the case of inflammation of the skin over the injection site, choose another harvest site).

Bone marrow aspirate is used for morphological examination of the developmental series of blood elements, i.e. differential cell budget in panoptic staining, and for special examinations. Special investigations include histochemical staining for enzyme activity or PAS reaction for glycogen content.

In recent years, immunological examination (presence of CD-antigens on the surface of white blood cells) and cytogenetic examination have become the basis of differential diagnosis.

Progression

 * Bone marrow is taken from the tibia in children up to 2 years of age, from the sternum in children > 2 years of age (it can also be obtained from other places, e.g. from the anterior and posterior ridges of the hip bones, from the projections of the vertebral bodies or from the femur),
 * adequate analgosedation is advisable before collection,
 * the skin at the injection site is widely disinfected as before surgery, and sterile surgical gloves are worn,
 * infiltrate the subcutaneous tissue at the injection site with a thin needle, approximately 2 to 3 ml of 1% Mesocaine as close to the periosteum as possible
 * wait 1 to 2 minutes after spraying,
 * we use special bone marrow aspiration needles, 18 to 19 G for larger children and 21 to 22 G for smaller children,
 * The needle has a mandrel and a screw-in, adjustable stop,
 * adjust the needle stop to the estimated distance (approx. 2 cm for larger and 1 cm for smaller children); the stop is used to prevent unintentional abnormally deep puncture,
 * penetrate the skin with the needle, preferably from an oblique angle, then set the needle perpendicular to the bone:


 * at the tibia in the upper third on the anterior wall, between the fingers of the other hand, which fix the tibia by holding it by both fingers,
 * u sterna to the manubrium sterni at the imaginary intersection of the perpendiculars of the middle of the jugula and the 2nd intercostal space,


 * with a gentle helical motion under constant slight pressure, insert the needle into the bone marrow, the resistance of the bone relaxes perceptibly when it reaches the marrow, the needle holds itself firmly in the bone,
 * remove the mandrin and aspirate the bone marrow with a 20 ml syringe,
 * stop aspiration when several drops (max 0.5 to 1 ml) of bone marrow appear in the syringe and are macroscopically indistinguishable from blood,
 * remove the needle and syringe, cover the injection site sterilely and compress with gentle pressure for 3 to 5 minutes,
 * immediately after aspiration, aspirate the bone marrow onto a prepared degreased slide and smear at least 5 to 10 additional slides (for immunological or cytogenetic testing, more marrow needs to be aspirated and the aspirate is injected into non-coagulant media),
 * In some special indications (especially in oncohematology), so-called trepanobiopsy is also performed, where the marrow is not aspirated, but a whole marrow sample with bone matrix is obtained.

Complications

 * Bleeding in thrombocytopenia or coagulopathy.

Source

 * HAVRÁNEK, Jiří: Sternální punkce. (upraveno)

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