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Bone Marrow Biopsy Indications & Pre-Procedural Care

Author Sara Stewart covers Bone Marrow Biopsy Indications & Pre-Procedural Care on BackTable MSK

Sara Stewart • May 7, 2024 • 46 hits

Bone marrow biopsy is frequently required for diagnosing various hematologic conditions before initiating treatment. Increasingly, interventional radiologists (IRs) are being tasked to perform bone marrow biopsy under imaging guidance and sedation, primarily due to enhanced patient comfort and satisfaction. Thus, it is imperative for interventional radiologists to comprehend the common indications for bone marrow biopsy referrals, effectively manage patient expectations in the pre-procedure setting, and employ efficient sedation techniques.

Drs. Aaron Fritts and Chris Beck talk through these topics and more in the BackTable MSK Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable MSK Brief

• Bone marrow biopsy is chiefly indicated for investigating anemia, hematologic abnormalities, and suspected hematologic malignancies like leukemia or lymphoma.

• Typically an outpatient procedure, bone marrow biopsy cases are commonly referred by hematologist-oncologists without requiring IR physicians to manage the patient pre- or post-procedure.

• Because sedated bone marrow biopsy can differ between IR and the traditional approach by hematologist-oncologists, it is crucial to manage patient expectations regarding pain and sedation prior to the procedure.

• Effective sedation management is pivotal for patient satisfaction, often utilizing medications like Benadryl, anxiolytics like Ativan and Valium, and antiemetics Zofran to ensure patient comfort and cooperation during the procedure.

• Starting sedation in the pre-procedural area under the supervision of licensed medical staff can expedite the procedure process and increase efficiency once the patient enters the operative suite.

Bone Marrow Biopsy Indications & Pre-Procedural Care

Table of Contents

(1) Bone Marrow Biopsy Indications

(2) Discussing Bone Marrow Biopsy with the Patient

(3) Sedation Protocol in Bone Marrow Biopsy

Bone Marrow Biopsy Indications

Referrals for bone marrow biopsy in interventional radiology primarily originate from hematologist-oncologists, with occasional referrals from nephrologists. Indications for these procedures encompass various hematologic concerns, notably anemia, thrombocytopenia, and suspected hematologic malignancies like leukemia or lymphoma. Despite the evolving role of interventionalists in clinical care, bone marrow biopsy consultations often involve a technician-like approach, where the procedure is performed based on oncologists' referrals without direct patient management pre- or post-procedure.

[Dr. Aaron Fritts]
First off, Dr. Chris Beck, why are we doing this? What's the most common indications that come across our plate when we're getting a consult to do a bone marrow biopsy?

[Dr. Chris Beck]
For me, in my practice, it's anemia. A majority of our bone marrow biopsies are outpatient. Not that we don't have some inpatients, but it's usually an anemia workup. Honestly, I know there's a big drive to make interventionalists more clinical, and I totally agree with that. This is not one of the spaces in which I really thrive in terms of knowing all the ins and outs. Basically, if the oncologist refers me a patient for a bone marrow biopsy, I'm going to do the bone marrow biopsy.

I don't see these patients in clinic beforehand. I don't see them afterwards. These are just like one-off procedures where I'm very much like a technician. Although I do look at the indication, I want to make sure that jives with why the patient is being referred over. Most commonly, I see some form of anemias or leukemia lymphoma workups.

[Dr. Aaron Fritts]
Yes, or like thrombocytopenia, something hematologic. The hematologic abnormality or concern for hematologic malignancy, and we're just obtaining hematopoietic cells basically from the source. I guess rarely, I think, that we've gotten it for stem cells for the purpose of tissue reconstruction, but that's very few and far between.

[Dr. Chris Beck]
I've never done that. If I'm doing that, I don't even. What they put on the referral sheet sometimes isn't always what they're working up, but I've never seen like obtain stem cells.

[Dr. Aaron Fritts]
You're right. I've known friends and relatives who've had it done for that reason.

[Dr. Chris Beck]
Cool.

[Dr. Aaron Fritts]
For me, it's more like, just like you said, anemia, workup for leukemia lymphoma sort of thing. Most often coming from the Hemonc docs for the most part.

[Dr. Chris Beck]
I think all mine are from Hemonc. I can't think of-- maybe nephrology every now and then. Maybe nephrology. Maybe.

Listen to the Full Podcast

Bone Marrow Biopsy Tools & Techniques with Dr. Christopher Beck on the BackTable MSK Podcast)
Ep 39 Bone Marrow Biopsy Tools & Techniques with Dr. Christopher Beck
00:00 / 01:04

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Discussing Bone Marrow Biopsy with the Patient

When undergoing a bone marrow biopsy facilitated by interventional radiology, patients typically receive sedation, a departure from the solely local anesthetic approach often used by other specialists like hematologist-oncologists during in-office biopsies. Consequently, thorough pre-procedural counseling is crucial, particularly for patients unfamiliar with sedated bone marrow biopsies.

Misconceptions regarding pain tolerance during the procedure necessitate careful management of patient expectations to ensure a satisfactory experience for both patient and provider. Although there's no standardized sedation regimen, a combination of Benadryl, an anxiolytic, and an antiemetic has proven effective in maintaining patient comfort during the procedure.

[Dr. Aaron Fritts]
…let's talk about what the conversation is like with the patient because you'll see the patient. Usually, they're waiting outside the CT or they're waiting outside. Rarely you have to maybe go up and talk to them, the family before, or especially when they're outpatient, you go talk to them in the waiting room to get consent. What's that conversation like?

[Dr. Chris Beck]
One, it just seems like such a terrible setup to have to go talk to the patients out in the waiting room. Is that where you have to talk to your patients?

[Dr. Aaron Fritts]
Sometimes. When it's an outpatient. There's a rule at one of our hospitals where, if they're getting sedation, you have to see them in their pre-op waiting area.

[Dr. Chris Beck]
Oh, okay. It's like a pre-op area, like there's a bay or something.

[Dr. Aaron Fritts]
Pre-op. Yes, it's a bay. Exactly. Yes.

[Dr. Chris Beck]
Okay. Nevermind. That seems okay.

[Dr. Aaron Fritts]
It used to be, they just wheel them back and talk to them right at the bed, before they jump on the table. A lot of that's changed now. They want to make sure that they're properly talked to, all questions are answered. It's not like a speedy, get them on the table and get them done.

[Dr. Chris Beck]
I actually like that. I like that. I was thinking for some reason you're out in the waiting area, where before they get called in. You have, a dedicated area where they're on the monitor or something, or a nurse has already seen them.

[Dr. Aaron Fritts]
Yes. These are pretty much 100% of the time getting sedation in my practice.

[Dr. Chris Beck]
Same. We also see them back, I think we just call it, pre-op holding. I'll go do a brief H&P, and I'm just checking for labs, sedation, basically risk stratification for sedation, which we also use sedation, not always, but maybe 90% of the cases and checking for allergies. Just a basic, very standard H&P and a brief physical exam. The conversation that informs consent is what takes up the majority of the time. What I really try and do is briefly talk about the risks. I think the risks are low, so I don't want to oversell it, but I do give a nice informed consent.

Then I spend a fair amount of time talking about the sedation and just managing expectations about what that's like, only because, at least in my experience, that there are certain patients that are expecting, zero pain. Sometimes that can be a little bit difficult due to the speed of this procedure. You don't have all the time in the world to get the anesthetic on board to where it's an absolutely painless, you're totally out procedure. I just do a little bit of expectation management in that regard. A lot of the conversation, a little bit of-- not a little bit. Full informed consent, brief, but then a lot of time talking about, how this procedure is going to feel, how it's going to go, how much time it's going to take, and recovery afterwards.

[Dr. Aaron Fritts]
Totally agree. I think that is the key. A key piece of doing this procedure is managing those expectations, because some people think, oh, I'm getting anesthesia, I'm going to be out, I'm not going to feel any pain. You're exactly right. That's why I tell the patient, I say, "Look, the advantage of doing this here with us and not in the office with the Hemonc doc is that you're going to get sedation. Which means that you're going to be much more comfortable than just local anesthetic in the office." Because that's the way they do them. That's the way they do them in the office.

They might give them a little bit of an anxiolytic, but that's it. They're not doing sedation in the office. What I like to tell them is, hey, show them where we're going. You can feel that big posterior iliac spine in the back. I said, "That's a nice big chunk of bone, and it's very superficial so we can get to it easily, but we do use imaging guidance, right? That helps speed things along. Because of how fast the procedure is, it is challenging to get you completely asleep. The goal is for you to just feel pressure. If you can feel pressure while we're doing the procedure, you'll hear us talking, but before you know it, we'll be done and we'll be getting you back in your room." I think that people like that. It's like offering one thing over another. It's like, "Okay, I'm not going to be fully asleep, but at least it's fast and I'll be getting out of here fast." They seem to like that.

[Dr. Chris Beck]
You must be just a better negotiator of people than me. I feel like in my practice, we're a little bit teed up for failure, and that the oncologists almost universally tell the patients that they were going to be completely asleep. Also because like in where I'm at, in the suburbs of New Orleans, a majority of these are still done by oncology and maybe some pathologists who aren't using sedation. There's this small referral of oncologists who were like, "Oh, you don't want to have it. You want it to be painless. Here, let me send you to interventional radiology where they're going to put you to sleep." These patients come with an expectation that it's going to be lights out.

I just find that that's a little bit hard to unwind. I do my best. I think these patients, ultimately just want to get this biopsy and move on. There's a fair amount of conversation around that. I really do. We try to get on top of it. I'll sometimes give a cocktail pre-procedurally. I'm sure you have a cocktail too, which you use for like the pre-op holding area for some super anxious patients.

[Dr. Aaron Fritts]
Yes. It's called Benadryl.

[Dr. Chris Beck]
Yes. I do that.

[Dr. Aaron Fritts]
I like to make them sleepy with the Benadryl. We talked about that one with Vishal, another episode I recommend people go and listen to, because we're talking about a lot of the same things.

[Dr. Chris Beck]
Right. Yes, exactly.

[Dr. Aaron Fritts]
Throw a little Benadryl in there, and a lot of times, they do just fall asleep, and then they just wake up when you're getting that core, and they're like, "Oh, okay, well that wasn't that bad."

[Dr. Chris Beck]
Yes. I like the Benadryl, Ativan/Valium and Zofran combo.

[Dr. Aaron Fritts]
Okay. Yes. Zofran is always good too. Right. Yes, man, I think that is one of the most challenging parts of it. Because it's technically-- we're going to talk through that technically. It's not a very challenging procedure. It depends on what tool you're using, but in terms of getting a good sample. The pain thing, I think, is key. What's nice, what you were just talking about is how sometimes these patients have already had one done in the office, and they have that to compare to. That's fantastic, because then you're like, "Well, this is going to be better than that. I can guarantee that."

[Dr. Chris Beck]
Yes, exactly. This is better than that. Yes. Exactly.

[Dr. Aaron Fritts]
That usually makes them happy. Even if they were expecting to be lights out, it's just like, look, I can make you lights out, but that's going to keep you here another hour afterwards. What would you rather?

[Dr. Chris Beck]
If I could make people lights out, I would. It's not that I don't have the patience to do it, but I just found that the hardest patients to get to fall asleep are the patients who want to be asleep and are very, very wound up about it. That's just my experience in my patient population. Those are the patients that tend to fight it, and they're like, they'll keep telling you, they're like, "I'm not asleep. I'm not asleep. I'm not asleep." We do a lot of tricks.

Sometimes I'll do what's called the silent procedure, where there's minimal talking throughout the staff. Just like, there's no external stimuli for them to anchor onto. We'll put a washcloth over their eyes, dim the lights, like a lot of things. Try and keep the room very quiet and subdued. Sometimes that works. These are all just little anesthesia tricks.

[Dr. Aaron Fritts]
That's a good idea. I go the opposite sometimes where I'm like, look, "I'm here, I'm going to talk you through every step. I'm going to let you know when you can expect a sting and when--." That way there's no surprises, because they are face down, remember. That adds some anxiety. You're right, I try to minimize chat, like people talking about what they're going to have for lunch or stuff like that.

[Dr. Chris Beck]
Exactly. Yes.

[Dr. Aaron Fritts]
I think that walking them through it, being like, " Here, I'm putting the light away now." "Okay. Here, you're going to feel some pressure here." That to me seems to help a little bit if they are still awake.

[Dr. Chris Beck]
I think you're right. I think there's some patients-- I'll just say that there's some patients that want to hear it, and there's some patients that don't, but I agree with you. I think there's definitely some patients, as long as you're talking them through it, and they know all this is expected, then they're very okay with that. Absolutely.

[Dr. Aaron Fritts]
They just want things to go as expected. According to plan.

[Dr. Chris Beck]
You're exactly right. For sure.

Sedation Protocol in Bone Marrow Biopsy

While a bone marrow biopsy is inherently a quick procedure for interventional radiologists, especially when using image guidance, the introduction of sedation complicates efficiency due to the required pre-procedural steps, including the time-out and ensuring adequate sedation before needle insertion. Therefore, streamlining this process is crucial for maintaining procedural speed without compromising patient safety or satisfaction. Implementing a pre-operative sedation plan, such as administering an anxiolytic in the pre-operative setting, can expedite the procedure by ensuring the patient is already calm when entering the procedure suite. This approach allows for a more seamless transition into the procedure, minimizing procedural delays associated with sedation onset.

[Dr. Aaron Fritts]
Now what throws a wrench in those gears is the sedation, because A, you got to do a timeout before you start the sedation. A lot of times in the hospitals I work at, the CT tech wants to do the timeout before they scan the patient. That means you got to be there. Because I agree with you, it'd be amazing. Because then you could basically walk in, confirm that they marked in the right spot, do the timeout real quick, and then scrub and put the lidocaine in and by five minutes the sedation should have started having effect within a couple minutes really. Then you're ready to go. It's just that whole timeout sedation, making sure there's sedated enough before you stick the needle in is the challenging part to speed it up.

[Dr. Chris Beck]
Absolutely. Totally agree. Every now and then you have somebody who either is getting done under local or doesn't care that much because they have these done all the time. We have some patients that have had five or six bone marrow biopsies, and they want the sedation, but they're not overly worried about it. I give them a little cocktail beforehand, and then when they're getting in the room, as soon as I walk in the room, we're doing the timeout. All of it is happening concurrently.

[Dr. Aaron Fritts]
I think if you give them a cocktail beforehand and they're already pretty sleepy then that definitely, you could knock it out. That's great.

[Dr. Chris Beck]
Yes. I agree that the slow part of the procedure is the sedation. No doubt.

Podcast Contributors

Dr. Christopher Beck discusses Bone Marrow Biopsy Tools & Techniques on the BackTable 39 Podcast

Dr. Christopher Beck

Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.

Dr. Aaron Fritts discusses Bone Marrow Biopsy Tools & Techniques on the BackTable 39 Podcast

Dr. Aaron Fritts

Dr. Aaron Fritts is a Co-Founder of BackTable and a practicing interventional radiologist in Dallas, Texas.

Cite This Podcast

BackTable, LLC (Producer). (2024, January 17). Ep. 39 – Bone Marrow Biopsy Tools & Techniques [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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