Anesthetic for Bone Marrow Harvest

  1. Hey guys,

    I have two cases tomorrow - both women with AML for bone marrow harvests. The only medical problems that both have is the leukemia...no current comorbidities. (as if CA isn't enough...)

    I have never done a harvest or a biopsy before, and I can't seem to find much in my books about anesthetic techniques - any ideas? Any preferences for regional vs. general? My initial thought was to do a general, but I read a little on the internet about doing spinals and epidurals for the harvests. Any experience with either of these? Thanks in advance!
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  2. 8 Comments

  3. by   lifeLONGstudent
    Heart,


    What did you use, how did it go? I know this is after the fact, but I'm still curious (since there were no replies to your question).

    Thanks for sharing,
    lifeLONGstudent
  4. by   heartICU
    Quote from lifeLONGstudent
    Heart,


    What did you use, how did it go? I know this is after the fact, but I'm still curious (since there were no replies to your question).

    Thanks for sharing,
    lifeLONGstudent
    Hey, thanks for asking...I ended up doing a general for both - both women said they would prefer to be completely out for it. I talked it over with my staff, and he was willing to do it under spinal, but he also suggested to me beforehand that both women had been through so much already, that they may prefer to just go to sleep. When I asked the patients if they had a preference, they both said they would just like to go to sleep.

    The first lady had just finished chemo recently, so I did a TIVA technique with her - tried to ward off the nausea/vomiting. Ran propofol/alfenta infusion (500mg propofol mixed with 2500mcg alfentanil) at 0.4 x her weight in kg (cc/hour). She did just fine, but did have some nausea when she woke up.

    The second one had not had chemo in over a year - (both the marrow harvests were for autodonation - for backup) so I did her with sevo and air. I read somewhere about the nitrous causing alterations in the neutrophil function, and although I couldn't remember where I read it, I decided to avoid it.

    Kept them both relaxed with rocuronium, and loaded the second lady with fent 2mcg/kg before incision and an additional 1mcg/kg before she woke up, and she woke up great, no pain. Some nausea, but no pain. Both were discharged the same day.
  5. by   Brenna's Dad
    Hey heartICU,

    I've only ever seen one bone marrow aspiration, and it was during my initial nursing training. There were two of us in the room watching and my partner passed out and hit the wall, putting a hole in it. Needless to say, I pursued a career in critical care, and she went into community health. I digress....

    Anyway, back then I'm pretty sure the patients were sedated (probably with Valium). Did you think about whether the cases could be done on MAC?
  6. by   heartICU
    I did consider it- but they had to be prone for it, and it would have to be a very deep MAC for them to tolerate the initial insertion and harvest (the insertion point was at the iliac). I wasn't really comfortable with someone being that deep while prone without a secured airway. I was willing to do a spinal or epidural with some light sedation, but I talked to the patients about both techniques (general and regional with sedation) and they were pretty adamant about not being awake. Also, they took about 1000-1200cc out, fairly rapidly, and I was kinda leery of taking that much out while also having a sympathectomy from the regional....the first patient was dry anyway (hypotensive and tachy) d/t severe nausea for the past few weeks. The general seemed to work pretty well. I would like to try a spinal for just a biopsy, if I ever get the chance again.

    Quote from Brenna's Dad
    Hey heartICU,

    I've only ever seen one bone marrow aspiration, and it was during my initial nursing training. There were two of us in the room watching and my partner passed out and hit the wall, putting a hole in it. Needless to say, I pursued a career in critical care, and she went into community health. I digress....

    Anyway, back then I'm pretty sure the patients were sedated (probably with Valium). Did you think about whether the cases could be done on MAC?
    Last edit by heartICU on Mar 27, '05
  7. by   jwk
    We have an active BMT service, so we do a fair number of bone marrow harvests.

    Choice of technique isn't that critical. The biggest thing to remember is that they're drawing off up to a liter of bone marrow in about 30 minutes or so. You need a big 2nd IV (14 or 16) and then run in IV fluids as fast as possible from the start. Three liters of fluid just for the blood/marrow loss, plus your replacement/maintenance fluid - you're looking at 4+ liters in a little over an hour or so.
  8. by   lifeLONGstudent
    The biggest thing to remember is that they're drawing off up to a liter of bone marrow in about 30 minutes or so.


    I had no idea that they took that much Bone marrow... yikes. I am rethinking my national bone marrow registry (kidding!). I was the lab supervisor at an oncology clinic lab and we did bone marrows in the office for staging/diagnosis. Poor patients nearly come off the table during the aspiration, even if they are given premeds (in office, usually got IV ativan). I can definately see why they would desire to be "out"

    thanks for the replies!
    lifeLONGstudent
    Last edit by lifeLONGstudent on Apr 6, '05 : Reason: clarification
  9. by   apaisRN
    Quote from lifeLONGstudent
    The biggest thing to remember is that they're drawing off up to a liter of bone marrow in about 30 minutes or so.


    I had no idea that they took that much Bone marrow... yikes. I am rethinking my national bone marrow registry (kidding!). I was the lab supervisor at an oncology clinic lab and we did bone marrows in the office for staging/diagnosis. Poor patients nearly come off the table during the aspiration, even if they are given premeds (in office, usually got IV ativan). I can definately see why they would desire to be "out"

    thanks for the replies!
    lifeLONGstudent
    IV ativan? yikes! That's a BIG needle they use! Seems there must be better, kinder ways. Personally I'd want analgesia, sedation and maybe some Versed for recall.
  10. by   lifeLONGstudent
    Quote from apaisRN
    IV ativan? yikes! That's a BIG needle they use! Seems there must be better, kinder ways. Personally I'd want analgesia, sedation and maybe some Versed for recall.
    It was a free standing (hospital was across the highway) out patient oncology clinic & versed (conscious sedation) was a no-no. Matter of fact, even when we do them on inpatients in the hospital, they don't get versed. Maybe it is just our onc group, but they will usually order morphine and ativan if they premed an inpatient.

    A lot of patients at the clinic did it without premeds. Ativan provides some amnesia - right? It was the best we could do under the circumstances and most of the patients tolerated it well (except for the aspiration part). Entire procedure would only take about 10-15 minutes. We would buffer the lidocaine -- try to make it not bite so much, but it still got to me when the doc would numb the iliac crest - and you could actually HEAR the needle make a 'pit, pit, pit' sound as it made contact with the bone (especially if they were a myeloma or elderly patient with soft bones... yuk).... oh yeah, and the larger patients that needed a 7 inch spinal needle to REACH the bone -- that was not pleasant to watch.

    I was the lab supv. at the time, so not sure what size IV was placed (that was the nurses deal). Many of the patients had mediports, so access was not a problem. Occasionally they would call me that the doc was ready to start and patient would need more meds.... I just remember the nurses pushing it VERY slowly.


    Staging for lymphomas was the WORST because had to do bilateral aspirates for staging and the disease is not uncommon in teens (we did not see pedi onc patients). And stage IV lymphoma patients have to have another marrow done to assess treatment after they finish their course of chemo (THAT is when I wish they had the versed for the recall).

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