What are the preparations for a patient undergoing a bone marrow procedure?

Preparing for a Bone Marrow Procedure

Patients should fast for at least 4 hours before the procedure (no food, simple sugars, or beverages except plain water), ensure adequate hydration with 1 liter of water 2 hours prior if contrast is planned, and avoid caffeinated beverages. 1

Pre-Procedure Patient Assessment

Essential Clinical Information to Obtain

• Current medications, particularly anticoagulants, antiplatelet agents, and any immunosuppressive therapy 1, 2
• Bleeding history including personal or family history of bleeding disorders, as patients with myeloproliferative neoplasms may have acquired von Willebrand syndrome that increases bleeding risk 2
• Current symptoms including pain, fractures, fever, night sweats, fatigue, and any B symptoms (unexplained fevers >38°C, drenching night sweats, weight loss >10% in 6 months) 1
• Comorbidities including chronic kidney disease, allergies (especially to contrast agents), thyroid dysfunction, infectious or inflammatory diseases, and other malignancies 1
• Height and body weight measured accurately to enable standardized uptake value (SUV) measurements if PET/CT imaging is planned 1

Laboratory Evaluation Required

• Complete blood count with differential and platelet count 1
• Serum glucose level, as hyperglycemia can affect diagnostic imaging if performed 1
• Renal function (serum creatinine and estimated glomerular filtration rate) if intravenous contrast is planned, given the high rate of myeloma-related kidney disease 1
• Coagulation studies if patient has bleeding risk factors or is on anticoagulation 2

Anticoagulation Management

Withholding anticoagulation prior to bone marrow biopsy is not routinely recommended, as the incidence of significant hemorrhage is very low (0.007-1.1%) and bone marrow biopsy is classified as having low to moderate bleeding risk. 2

• Assessment and optimization of bleeding risk factors should be done on an individual basis rather than routinely interrupting anticoagulation 2
• Strategies exist to minimize bleeding risk for anticoagulated patients without stopping therapy 2
• Extra vigilance is required for patients with myeloproliferative neoplasms due to potential acquired von Willebrand syndrome 2

Day-of-Procedure Preparation

Fasting and Hydration Protocol

• No food, simple sugars, or beverages (except plain water) for minimum 4 hours before the procedure 1
• Intravenous glucose solutions and parenteral nutrition should be halted at least 4 hours before the procedure 1
• Adequate prehydration with 1 liter of water 2 hours prior if contrast imaging is planned, to ensure low urine concentration and minimize kidney injury risk 1
• Avoid coffee or caffeinated beverages even if "sugarless," as they may contain traces of simple carbohydrates and induce excitant effects 1

Positioning and Comfort Measures

• Keep patient warm beginning 30-60 minutes prior to procedure and continuing during uptake period if PET imaging is involved, to reduce brown fat activation 1
• Patient should remain seated or lying down and quiet during any uptake period to limit muscle uptake of tracers 1
• Void immediately prior to the procedure to reduce bladder activity 1
• Screen for claustrophobia when scheduling to facilitate planning for premedication if needed, though routine sedatives are not recommended 1

Pain Management Considerations

• Adequate local anesthesia is essential and can minimize discomfort during the procedure 3
• The bone marrow procedure can be performed with minimal discomfort if proper anesthesia is utilized 3
• Inquire about pain tolerance and anxiety levels to determine if additional comfort measures are needed 1

Special Considerations for Specific Patient Populations

Patients with Renal Impairment

• Volume repletion prior to the study is protective if intravenous contrast is required, as volume depletion may predispose to acute kidney injury by enhancing light chain precipitation within renal tubules 1
• In most cases, whole body low-dose CT without contrast can be considered sufficient for anatomic evaluation 1

Patients with Contrast Allergies

• Document any previous contrast reactions (idiosyncratic/anaphylactoid vs. non-idiosyncratic) 1
• Premedication reduces risk of recurrent anaphylaxis if contrast is required; referring physician must indicate premedication protocol 1
• For patients with history of severe contrast reaction, unenhanced CT examination is preferred 1

Women of Childbearing Age

• Pregnancy test should be performed before undergoing any treatment or diagnostic procedures 1

Common Pitfalls to Avoid

• Do not assume all patients need to stop anticoagulation, as bleeding risk is very low and interruption may increase thromboembolic risk 2
• Do not allow patients to consume "sugar-free" beverages, as these may still contain traces of carbohydrates that affect diagnostic imaging 1
• Do not skip warming measures if PET imaging is planned, as brown fat activation can interfere with interpretation 1
• Do not proceed without adequate local anesthesia, as this is the primary determinant of patient comfort 3