1. Anemia -Persistent or severe nonmocytic anemia (in the absence of hemolysis or blood loss) -Macrocytic anemia without obvious etiology .
2. Thrombocytopenia -ITP (some cases) -Unexplained thrombocytopenia
3. Leukemia
4. Leukopenia -Some undiagnosed cases of prolonged leukopenia
5. Pancytopenia -Leukemia -Aplastic anemia -Neuroblastoma -Lymphohistiocytic disorders -Myelodysplastic syndromes
6. Malignant Solid Tumors -Diagnostic and metastatic evaluation of some solid tumors

Disorders in WhichMarrow ExaminationUsually Is Not Necessary

1. Microcytic anemias
2. Normocytic anemias dueto hemolysis or blood loss
3. Mild normocytic anemiasassociated with acute illnesses
4. Most macrocytic anemias
5. Reactive lymphocytosis
6. Storage diseases
7. Leukocytosis in the absenceof blasts or neutropenia
8. Thrombocytosis

Standarized Procedure for Bone Marrow Aspiration and cytology-

Materials required:

• 1. Lidocaine cream with occlusive dressing
• 2. 16-gauge 2-1/2 or V bone marrow needle
• 3. (3) 10ml syringes
• 4. 25-gauge needles
• 5. 20-gauge needles
• 6. 4 x 4 and 2 x 2 gauze pads
• 7. Povidone-iodine swabs
• 8. Sterile drapes
• 9. Lidocaine 1% multidose vial
• 10. Alcohol swabs
• 11. Elastoplast adhesive, or other pressure dressing
• 12. Sterile gloves

Procedure:
1. Prior to the procedure
• Obtain consent for procedure.
• Notify hematology to schedule BM tech.
• Determine and obtain appropriate type and dose of sedation and pain medications.

Schedule child for anesthesia if elective and child/adolescent have no contraindications for anesthesia.

Instruct patient/family in NPO requirements.

• Prepare the patient for the procedure:

2. Apply Lidocaine cream 1-2 hours prior to the procedure: either the staff RN
or the NP should apply the cream on the right or left iliac crest, covering an
area of approximately 3-4 cm in diameter. A transparent occlusive dressing is
then applied.

3. At the time of the procedure:
• Wash hands.
• Assemble supplies and medications, checking expiration date on BMA tray.
• Complete a time out with all elements of the preprocedure process.
• Administer sedation medications, monitoring vital signs, pulse oximetry,level of sedation.
• Remove outer wrapping from bone marrow tray using clean technique.
• Position patient in prone or side-lying position.
• Expose area for aspiration and locate posterior superior iliac crest.Remove Lidocaine from aspirate site. A towel roll or small pillow placed under the hips may allow easier location of the iliac crest.
• If necessary, a member of the nursing staff will help secure the patient’s position.
• Position the parent near the child’s head in order to more easily comfort the child during the procedure.
• Expose contents of bone marrow tray using aseptic technique.
• Put on sterile gloves.
• Swab bone marrow site with povidone-iodine swab stick, applying some friction and working in a circular motion beginning in the center and moving outward. Repeat x 2 with new swabs.
• Allow povidone-iodine to dry.
• Remove povidone-iodine with alcohol swab using concentric motion beginning in the center. Repeat with new swab x 2 (optional).
• Allow area to dry.
• Apply sterile drape.
• Draw up 2-3ml lidocaine 1% from a vial held by an assistant into a 3 ml syringe with a 22 gauge 1 ” needle.
• Location exact point for aspiration and outline area between thumb and index finger.
• Perpendicularly inject lidocaine subcutaneously and into periosteum. Avoid injecting too much and obscuring landmarks.

4. While allowing 2-3 minutes for lidocaine to take effect:
• Prepare bone marrow needle, assuring stylet moves freely.
• Prepare (2) 10ml syringes, assuring plungers move freely. Remove top from one syringe and set aside. Prepare second syringe (if needed for special studies) using 0.2ml heparin and rinsing inside of syringe. Set aside.
• Stretch skin taunt over puncture site, keeping crest between thumb and index finger of one hand.
• Holding bone marrow needle with stylet in place, puncture skin and advance through subcutaneous tissue, periosteum and into marrow cavity using a steady, controlled pressure with a twisting motion. When the needle is firmly in place and a slight give in pressure is felt, the cavity has been entered.
• Remove the stylet and quickly attach the plain syringe to the needle hub.
• Apply strong, quick suction and obtain approximately 0.5ml marrow.
• Hand syringe to the lab technician.
• Obtain other samples with heparinized syringe as needed.
• Remove needle with syringe attached with slight twisting motion.
• Maintain pressure over site approximately 2 minutes until bleeding has stopped.
• Meanwhile, remove sterile drape and cleanse povidone-iodine from skin with alcohol swab to avoid burn.
• Apply dry 2×2 gauze folded into quarters and secured with tightly stretched Elastoplast.
• Praise the patient’s cooperation.
• Inform patients / parents and child of marrow result when obtained.

5. Patient conditions requiring consultation:
• Unusual bleeding, pain or signs/symptoms of concern to the practitioner will be brought to the attention of the responsible fellow or attending physician.
• After two unsuccessful attempts by the NP, a fellow, attending or another NP will complete the procedure.

6. Patient education:
• The parents and/or patient are instructed to remove the dressing after 24 hours, observing for signs of infection, unusual bleeding, or any other drainage on the dressing. If either is noted, the practitioner should be informed. The site should be checked daily thereafter until healed for signs of infection.

• It is not unusual to feel an aching or bruised feeling for several days after the procedure. This may be relieved with a warm pack. The nurse practitioner should be notified if pain persists beyond several days or worsening pain.

V. Documentation
A. Inpatient documentation is in the UCARE procedure note and outpatient will be in the event note.
1. Documentation of the pretreatment evaluation
2. Record the time out, procedure, the outcome, patient tolerance, medications given, and the plan in the progress note.

References-

American Academy of Pediatrics Journal.

http://www.ucsfmedicalcenter.org/medstaffoffice/Standardized_Procedures/Bone%20Marrow%20Aspiration.pdf

1. Things that are hard to understand can be learned watching animations. These provide an excellent way to remember. Videos can even include mnemonics.
2. Things that cannot be imagined from text can be seen in the videos.
3. One can take online lessons via medical lectures available in the web.
4. Funny and entertaining clips also make learning a lot more enjoyable.

Completing medical education requires acquisition of vast knowledge in Basic medical sciences (Anatomy, Physiology, Biochemistry, Microbiology, Pathology, Pharmacology) and Clinical medical sciences (Medicine, Surgery, Dermatology, Psychiatry, Pediatrics, Orthopedics, etc) which is a chore unless you learn with interest, building concepts and by understanding. Educational videos aids in making such learning process effective and easier.

Medchrome Online Medical Magazine presents a new medical video blog “MedchromeTube“. Founded in 2011, MedchromeTube allows people to discover and watch medical and health videos from YouTube. MedchromeTube provides a simple platform for medical students, doctors and others related to the medical profession across the globe that makes learning process of medical science more fun and interactive.

List of Medical Videos Available:

June 2011

• [09] How to Remember the branches of External Carotid Artery (ECA)?

May 2011

• [14] Draw to Know it – Branches of Celiac Artery and Blood Supply of Stomach
• [10] Pathogenesis of Atherosclerosis : Video Animation
• [06] Baroreceptor Reflex Animation Video
• [05] Lipoprotein Metabolism : Animation video
• [03] Lecture Video: Cell Adaptation, Cell Injury and Cell Death
• [03] Tracheotomy Procedure : Animation

April 2011

• [29] Examination of Cranial Nerves III, IV, V, VI, VII, VIII, IX, X, XI and XII
• [29] 12 Lead ECG Placement Video
• [28] Fetal Circulation Explained with Video
• [26] Coronary Circulation : Anatomy Demonstration Video
• [26] Development of Heart : Embryology Video
• [25] How to draw brachial plexus : Video
• [24] Transcription and Translation : Best Animation
• [24] Hemostasis Animation Video
• [17] Mechanism of cough reflex

November 2010

• [06] Pathogenesis of AIDS and Replication of HIV
• [05] Nasal Myiasis Removal Video

October 2010

• [31] Tumorman and Pathology of Neurofibromatosis
• [20] Fate of RBC / Hemoglobin Video
• [18] Shock and its types
• [18] Gastrulation Animation Video
• [17] Muscles of Mastication Video
• [17] Muscles of the facial expression : Demonstration Video
• [17] Cranial Nerves Mnemonic Song
• [14] Biosynthesis of Protein : Translation Process Video

In 2012, war broke out. Soon the war was fought all over the world. This time the enemy were not human neither aliens. They were invisible , tiny but lethal. The war was between doctors and bacteria.
Doctors used every weapon they had – antibiotics but the bacteria had become too resistant.

“Once upon a time, penicillin was discovered and it could cure almost every disease. The germs retreated but soon they were back for the revenge with weapons like Penicillinase- Methicillin and Vancomycin Resistance. They researched on genetics and modified themselves against antibiotics.
Soon doctors had few useful weapons, but cost was always an issue”

By April 2013, VRSA had become widespread infecting entire world including the doctors. Most of the infected died.

Watch this short animation which is almost self explanatory:

Are we prepared for it?

Level of Block

Spinal Anaesthesia also called Subarachnoid block or Intrathecal Block.

Operations

Indications:

1. Abdominal & vaginal hysterectomies
2. Laparoscopy Assisted Vaginal Hysterectomies (LAVH) combined with general anaesthesia
3. Caesarean sections
4. Hernia (inguinal or epigastric)
5. Piles fistulae & fissures
6. orthopaedic surgeries on the pelvis, femur, tibia and the ankle
7. nephrectomy
8. cholecystectomies
9. trauma surgery on the lower limbs, especially if the patient is full-stomach
10. Open tubectomies
11. Trans-urethral resection of prostate

Position- Lateral, Sitting or Prone.

Approach- Midline, Paramedian or Lumbosacral ( Taylor- 1 cm medial, 1 cm lateral to Posterior Superior Iliac Spine)

Space- L3-L4 or L4-l5

Site of action- Spinal Nerves and dorsal ganglia minimally on Spinal cord.

Drugs used-

Local Anaesthetics-

1. Xylocaine 5% in 7.5% Dextrose ( Hyperbaric 1.03333 spg)

2.Bupivacaine 0.5% in 8% dextrose

3. Tetracaine 1% in 5 D

4. Procaine 10% in 5D

Opioids

Ketamine

Needle Used- Duracutting- Quincke-Babcock and Greene  and Duraseparating -pencil tip point end ( Whitcre, Sporte and Pitkin)

Factors Affecting Block-

Volume, Baricity,Position of patient,Intra-abdominal pressure, Spinal curvature and factors like age,obesity and height

Complications

• * Spinal shock.
• * Cauda equina injury.
• * Cardiac arrest.
• * Hypothermia.
• * Broken needle.
• * Bleeding resulting in hematoma, with or without subsequent neurological sequelae due to compression of the spinal nerves
• * Infection: immediate within six hours of the spinl anaesthetic manifesting as meningism or meningitis or late, at the site of injection, in the form of pus discharge, due to improper sterilization of the LP set.
• * PDPH:post dural puncture head ache or post spinal head ache

Post-op: Urine Retention

Source : Youtube Video