  |
|
|
||||
|
||||||
| Journal of the New Zealand Medical Association,
16-December-2005, Vol 118 No 1227
|
||||||
|
Massive haemorrhage caused by a bone marrow aspirate and
trephine (BMAT) procedure in a uraemic patient
Nicholas Gray, Geoffrey Hawson, Peter Hollett, Andrew
Cluer
Bone marrow aspirate and trephine (BMAT) is generally
considered a safe procedure. We report a case of massive haemorrhage following
BMAT that indirectly contributed to the patient’s death.
Case reportA 60-year-old man with a history of monoclonal gammopathy of
uncertain significance presented with oliguric renal failure requiring dialysis.
Investigations revealed a positive urinary Kappa Bence Jones protein of 615 mg/L
and a monoclonal Kappa IgG paraprotein of 27 g/L on serum protein
electrophoresis. Renal biopsy showed cast nephropathy with involvement of 10% of
renal tubules.
He was transferred to another hospital where a BMAT at the
right posterior superior iliac spine confirmed the diagnosis of myeloma with 36%
plasma cells. The procedure was not technically difficult despite the patient
weighing 120 kg. Platelet count and coagulation studies (prothrombin time 12
seconds, activated partial thromboplastin time 33 seconds, fibrinogen 3.2 g/L)
were normal. The patient did not have a history of a bleeding diathesis.
The next day he developed painful swelling of the right
buttock and falling haemoglobin. Eighteen units of packed red cells (PRC) were
transfused over 4 days. During this time he completed one cycle of VAD
chemotherapy (with a reduced dose of adriamycin). He had three cycles of plasma
exchange with fresh frozen plasma replacement to remove plasma light chains in
an effort to improve renal function and prognosis.1 He was transferred back to
the original hospital.
An MRI scan showed extensive haematoma involving the right
thigh (Figure 1). Eleven units of PRC were transfused over the next 2 weeks.
Coagulation studies and platelet count remained normal. Despite diminishing
transfusion requirements, he continued to deteriorate and developed
Klebsiella oxytoca septicaemia. Fine
needle aspirate confirmed the focus of infection as the right thigh haematoma
which was incised and drained.
He was admitted to intensive care post operatively where a
total of 42 units of PRC were transfused over 10 days. Bleeding continued until
a false aneurysm in a third degree branch of the right internal iliac artery was
identified at angiography (Figure 2) and successfully embolised. The false
aneurysm was adjacent to the anterior iliac crest, some distance from the
original site of the BMAT. Platelet function testing with collagen/epinephrines,
haemophilia (factor 8 and 9) screens and Von Willebrand screens were performed
when the active bleeding had resolved and were normal.
Pneumocystis pneumonia and multiple episodes of dialysis
access related septicaemia followed. He was discharged 112 days after admission
but was never well enough to tolerate further chemotherapy. He died 4 months
later.
DiscussionThis case demonstrates that BMAT can cause life-threatening
haemorrhage.
A retrospective survey reported 54890 marrow biopsies, of
which 67% also had a trephine.2 There were 26 adverse events including 14
haemorrhages, 7 broken needles, 3 infections, and 2 miscellaneous events. The
haemorrhages resulted in prolonged hospitalisation, 1 death, 6 cases needing PRC
transfusion, and 1 case needing a platelet transfusion. Risk factors for
bleeding were myeloproliferative disorders (due to platelet dysfunction),
aspirin, warfarin, disseminated intravascular coagulation, and obesity. The
overall serious adverse event rate was 0.05%.
A prospective study reported 13,506 bone marrow
examinations, of which 3927 were aspiration alone, and 9579 were aspiration and
trephine.3 There were 17 adverse events including 10 haemorrhages, 4 infections,
2 needle failures, and 1 of pain. Haemorrhage was managed conservatively in 4
cases, required PRC transfusion in 3 cases, and contributed to death in 1 case.
Risk factors were myeloproliferative disorders, thrombocytopenia, platelet
dysfunction, warfarin, and heparin.
Renal impairment is associated with an increased tendency to
bleed due to platelet dysfunction. This may be reduced by correction of anaemia
with red cell
transfusion,4
correction of uraemia with dialysis,5 intravenous deamino-8-D-arginine
vasopressin,5 and administration of intravenous or topical oestrogen.7,8 These
measures were all attempted in this case.
BMAT is an important diagnostic investigation which can be
associated with significant adverse events, particularly haemorrhage. The risk
may be reduced by ceasing antiplatelet agents and anticoagulation before the
procedure. Platelet dysfunction due to renal impairment possibly increases the
risk of haemorrhage following BMAT.
Author information:
Nicholas A Gray, Nephrologist; Geoffrey AT Hawson, Director of
Oncology/Haematology; Peter R Hollett, Nephrologist; Andrew J Cluer, Resident
Medical Officer; Nambour General Hospital, Nambour, Queensland, Australia
Correspondence: Dr
Nicholas Gray, Nephrologist, Nambour General Hospital, PO Box 547, Nambour, QLD,
Australia, 4560. Fax: +61 7 54706656; email: Nicholas_Gray@health.qld.gov.au
References:
|
|
||||
| | Current
issue | Search journal |
Archived issues | Classifieds
| Hotline (free ads) Subscribe | Contribute | Advertise | Contact Us | Copyright | Other Journals |
|