&
Bone Marrow Puncture
dr. Riska Y Viandini, MMR
1
DEFINISI PUNGSI LUMBAL
Adalah tindakan
memasukkan jarum
pungsi ke dalam
ruang sub arachnoid
medula spinalis
pada daerah cauda
equina melalui
daerah segmen
lumbalis columna
vertebralis dengan
teknik aseptik.
2
TUJUAN PUNGSI LUMBAL
A. TUJUAN DIAGNOSTIK
B. TUJUAN TERAPI
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PROSEDUR PELAKSANAAN
LUMBAL PUNGSI
3. Pemeriksa duduk menghadap
punggung pasien
4. Pemeriksa cuci tangan dengan
alkohol dan memakai sarung
tangan dengan prinsip aseptik
5. Membersihkan tempat untuk
pungsi di daerah lumbal dengan
mengolesi betadine dan dicuci
dengan alkohol dari arah dalam
ke luar 8
PROSEDUR PELAKSANAAN
LUMBAL PUNGSI
6. Dapat atau tanpa dipasang kain duk lobang steril
7. Menentukan tempat tusukan untuk pungsi lumbal.
Tusukan dilakukan di daerah inter spinal L3-L4
dengan cara menarik garis lurus antara 2 SIAS
dan perpotongannya dengan columna vertebralis,
dipilih yang paling longgar ruang inter spinalnya
dengan meraba tonjolan processus spinosus
9
PROSEDUR PELAKSANAAN
LUMBAL PUNGSI
8. Memberi anaestesi lokal pada tempat
tusukan dengan suntikan lidocain,
tusukan secara tegak lurus kemudian
disuntikkan di bagian subcutan,
intramuskuler, dan juga intraspinalis,
dengan menggunakan spuit 3cc
9. Melakukan tusukan dengan jarum pungsi
sampai pada tempatnya. Jarum pungsi
dimasukkan pelan-pelan diarahkan ke
ruang sub arachnoid. Pada waktu jarum
menembus durameter terasa ada
hambatan.
10
PROSEDUR PELAKSANAAN
LUMBAL PUNGSI
10. Mandrin dilepas dan cairan serebrospinal akan keluar dan
ditampung dalam 3 botol sesuai keperluan. Bila cairan
tidak keluar, tusukan dapat diteruskan atau diulangi
dengan merubah arah jarum pungsi, jangan lupa mandrin
dimasukkan terlebih dahulu.
Perlu diketahui!
Sebelum masuk ruang sub arachnoid jarum menembus :
kulit, jaringan subkutan, fascia thoracolumbal,
lig.supraspinosus, lig. infraspinosus, lig.flavum, ruang
epidural, durameter, arachnoid,
ruang subarachnoid (terdapat LCS)
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PROSEDUR PELAKSANAAN
LUMBAL PUNGSI
11. Bekas tusukan diberi betadine dan ditutup dengan kassa
steril dan di plester
12. Mencabut jarum pungsi dengan benar, setelah cukup
pengambilan cairan serebrospinalis, jarum pungsi dapat
ditarik kembali dengan memasukkan mandrin terlebih
dahulu
13. Pasien tiduran kembali dengan posisi terlentang selama
30 menit.
14. Memberikan penjelasan kepada pasien agar tirah baring
selama 12 jam untuk menghindari komplikasi
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BONE MARROW PUNCTURE
INDICATIONS :
Diagnostic :
- Idiopathic Thrombocytopenic Purpura
- Aplastic Anemia
- Leukemia
- Megaloblastic Anemia
- Infections e.g. Kala Azar
- Storage disorders e.g. Gaucher’s disease
- Myelofibrosis
Therapeutic :
- Bone Marrow Transplantation
CONTRAINDICATIONS :
Hemorrhagic disorders such as congenital
coagulation factor deficiencies (eg, hemophilia),
disseminated intravascular coagulation and
concomitant use of anticoagulants.
Skin infection or recent radiation therapy at the
sampling site.
Bone disorders such as osteomyelitis or
osteogenesis imperfecta.
PROCEDURE :
Obtain consent from a parent or guardian.
If the posterior iliac crest is the chosen site, patients are
generally placed in the lateral decubitus position or the
prone position
Sterilize the site with the sterile solution
Place a sterile drape over the site, and administer local
anesthesia, letting it infiltrate the skin, soft tissues, and
periosteum.
After local anesthesia has taken effect, make an incision
through which the bone marrow aspiration needle can be
introduced .
If a guard is present, should be removed before starting bone
marrow aspiration, to ensure adequate depth of penetration..
In general, the needle should be advanced at an angle
completely perpendicular to the bony prominence of the iliac
crest.
Once the needle passes through the cortex and enters the
marrow cavity, it should stay in place without being held.
Once the periosteum has been penetrated, pressure is used
to advance the needle through the cortex and rotate the
needle in a semicircular motion, alternating clockwise and
counterclockwise movements.
If the patient is in the lateral position, the hip may be
stabilized with the other hand to get a better feel for the
position and depth of the needle.
The thumb of this hand can be to mark the desired site
and to prevent accidental repositioning of the needle.
A slight give will be felt, after which you will feel that the
needle is fixed solidly within the bone.
Remove the stylet and aspirate approximately 1 ml of
unadulterated bone marrow into a syringe.
Specimen is taken and is assessed for the presence of
bony spicules.
If the specimen shows spicules, the specimen should be
used to make smear slides immediately.
If spicules are sparse or are not present, a new sample
should be obtained from a slightly different site.
The needle is left in place and sequential syringes are filled
that have been prepared with heparin or other
anticoagulants or preservatives, depending on the
requirements for specific studies to withdraw samples for
additional analysis.
Then remove the needle, either after reinserting the stylet or
with the syringe attached.
COMPLICATIONS :
Hemorrhage
Infection
Persistent pain at the marrow site
Retroperitoneal hematomas
Trauma to neighboring structures (e.g., lacerations
of a branch of the gluteal artery) and soft tissues
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