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Sternal puncture for harvesting bone marrow is a procedure with potentially lethal complications. Both the occurrence of pneumothorax and sternal fracture are reported. We present two patients with a cardiac tamponade following elective sternal puncture. (See Editorial p. 4).
Fatal complications of sternal puncture are, as a rule, the result of penetration of the needle through the sternum followed by lesion of the pericardium and myocardium and finally pericardial tamponade and death. Thirty-four such cases are studied with a view to the technique and especially the site on the sternum where the puncture was made. It was supposed that the punctures in the sternum in the fatal cases were performed below the level of the second intercostal space and that that was the primary cause of the fatal outcome as the heart and pericardium here are very close to the sternum. Punctures at the level of the second intercostal space and higher should be reasonably safe. To the astonishment of the author, it was found that many of the fatal punctures were made in the sternum at the level of the second intercostal space or higher. The many reports in the literature were examined again and it was concluded that the complications might be due to inexperience and lack of training of the person who performed the puncture. It is concluded that puncture of the iliac crest with marrow aspiration and biopsy is preferable for better diagnostic value and a safer procedure.
OBJECTIVES: Poststernotomy mediastinitis after cardiac operations is a nosocomial infection involving the mediastinal space and the sternum, with a high mortality rate mostly related to a late diagnosis. We investigated whether sternal puncture might facilitate and shorten the delay in the diagnosis of mediastinitis. METHODS: Of 1024 patients undergoing sternotomy for cardiac surgery, sternal puncture was performed in a subgroup of 49 patients in whom mediastinitis was suspected. RESULTS: Sternal puncture culture results were positive for all patients with true mediastinitis (n = 23) and negative in 24 of 26 patients without mediastinitis. In addition, sternal puncture allowed diagnosis of mediastinitis with a shorter delay (9 +/- 5 days vs 13 +/- 8 days, P =.04) and caused a reduction in the length of mechanical ventilation (3 +/- 4 days vs 10 +/- 13 days, P =.02) and stay in the intensive care unit (9 +/- 7 days vs 18 +/- 15 days, P =.02) compared with that found in another group of patients (n = 20) operated on for true mediastinitis on the basis of the presence of classic, delayed, clinical signs. CONCLUSIONS: Our study shows that sternal puncture is a rapid and safe method to ensure the diagnosis of poststernotomy mediastinitis.
Iatrogenic cardiac injury due to diagnostic sternal puncture occurred in 5 patients, 2 women and 3 men, aged 14 to 37 years. Four cases ended fataly but 1 patient survived after immediate thoracotomy and suture of the damaged heart. Perforation of the anterior wall of the right ventricle resulting in pericardial tamponade was present in all patients. All fatalities resulted in conviction, under criminal law, of the clinician who carried out the puncture (Paragraph 222 StGB--causing death through negligence).
The thickness of the manubrium, the width and thickness of the body of the sternum at the level of second intercostal space as well as the thickness of the spongiosa and outer and inner compact layers have been measured in 67 human cadavers. Consequently, it is recommended that sternal puncture be made at the level of the second intercostal space in the adult and at the manubrium in children. Depth of puncture should not exceed 4 mm. Sternal puncture can thereby be done with greater confidence of avoiding penetration of the sternum, a potentially serious complication.
The needles most commonly used for obtaining bone marrow aspirates from the sternum are the Salah and Klima needles. They were designed in the 1930s, and except for the introduction of different kinds of stops and guards there has been no change in their basic structure and design. These instruments are small, do not fit properly in the operator's hand, and the lack of a T-bar handle often makes them difficult to manoeuvre; their introduction into the sternum by twisting or rotary movement of the hand can be cumbersome. To overcome all of these disadvantages an instrument was designed which is larger, provides better grip, and offers improved maneuverability. The stilette of this aspiration needle has a domed handle which rests snugly in the operator's hand and affords operator comfort, while the specially shaped large T-bar handle at the proximal end of the needle provides adequate and firm grip and also ensures precise control during the sternal puncture procedure.
The case of a 57 year old female patient suffering from plasmocytoma with a sternal fracture after local puncture characterized by a late healing tendency is reported. According to the literature the complications of this diagnostic method, known up to now, are described with special emphasis to the pathomechanism and the clinical course of the mostly fatal sternal perforation with cardiac tamponade. Puncture of the iliac crest instead of the sternal region is recommended in cases with serious osteoporotic or osteolytic defects of the sternal bone.
The case of a woman aged 65 who presented pneumothorax following sternal marrow needle biopsy after diagnosis of thrombocytosis is reported. The complication was certainly attributable to the biopsy because chest X-ray immediately prior had been perfectly normal. No other cases of the kind have been reported. It is probable that this complication occurred because air passed into the pleural cavity, probably through a fracture rim at the internal face of the sternal bone trabeculae.
INTRODUCTION: Penetrating thoracic aorta wounds are rare but responsible for a high mortality when medical and surgical management is delayed. OBSERVATION: We report the case of a 71 year-old patient with malignant lymphoma who sustained an accidental penetrating injury of the ascending thoracic aorta while undergoing trephine biopsy of the sternum. He was successfully treated with emergency sternotomy and aortic suture-repair. CONCLUSION: This case report highlights the limits of sternal trephine biopsy, notably in patients whose bones are weakened by a malignant haematological process, and proposes preventive measures in order to avoid accidents.
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