Procedural Pain and Serious Adverse Events with Bone Marrow Aspiration and Biopsy: Real World Experience from India
Authors: Philip Chepsy C , Singh Inderjit , Thaper Rachel , David Alice , Singh Suvir , Mathew Amrith , John M. Joseph 
Published: February 2021

Background:
Bone Marrow aspiration and Biopsy (BMAB) is perceived by patients as a painful procedure with fearsome complications. Though informed as safe and well tolerated; there is limited data about the complications and degree of pain experienced by patients undergoing BMAB.[1] Further scarce is data from the developing world where procedural fear discourages patients from pursuing treatment and diagnosis.[2]
Methods
Aims: To estimate the level of pain and frequency of serious adverse eventsexperienced by patients undergoing BMAB at our center. We also attempted to identify factors associated with increased pain perception.
Study setting: This study was conducted at a tertiary level teaching hospital, the Christian Medical College & Hospital, Ludhiana. Ethics approval was obtained from the Institutional research committee (CMC/1495).
Study period: 01 April 2015 through 30 Nov 2019
Study Design: This is a comparative cross sectional study where comparison of those with relatively more pain to those with less was done to elicit the factors associated with pain perception.
Study Population: All consecutive patients who underwent a BMAB and provided informed consent which was taken pre-procedure, were included. We excluded patients who underwent the procedure under general anesthesia.
Logistics of the Study: The BMAB was performed variably by Consultant Physicians, Trainee Physicians and Physician Assistants. All patients were pre-medicated with tramadol intravenous pre-procedure, and the preferred approach was from the posterior superior iliac spine (PSIS) in a left lateral decubitus under local anesthesia with lignocain. Patients were sent home or returned to their ward after upto 60 minutes of observation. A serious adverse event was considered as one requiring a prolonged observation beyond routine practice or extending to an admission to manage adverse events following and related to the BMAB.
Data sources and variables
Information regarding age at diagnosis, address and sex, indication to perform the BMAB, coded as malignant and non-malignant was collected from each patient. Number of prior procedures and details regarding food intake were collected as recalled by the patient. Level of pain was noted soon after the BMAB using a combined Wong-Baker grimace with numeric pain scale by the patient themselves.
Statistical Analysis: Descriptive statistics were used to characterize variables. Univariate and Multivariate Logistic Regression were used to identify factors associated with higher pain severity (Score &gt;2).
Results:
A total of 942 BMAB procedures were performed in this period. Baseline characteristics as tabulated below (Table1). Although the Mean + SD pain score was only 2.7 + 1.39, fourteen patients (1.48%) reported severe pain (&gt;8). The following risk-factors were associated with increased pain on multivariate analysis: those experiencing their first BMAB procedure had very low odds of pain (OR (95 % CI): 0.23 (0.15-0.37)). However, when more than one attempt of biopsy was made, the odds of pain was much higher (OR (95 % CI): 1.62 (1.29-2.05)). Food and drink intake prior to procedure was associated only at the univariate level. Those who did not take any food prior to procedure had very high odds of pain (odds ratio (OR) 1.81 (95 % CI 1.01-3.22)). However, those who took juice had very low odds (OR (95 % CI): 0.619 (0.43-0.90)).
Nine (0.95%) serious adverse events were reported. There were no deaths. The major serious adverse event was hemorrhage resulting from pseudo-aneurysm of the posterior iliac artery, which comprised 2 of the 9 serious adverse events. Other serious adverse events included persistent vomiting and severe aching pain in the ipsilateral leg.
Conclusions:
In our analysis BMAB is associated with a low level of procedural pain and is safe. The pain perception was not influenced
by the operator. Factors associated with decreased pain perception were first procedural BMAB experience and successful completion of the procedure in the first attempt. Having at least a snack or a juice pre-procedure could reduce pain perception. Serious adverse events are rare in our experience.

Disclosures
No relevant conflicts of interest to declare.