I. Lub Hom Phiaj

Pob txha pob txha puncture yog ib qho tseem ceeb invasive txheej txheem nyob rau hauv hematology thiab kho mob tshuaj loj, muaj ob qho tib si.diagnostic value thiab kho qhov tseem ceeb.

1. Lub luag haujlwm kuaj mob

Los ntawm kev nqus cov kua dej hauv cov pob txha, ntau-dimensional thiab multi- qib kev soj ntsuam hauv chav kuaj tuaj yeem ua tau los muab cov ntaub ntawv tseem ceeb rau kev kho mob rau kev txiav txim siab- ua:

2. Lub luag haujlwm kho mob

Kev Saib Xyuas Kev Kho Mob thiab Kev Ntsuas: Dynamic ntsuam xyuas ntawm kev kho mob teb nyob rau hauv hematological kab mob, muab pov thawj rau kev kho mob regimen.

Pob txha pob txha Transplantation: Muab qhov ntim txaus thiab tsim nyog ntawm hematopoietic qia hlwb rau allogeneic lossis autologous transplantation.

II. Cov lus qhia

Cov lus qhia rau pob txha pob txha pob txha yog qhov dav, npog tag nrho txuas ntxiv los ntawm kev kuaj xyuas thawj zaug mus rau qhov kawg- kev ntsuas kev kho mob theem:

Hematological Disorders: Kev kuaj mob thiab kev kuaj mob sib txawv ntawm ntau yam anemias, leukemias, lymphomas, ntau yam myeloma, myelodysplastic syndromes (MDS), thiab myeloproliferative neoplasms (MPN); Kev ntsuam xyuas seb puas muaj kab mob malignancies tau nkag mus lossis metastasized rau cov pob txha pob txha.

Unexplained Symptom Complexes: Unexplained hepatosplenomegaly los yog lymphadenopathy, thiab kub taub hau ntawm tsis paub keeb kwm (FUO) undiagnosed los ntawm niaj hnub kuaj.

Kab Mob Sib Kis: Cov kab mob hauv pob txha ua haujlwm ua "kab kawg ntawm kev tiv thaiv" rau typhoid thiab paratyphoid fever (nrog rau cov txiaj ntsig zoo dua li ntshav kab lis kev cai); parasitological kev pom zoo ntawm malaria thiab kala-azar (visceral leishmaniasis) los ntawm kev kuaj smear.

Metabolic thiab Genetic Disorders: Gaucher kab mob -Kev txheeb xyuas ntawm Gaucher hlwb ntawm cov pob txha pob txha smear yog tus qauv kub rau kev kuaj pom tseeb; Niemann- Xaiv kab mob, thiab lwm yam.

Kev ntsuam xyuas teb: Dynamic saib xyuas ntawm pob txha pob txha rhiab heev thiab rov qab los tom qab siv tshuaj khomob lossis kev kho mob rau hematological malignancies.

Hematopoietic Stem Cell Transplantation: Sau tus naj npawb txaus ntawm CD34⁺ hematopoietic qia hlwb rau kev hloov pauv.

III. Contraindications

Cov contraindications rau pob txha pob txha puncture yogtxwv tsis pub dhau, qhia txog kev nyab xeeb profile ntawm cov txheej txheem no. Txawm li cas los xij, cov xwm txheej hauv qab no yuav tsum tau ceev faj txog kev pheej hmoo - kev ntsuas txiaj ntsig:

⚠️ Kev piav qhia tseem ceeb: Thrombocytopenia ib leeg tsis yog contraindication rau pob txha pob txha.​ Rau cov neeg mob uas muaj lub cev tiv thaiv kab mob thrombocytopenia (ITP) los yog leukemia -induced thrombocytopenia, cov txheej txheem tseem tuaj yeem ua tau yam xyuam xim nrog kev tuav tes txaus rau hemostasis. Qhov kev nkag siab no yog qhov tseem ceeb rau kev txiav txim siab hauv chaw kho mob- ua - ntau tus neeg pib tshiab tsis tas yuav ncua qhov tseem ceeb ntawm kev kuaj mob pob txha vim kev ntshai los ntshav ntau dhau.

IV. Ua ntej-Kev Npaj Ua Haujlwm

4.1 Kev Npaj Tus Neeg Mob

Kev Sib Txuas Lus Qhia: Ua ntej- kev sib txuas lus ua haujlwm yuav tsum tsis yog ib qho qauv xwb. Nws yog ib qho tseem ceeb kom qhia rau tus neeg mob ua ntej qhov ntawd"Qhov mob luv luv thaum lub sij hawm aspiration yog qhov qub,"tiv thaiv tus neeg mob tam sim ntawd txav los ntawm kev ntshai uas tuaj yeem ua rau rab koob sib txawv lossis raug mob raug mob.

4.2 Kev npaj khoom

Standard Equipment Checklist ntawm Tus Txheej Txheem Txheej Txheem:

4.3 Kev Npaj Ua Haujlwm

Kev txheeb xyuas tus neeg mob: Ua nruj me ntsis ua "peb daim tshev thiab xya qhov pov thawj" kom paub meej tias tus neeg mob lub npe, tus naj npawb ntawm cov ntaub ntawv kho mob, thiab qhov chaw npaj rau kev sib tsoo.

Kev paub hauv paus: Ua tib zoo nkag siab txog cov lus qhia, contraindications, cov txheej txheem txheej txheem, thiab kev tswj cov teeb meem rau pob txha pob txha.

Kev soj ntsuam kuaj mob: Saib xyuas tus neeg mob lub hauv paus mob, coagulation xwm txheej, thiab keeb kwm ntawm punctures yav dhau los.

Qhov chaw: Pab tus neeg mob mus rau hauv txoj hauj lwm kom raug, palpate thiab khij qhov chaw puncture xaiv nrog daim tawv nqaij marker.

Kev npaj aseptic: Ua xya-kev tu cev, hnav lub kaus mom thiab daim npog ntsej muag.

Smear muaj peev xwm: Muaj peev xwm npaj cov pob txha pob txha smears raws li lub hom phiaj kev kuaj mob - cov kauj ruam davhlau ya nyob twg feem ntau saib xyuas los ntawm cov neeg pib tab sis tseem ceeb heev.

V. Cov txheej txheem txheej txheem

5.1 Patient Positioning

Qhov kev xaiv ntawm txoj hauj lwm nyob ntawm qhov chaw anatomical ntawm qhov chaw xaiv qhov chaw:

5.2 Puncture Xaiv qhov chaw - Lub tswv yim thiab qhov tseem ceeb

Localization Txoj Cai: Qhov chaw puncture yuav tsumzam kev kis kab mob hauv zos. Thaum txiav txim siab, kos nws kom meej nrog daim tawv nqaij kom tiv thaiv tsis tau siv tom qab draping.

5.3 Disinfection thiab Draping

5.4 Tshuaj loog - "Tshuaj loog ib cheeb tsam, Tsis yog ib qho taw tes xwb"

Cov txheej txheem tseem ceeb ntawm kev siv tshuaj loog nyob hauv ntau -point periosteal infiltration - qhov no yog qhov tseem ceeb ntawm tus neeg mob qhov kev mob tshwm sim:

Wheal tsim: Kos 2% lidocaine rau hauv 5 ml syringe; txhaj tshuaj subcutaneously ntawm qhov chaw puncture los tsim daim tawv nqaij wheal.

Txheej infiltration: Ua ntej cov koob perpendicularly, aspirating intermittently (kom paub meej tias tsis muaj ntshav rov qab), thiab txhaj tshuaj loog thaum tshem tawm, infiltrating subcutaneous cov ntaub so ntswg, fascia, thiab periosteum txheej los ntawm txheej.

Periosteal anesthesia (cov kauj ruam tseem ceeb): Thaum rab koob txuas nrog lub periosteum, khaws nws perpendicular thiab uamulti-point kiv cua- zoo li txhaj tshuaj hla lub periosteal nto nruab nrab ntawm qhov taw tes​ - piv txwv li, "anesthetize ib cheeb tsam" es tsis yog lub koob nkag point xwb. Qhov no zoo tiv thaiv periosteal stretch mob tshwm sim los ntawm ib qho kev tsis sib haum xeeb ntawm qhov sib tsoo thiab qhov chaw tshuaj loog.

Kev kaw qhov tob: Thaum lub koob tshuaj loog kov lub periosteum, nco ntsoov qhov tob ntawm qhov ntxig los qhia kev hloov kho tom qab ntawm qhov ntev ntawm rab koob.

5.5 Puncture - Tus Txheej Txheem

(1) Koob Length Kho

Ua a"kev sib piv koob"nruab nrab ntawm rab koob aspiration thiab koob tshuaj loog: kho qhov tob nres kom lub aspiration needle tip extends0.5-1.0 cm siabqhov tob ntawm qhov koob tshuaj loog mus txog periosteum.

(2) Puncture Technique - Site-Tshwj xeeb Variations

Posterior/Anterior Superior Iliac Spine Puncture:

Kho daim tawv nqaij ntawm qhov chaw puncture ntawm tus ntiv tes xoo thiab ntiv tes taw.

Tuav lub koob aspiration ntawm sab tes xis thiab ntxig nwsperpendicular rau pob txha nto.

Thaum rab koob txuas nrog pob txha,tig nws raws nws cov axis ntev (xws li tig lub hau ntswj)maj mam nkag mus rau lub cortex.

Thaum tam sim nopoob ntawm tsis kam ("pop")yog hnov, lub koob taub tau nkag mus rau hauv cov hlab ntsha kab noj hniav.

Insertion qhov tob: kwv yees li1 cm ibdhau ntawm lub periosteum.

⚠️ Txwv tsis pub ua: Thaum lub sijhawm ua haujlwm,Tsis txhob viav vias rab koob lub cev dav lossis quab yuam nws mus rau pem hauv ntej hnyav​ - cov no yog thawj qhov ua rau koob tawg.

Sternal Puncture (High-Risk Procedure - Exercise Extreme Caution):

Sab laug tes fixation; sab tes xis tuav rab koob nrog tusbevel tig rau ntawm lub plab kab noj hniav thiab rab koob taw qhia rau tus neeg mob lub taub hau.

Ntxig rau ntawm lub kaum sab xis ntawm70℃-80 degreemus rau sternal nto (tsis yog perpendicular!).

Ua ntej maj mam nrog rotational motion; qhov tob tswj ntawm0.5-1.0 cm.

Feem ntau, tsis muaj qhov sib txawv ntawm qhov tsis kam; tso siab rau kev tswj qhov tob thiab kev tawm tswv yim tactile.

Rau cov neeg laus uas muaj mob pob txha lossis cov neeg uas muaj ntau yam myeloma, qhov pib quab yuam yuav tsum yog qhov tshwj xeeb.

Lumbar Spinous txheej txheem Puncture:

Ntxig rau ntawm cov pob txha nto, ua ntej maj mam nrog kev sib hloov; qhov tob 0.5-1.0 cm.

Feem ntau tsis muaj qhov poob ntawm kev tiv thaiv; cia siab rau kev tswj qhov tob.

(3) Aspiration - Lub Sij Hawm Tseem Ceeb ntawm Kev Ua tiav

Tshem tawm cov stylet thiab muab tso rau ntawm lub tais uas tsis muaj menyuam.

Txuas aqhuav 10 ml syringe​ (dryness yog qhov tseem ceeb - ya raws yuav ua rau cov qog nqaij hlav los ntshav los yog hloov cell morphology).

Aspirate kom txog thaum cov kua hauv pob txha tshwm (kwv yees li0.2-0.5 ml yog txaus; dhau- yuav tsum zam kom tsis txhob muaj kev cia siab​ - ntau dhau ntawm cov ntshav peripheral dilution cuam tshuam qhov kev ntsuam xyuas cytomorphological).

Kev ceeb toom ua ntej rau tus neeg mob: A luv luv mobthaum aspiration yog ib txwm; qhia rau tus neeg mob ua ntej tiv thaiv kev txav mus los ntawm kev ntshai.

Tswj Aspiration Failure: Yog tias tsis muaj cov kua dej hauv cov quav, rov tso cov stylet, tig me ntsis los yog nce mus ntxiv 0.1-0.2 cm, tom qab ntawd rov muab cov koob txhaj tshuaj thiab rov ua dua. Tsis txhob rov kho qhov loj.

5.6 Smear Preparation - The Terminal Kauj Ruam Uas Txiav Txim Siab Zoo

Smear Thickness Kho Txoj Cai:

Markedly hypercellular pob txha(piv txwv li, mob myeloid leukemia): Smears yuav tsum yognyias nyiaslos tiv thaiv kev sib tshooj ntawm tes uas cuam tshuam nrog kev suav qhov sib txawv.

Hypocellular los yog mob heev hypocellular marrow(piv txwv li, aplastic anemia): Smears yuav tsum yogtuab duakom paub meej tias cov kab mob hematopoietic puas tuaj yeem txheeb xyuas tau.

5.7 Koob Tshem Tawm thiab Tom Qab- Kev Saib Xyuas Txheej Txheem

Koob tshem tawm: Reinsert lub stylet thiab thim lub koob kom zoo raws li qhov ntxig axis.

Hemostasis: Npog qhov chaw puncture nrog sterile gauze; tus neeg teb xov tooj lossis tus pab cuam yuav tsum thovnruam phau ntawv ceev rau 1-3 feeb​ (1 minute is usually sufficient for patients with normal coagulation; extend to >5 feeb rau cov uas muaj coagulation txawv txav).

Hnav khaub ncaws: Ruaj ntseg lub gauze nrog daim kab xev nplaum; qhia tus neeg mob/tsev neeg rauKhaws qhov chaw puncture kom qhuav thiab tsis txhob raug dej rau 3 hnub.

Qauv thauj: Xa smears rau kev ua tam sim (kom tiv thaiv cell autolysis); maj mam invert anticoagulation hlab 4-5 zaug ua ntej xa mus rau qhov chaw kuaj.

VI. Teeb meem thiab kev tswj xyuas

6.1 Perforation of the Posterior Sternal Cortex - Qhov Teeb Meem Txaus Ntshai Tshaj Plaws

6.2 Koob tawg - Ua los ntawm tus neeg ua haujlwm yuam kev

VII. Lub hom phiaj tseem ceeb rau kev ua tiav pob txha pob txha puncture

Kev lees paub thiab kev tswj hwm ntawm "Dry Kais": Yog tias tsis muaj cov kua hauv plab tuaj yeem nqus tau txawm tias muaj ntau yam kev hloov kho, thiab cov smear qhia tsuas yog cov ntshav peripheral xwb, xav txog cov hauv qab no: ① Myelofibrosis; ② Cov kab mob malignant ntau heev (piv txwv li, mob qog noj ntshav metastatic); ③ Cov kab mob leukemic cell hypercellularity ua rau cov pob txha mos; ④ Technical yam. Hauv cov xwm txheej zoo li no, suav nrog kev tshawb pom cov ntshav peripheral smear, cov pob txha pob txha biopsy (siv cov koob trephine biopsy), thiab cov kev tshawb fawb duab rau kev ntsuam xyuas.

Daim Ntawv Qhia Ntxiv: Pob Txha Pob Txha Txhaum Cai Ua Haujlwm