Standard Operating Procedure
VUH Protocol for Surgical Bone Donation SOP
Date 4/30/2012
Applicable to: Vanderbilt Operating Room (VOR), Children’s Hospital.
Team Members Performing: Perioperative OR personnel
I.
Purpose:
Autologous bone must be collected aseptically, assigned a unique identifier, and.
required microbiology samples must be collected.
II.
Procedure:
A. Pre-Collection
1. Ensure informed consent is documented prior to specimen collection.
2. The circulating nurse will obtain a Surgical Bone Collection Kit from the
MOR Core or VCH Core.
3. Upon receiving the kit, the circulating nurse will open the sterile bone
container package and allow the scrub nurse/technician (SN/T) to remove
the contents. The package has 2 containers:
I.
II.
one small container and lid (16 oz.)
one large container and lid (32 oz.)
4. The SN/T will need BOTH small and large containers and lids.
5. The SN/T should inspect the containers for any damage or defects
including broken rims of outer lip on the side of the container, cracks or
punctures, etc.
6. If contents are damaged/defective, the SN/T should notify the circulating
nurse. The circulating nurse should obtain another Collection Kit from the
MOR Core and discard.
B.
Collection of Surgical Bone:
1. The SN/T should receive the donated bone from the surgeon.
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Instrument Tracking System
2. Anaerobic and aerobic cultures should be taken from the articular surface
of the bone and the medullary cavity (the inside of the bone). The
anaerobic cultures should be put in a Port-a-cul transport tube. Four
cultures should be sent to the Microbiology lab; the anaerobic and
aerobic cultures from both sites.
3. The SN/T should package the bone as follows:
NOTE: OMISSION OF ANY OF THE PROCEDURES MAY
RESULT IN THE DONATED BONE BEING DISCARDED.
i. Measure the diameter of the bone.
ii. Place the donated bone in the small container and secure the
appropriate lid by pressing in the center as the sides are sealed
(similar to “burping” air from a plastic container). Visually
inspect the closed container to be sure the lid is in place but
DO NOT REOPEN ONCE THE LID IS IN PLACE.
iii. Place the small container with the enclosed bone inside the
larger container. Secure the appropriate lid, and inspect as in #
2 above.
iv. If the collected bone is too large for either container, wrap in at
least two sterile towels and place inside a Vi-Drape isolation
bag. Tie two drawstrings to secure the bag. Place the wrapped
bone in another Vi-Drape isolation Bag and tie to secure.
v. Place container on ice.
vi. The SN/T should hand the sterile bone package and cultures to
the circulating nurse.
C.
Post- Collection (Circulating Nurse):
1.
The circulating nurse is responsible for labeling ALL samples and
the bone package.
2.
Microbiology samples should be labeled with an addressograph
label on each sample, noting the site of collection. The cultures
must be received by the Microbiology Lab within ONE HOUR of
collection.
3.
Label the bone container with the provided label (see attachment,
Autologous Bone Collection label); making sure the label is filled
out completely. If the bone was too large for the Bone Collection
Kit and is wrapped in Vi-Drape Isolation Bag, attach label to the
outside of the bag.
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Instrument Tracking System
III.
References:
A.
AATB Technical Manual, 2001 edition, American Association of Blood
Banks, Bethesda, MD.
B.
Standards for Blood Banks and Transfusion Services, 21st edition,
American Association of Blood Banks, 2002.
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