Attitudes of children with leukemia toward repeated deep sedations with propofol

A Survey of Sedation Practices for Adolescents and Young Adults With Acute Lymphoblastic Leukemia Undergoing Lumbar Puncture

PURPOSE

Lumbar puncture is a frequently performed procedure for patients undergoing treatment for acute lymphoblastic leukemia. This brief procedure is frequently performed with sedation in young patients but with only local anesthesia in adults. Adolescent and young adult patients may be cared for by physicians with different training backgrounds and sedation preferences, making the utilization of sedation for lumbar punctures variable among providers. The benefits of sedation for young adults with leukemia undergoing lumbar puncture (analgesia, anxiolysis, safety) must be weighed against the obligate fasting interval, hospital cost, and resource allocation that is required.

METHODS

We conducted a survey of pediatric and medical oncologists who care for patients with acute lymphoblastic leukemia to assess their use of sedation for adolescents and young adults undergoing lumbar punctures as part of their cancer therapy. (see Supplemental Digital Content 1, http://links.lww.com/JPHO/A723 ).

RESULTS

Twenty-six percent of pediatric oncologists and 28% of medical oncologists completed the survey. Pediatric oncologists were more likely to perform lumbar punctures under sedation as compared with medical oncologists. This pattern remained consistent across all patient age ranges surveyed, despite no significant difference in the expected cumulative number of lumbar punctures that a patient was to undergo. Medical oncologists reported topicalization with local anesthetics before lumbar puncture more often than pediatric oncologists.

CONCLUSION

Sedation practices for lumbar puncture during acute lymphoblastic leukemia treatment varies by specialty of treating oncologist.

Duress and Distress Versus a Neurocognitive Mess: The Challenges of Procedural Sedation in Pediatric B-ALL

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

Application of Nonhuman Primate Models in the Studies of Pediatric Anesthesia Neurotoxicity

Numerous animal models have been used to study developmental neurotoxicity associated with short-term or prolonged exposure of common general anesthetics at clinically relevant concentrations. Pediatric anesthesia models using the nonhuman primate (NHP) may more accurately reflect the human condition because of their phylogenetic similarity to humans with regard to reproduction, development, neuroanatomy, and cognition. Although they are not as widely used as other animal models, the contribution of NHP models in the study of anesthetic-induced developmental neurotoxicity has been essential. In this review, we discuss how neonatal NHP animals have been used for modeling pediatric anesthetic exposure; how NHPs have addressed key data gaps and application of the NHP model for the studies of general anesthetic-induced developmental neurotoxicity. The appropriate application and evaluation of the NHP model in the study of general anesthetic-induced developmental neurotoxicity have played a key role in enhancing the understanding and awareness of the potential neurotoxicity associated with pediatric general anesthetics.

The efficacy of interactive group psychoeducation for children with leukaemia: A randomised controlled trial

OBJECTIVE

To evaluate an interactive group psychoeducation programme for children treated for leukaemia.

METHODS

A longitudinal randomised controlled study across four UK hospitals with an immediate (N = 26) and delay control group (N = 32). The intervention covered the pathophysiology of leukaemia, its treatment, side effects and the importance of positive health behaviours. Primary outcomes were parent-reported child health related quality of life (HRQoL) and behavioural difficulties. Secondary outcomes were child-reported HRQoL, cancer-specific HRQoL, child confidence, caregiver burden, and treatment anxiety. Measures were completed pre- and immediately post-intervention, and at 13 and 26-weeks follow-up. Change over time was analysed using multilevel modelling. Acceptability questionnaires rated the intervention on benefits, recommendations, and barriers to participation.

RESULTS

The intervention significantly improved parent-reported child HRQoL but did not have a significant effect on other outcomes. Acceptability of the intervention was high.

CONCLUSIONS

This study provides initial evidence that interactive group psychoeducation is acceptable to families and improves HRQoL in children with leukaemia. Difficulties with recruitment removed power to detect effect sizes that are plausible for psychoeducational interventions.

PRACTISE IMPLICATIONS

Further studies to explore the potential of psychoeducation to improve outcomes for children with leukaemia and an examination of barriers to participation within this population are warranted.

General anesthesia, conscious sedation, or nothing: Decision-making by children during painful procedures

BACKGROUND

Following diagnosis, children with cancer suddenly find themselves in an unknown world where unfamiliar adults make all the important decisions. Children typically experience increasing levels of anxiety with repeated invasive procedures and do not adapt to the discomfort. The aim of the present study is to explore the possibility of asking children directly about their medical support preferences during invasive procedures.

PROCEDURE

Each patient was offered a choice of medical support on the day of the procedure, specifically general anesthesia (GA), conscious sedation (CS), or nothing. An ad hoc assessment tool was prepared in order to measure child discomfort before, during, and after each procedure, and caregiver adequacy was measured. Both instruments were completed at each procedure by the attending psychologist.

RESULTS

We monitored 247 consecutive invasive procedures in 85 children and found that children in the 4 to 7 year age group showed significantly higher distress levels. GA was chosen 66 times (26.7%), CS was chosen 97 times (39.3%), and nothing was chosen 5 times and exclusively by adolescents. The child did not choose in 79 procedures (32%). The selection of medical support differed between age groups and distress level was reduced at succeeding procedures.

CONCLUSIONS

Offering children the choice of medical support during invasive procedures allows for tailored support based on individual needs and is an effective modality to return active control to young patients, limiting the emotional trauma of cancer and treatment.

Evaluating the Need for Pediatric Procedural Sedation Training in Pediatric Critical Care Medicine Fellowship

OBJECTIVES

Pediatric procedural sedation has been increasingly performed by pediatric intensivists over the past decade. Pediatric Critical Care Medicine fellowship guidelines do not specify how fellows obtain proficiency in pediatric procedural sedation. We sought to survey the state of pediatric procedural sedation training during fellowship and whether fellows thought it was sufficient.

DESIGN

A 21-question survey gathered data on pediatric procedural sedation training provided to Pediatric Critical Care Medicine fellows. Surveys were sent to fellowship directors with instructions to distribute to second- and third-year fellows or recent graduates. Over 2 months, up to three e-mail reminders were sent to fellowship directors whose program had not completed at least one survey.

SUBJECTS

Senior fellows and graduates of 65 active Accreditation Council for Graduate Medical Education Pediatric Critical Care Medicine fellowship programs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sixty-five percent of fellowship programs (42/65) returned at least one response. Ninety senior fellows and 27 recent graduates responded. Of respondents, 38% received pediatric procedural sedation training during the fellowship, and 32% reported mandatory training. Nine percent of programs used simulation. Although 61% who received training felt adequately prepared to perform pediatric procedural sedation, 25% needed additional preceptorship to sedate independently. Nearly one third (31%) reported that completion of a predetermined number of cases was required to sedate independently. Forty-eight percent reported a minimum number of cases was required for hospital credentialing. Nearly 45% were allowed to perform pediatric procedural sedation off the unit after receiving credentials. When asked if inadequate pediatric procedural sedation training would be a deterrent to applying for a position that included pediatric procedural sedation, 8.6% replied yes, 52.6% replied no, and 38.8% replied they were unsure.

CONCLUSIONS

Pediatric procedural sedation lacks a clearly defined training pathway. Most fellows find pediatric procedural sedation a valuable skill set. We propose that all Pediatric Critical Care Medicine fellows receive training that includes pediatric procedural sedation critical incident simulation and cases performed outside the PICU to establish proficiency.

A systematic review of interventions to reduce psychological distress in pediatric patients receiving radiation therapy

OBJECTIVE

Radiation therapy (RT) is a cornerstone for management of pediatric cancer. For younger patients, unintended radiation to critical organs is a concern and children need to remain immobile. Distress in children is common so many centres sedate pediatric patients. Children often are unable to remain still, due to anxiety. Interventions to reduce distress could also reduce sedation rates. The objectives of this systematic review were to: review the interventions used to address pediatric RT patients' distress and anxiety and assess their effectiveness.

METHODS

A systematic search of qualitative and quantitative studies from 1996 to 2016 was conducted using PRISMA guidelines. Nine articles were identified for inclusion in the final review. These articles were reviewed using a quality rating.

RESULTS

Participants included patients 19 years of age or younger, parents and RTs. All were single-site studies. Five studies had a control group, 3 studies had no control group, and 1 study was qualitative. Quality was not high. Six studies reported significant effects. Only one study reported group differences in children's reported anxiety.

CONCLUSION

Cognitive behavioural approaches appear to be worth exploring further, as are approaches grounded in child development. Therapeutic play, particularly procedural preparation via play, also seems to be a useful starting point.

Better Pairing Propofol Volume With Procedural Needs: A Propofol Waste Reduction Quality Improvement Project

BACKGROUND AND OBJECTIVES

Propofol facilitates deep sedation without requiring intubation and is often used by infusion to maintain sedation. Variability in ordering and preparation strategies resulted in significant propofol volumes wasted at the conclusion of procedures in our clinic. With drug shortages now common, we designed a quality improvement initiative to reduce our propofol waste.

METHODS

Data collection during the preintervention phase reflected current practice trends. Two propofol dosing tables (≥50 or <50 kg) were designed to estimate the volume of propofol infusion required for sedations spanning 15 to 180 minutes. Nurses prepared propofol infusions as directed by these tables. The primary outcome measure was reduction in waste when the infusion was prepared by standardized strategy versus usual practice. Balancing measures included occurrences of insufficient infusion volume and premature awakenings from deep sedation. Waste volumes were plotted and displayed chronologically in statistical process control charts for the clinic and individual providers.

RESULTS

A total of 155 patients received a propofol infusion to maintain deep sedation. The preintervention phase included 77 patients, and the intervention phase included 78 patients. Special cause variation was achieved in the intervention phase. Median (interquartile range) propofol waste volume per procedure declined from 45.6 mL (24.3-71 mL) to 14.3 mL (9.6-19.4 mL), representing a 68% waste reduction.

CONCLUSIONS

Using an internally derived systematic approach to ordering and preparing a propofol infusion, we reduced variability, reduced propofol waste, and created cost savings for our organization. This approach is tailorable to other infusions and clinical settings.

Sedation and analgesia with fentanyl and etomidate for intrathecal injection in childhood leukemia patients

In this study, we tried to find a safe as well as fast effective treatment for sedation and analgesia for intrathecal injection in childhood leukemia patients, relieving treatment difficulties and pain, increasing the success rate of single intrathecal injection.The patients were divided into the experimental group (fentanyl combined with etomidate) and the control group (lidocaine only) randomly. The experimental group was given fentanyl 1 to 2 μg/kg intravenously first, then etomidate 0.1 to 0.3 mg/kg intravenously after the pipe washed. The patients younger than 1.5 years or who did not achieve satisfied sedative and analgesic situation received an additional time of etomidate (0.1-0.3 mg/kg). The patients were given oxygen at the rate of 4-5 L/min during the whole operation, and the finger pulse oximeter was used simultaneously to detect the changes in heart rate (HR) and blood oxygen saturation (SpO2). The doctors who performed the procedures assessed the quality of sedation and analgesia.In the experimental group, the patients' HR increased slightly after given fentanyl combined with etomidate. The patients' SpO2 was stable. Most patients achieved a good sedative and analgesic state within 1 to 2 minutes, and no case of respiration depression or cardiac arrhythmias occurred during the whole operation. The wake-up time was 55.42 ± 20.62 min. In the control group, the patients were not very cooperative during the intrathecal injection, which made the procedures very difficult.During intrathecal injection, pain obviously reduced and the success rate of single lumbar puncture increased. It is safe and effective to apply fentanyl combined with etomidate for sedation and analgesia.

Procedural pain in children: education and management. The approach of an Italian pediatric pain center

Pain management should be warranted for all children in every situation. Italian legislation proposes a model for pain assistance based on specialized tertiary centers which provide direct clinical management for complex cases and assure continuous cooperation with hospitals and family pediatricians for managing painful conditions every day. The Procedural Pain Service of the University of Padua Department of Pediatrics applies such model for procedural pain management. We describe activities of Service since January 1, 2006 on two levels: education and training for territorial services and sedation-analgesia when required for invasive and painful procedures. Since 2006 to date, the Service team produced an internal protocol for procedural sedation, developed two master courses, and organized a training program for procedural pain management in the territorial context. Procedural sedation-analgesia service provided overall 10,832 sedations to perform 14,264 procedures for 3,815 patients, median age of 6 years old. The most frequently performed procedures were lumbar puncture and bone marrow aspiration, followed by gastroscopy and bronchoscopy. Most frequently administered drug combinations were local analgesia + intravenous midazolam alone or midazolam and propofol or midazolam and propofol and ketamine; most frequently used non-pharmacological methods were distraction using cartoons and bubbles. Minor adverse events were recorded in 281 cases (2.5%), the most common being desaturation (2.1%). In conclusion, our model functions on two integrated levels, and it can be considered generally applicable as a solution for pain management.

The management of procedural pain at the Italian Centers of Pediatric Hematology-Oncology: state-of-the-art and future directions

PURPOSE

The quality of life of children with cancer can be affected by the experience of cancer-related pain, treatment-related pain, procedural pain, generalized pain, and long-term chronic pain, and the consequences may be permanent. Treatment-related pain and procedural pain are often reportedly the most painful experiences relating to their illness. Procedural pain treatment is therefore now considered essential. This multicenter survey investigated how procedural pain is managed at Italian Pediatric Hematology-Oncology Centers.

METHODS

From April to October 2010, questionnaires were collected from the directors and/or referent of the Italian Centers of Pediatric Hematology-Oncology about the management of lumbar punctures, bone marrow aspirates, and biopsies.

RESULTS

We received responses from 67% of the centers (which performed a total of 13,271 procedures per year). Fifty percent of the procedures were performed in the operating room. The sedation-analgesia was provided "almost always" for 84% of procedures. Non-pharmacological treatments were used in 55% of the centers. The specialist who practiced analgesia was the anesthetist in 83.3% of the cases.

CONCLUSIONS

A nationwide multicentre survey has been conducted for the first time to verify the management of procedural pain in Pediatric Hematology-Oncology patients. The results indicate that many aspects in the management of procedural pain appear consistent with the international guidelines. Some problems still remain, including the inability to ensure adequate sedation-analgesia in all the patients--often due to the lack of adequate staff, the frequent use of the operating room, and an underdeveloped use of non-pharmacological therapies.

Procedural pain management in Italy: learning from a nationwide survery involving centers of the Italian Association of Pediatric Hematology-Oncology

Procedural pain is an important aspect of care in pediatrics, and particularly in pediatric oncology where children often consider this to be the most painful experience during their illness. Best recommended practice to control procedural pain includes both sedative-analgesic administration and non-pharmacological treatments, practiced in an adequate and pleasant setting by skilled staff. A nationwide survey has been conducted among the Italian Centers of Pediatric Hematology-Oncology to register operators' awareness on procedural pain, state of the art procedural pain management, operators' opinions about pain control in their center, and possible barriers impeding sedation-analgesia administration. Based on indications in the literature, we discuss the results of the survey to highlight critical issues and suggest future directions for improvement. Future objectives will be to overcome differences depending on size, improve operators' beliefs about the complexity of pain experience, and promote a global approach to procedural pain.

Safety of general anesthesia for lumbar puncture and bone marrow aspirate/biopsy in pediatric oncology patients

INTRODUCTION

Painful short duration procedures such as bone marrow aspiration/biopsy and the lumbar puncture with or without intrathecal chemotherapy are frequently performed during the treatment of children with cancer. This study evaluated the frequency and severity of complications of bone marrow aspiration biopsy and lumbar puncture/intrathecal chemotherapy under general anesthesia.

PATIENTS AND METHODS

A prospective observational study was performed from November 2003 to August 2005. Patients with cancer younger than 21 years old, receiving treatment at the Pediatric Oncology Unity of Hospital de Clínicas de Porto Alegre, undergoing diagnostic and/or therapeutic short duration procedures carried out under general anesthesia in the outpatient surgery unit.

RESULTS

One hundred and thirty-seven patients were submitted to 423 procedures under general anesthesia. There were 61% boys, mean age of 7.5 years (0.2 to 21) and ASA II 98%. Eighty seven percent of the procedures were carried out in patients with leukemia or lymphoma. The majority of the procedures had no adverse events during intraoperative and postoperative periods. No procedure had to be suspended after it had begun. One patient had lumbar pain after the procedure and was admitted to the ward with suspected subdural bleeding, but this was not confirmed. No patient needed cardiopulmonary reanimation or treatment in the intensive care unit.

CONCLUSIONS

General anesthesia for short duration painful procedures in children undergoing treatment for malignancies is safe when carried out by trained professionals in outpatient clinical surgery unit.

Sedative preference of families for lumbar punctures in children with acute leukemia: propofol alone or propofol and fentanyl

Propofol is a common sedative/anesthetic used for invasive procedures in children with cancer. The purpose of this study was to determine whether families of children with acute leukemia prefer propofol alone or propofol plus fentanyl for lumbar puncture (LP) sedation. We conducted a randomized, placebo controlled, double blind, crossover study. Each patient was studied twice, once with propofol/placebo and once with propofol/fentanyl. Data collected included the modified Yale Preoperative Anxiety Score (M-YPAS) at baseline and after placebo or fentanyl, Induction Compliance Checklist, recovery excitement, recovery time, and adverse events. After the study, families were asked which sedative regimen they preferred for future LPs. Twenty-two patients received 44 LP sedations: propofol 22, propofol/fentanyl 22. The average age was 6.4+/-4.2 years (mean+/-SD). There were no significant differences between groups in M-YPAS, Induction Compliance Checklist or recovery excitement. Adverse events occurred in 11/22 patients (50%) propofol and 4/22 (18.2%) propofol/fentanyl (P=0.0196). Average recovery time (mean+/-SD) was 36.86+/-17.1 minutes propofol versus 26.36+/-16.4 minutes propofol/fentanyl (P=0.047). Sixteen families (72.7%) chose propofol with fentanyl for future LP sedations (P=0.05). In conclusion, most families prefer propofol and fentanyl for LPs. Propofol with fentanyl was also associated with fewer adverse events and faster recovery.

Predicting pediatric distress during radiation therapy procedures: the role of medical, psychosocial, and demographic factors

OBJECTIVES

The purpose of this work was to identify demographic, medical, and psychosocial variables that predict radiation therapy-related distress among pediatric patients with cancer.

PATIENTS AND METHODS

Seventy-nine children between the ages of 2 and 7 years were consecutively enrolled in the study. Radiation therapy-related distress was measured by rates of anesthesia, observed behavioral distress, and heart rate.

RESULTS

Younger age and higher observed behavioral distress predicted the use of anesthesia, higher baseline heart rate predicted lower initial observed behavioral distress, and prone treatment position was associated with increases in both observed behavioral distress and heart rate relative to baseline.

CONCLUSIONS

Modifiable treatment and psychological variables directly relate to pediatric radiation therapy-related distress. Implementation of developmentally appropriate and cost-effective interventions to reduce procedural radiation therapy distress is warranted.

Demographics and trends in nonoperating-room anesthesia

PURPOSE OF REVIEW

Nonoperating-room anesthesia includes sedation or anesthesia for radiological imaging, cardiac catheterization, office-based surgery, and pediatric procedures or investigations, all of which have seen explosive growth over the last decade. This review discusses the factors that are driving this growth and the challenges we face as a profession to accommodate new practice paradigms.

RECENT FINDINGS

Many departments have difficulty providing services for nonoperating-room anesthesia. A shortage of providers, insufficient reimbursement, and lack of institutional support have been identified as barriers limiting delivery of pediatric nonoperating-room sedation services. Practitioners from other specialties appear increasingly eager to provide sedation at an institutional level. The use of propofol by nonanesthesiologists is widespread, and the issue of provider credentialing has yet to be fully resolved. The shift to nonoperating-room locations will continue, driven by cost savings and convenience for patients and providers.

SUMMARY

Nonoperating-room anesthesia will play a central role in anesthesia practice in the future. Provision of these services requires planning, personnel, and institutional resources. This should be a high priority for anesthesiology departments to ensure delivery of the highest quality of patient care in a cost-effective and organized manner.