guided imagery managing painful procedures in children with.10

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Managing Painful Procedures in Children With Cancer Marilyn J. Hockenberry, PhD, RN-CS, PNP, FAAN,* Kathy McCarthy, BSN, RN,* Olga Taylor, MPH,* Meredith Scarberry, MS,* Quinn Franklin, MS, CCLS,w Chrystal U. Louis, MD, MPH,* and Laura Torres, MDz Summary: Children with cancer experience repeated invasive and painful medical procedures. Pain and distress does not decrease with repeated procedures and may worsen if pain is not adequately managed. In 1990, the first recommendations on the management of pain and anxiety associated with procedures for children with cancer were published. Guiding principles described in the recommenda- tions continue to hold true today: maximize comfort and minimize pain, use nonpharmacologic and pharmacologic interventions, prepare the child and family, consider the developmental age of the child, support family and child involvement, assure provider competency in performing procedures and sedation, and use appropriate monitoring to assure safety. This article reviews these key components for managing painful procedures in children and reviews the latest pharmacological and nonpharmacological inter- ventions most effective in minimizing pain and discomfort. Key Words: procedures in children with cancer, procedure sedation, managing bone marrow aspirations with sedation, managing lumbar punctures with sedation (J Pediatr Hematol Oncol 2011;33:119–127) T here is evidence to support that pain and distress does not decrease with repeated procedures and may worsen if pain is not adequately managed. 1,2 In 1990, the first recommendations on the management of pain and anxiety associated with procedures for children with cancer were published by the American Academy of Pediatrics. 1 Guiding principles described in the recommendations continue to hold true today: Maximize comfort and minimize pain. The ideal goal for procedure pain management is to make the experience as comfortable as possible for the child and parents. Use nonpharmacologic and pharmacologic interventions. Nonpharmacologic interventions like cognitive-behavioral interventions (CBI) should be taught to every child who is developmentally able to use these strategies to decrease anxiety and distress. Pharmacologic therapies are safe and effective when carefully administered and monitored by appropriately trained personnel. Prepare the child and family. The key to managing procedure-related pain and distress is preparation and education. Parents and children should receive appro- priate information regarding what to expect before, dur- ing, and after the procedure. Stress reducing techniques can be taught for use before, during, and after procedures. Consider the developmental age of the child. The child’s cognitive development provides the foundation for esta- blishing standards of care for children undergoing pain- ful procedures. Support family and child involvement. Families should be involved in choices offered for pharmacologic and nonpharmacologic therapies. Assure provider competency in performing procedures and sedation. Procedures must be performed by persons with technical expertise or by providers directly super- vised by experts. Use appropriate monitoring to assure safety. Sedation and anesthesia should be administered in a monitored setting with immediately available resuscitative drugs and equipment. 3 Key components to managing painful procedures in children with cancer include effective parent teaching and education, appropriate preparation for the procedure for both parent and child, and optimal analgesia and sedation. This article provides a review of child and family preparation for painful procedures and a review of the latest pharmaco- logical and nonpharmacological interventions most effective in minimizing pain and discomfort. CHILD AND FAMILY PREPARATION FOR PROCEDURES Children and their families should be prepared before the procedure and well supported during and after painful procedures. 4,5 By first establishing rapport with the child and family, the clinician is able to assess the family’s knowledge of the procedure, expectations, and preferred learning style. 5 This assessment should include discussion of the child’s developmental level, coping strategies, and previous experi- ences with procedures that can greatly impact his/her anxiety level. 2,4 Table 1 provides a developmental overview of important aspects to consider when preparing children of all ages and their families for painful procedures. Inclusion of child life programs in pediatric settings has become widely accepted and advocated by the American Academy of Pediatrics. 6 With expertise in child development, child life specialists (CLS) promote effective coping and adjustment during potentially stressful situations through play, psychological preparation, education, and support. CLS prepare children psychologically for medical procedures and events to increase their sense of mastery, reduce anxiety, and plan and rehearse coping strategies. Psychological prepara- tion is patient focused and is defined as a “process of communicating accurate and developmentally appropriate information, identifying potential stressors, as well as planning and practicing coping strategies.” 6 Copyright r 2011 by Lippincott Williams & Wilkins Received for publication April 9, 2010; accepted July 9, 2010. From the *Pediatric Hematology Oncology, Baylor College of Medicine, Texas Children’s Cancer Center; wEvidence-Based Outcomes Center; and zAnesthesiology, Texas Children’s Hospital, Houston, TX.. Reprints: Marilyn J. Hockenberry, PhD, RN-CS, PNP, FAAN, Texas Children’s Hospital, 6621 Fannin St, Houston TX 77030 (e-mail: [email protected]). ORIGINAL ARTICLE J Pediatr Hematol Oncol Volume 33, Number 2, March 2011 www.jpho-online.com | 119

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Page 1: Guided Imagery Managing Painful Procedures in Children With.10

Managing Painful Procedures in Children With Cancer

Marilyn J. Hockenberry, PhD, RN-CS, PNP, FAAN,* Kathy McCarthy, BSN, RN,*Olga Taylor, MPH,* Meredith Scarberry, MS,* Quinn Franklin, MS, CCLS,w

Chrystal U. Louis, MD, MPH,* and Laura Torres, MDz

Summary: Children with cancer experience repeated invasive andpainful medical procedures. Pain and distress does not decrease withrepeated procedures and may worsen if pain is not adequatelymanaged. In 1990, the first recommendations on the management ofpain and anxiety associated with procedures for children with cancerwere published. Guiding principles described in the recommenda-tions continue to hold true today: maximize comfort and minimizepain, use nonpharmacologic and pharmacologic interventions,prepare the child and family, consider the developmental age ofthe child, support family and child involvement, assure providercompetency in performing procedures and sedation, and useappropriate monitoring to assure safety. This article reviews thesekey components for managing painful procedures in children andreviews the latest pharmacological and nonpharmacological inter-ventions most effective in minimizing pain and discomfort.

Key Words: procedures in children with cancer, procedure sedation,

managing bone marrow aspirations with sedation, managing

lumbar punctures with sedation

(J Pediatr Hematol Oncol 2011;33:119–127)

There is evidence to support that pain and distress doesnot decrease with repeated procedures and may worsen

if pain is not adequately managed.1,2 In 1990, the firstrecommendations on the management of pain and anxietyassociated with procedures for children with cancer werepublished by the American Academy of Pediatrics.1

Guiding principles described in the recommendationscontinue to hold true today:

� Maximize comfort and minimize pain. The ideal goal forprocedure pain management is to make the experience ascomfortable as possible for the child and parents.� Use nonpharmacologic and pharmacologic interventions.Nonpharmacologic interventions like cognitive-behavioralinterventions (CBI) should be taught to every child who isdevelopmentally able to use these strategies to decreaseanxiety and distress. Pharmacologic therapies are safe andeffective when carefully administered and monitored byappropriately trained personnel.� Prepare the child and family. The key to managingprocedure-related pain and distress is preparation andeducation. Parents and children should receive appro-priate information regarding what to expect before, dur-

ing, and after the procedure. Stress reducing techniquescan be taught for use before, during, and after procedures.� Consider the developmental age of the child. The child’scognitive development provides the foundation for esta-blishing standards of care for children undergoing pain-ful procedures.� Support family and child involvement. Families shouldbe involved in choices offered for pharmacologic andnonpharmacologic therapies.� Assure provider competency in performing proceduresand sedation. Procedures must be performed by personswith technical expertise or by providers directly super-vised by experts.� Use appropriate monitoring to assure safety. Sedationand anesthesia should be administered in a monitoredsetting with immediately available resuscitative drugs andequipment.3

Key components to managing painful procedures inchildren with cancer include effective parent teaching andeducation, appropriate preparation for the procedure forboth parent and child, and optimal analgesia and sedation.This article provides a review of child and family preparationfor painful procedures and a review of the latest pharmaco-logical and nonpharmacological interventions most effectivein minimizing pain and discomfort.

CHILD AND FAMILY PREPARATIONFOR PROCEDURES

Children and their families should be prepared beforethe procedure and well supported during and after painfulprocedures.4,5 By first establishing rapport with the child andfamily, the clinician is able to assess the family’s knowledgeof the procedure, expectations, and preferred learning style.5

This assessment should include discussion of the child’sdevelopmental level, coping strategies, and previous experi-ences with procedures that can greatly impact his/her anxietylevel.2,4 Table 1 provides a developmental overview ofimportant aspects to consider when preparing children ofall ages and their families for painful procedures.

Inclusion of child life programs in pediatric settings hasbecome widely accepted and advocated by the AmericanAcademy of Pediatrics.6 With expertise in child development,child life specialists (CLS) promote effective coping andadjustment during potentially stressful situations throughplay, psychological preparation, education, and support. CLSprepare children psychologically for medical procedures andevents to increase their sense of mastery, reduce anxiety, andplan and rehearse coping strategies. Psychological prepara-tion is patient focused and is defined as a “process ofcommunicating accurate and developmentally appropriateinformation, identifying potential stressors, as well asplanning and practicing coping strategies.”6Copyright r 2011 by Lippincott Williams & Wilkins

Received for publication April 9, 2010; accepted July 9, 2010.From the *Pediatric Hematology Oncology, Baylor College of

Medicine, Texas Children’s Cancer Center; wEvidence-BasedOutcomes Center; and zAnesthesiology, Texas Children’s Hospital,Houston, TX..

Reprints: Marilyn J. Hockenberry, PhD, RN-CS, PNP, FAAN, TexasChildren’s Hospital, 6621 Fannin St, Houston TX 77030 (e-mail:[email protected]).

ORIGINAL ARTICLE

J Pediatr Hematol Oncol � Volume 33, Number 2, March 2011 www.jpho-online.com | 119

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Whether taught by a CLS or nurse, educationalpreparation for the procedure emphasizes sensory aspectsof the procedure: what the child will feel, see, hear, smell,and touch and what the child can do during the procedure(eg, lie still, count out loud, squeeze a hand, hug a doll).Allow for ample discussion during educational preparationto prevent information overload and confusion and ensuresatisfactory feedback. Allow the child to practice proce-dures and be comfortable with the sequence of events thatwill require cooperation (eg, deep breathing). Teachingdolls are frequently used to help children understand whereon the body the procedure will be performed. Allowing thechild choices when possible and empowering the child bygiving them specific roles or jobs during the proceduredecreases fear and anxiety. Emphasize that the procedurewill end quickly and stress any pleasurable events afterward(eg, going home, seeing parents). Provide a positive ending,praising efforts at cooperation and coping.

Like the child, parents also experience high levels ofstress during procedures, and their anxiety does notdecrease during treatment. However, parent anxiety levelscan be minimized when the child is adequately prepared.7–9

Several studies report a positive impact on parental distressand satisfaction and no difference in technical complica-tions when parents remain with children.8,10,11

CBICBI are techniques intended to alter the procedure

experience by changing the child’s thoughts through

attention diversion, images, and self-determina-tion.1,2,7,11–19 Examples of common CBI strategies usedwith children with cancer include distraction through musicor other pleasant diversions, story telling, deep breathing,relaxation, guided imagery, massage, and yoga. CBItechniques are known to decrease anxiety and discomfortduring painful procedures 1,2,12–19 and a variety oftechniques are available to facilitate the child and family’scoping during the procedure (Table 2). Distraction involvesconcentrating on an event or object other than the pain.Distraction is a powerful coping strategy during painfulprocedures.20 Infants and toddlers are easily distractedbecause of their short attention span. Distraction isaccomplished by focusing the child’s attention on some-thing other than the procedure. Singing favorite songs,listening to music with a headset, counting aloud, orblowing on a magic wand are effective techniques.

Older children can be distracted with activities such asvideo games, television, and music. Guided imagery workswell with school-aged children and adolescents who canvisualize an enjoyable experience or pleasant memory. Thechild describes the event in detail as he or she visualizes it.The child describes details of the event, including as manysenses as possible (eg, “feel the cool breezes,” “see thebeautiful colors,” “hear the pleasant music”). The childconcentrates only on the pleasurable event during the painfultime by enhancing the image, often by reading a script orplaying a tape. The effectiveness of this method is enhancedby the use of a coach. The coach may be a parent or otheradult who discusses the event with the child and keeps the

TABLE 1. Preparation for Procedures and Development

Infant Toddler/Preschooler School Age Adolescent

Involve parent in procedureif desired.

If parent is unable to bewith infant, place familiarobject with infant (eg,stuffed toy).

Have usual caregiversperform or assist withprocedure.

Make advances slowlyand in anonthreatening manner.

Limit number ofstrangers entering roomduring procedure.

During procedure usesensory soothing measures(eg, stroking skin, talkingsoftly, giving pacifier).

Cuddle and hug infantafter stressful procedure;encourage parent to comfortinfant.

Perform painfulprocedures in a separateroom, not in crib (or bed).

Use same approaches as forinfant, plus the following.

Explain procedure in relationto what child will see, hear,taste, smell, and feel.

Use play; demonstrate on dollbut avoid child’s favorite doll.

Emphasize those aspects ofprocedure that require cooperation(eg, lying still).

Tell child it is okay to cry, yell,or use other means to expressdiscomfort verbally. Expecttreatments to be resisted; childmay try to run away.

Use firm, direct approach.Ignore temper tantrums.Use a few simple terms familiarto child.

Give child one directionat a time (eg, “lie down,” then“hold my hand”).

Prepare child shortly orimmediately before procedure.

Keep teaching sessions short(about 5-10min).

Tell child when procedureis completed.

Allow choices whenever possiblebut realize that child may stillbe resistant and negative.

Allow child to participate in careand to help whenever possible.

Explain procedures usingcorrect medical terminology.

Explain procedure usingsimple

diagrams and photographs.Discuss why procedure is

necessary; concepts of illnessand bodily functions areoften vague.

Explain function andoperation

of equipment in concreteterms.

Allow child to manipulateequipment; use doll oranother person as model topractice using equipment

Allow time before and afterprocedure for questionsand discussion.

Plan for longer teachingsessions (about 20min).Prepare up to 1 day inadvance of procedure toallow for processing ofinformation.

Include child in decisionmaking when possible(eg, time of day to performprocedure, preferred site).

Encourage activeparticipation.

Discuss why procedure isnecessary or beneficial.

Explain long-termconsequences of procedures;include information aboutbody systems workingtogether.

Encourage questioningregarding fears, options,and alternatives.

Provide privacy; describe howthe body will be covered andwhat will be exposed.

Discuss how procedure mayaffect appearance (eg, scar)and what can be done tominimize it.

Emphasize any physicalbenefits of procedure.

Involve adolescent in decisionmaking and planning.

Impose as few restrictionsas possible.

Explore what coping strategieshave worked in the past;they may need suggestionsof various techniques.

Accept regression to morechildish methods of coping.

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image alive during the procedure. Muscle relaxation isanother CBI that is useful in children and adolescents. Thechild is asked to take a deep breath and “go limp as a ragdoll” while exhaling slowly; then ask child to yawn. Beginprogressive relaxation by starting with the toes, and system-atically instructing the child to let each body part “go limp”or “feel heavy”; if child has difficulty relaxing, instruct childto tense or tighten each body part and then relax it. The childcan keep eyes open, as children may respond better if eyesare open rather than closed during relaxation.

As parent participation plays a major role in reducinga child’s anxiety associated with procedures,4,5 whenpossible, parents should have the option to remain withtheir child during the procedure and be involved in the CBItechniques used.

SEDATION FOR PROCEDURESThere are 3 main categories of sedation used for

painful procedures: minimal sedation, moderate sedation,and deep sedation/general anesthesia. CBI should be usedin combination with sedation/analgesic agents. Table 3provides a brief description of each sedation category.

Minimal SedationChildren receiving minimal sedation are able to

respond to verbal commands; airway, spontaneous ventilation,

and cardiovascular function are unaffected.3 This type ofsedation is achieved by administering agents to treatsymptoms of anxiety (Table 4). The benefits of anxiolytictherapy should be carefully considered as there are sideeffects including paradoxical effects resulting in agitation.It remains important to work with each child, using CBIduring their procedure so they develop coping skills overtime. Once the child’s anxiety lessens, nonpharmacologicinterventions may become sufficient and anxiolytics may nolonger be needed.

Moderate SedationModerate sedation is a drug-induced depression of

consciousness during which the patient responds purposefullyto verbal command, either alone or accompanied by lighttactile stimulation.3 Usually no interventions are necessary tomaintain a patent airway. Spontaneous ventilation isadequate and cardiovascular function is maintained. Numer-ous studies report midazolam, fentanyl, and ketamine as safeand effective agents for moderate sedation for painfulprocedures in children with cancer (Table 5).22–29 Two agentsare often combined to provide both sedation and analgesia.Ketamine, fentanyl, and midazolam can be administered by anonanesthesiologist outside of the operating room whenproper monitoring and trained personnel are avail-able.7,24–27,29–32 It is essential to continue using CBI withthese children to develop coping skills over time, even whenmoderate sedation is used.

Midazolam is a benzodiazepine with no analgesicproperties of its own. Fentanyl is an opioid analgesic, andketamine is a dissociative anesthetic/analgesic. These drugs

TABLE 2. Cognitive-Behavioral Interventions and Development

Age Range Techniques

Infants (0-12mo) Parent’s voice (eg, talking, singing on tape), touching (eg, holding and rocking),pacifier, music, swaddling, massage

Toddlers (12-36mo) Same as infants in addition to: pinwheels, storytelling, peek-a-boo, busy boxPreschoolers (3-5 y) Pinwheels, party blowers, feathers, pop-up books storytelling, comfort item,

music, singing, manipulativesSchool agers (6-12 y) Electronic toys (eg, Nintendo DS, PSP, IPOD), pop-up books, I Spy books,

participation in procedure, imagery, storytelling, breathing techniques, muscle relaxationAdolescents (13-18 y) Music, comedy tapes, imagery massage, muscle relaxation, TV, video, other electronics

TABLE 3. Categories of Sedation21

Minimal sedation (anxiolysis)Patient responds to verbal commandsCognitive function may be impairedRespiratory and cardiovascular systems unaffected

Moderate sedation (previously conscious sedation)Patient responds to verbal commands but may not respond tolight tactile stimulation

Cognitive function is impairedRespiratory function adequate; cardiovascular unaffected

Deep sedationPatient cannot be easily aroused except with repeated or painfulstimuli

Ability to maintain airway may be impairedSpontaneous ventilation may be impaired; cardiovascularfunction is maintained

General anesthesiaLoss of consciousness, patient cannot be aroused with painfulstimuli

Airway cannot be maintained adequately and ventilation isimpaired

Cardiovascular function may be impaired

TABLE 4. Anxiolytic Agents*

Agent Dose

Diazepam Children:Oral: 0.12-0.8mg/kg/d in divided doses every 6-8 hIV: 0.04-0.3mg/kg/dose every 2-4 h;a maximum of 0.6mg/kg, OR 10mg within 8 h

Adults:Oral: 2-10mg given 2-4 times/dIV: 2-10mg, may repeat in 3-4 h if needed

Neonates, infants, and children:Oral, IV: 0.05mg/kg/dose every 4-8 h;Max: 2mg/dose

Lorazepam Adults:Oral: 1-10mg/d in 2-3 divided doses;usual dose: 2-6mg/d in divided doses

*Dosages from Lexicomp online.IV indicates intravenous; Max, maximum dose; OR, operating room.

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are administered in combination to provide both sedationand analgesia. However, combining midazolam and keta-mine in some childhood cancer patients is associated withhypoxia, hypertension, tachypnea, vomiting, and hallucina-tions.25,28,29 Combining midazolam and fentanyl may causedecreased heart rate and blood pressure, oxygen desatura-tion, and emesis.24 Administering ondansetron with theanalgesia agents reduces vomiting or retching after theprocedure.30

The risk for ketamine complications is dose and agedependent. In a 2009 meta-analysis on emergency depart-ment procedural sedation, ketamine caused increased airwayor respiratory adverse events, emesis, and recovery agitationwhen administered in an unusually high intravenous dose(initial dose Z2.5mg/kg or total dose Z5.0mg/kg).22,23

Ketamine was associated with adverse airway and respira-tory events in children younger than 2 years and those 13years and older, as well as increased emesis in younger

adolescents. Older children have less distress with proceduresthan younger children when moderate sedation is used.7,33

Distress is further reduced by adding nonpharmacologicinterventions to the sedation drug regimen.7,32,34–37

Nitrous oxide (N2O) is an anesthetic gas that providesmoderate sedation and is most commonly used for painfuldental procedures in children.38,39 In a small number ofstudies, N2O was effective in reducing pain and anxiety inchildren undergoing various painful nondental procedures[eg, venous cannulation, lumbar puncture (LP), bone mar-row aspiration (BMA), and dressing change].40–42 In thesestudies, concentrations of N2O varied (ranging from 0% to70% N2O in oxygen) and were administered by certifiednurses or physicians in a controlled setting such as a clinic,procedure room, or operating room. Patients who receivedN2O before procedures had lower levels of distress, lowerpain scores, were more relaxed, and many had norecollection of the procedure.40–42

TABLE 5. Sedation Agents*

Agent Moderate Sedation Deep Sedation Onset/Duration Adverse Effects Comments

Fentanyl <12 yIV: 1-2mg/kg/dose,may repeat fulldose in 5min ifneeded. MAXcumulative dose:50 mg

Z12 y or >50kgIV: 0.5-1mg/kg/dose or 25-50mg/dose, may repeatfull dose in 5min ifneeded, MAXcumulative dose:100mg

Neonates, infants,children, andadultsIV: >2mg/kg/doseor >MAXcumulative dose100mg

Onset: IV: 4-5minDuration:20-60min

Respiratory depression,apnea; muscle rigidityand chest wall spasmoccur after rapid IVadministration;hypotension,bradycardia, seizures,delirium

Provides rapid onset ofaction with a shortduration of action;minimal hemodynamicchanges

Midazolam >6mo-<12 y IV:0.05-0.1mg/kg/dose; MAXcumulative dose:10mg

Z12 yIV: 0.5-2mg/dose;MAX cumulativedose: 10mg

NA Onset: IV: 1-2minDuration: 2-6 h

Respiratory depression,bitter taste, amnesia,blurred vision,headache, hiccoughs,nausea, vomiting,coughing, sedation;cardiac arrest, andhypotension haveoccurred afterpremedication witha narcotic

Provides no analgesia;effective anxiolytic,sedative, amnesic; fewercardiac complications

Ketamine Children and adultsIV: 0.5-1mg/kg/dose over 2-3min;may repeat asneeded up to MAXcumulative dose of100mg or 2mg/kgin a 30min timeperiod

Children and adultsIV: >1mg/kg/dose, or cumulativedose of 100mg or2mg/kg in a 30mintime period

Onset: IV: 1-2minDuration:10-15min

Hypertonicity, nystagmus,diplopia;contraindicated inpatients in which arapid rise in bloodpressure would bedetrimental and inpatients with increasedICP

Good sedative, amnesic,analgesic; providesbronchial smoothmuscle relaxation;airway protectivereflexes remain intact;eyes usually open withblank stare; administerby slow IV push todecrease risk ofrespiratory depression

Propofol NA Children and adultsIV bolus: 1mg/kg/dose IV infusion:50-200mg/kg/min;MAX: 200mg/kg/min

Onset: IV: <1minDuration:5-10min

Hypotension, injectionsite burning, apnea,hypertension,arrhythmia, pruritus,rash

Children and adults>50 kg should be dosedin 20-50mg increments

*Dosages from Lexicomp online.IV indicates intravenous; ICP, increased intracranial pressure; MAX, maximum dose; NA, nonavailable.

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A small percentage of patients (ranging from 5% to15%) experienced minor side effects from N2O; the mostcommon included nausea, vomiting, excitement, dysphoria,and oxygen desaturation.40,41 More serious complicationssuch as inhibition of the methionine pathway, hematologi-cal, neurological, and/or myocardial injury were associatedwith prolonged N2O use (>6h) and higher concentrations(>70% N2O in oxygen).43 Serious side effects are not foundin the review of studies using N2O for procedures thatinvolve short-term sedation. Adequate room ventilationand effective scavenging systems are required when usingN2O to reduce exposure to ambient gas.39,44,45 In addition,the N2O system must be capable of administering 100%oxygen (never <30% oxygen), and be regularly checkedand calibrated.39,44

Dexmedetomidine has also received recent attention asa moderate sedation agent. Dexmedetomidine, an a-2agonist with analgesic properties that control stress,anxiety, and pain, is effective as a single agent for sedationfor noninvasive procedures and is used most often forlengthy radiological imaging such as magnetic resonanceimaging.46–50 However, when used alone it does not providedeep enough sedation to be beneficial for painful proce-dures such as BMA or LP.

Deep SedationDeep sedationis a drug-induced depression of con-

sciousness when the child cannot be easily aroused butresponds purposefully after repeated or painful stimulation.Medications used for moderate sedation can cause deepsedation and the trained sedation specialist should be ableto manage any complications as the ability to indepen-dently maintain ventilatory function may be impaired.Children may require assistance in maintaining a patentairway, and spontaneous ventilation may be inadequate.Cardiovascular function is usually maintained.3

General AnesthesiaGeneral anesthesia is a drug-induced loss of con-

sciousness when the child is not arousable, even by painfulstimulation. Children often require assistance in maintain-ing an airway, and positive pressure ventilation is oftenused because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovas-cular function may be impaired.3

Propofol, a short-acting sedative hypnotic, is one ofthe most widely used agents for brief invasive procedurespreformed on children with cancer. It is administeredintravenously either by continuous infusion or intermittentboluses (Table 5). Propofol, when administered slowly overat least 1 minute, provides rapid anesthesia induction,amnesia; during recovery this agent causes less agitationand has a lower incidence of nausea and vomiting.51,52

Propofol has no analgesic properties and short-actingopioids such as fentanyl may be used in combination toalleviate pain. The addition of an analgesic agent such asfentanyl can result in lower propofol doses (median 3.1mg/kg vs. 4.6mg/kg), fewer adverse effects (18% vs. 50%), anda shorter recovery period (37min vs. 26min).53–55 Whenremifentanil, an ultra-short-acting opioid, was used incombination with propofol in 80 children undergoingBMAs, it allowed for an overall propofol dose reductionand decreased time to discharge, but it increased the risk ofrespiratory depression.56

Whether used alone or in combination, propofol cancause apnea, hypotension, and airway obstruction. There-fore, this agent must be administered in a controlled settingwith experienced personnel trained in advanced airwaymanagement skills with resuscitative equipment readilyavailable.9,21,33,51,52,55,57,58

HOW TO CHOOSE THE SEDATION CATEGORYThere are several choices for sedation that can be

administered in outpatient and inpatient cancer settings.Minimal sedation can be safely administered in the clinic oran inpatient unit. Moderate and deep sedation can also beadministered in similar areas, but require the immediateavailability of resuscitation drugs and equipment andtrained personnel who are competent in airway manage-ment and sedation.

General anesthesia is administered by anesthesiologistsin the operating room and sites outside the operating roomspecifically established for safe delivery of general anesthetics.

Practitioners administering sedative agents and mon-itoring patients should have documented sedation compe-tency. For all patients receiving moderate deep sedation,recommended monitoring includes continuous pulse oxi-metry, observation of ventilation, and blood pressuremeasurement. For patients whose ventilation cannot beobserved directly during moderate or deep sedation, eitherexhaled/end-tidal carbon dioxide can be monitored orcapnography can be used. Level of consciousness should beassessed at regular intervals throughout the sedationprocess. During deep sedation, practitioners must beproficient in airway management and advanced life supportto rescue patients from a deeper level of sedation thanintended to reduce the risk of hypoxia, hypoventilation,and hypotension. Advanced life support equipment must beimmediately accessible and supplemental oxygen should beadministered unless contraindicated.

The American Society of Anesthesiologists describesmonitored anesthesia care as an assortment of postproce-dure responsibilities, beyond the expertise of practitionersproviding moderate sedation, that assures a return to fullconsciousness, relief of pain, management of adversephysiological responses, or side effects from medicationsadministered during the procedure, while considering coex-isting medical problems.59 A clinical algorithm developed toguide the decision making process for the type of sedationbased on the specific procedure is found in Figure 1.Considerations for deep sedation or general anesthesiashould include the:

� Type of procedure� Length of procedure� Number of procedures� Newly diagnosed oncology patients� Downs syndrome/cognitively impaired patients� Patients who had problems with procedures or obtainingadequate sedation in the clinic or inpatient setting� Patients with allergic reactions to sedative medications� Patients with medical conditions requiring an anes-thesiologist to administer sedation or general anesthesia.

Any child with unusual circumstances should bediscussed with an anesthesiologist before determining thetype of sedation. Children at risk for difficult airways mayinclude morbidly obese patients (body mass index Z35)

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and patients with craniofacial anomalies (eg, Treacher-Collins, Pierre Robin) and patients with mucopolysacchar-idoses (eg, Hurler, Hunter, Morquio). It is recommendedthat the following types of patients be managed by ananesthesiologist in the operating room:

� Infants <6 months of age� Patients who have an oxygen requirement� Patients in shock, hypotensive, impending septic shock(eg, patients with high fevers and unstable volume statusrequiring fluid boluses on the day of the procedure)

FIGURE 1. Clinical Algorithm for Managing Painful Procedures. BMA indicates bone marrow aspirates; BMI, body mass index; BMX,bone marrow biopsies; LPs, lumbar punctures.

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BMA and BiopsyWhen possible, all first time BMAs and biopsies

should be performed under deep sedation or generalanesthesia, regardless of age. As children do not habituateto this painful procedure, deep sedation/general anesthesiais recommended for all bone marrow biopsies. However,there are selected children who can undergo BMA withoutsedation, and each child’s management should be indivi-dualized. A local anesthetic using 1% buffered-lidocaineshould always be used for the BMA and biopsy. The use ofa local anesthetic, when carried out properly is key tominimizing discomfort (Table 6).

LPChildren receiving frequent LPs during the first few

months of cancer therapy may require sedation. Optionsfor having LPs performed without sedation should bediscussed with the parents and child after the initialdiagnostic period. A topical anesthetic should be used forall LPs, especially when sedation is not administered. Forchildren with suspected leukemia, a practitioner experi-enced at procedures should perform the first diagnostic LP,as well as the first procedure in which the patient istransitioning from moderate to minimal sedation. Deepsedation or general anesthesia should always be consideredfor children undergoing more than one procedure (eg, bothBMA and LP).

FUTURE DIRECTIONSAlthough significant advances in procedure manage-

ment have been made in the last 25 years since the days ofchloral hydrate and the demoral, phenergan and thorazinecocktail, there remains a continued need to explore moreeffective agents that provide short-term sedation withminimal side effects. There is limited research on the useof newer agents such as remifentanyl, a short-acting opioid,or short-term sedation with agents such as N2O. Continueduse of CBI for all children should be a standard of care andcreative interventions developed and tested to increasechildren’s coping skills are still needed.

SUMMARYThe guiding principles established 20 years ago for

effectively managing painful procedures in children withcancer hold true today.1 Essential components for aprocedure management program must include effectiveparent teaching and education, procedure preparation forboth parent and child, and appropriate analgesia andsedation. Although new and better pharmacologic agentsnow exist, management of painful procedures in childrenwith cancer must be tailored to the individual patient byeffective communication between the child, parents, andmedical staff of successful multimodal interventions.

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TABLE 6. How to Administer a Local Anesthetic for Bone MarrowAspirate/Biopsy

� Draw up 2-3mL of 1% lidocaine solution, always use bufferedlidocaine except in PACU or OR settings.� Insert a 27 gauge needle at a 45 degrees angle just under theskin and create a small bleb with <0.2-0.3mL of fluid.� Straighten needle to a 90 degrees angle and insert all the way tothe periosteum. Begin administering the lidocaine. Use atechnique of pushing the needle down to the periosteum andpulling back the needle gently while continuing to administerprovides better effect. There is no need to enter the skin morethan once and gentle movements using the push/pull needlemethod off the periosteum should always be used.� When using buffered lidocaine in patients receiving mild-to-moderate sedation, administer very, very slowly to minimizediscomfort. In the PACU or OR the local anesthetic can beperformed quickly.

OR indicates operating room; PACU, post anesthesia care unit.

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