1. Introduction
The outcomes for children with acute lymphoblastic leukemia (ALL) have improved greatly over the past five decades, with five-year overall survival rates currently around 90%. 1 As survival rates improve, attention toward minimizing the late effects of treatment has increased. Performing painful procedures such as lumbar punctures (LPs) under sedation has become routine at most pediatric cancer centers. A recent study showed that among 64 Children’s Oncology Group (COG) institutions, >95% of patients with ALL received LPs with sedation. Propofol was by far the most used sedating agent, with “propofol alone” being the most commonly used sedation regimen (56% of institutions), and “propofol with opioid and/or midazolam” being used in an additional 31% of institutions. 2 Although previous studies have documented that procedural sedation with propofol provides short-term safe and effective control of pain and anxiety3, long-term consequences are just beginning to be understood. In December 2016, the US Food and Drug Administration published a warning that repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children may affect a child’s brain development.4 In corroboration of these concerns, a recent study of over 200 survivors of childhood leukemia revealed a 40% increased risk of neurocognitive impairment in patients who received high cumulative doses of propofol sedation.5
Contemporary COG protocols for the treatment of ALL involve a minimum of 20 LPs. This number is higher for patients with central nervous system involvement or relapsed disease. Even then, this number does not account for the entire sedation burden these patients experience as they also often require sedation for other procedures such as port placement, bone marrow biopsies, and radiographic imaging. In addition to the risk of neurocognitive deficits, sedated procedures impose a significant financial burden on hospitals and patients, due to the involvement of the anesthesia team, use of procedure rooms, and a high frequency of cancelled procedures (low blood counts, respiratory infections, violation of nothing by mouth (NPO) policies, etc.).
The COVID-19 pandemic necessitated many changes to the way our medical systems operate. Starting in March 2020, a negative COVID-19 test has been required within 24 hours of sedated procedures at our institution. Prior to the availability of rapid testing, this necessitated an on-site hospital visit the day before the procedure which generated additional burdens for families, particularly those living with geographic or financial disparity. Due to the medical and operational challenges associated with sedated LPs, a quality improvement project was designed to reduce the number of LPs performed with sedation on ALL patients at our institution.