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.