ORIGINAL ARTICLE

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 rst recommendations on the management of
pain and anxiety associated with procedures for children with cancer
were published. Guiding principles described in the recommendations 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 interventions most eective 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;33:119127)

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 rst
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
eective 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 appropriate information regarding what to expect before, durReceived for publication April 9, 2010; accepted July 9, 2010.
From the *Pediatric Hematology Oncology, Baylor College of
Medicine, Texas Childrens Cancer Center; wEvidence-Based
Outcomes Center; and zAnesthesiology, Texas Childrens Hospital,
Houston, TX..
Reprints: Marilyn J. Hockenberry, PhD, RN-CS, PNP, FAAN, Texas
Childrens Hospital, 6621 Fannin St, Houston TX 77030 (e-mail:
mjhocken@txccc.org).
Copyright r 2011 by Lippincott Williams & Wilkins

J Pediatr Hematol Oncol




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 childs
cognitive development provides the foundation for establishing standards of care for children undergoing painful procedures.
Support family and child involvement. Families should
be involved in choices oered 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 supervised 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 eective 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 pharmacological and nonpharmacological interventions most eective
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 rst establishing rapport with the child and
family, the clinician is able to assess the familys knowledge
of the procedure, expectations, and preferred learning style.5
This assessment should include discussion of the childs
developmental level, coping strategies, and previous experiences 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 eective 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 preparation is patient focused and is dened as a process of
communicating accurate and developmentally appropriate
information, identifying potential stressors, as well as
planning and practicing coping strategies.6

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TABLE 1. Preparation for Procedures and Development

Infant
Involve parent in procedure
if desired.
If parent is unable to be
with infant, place familiar
object with infant (eg,
stued toy).
Have usual caregivers
perform or assist with
procedure.
Make advances slowly
and in a
nonthreatening manner.
Limit number of
strangers entering room
during procedure.
During procedure use
sensory soothing measures
(eg, stroking skin, talking
softly, giving pacier).
Cuddle and hug infant
after stressful procedure;
encourage parent to comfort
infant.
Perform painful
procedures in a separate
room, not in crib (or bed).

Toddler/Preschooler

School Age

Adolescent

Use same approaches as for

infant, plus the following.
Explain procedure in relation
to what child will see, hear,
taste, smell, and feel.
Use play; demonstrate on doll
but avoid childs favorite doll.
Emphasize those aspects of
procedure that require cooperation
(eg, lying still).
Tell child it is okay to cry, yell,
or use other means to express
discomfort verbally. Expect
treatments to be resisted; child
may try to run away.
Use rm, direct approach.
Ignore temper tantrums.
Use a few simple terms familiar
to child.
Give child one direction
at a time (eg, lie down, then
hold my hand).
Prepare child shortly or
immediately before procedure.
Keep teaching sessions short
(about 5-10 min).
Tell child when procedure
is completed.
Allow choices whenever possible
but realize that child may still
be resistant and negative.
Allow child to participate in care
and to help whenever possible.

Explain procedures using

correct medical terminology.
Explain procedure using
simple
diagrams and photographs.
Discuss why procedure is
necessary; concepts of illness
and bodily functions are
often vague.
Explain function and
operation
of equipment in concrete
terms.
Allow child to manipulate
equipment; use doll or
another person as model to
practice using equipment
Allow time before and after
procedure for questions
and discussion.
Plan for longer teaching
sessions (about 20 min).
Prepare up to 1 day in
advance of procedure to
allow for processing of
information.
Include child in decision
making when possible
(eg, time of day to perform
procedure, preferred site).
Encourage active
participation.

Discuss why procedure is

necessary or benecial.
Explain long-term
consequences of procedures;
include information about
body systems working
together.
Encourage questioning
regarding fears, options,
and alternatives.
Provide privacy; describe how
the body will be covered and
what will be exposed.
Discuss how procedure may
aect appearance (eg, scar)
and what can be done to
minimize it.
Emphasize any physical
benets of procedure.
Involve adolescent in decision
making and planning.
Impose as few restrictions
as possible.
Explore what coping strategies
have worked in the past;
they may need suggestions
of various techniques.
Accept regression to more
childish methods of coping.

Whether taught by a CLS or nurse, educational

preparation for the procedure emphasizes sensory aspects
of 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 preparation
to prevent information overload and confusion and ensure
satisfactory feedback. Allow the child to practice procedures and be comfortable with the sequence of events that
will require cooperation (eg, deep breathing). Teaching
dolls are frequently used to help children understand where
on the body the procedure will be performed. Allowing the
child choices when possible and empowering the child by
giving them specic roles or jobs during the procedure
decreases fear and anxiety. Emphasize that the procedure
will end quickly and stress any pleasurable events afterward
(eg, going home, seeing parents). Provide a positive ending,
praising eorts at cooperation and coping.
Like the child, parents also experience high levels of
stress during procedures, and their anxiety does not
decrease during treatment. However, parent anxiety levels
can be minimized when the child is adequately prepared.79
Several studies report a positive impact on parental distress
and satisfaction and no dierence in technical complications when parents remain with children.8,10,11

CBI
CBI are techniques intended to alter the procedure
experience by changing the childs thoughts through

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attention
diversion,
images,
and
self-determination.1,2,7,1119 Examples of common CBI strategies used
with children with cancer include distraction through music
or other pleasant diversions, story telling, deep breathing,
relaxation, guided imagery, massage, and yoga. CBI
techniques are known to decrease anxiety and discomfort
during painful procedures 1,2,1219 and a variety of
techniques are available to facilitate the child and familys
coping during the procedure (Table 2). Distraction involves
concentrating on an event or object other than the pain.
Distraction is a powerful coping strategy during painful
procedures.20 Infants and toddlers are easily distracted
because of their short attention span. Distraction is
accomplished by focusing the childs attention on something other than the procedure. Singing favorite songs,
listening to music with a headset, counting aloud, or
blowing on a magic wand are eective techniques.
Older children can be distracted with activities such as
video games, television, and music. Guided imagery works
well with school-aged children and adolescents who can
visualize an enjoyable experience or pleasant memory. The
child describes the event in detail as he or she visualizes it.
The child describes details of the event, including as many
senses as possible (eg, feel the cool breezes, see the
beautiful colors, hear the pleasant music). The child
concentrates only on the pleasurable event during the painful
time by enhancing the image, often by reading a script or
playing a tape. The eectiveness of this method is enhanced
by the use of a coach. The coach may be a parent or other
adult who discusses the event with the child and keeps the
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Managing Painful Procedures in Children With Cancer

TABLE 2. Cognitive-Behavioral Interventions and Development

Age Range

Techniques

Infants (0-12 mo)

Toddlers (12-36 mo)
Preschoolers (3-5 y)
School agers (6-12 y)
Adolescents (13-18 y)

Parents voice (eg, talking, singing on tape), touching (eg, holding and rocking),
pacier, music, swaddling, massage
Same as infants in addition to: pinwheels, storytelling, peek-a-boo, busy box
Pinwheels, party blowers, feathers, pop-up books storytelling, comfort item,
music, singing, manipulatives
Electronic toys (eg, Nintendo DS, PSP, IPOD), pop-up books, I Spy books,
participation in procedure, imagery, storytelling, breathing techniques, muscle relaxation
Music, comedy tapes, imagery massage, muscle relaxation, TV, video, other electronics

image alive during the procedure. Muscle relaxation is

another CBI that is useful in children and adolescents. The
child is asked to take a deep breath and go limp as a rag
doll while exhaling slowly; then ask child to yawn. Begin
progressive relaxation by starting with the toes, and systematically instructing the child to let each body part go limp
or feel heavy; if child has diculty relaxing, instruct child
to tense or tighten each body part and then relax it. The child
can keep eyes open, as children may respond better if eyes
are open rather than closed during relaxation.
As parent participation plays a major role in reducing
a childs anxiety associated with procedures,4,5 when
possible, parents should have the option to remain with
their child during the procedure and be involved in the CBI
techniques used.

SEDATION FOR PROCEDURES

There are 3 main categories of sedation used for
painful procedures: minimal sedation, moderate sedation,
and deep sedation/general anesthesia. CBI should be used
in combination with sedation/analgesic agents. Table 3
provides a brief description of each sedation category.

Minimal Sedation
Children receiving minimal sedation are able to
respond to verbal commands; airway, spontaneous ventilation,

TABLE 3. Categories of Sedation21

Minimal sedation (anxiolysis)
Patient responds to verbal commands
Cognitive function may be impaired
Respiratory and cardiovascular systems unaected
Moderate sedation (previously conscious sedation)
Patient responds to verbal commands but may not respond to
light tactile stimulation
Cognitive function is impaired
Respiratory function adequate; cardiovascular unaected
Deep sedation
Patient cannot be easily aroused except with repeated or painful
stimuli
Ability to maintain airway may be impaired
Spontaneous ventilation may be impaired; cardiovascular
function is maintained
General anesthesia
Loss of consciousness, patient cannot be aroused with painful
stimuli
Airway cannot be maintained adequately and ventilation is
impaired
Cardiovascular function may be impaired

2011 Lippincott Williams & Wilkins

and cardiovascular function are unaected.3 This type of

sedation is achieved by administering agents to treat
symptoms of anxiety (Table 4). The benets of anxiolytic
therapy should be carefully considered as there are side
eects including paradoxical eects resulting in agitation.
It remains important to work with each child, using CBI
during their procedure so they develop coping skills over
time. Once the childs anxiety lessens, nonpharmacologic
interventions may become sucient and anxiolytics may no
longer be needed.

Moderate Sedation
Moderate sedation is a drug-induced depression of
consciousness during which the patient responds purposefully
to verbal command, either alone or accompanied by light
tactile stimulation.3 Usually no interventions are necessary to
maintain a patent airway. Spontaneous ventilation is
adequate and cardiovascular function is maintained. Numerous studies report midazolam, fentanyl, and ketamine as safe
and eective agents for moderate sedation for painful
procedures in children with cancer (Table 5).2229 Two agents
are often combined to provide both sedation and analgesia.
Ketamine, fentanyl, and midazolam can be administered by a
nonanesthesiologist outside of the operating room when
proper monitoring and trained personnel are available.7,2427,2932 It is essential to continue using CBI with
these children to develop coping skills over time, even when
moderate sedation is used.
Midazolam is a benzodiazepine with no analgesic
properties of its own. Fentanyl is an opioid analgesic, and
ketamine is a dissociative anesthetic/analgesic. These drugs

TABLE 4. Anxiolytic Agents*

Agent

Dose

Diazepam

Children:
Oral: 0.12-0.8 mg/kg/d in divided doses every 6-8 h
IV: 0.04-0.3 mg/kg/dose every 2-4 h;
a maximum of 0.6 mg/kg, OR 10 mg within 8 h
Adults:
Oral: 2-10 mg given 2-4 times/d
IV: 2-10 mg, may repeat in 3-4 h if needed
Neonates, infants, and children:
Oral, IV: 0.05 mg/kg/dose every 4-8 h;
Max: 2 mg/dose
Lorazepam Adults:
Oral: 1-10 mg/d in 2-3 divided doses;
usual dose: 2-6 mg/d in divided doses
*Dosages from Lexicomp online.
IV indicates intravenous; Max, maximum dose; OR, operating room.

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TABLE 5. Sedation Agents*

Agent

Moderate Sedation

Deep Sedation

Onset/Duration

Fentanyl

<12 y
IV: 1-2 mg/kg/dose,
may repeat full
dose in 5 min if
needed. MAX
cumulative dose:
50 mg
Z12 y or >50 kg
IV: 0.5-1 mg/kg/
dose or 25-50 mg/
dose, may repeat
full dose in 5 min if
needed, MAX
cumulative dose:
100 mg
>6 mo-<12 y IV:
0.05-0.1 mg/kg/
dose; MAX
cumulative dose:
10 mg
Z12 y
IV: 0.5-2 mg/dose;
MAX cumulative
dose: 10 mg

Neonates, infants,
children, and
adults
IV: >2 mg/kg/dose
or >MAX
cumulative dose
100 mg

Onset: IV: 4-5 min

Duration:
20-60 min

Respiratory depression,
apnea; muscle rigidity
and chest wall spasm
occur after rapid IV
administration;
hypotension,
bradycardia, seizures,
delirium

Provides rapid onset of

action with a short
duration of action;
minimal hemodynamic
changes

NA

Onset: IV: 1-2 min

Duration: 2-6 h

Respiratory depression,
bitter taste, amnesia,
blurred vision,
headache, hiccoughs,
nausea, vomiting,
coughing, sedation;
cardiac arrest, and
hypotension have
occurred after
premedication with
a narcotic
Hypertonicity, nystagmus,
diplopia;
contraindicated in
patients in which a
rapid rise in blood
pressure would be
detrimental and in
patients with increased
ICP

Provides no analgesia;
eective anxiolytic,
sedative, amnesic; fewer
cardiac complications

Midazolam

Ketamine

Children and adults

IV: 0.5-1 mg/kg/
dose over 2-3 min;
may repeat as
needed up to MAX
cumulative dose of
100 mg or 2 mg/kg
in a 30 min time
period

Children and adults

IV: >1 mg/kg/
dose, or cumulative
dose of 100 mg or
2 mg/kg in a 30 min
time period

Onset: IV: 1-2 min

Duration:
10-15 min

Propofol

NA

Children and adults

IV bolus: 1 mg/kg/
dose IV infusion:
50-200 mg/kg/min;
MAX: 200 mg/kg/
min

Onset: IV: <1 min

Duration:
5-10 min

Adverse Eects

Hypotension, injection
site burning, apnea,
hypertension,
arrhythmia, pruritus,
rash

Comments

Good sedative, amnesic,

analgesic; provides
bronchial smooth
muscle relaxation;
airway protective
reexes remain intact;
eyes usually open with
blank stare; administer
by slow IV push to
decrease risk of
respiratory depression
Children and adults
>50 kg should be dosed
in 20-50 mg increments

*Dosages from Lexicomp online.

IV indicates intravenous; ICP, increased intracranial pressure; MAX, maximum dose; NA, nonavailable.

are administered in combination to provide both sedation

and analgesia. However, combining midazolam and ketamine in some childhood cancer patients is associated with
hypoxia, hypertension, tachypnea, vomiting, and hallucinations.25,28,29 Combining midazolam and fentanyl may cause
decreased heart rate and blood pressure, oxygen desaturation, and emesis.24 Administering ondansetron with the
analgesia agents reduces vomiting or retching after the
procedure.30
The risk for ketamine complications is dose and age
dependent. In a 2009 meta-analysis on emergency department procedural sedation, ketamine caused increased airway
or respiratory adverse events, emesis, and recovery agitation
when administered in an unusually high intravenous dose
(initial dose Z2.5 mg/kg or total dose Z5.0 mg/kg).22,23
Ketamine was associated with adverse airway and respiratory events in children younger than 2 years and those 13
years and older, as well as increased emesis in younger

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adolescents. Older children have less distress with procedures

than younger children when moderate sedation is used.7,33
Distress is further reduced by adding nonpharmacologic
interventions to the sedation drug regimen.7,32,3437
Nitrous oxide (N2O) is an anesthetic gas that provides
moderate sedation and is most commonly used for painful
dental procedures in children.38,39 In a small number of
studies, N2O was eective in reducing pain and anxiety in
children undergoing various painful nondental procedures
[eg, venous cannulation, lumbar puncture (LP), bone marrow aspiration (BMA), and dressing change].4042 In these
studies, concentrations of N2O varied (ranging from 0% to
70% N2O in oxygen) and were administered by certied
nurses or physicians in a controlled setting such as a clinic,
procedure room, or operating room. Patients who received
N2O before procedures had lower levels of distress, lower
pain scores, were more relaxed, and many had no
recollection of the procedure.4042
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A small percentage of patients (ranging from 5% to

15%) experienced minor side eects from N2O; the most
common included nausea, vomiting, excitement, dysphoria,
and oxygen desaturation.40,41 More serious complications
such as inhibition of the methionine pathway, hematological, neurological, and/or myocardial injury were associated
with prolonged N2O use (>6 h) and higher concentrations
(>70% N2O in oxygen).43 Serious side eects are not found
in the review of studies using N2O for procedures that
involve short-term sedation. Adequate room ventilation
and eective scavenging systems are required when using
N2O 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 checked
and calibrated.39,44
Dexmedetomidine has also received recent attention as
a moderate sedation agent. Dexmedetomidine, an a-2
agonist with analgesic properties that control stress,
anxiety, and pain, is eective as a single agent for sedation
for noninvasive procedures and is used most often for
lengthy radiological imaging such as magnetic resonance
imaging.4650 However, when used alone it does not provide
deep enough sedation to be benecial for painful procedures such as BMA or LP.

Deep Sedation
Deep sedationis a drug-induced depression of consciousness when the child cannot be easily aroused but
responds purposefully after repeated or painful stimulation.
Medications used for moderate sedation can cause deep
sedation and the trained sedation specialist should be able
to manage any complications as the ability to independently maintain ventilatory function may be impaired.
Children may require assistance in maintaining a patent
airway, and spontaneous ventilation may be inadequate.
Cardiovascular function is usually maintained.3

General Anesthesia
General anesthesia is a drug-induced loss of consciousness when the child is not arousable, even by painful
stimulation. Children often require assistance in maintaining an airway, and positive pressure ventilation is often
used because of depressed spontaneous ventilation or druginduced depression of neuromuscular function. Cardiovascular function may be impaired.3
Propofol, a short-acting sedative hypnotic, is one of
the most widely used agents for brief invasive procedures
preformed on children with cancer. It is administered
intravenously either by continuous infusion or intermittent
boluses (Table 5). Propofol, when administered slowly over
at least 1 minute, provides rapid anesthesia induction,
amnesia; during recovery this agent causes less agitation
and has a lower incidence of nausea and vomiting.51,52
Propofol has no analgesic properties and short-acting
opioids such as fentanyl may be used in combination to
alleviate pain. The addition of an analgesic agent such as
fentanyl can result in lower propofol doses (median 3.1 mg/
kg vs. 4.6 mg/kg), fewer adverse eects (18% vs. 50%), and
a shorter recovery period (37 min vs. 26 min).5355 When
remifentanil, an ultra-short-acting opioid, was used in
combination with propofol in 80 children undergoing
BMAs, it allowed for an overall propofol dose reduction
and decreased time to discharge, but it increased the risk of
respiratory depression.56
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Managing Painful Procedures in Children With Cancer

Whether used alone or in combination, propofol can

cause apnea, hypotension, and airway obstruction. Therefore, this agent must be administered in a controlled setting
with experienced personnel trained in advanced airway
management skills with resuscitative equipment readily
available.9,21,33,51,52,55,57,58

HOW TO CHOOSE THE SEDATION CATEGORY

There are several choices for sedation that can be
administered in outpatient and inpatient cancer settings.
Minimal sedation can be safely administered in the clinic or
an inpatient unit. Moderate and deep sedation can also be
administered in similar areas, but require the immediate
availability of resuscitation drugs and equipment and
trained personnel who are competent in airway management and sedation.
General anesthesia is administered by anesthesiologists
in the operating room and sites outside the operating room
specically established for safe delivery of general anesthetics.
Practitioners administering sedative agents and monitoring patients should have documented sedation competency. For all patients receiving moderate deep sedation,
recommended monitoring includes continuous pulse oximetry, observation of ventilation, and blood pressure
measurement. For patients whose ventilation cannot be
observed directly during moderate or deep sedation, either
exhaled/end-tidal carbon dioxide can be monitored or
capnography can be used. Level of consciousness should be
assessed at regular intervals throughout the sedation
process. During deep sedation, practitioners must be
procient in airway management and advanced life support
to rescue patients from a deeper level of sedation than
intended to reduce the risk of hypoxia, hypoventilation,
and hypotension. Advanced life support equipment must be
immediately accessible and supplemental oxygen should be
administered unless contraindicated.
The American Society of Anesthesiologists describes
monitored anesthesia care as an assortment of postprocedure responsibilities, beyond the expertise of practitioners
providing moderate sedation, that assures a return to full
consciousness, relief of pain, management of adverse
physiological responses, or side eects from medications
administered during the procedure, while considering coexisting medical problems.59 A clinical algorithm developed to
guide the decision making process for the type of sedation
based on the specic procedure is found in Figure 1.
Considerations for deep sedation or general anesthesia
should 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 obtaining
adequate sedation in the clinic or inpatient setting
 Patients with allergic reactions to sedative medications
 Patients with medical conditions requiring an anesthesiologist to administer sedation or general anesthesia.
Any child with unusual circumstances should be
discussed with an anesthesiologist before determining the
type of sedation. Children at risk for dicult airways may
include morbidly obese patients (body mass index Z35)
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FIGURE 1. Clinical Algorithm for Managing Painful Procedures. BMA indicates bone marrow aspirates; BMI, body mass index; BMX,
bone marrow biopsies; LPs, lumbar punctures.

and patients with craniofacial anomalies (eg, TreacherCollins, Pierre Robin) and patients with mucopolysaccharidoses (eg, Hurler, Hunter, Morquio). It is recommended
that the following types of patients be managed by an
anesthesiologist in the operating room:

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 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 status
requiring uid boluses on the day of the procedure)

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TABLE 6. How to Administer a Local Anesthetic for Bone Marrow

Aspirate/Biopsy
 Draw up 2-3 mL of 1% lidocaine solution, always use buered
lidocaine except in PACU or OR settings.
 Insert a 27 gauge needle at a 45 degrees angle just under the
skin and create a small bleb with <0.2-0.3 mL of uid.
 Straighten needle to a 90 degrees angle and insert all the way to
the periosteum. Begin administering the lidocaine. Use a
technique of pushing the needle down to the periosteum and
pulling back the needle gently while continuing to administer
provides better eect. There is no need to enter the skin more
than once and gentle movements using the push/pull needle
method o the periosteum should always be used.
 When using buered lidocaine in patients receiving mild-tomoderate sedation, administer very, very slowly to minimize
discomfort. In the PACU or OR the local anesthetic can be
performed quickly.
OR indicates operating room; PACU, post anesthesia care unit.

BMA and Biopsy

When possible, all rst time BMAs and biopsies
should be performed under deep sedation or general
anesthesia, regardless of age. As children do not habituate
to this painful procedure, deep sedation/general anesthesia
is recommended for all bone marrow biopsies. However,
there are selected children who can undergo BMA without
sedation, and each childs management should be individualized. A local anesthetic using 1% buered-lidocaine
should always be used for the BMA and biopsy. The use of
a local anesthetic, when carried out properly is key to
minimizing discomfort (Table 6).

LP
Children receiving frequent LPs during the rst few
months of cancer therapy may require sedation. Options
for having LPs performed without sedation should be
discussed with the parents and child after the initial
diagnostic period. A topical anesthetic should be used for
all LPs, especially when sedation is not administered. For
children with suspected leukemia, a practitioner experienced at procedures should perform the rst diagnostic LP,
as well as the rst procedure in which the patient is
transitioning from moderate to minimal sedation. Deep
sedation or general anesthesia should always be considered
for children undergoing more than one procedure (eg, both
BMA and LP).

FUTURE DIRECTIONS
Although signicant advances in procedure management have been made in the last 25 years since the days of
chloral hydrate and the demoral, phenergan and thorazine
cocktail, there remains a continued need to explore more
eective agents that provide short-term sedation with
minimal side eects. There is limited research on the use
of newer agents such as remifentanyl, a short-acting opioid,
or short-term sedation with agents such as N2O. Continued
use of CBI for all children should be a standard of care and
creative interventions developed and tested to increase
childrens coping skills are still needed.
r

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Managing Painful Procedures in Children With Cancer

SUMMARY
The guiding principles established 20 years ago for
eectively managing painful procedures in children with
cancer hold true today.1 Essential components for a
procedure management program must include eective
parent teaching and education, procedure preparation for
both parent and child, and appropriate analgesia and
sedation. Although new and better pharmacologic agents
now exist, management of painful procedures in children
with cancer must be tailored to the individual patient by
eective communication between the child, parents, and
medical sta of successful multimodal interventions.

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