Arane Karen, Li Daphne, Baxter Tara, Gandhi Bina, Positano Karyn, Howlett Melissa, Everett Tobias, Alexander Sarah
Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Canada.
Department of Pediatrics, University of Toronto, Toronto, Canada.
Pediatr Blood Cancer. 2025 Sep;72(9):e31843. doi: 10.1002/pbc.31843. Epub 2025 Jun 2.
Curative therapy for most children with leukemia and lymphoma includes multiple lumbar punctures (LPs) for the administration of intrathecal chemotherapy, commonly facilitated with deep sedation or general anesthesia (GA). There is ongoing concern about the potential for neurocognitive deficits induced by GA in the developing brain. The objective of this quality improvement (QI) project was to implement and evaluate a process whereby children received the level of sedation they need for their LPs and not GA by default.
We included children at our center aged 5-18 years who required LPs as part of leukemia and lymphoma therapy. Eligible patients were approached by the primary oncology team, provided with educational materials, and offered the opportunity to participate by selecting their preferred level of sedation. Nonpharmacological anxiety reduction strategies were maximized, and pharmacological interventions were minimized, but not withheld, and customized to each patient's needs.
The baseline rate of LPs without GA (pre-intervention) was 3%. During the QI project, LPs without GA increased to 11% (p = 0.049). There was a significant increase in patients aged 5-9 completing LPs without anesthesia (0% to 6%, p = 0.029). The majority of patients completed LPs with IV midazolam (63%). Most patients (80%) had more than one LP without GA.
Our QI initiative was successful in improving the rates of LPs completed without GA. Future efforts will be aimed to increase GA-free LP rates and explore the applicability of these methods to other procedures requiring anesthesia in pediatric care.
大多数白血病和淋巴瘤患儿的根治性治疗包括多次腰椎穿刺（LP）以进行鞘内化疗，通常在深度镇静或全身麻醉（GA）的辅助下进行。人们一直担心GA会对发育中的大脑造成神经认知缺陷。本质量改进（QI）项目的目的是实施并评估一个流程，使儿童在进行LP时能按需接受镇静水平而非默认接受GA。
我们纳入了本中心5至18岁因白血病和淋巴瘤治疗需要进行LP的儿童。肿瘤学初级团队与符合条件的患者进行沟通，为其提供教育材料，并提供通过选择其偏好的镇静水平来参与的机会。最大限度地采用非药物性焦虑缓解策略，尽量减少药物干预，但不停止使用，并根据每个患者的需求进行定制。
无GA的LP基线率（干预前）为3%。在QI项目期间，无GA的LP增加到11%（p = 0.049）。5至9岁儿童在无麻醉情况下完成LP的比例显著增加（从0%增至6%，p = 0.029）。大多数患者通过静脉注射咪达唑仑完成LP（63%）。大多数患者（80%）进行了不止一次无GA的LP。
我们的QI举措成功提高了无GA完成LP的比例。未来的努力将旨在提高无GA的LP率，并探索这些方法在儿科护理中其他需要麻醉的操作中的适用性。
