Reducing General Anesthesia for Lumbar Punctures in Pediatric Patients With Leukemia and Lymphoma, a Quality Improvement Project.

PURPOSE: 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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.