Anxiety and pain during bone marrow aspiration and biopsy

Procedural pain in patients with cancer: a Delphi expert management consensus

OBJECTIVES

Diagnosis, treatment and care of cancer often involve procedures that may be distressing and potentially painful for patients. The PROCEDIO Study aimed to generate expert-based recommendations on the management of moderate to severe procedural pain in inpatients and outpatients with cancer.

METHODS

Using a two-round Delphi method, experts from pain and palliative care units, medical and radiation oncology and haematology departments expressed their agreement on 24 statements using a 9-point Likert scale, which were classified as appropriate (median 7-9), uncertain (4-6) or inappropriate (1-3). Consensus was achieved if at least two-thirds of the panel scored within the range containing the median.

RESULTS

With an overall agreement on the current definition of procedural pain, participants suggested a wider description based on evidence and their clinical experience. A strong consensus was achieved regarding the need for a comprehensive pre-procedural pain assessment and experts emphasised that healthcare professionals involved in procedural pain management should be adequately trained. Most panellists (98.2%) agreed that pharmacological treatment should be chosen considering the duration of the procedure. Transmucosal fentanyl (96.5%) and morphine (71.7%) were recommended as the most appropriate drugs. Oral and nasal transmucosal fentanyl were agreed as the most suitable for both outpatients and inpatients, while consensus was reached for intravenous and subcutaneous morphine for inpatients.

CONCLUSIONS

These results provide updated expert-based recommendations on the definition, prevention and treatment of moderate to severe procedural pain, which could inform specialists involved in pain management of patients with cancer.

The Effect of Video Streaming With Virtual Reality on Anxiety and Pain During Bone Marrow Aspiration and Biopsy Procedure

BACKGROUND

Pain and anxiety are among the most common symptoms in patients undergoing invasive procedures. Increased pain levels tend to worsen anxiety, and anxiety often leads to more frequent or severe pain.

AIMS

The study was conducted to determine the efficacy of virtual reality goggles (VRG) on pain and anxiety during bone marrow aspiration and biopsy (BMAB) procedure.

DESIGN

A randomized controlled experimental study.

SETTINGS

The outpatient unit of an adult hematology clinic of a tertiary care university hospital.

PARTICIPANTS/SUBJECTS

The study was conducted in patients aged 18 years and older who underwent a BMAB procedure. Thirty-five patients in the experimental (VRG) group and 40 patients in the control group.

METHODS

Patient identification form, visual analogue scale (VAS), state and trait anxiety inventory (STAI), and VRG were used to collect the data.

RESULTS

Postprocedural state anxiety mean scores were found to be statistically significantly higher in the control group than in the VRG group (p = .022). A statistically significant difference was found between groups in terms of procedure-related pain (p = .002). The postprocedural mean pain scores were found to be statistically significantly higher in the control group than in the VRG group (p < .001). A statistically significant but moderate positive correlation was found between the postprocedural pain and preprocedural state anxiety variable (r = 0.477). A statistically significant and strong positive correlation was found between the postprocedural pain and the postprocedural state anxiety variable (r = 0.657). A statistically significant but moderate positive relationship was found between preprocedural and postprocedural state anxiety variables (r = 0.519).

CONCLUSIONS

We determined that video streaming with VRG reduces pain and anxiety felt by adult patients during the BMAB procedure. VRG can be recommended to use in controlling pain and anxiety in patients undergoing a BMAB procedure.

Using Alprazolam before phacoemulsification cataract surgery reduces complications and duration of the surgery

PURPOSE

To evaluate the effect of preoperative Alprazolam on complications of phacoemulsification cataract surgery, duration of surgery and early reoperation rate.

METHODS

Records of 1026 eyes of 1026 consecutive patients underwent phacoemulsification with topical and intracameral anesthesia between 2016 and 2020 years were retrospectively reviewed. Patients were divided into two groups, with or without using Alprazolam before surgery. Patients with planned first-time surgery for senile cataract and at least three months follow-up postoperatively were included. Those who had pseudoexfoliation, small pupil, zonular weakness, corneal and hearing problem as well as traumatic, brown, mature, hypermature, and posterior polar cataracts were excluded. Main outcome measures were duration of surgery, posterior capsule rupture, rapid posterior capsule opacification (PCO) formation requiring the neodymium: yttrium-aluminum-garnet (Nd:YAG) laser and reoperation rate in early postoperative periods.

RESULTS

Alprazolam and control groups included 490 and 536 eyes, respectively. Mean surgical time was shorter in Alprazolam group (10.2 ± 3 versus 12.2 ± 4 min; < 0.001). Rate of posterior capsule rupture was higher in control group (4 versus 15 eyes; = 0.02). Four eyes (0.8%) in control group underwent unplanned secondary surgical procedures in early postoperative period (P = 0.126). Rate of rapid PCO formation was higher in control group (1 versus 9 eyes; = 0.027).

CONCLUSIONS

Using Alprazolam before phacoemulsification can lead to less posterior capsule rupture, short operation time and prevent repetitive surgery. It also reduces rapid PCO formation and, thus, early Nd:YAG laser intervention due to better cleaning the posterior capsule during surgery. We conclude that Alprazolam not only reduces intraoperative complications, but also facilitates their management.

A study of patient-reported pain during bone marrow aspiration and biopsy using local anesthesia alone compared with local anesthesia with intravenous midazolam coadministration at a tertiary academic hospital in South Africa

INTRODUCTION

During the bone marrow aspiration and biopsy (BMAB) procedure, patients report pain of widely variable intensity. There is limited literature on the factors associated with the pain. The use of local anesthesia (LA) only is still widespread although it does not abolish the pain. Midazolam is the most commonly used benzodiazepine for conscious sedation. Our center introduced universal midazolam sedation unless there is a contraindication to its use, 4 years ago. This study assessed the impact of the universal use of intravenous midazolam for BMAB compared to use of LA only. The factors associated with the pain of BMAB, were analyzed.

METHODS

A retrospective cross-sectional study was performed on adult patients who had a BMAB procedure from July 1, 2018 to March 30, 2019. A questionnaire incorporating a visual analog pain scale, was used for data collection.

RESULTS

A total of 182 BMAB procedures were included in the study. Pain was reported in all procedures performed under LA and only in 29.1% of procedures performed with midazolam. Age, sex, race, level of education, body mass index (BMI), indication and diagnosis had no influence on pain. Patients who had previous BMAB experienced less pain. Experience of operator had a significant effect on pain. Midazolam dose showed a negative correlation with pain.

CONCLUSION

LA only is not enough to abolish pain of BMAB. Midazolam conscious sedation used with LA reduces pain to acceptable levels. Patients with previous experience of BMAB under midazolam premedication reported less pain. Furthermore, the experience of operator reduced the pain significantly.

Health-Related Quality of Life and Influencing Factors in Adults with Nonadvanced Mastocytosis-A Cross-Sectional Study and Qualitative Approach

BACKGROUND

Mastocytosis comprises a heterogeneous group of disorders characterized by an accumulation of mast cells in 1 or more organs. Symptoms range from mild complaints to severe and life-threatening events. Impact on quality of life seems to vary widely, but influencing factors are poorly understood so far.

OBJECTIVE

To examine impairments, psychological burden, health-related quality of life (HRQOL), and possible influencing factors in patients with mastocytosis.

METHODS

In semistructured telephone interviews, patients provided information on impairments in everyday life and psychological burden caused by mastocytosis. HRQOL was measured using the Mastocytosis Quality of Life (MC-QoL) questionnaire. Clinical data were collected from patient files.

RESULTS

A total of 101 adult patients with mastocytosis (74.3% women; mean age, 47.7 ± 13.5 years) were included. Half of the interviewed patients (50.6%) reported disease-related impairments in everyday life, and 42.4% stated a psychological burden. MC-QoL questionnaire scores showed a broad distribution, with a mean total score at a "mild" impairment level (mean total score, 34.7 ± 22.5). One-third of patients felt moderately (22.8%) or severely (13.9%) impaired, whereas one-third reported no impairment at all (30.7%). Symptoms of mast cell activation and perceived food intolerance had the highest impact on HRQOL. Higher age, higher body mass index, higher tryptase level, and longer duration of symptoms, as well as current drug therapy and pathological bone density, were each associated with reduced HRQOL.

CONCLUSIONS

A high level of suffering and strong associations between impairments and symptom-related factors indicate the importance of addressing patients' concerns and adequate symptom management in mastocytosis.

Management of Pain and Anxiety during Bone Marrow Aspiration: An Italian National Survey

BACKGROUND

Bone marrow aspiration (BMA) or biopsy is a necessary and frequent procedure for diagnosis and monitoring of hematological diseases. Pharmacological pain management approaches exist; however, previous experience and psychological preparation for BMA may impact pain perception.

AIMS

This study aimed to explore current practices in procedural pain management for BMA or biopsy.

DESIGN/SETTING/PARTICIPANTS

A cross-sectional internet-based survey was performed by the Nurses Group of the Italian Transplant Group (GITMO). Participants were nurses working in bone marrow transplant centers regularly performing BMA/biopsies.

RESULTS

Sixty out of 94 centers receiving the survey responded (63.8%), 47 adult and 13 pediatric centers. The majority of them (75%) provided only verbal information for patient preparation before BMA. . Injected local anesthetics were used in 55.4% of centers, and combined with topical anesthetics in 33.9% of centers. Use of oral anesthetics was rare; however, anxiolytics and benzodiazepines were occasionally used (18.3%, 18.3% respectively). All pediatric centers used deep sedation for the procedure (p < .001), but drug choice depended on anesthetist preference. Ice packs (35.0%) and oral analgesia as required (40.0%) were used for postprocedural pain. Nurses perceived their patients' pain scores as relatively low (3.5 on scale 0-10), but recognized that it was a painful procedure provoking anxiety, and that pain management could be improved.

CONCLUSIONS

Results revealed the lack of a standardized approach to procedural pain management for BMA in this study sample. Assessing a patient's pain experience is a key component to identifying effective pain management for BMA.

Pain assessment and factors influencing pain during bone marrow aspiration: A prospective study

Although bone marrow aspiration (BMA) is still considered a painful procedure, pain level remains poorly documented. We therefore conducted a prospective study intended to evaluate pain level in adult patients undergoing BMA at the sternal or iliac crest site to identify factors associated with pain. We enrolled a total of 448 patients who underwent 461 BMA and asked those patients to score their pain intensity after BMA using numerical pain rating scale (NPRS). The following factors: level of anxiety, quality of the information given to the patient, operator’s experience, and bone texture were recorded using a standardized questionnaire. The median NPRS score was 3.5 (IQR [2.0; 5.0]) the sternal site (n = 405) was associated with an increased median NPRS score (3.5 [2.0; 5.0]) compared to the iliac crest (n = 56, 2.5 [1.0; 4.0]; p<0.0001). For those patients who underwent sternal BMA, the median NPRS score was significantly lower when using lidocaine infiltration (p = 0.0159) as compared with no anesthetic use. Additionally there was no significant effect of anesthetic cream found. After multivariate analysis, the model of NPRS score at the sternal site included patient anxiety (p<0.0001) and the use of lidocaine infiltration (0.0378). This study underlines the usefulness of a comprehensive management including pain relief and efforts to reduce anxiety including appropriate information given to the patient during BMA.

Bone marrow aspirations in oncological patients: experience from an in-house standard in paediatrics

BACKGROUND

Nearly all paediatric patients require deep sedation when undergoing bone marrow aspiration (BMA). We analyzed the data from our protocols documented in a standardised procedure for bone marrow puncture over a period of 2 years.

METHODS

Our standard included the documentation of personal data as well as vital parameters. In addition, we documented all medications administered, potential complications and required intervention measures, as necessary.

RESULTS

A total of 107 protocols were available for the evaluation. Our standard covered the usage of midazolam and S‑ketamine and resulted in complications in just 9 patients, which could be remedied using simple measures. For both active substances, the dosage necessary to reach sufficient deep analgosedation was significantly higher for patients under 24 months of age.

CONCLUSIONS

Our standard for BMA provides a practical and feasible procedure. In addition to good examination conditions, our standard also helps ensure the safety of our patients.

Trained clinical nurse specialists proficiently obtain bone marrow aspirates and trephine biopsies in a nearly painless procedure--a prospective evaluation study

Patients often experience bone marrow examinations (BMEs) as frightening and painful. Varying operators and uncertainty about who will perform the BME worsen their anxiety. In our study, clinical nurse specialists (CNSs) were trained to perform BMEs to ensure continuity and to test the feasibility, patient satisfaction, and biopsy quality. This exploratory evaluation assessed 574 BMEs at our tertiary center between January 2012 and February 2013, 398 BMEs performed by CNS and 176 by physicians. Our aims were to determine whether BMEs by CNS yield results similar to those of physicians, analyzing (1) patient satisfaction with the BME (a) consent and (b) performance, (2) induced pain, and (3) quality of aspirates and length of trephine biopsies. When performed by CNS, 100 % of the patients were satisfied with the consent procedure and 99 % with the BME performance (physicians 99 and 91 %, respectively). The median pain score was low when both CNS and physicians performed the BME, with no or only mild pain in 92 and 76 % of patients, respectively. Bone marrow (BM) aspirates by CNS and physicians were assessed as technically evaluable in ~70 %; moreover, the median length of trephine biopsies was similar when performed by CNS or physicians with 12 and 13 mm, respectively. In conclusion, BMEs conducted by motivated CNS and within a structured training program are feasible and yield equal outcomes compared to physicians. The use of adequate pain management during BMEs by trained and experienced operators results in an extremely rare use of sedatives, low pain scores, and high patient satisfaction.

Nitrous oxide analgesia for bone marrow aspiration and biopsy - A randomized, controlled and patient blinded study

Background and aims Bone marrow aspiration and/or biopsy (BMAB), performed under local anaesthesia in adults, is a common and often painful procedure. Anxiety is known to intensify pain during the procedure. Nitrous oxide (N2O), known for its sedative and analgesic benefit in various short medical procedures and labour pain, could be advantageous also for pain relief during bone marrow examination. N2O acts rapidly and is eliminated in a couple of minutes once the inhalation is stopped, and occasional side effects (e.g. dizziness and nausea) are mild. The aim of this study was to compare the analgesic effects of inhaled 50% mixture of nitrous oxide and oxygen to 50% oxygen during bone marrow examination. Methods In this randomized, controlled, patient and observer blinded study patients received either 50% mixture of nitrous oxide and oxygen or 50% mixture of oxygen in air during bone marrow examination, in addition to local analgesia. Both patient groups comprised 35 adult patients. Pre-procedural anxiety and procedural pain were rated on the Numeral Rating Scale (NRS 0‒10). Cognitive function was measured before and 30 min after the procedure. Possible side effects were recorded. A telephone interview was performed 24 h later. Results There were no statistically significant differences in pain scores of the procedural steps (median NRS ranging 3.0‒4.0) between the study groups. High pain scores of 8‒10 comprised 0% vs. 8.6% of the scores during infiltration, 2.9% vs. 5.7% during puncture, 11.4% vs. 14.3% during aspiration and 2.9% vs. 2.9% during biopsy in N2O and 50% O2 groups, respectively (NS). Pre-procedural anxiety (median NRS 3.5 in both groups), measured in the outpatient clinic just prior to procedure, correlated with pain intensity during bone marrow aspiration (P = 0.045). There were no significant differences between side effects. During the BMAB four patients (3 in N2O group, 1 in 50% O2 group) reported dizziness and one patient in the N2O group reported nausea. Gas inhalation did not affect the cognitive function of the participants. In both groups the majority (>80%) of the patients was satisfied with the inhalation technique. During the 24 h interview, most of the participants were pain free and they did not report any serious adverse effects. Conclusions In spite of similar moderate to strong procedural pain in both groups and no benefit of N2O, most patients were satisfied with the inhalational techniques. We assume that the bedside presence of an anaesthesiologist and the distraction caused by the inhalational arrangements introduced positive context-sensitive therapeutic effect independent of the gas used. Pre-procedural anxiety predicted pain associated with bone marrow aspiration. Implications Inhaled 50% nitrous oxide was not an effective analgesic during bone marrow examination in our unselected outpatient population. Further studies should concentrate on its use with patients predicted to be at increased risk of suffering intense pain during the procedure, such as very anxious patients or those who have a painful history of previous bone marrow examinations.

Warmed and buffered lidocaine for pain relief during bone marrow aspiration and biopsy. A randomized and controlled trial

Background and purpose Local infiltration anaesthesia is frequently painful due to low pH of the used anaesthetics, such as lidocaine. Usually pH of the solution is near 4.0, which causes tissue irritation and excitation of the pain mediating nerve endings. Warming and buffering the local anaesthetic solution have been shown to reduce the patient's experience of pain and unpleasantness during infiltration. Buffering reduces the dissociation of the local anaesthetic molecule and may enhance the anaesthetic's entrance into nerve cells. In this randomized placebo-controlled trial warmed and buffered lidocaine with adrenaline was compared to room temperature unbuffered lidocaine with adrenaline infiltrated before bone marrow aspiration and/or biopsy (BMAB). The aim was to find out to what extent warming and buffering would diminish pain during infiltration and whether this would be reflected in less pain also during subsequent steps of the BMAB procedure. Methods One hundred patients scheduled to undergo BMAB were interviewed regarding subjective experiences from previous medical procedures, current chronic and temporary medications, and their present state of anxiety before the BMAB procedure. They received local anaesthetic infiltration of lidocaine prior to BMAB. The solution used was either warmed lidocaine 20 mg/ml with adrenaline buffered with sodium bicarbonate 75 mg/ml (warmed and buffered group, 50 patients, pH approximately 7.3, 32°C) or unbuffered lidocaine 20 mg/ml with adrenaline mixed with NaCl 0.9% solution (control group, 50 patients, pH approximately 3.7, room temperature). The lidocaine concentration was similar in both groups. The bone marrow sampling needle was inserted 2 min after local anaesthetic infiltration. The grade of preprocedural anxiety, and pain sensations during the BMAB, both rated on NRS (numeral rating scale, 0-10) were compared between the groups. Results In comparison with the use of an unbuffered solution at room temperature warmed and buffered lidocaine with adrenaline caused less pain during infiltration (median NRS 4.0 vs. 2.0, P < 0.002) but it did not make performing the other phases of BMAB any less painful. As expected, painful experiences from previous medical, other than BMAB, or dental procedures and anxiety were associated with local anaesthetic infiltration pain during BMAB. Patients' own pain or anxiolytic medication did not lessen pain during BMAB. Conclusions By warming and buffering the lidocaine solution containing adrenaline it is possible to make the pain during infiltration less intense. Unfortunately, such benefit was not detected during the following steps of BMAB, initiated 2 min later. Preprocedural anxiety made procedural pain more intense including that of the local anaesthetic infiltration. Implications Warming and buffering the local anaesthetic prior to its administration is an effective and simple way of diminishing pain during infiltration. This benefit seems to be underutilized in the BMAB procedure. However, warming and buffering are not sufficient enough to diminish pain during bone marrow sampling and thus additional pain alleviating methods should be used, particularly in patients showing preprocedural anxiety.