Inhaled nitrous oxide (Entonox) as a short acting sedative during bone marrow examination

Intraosseous Treatment of Bone Marrow Lesions in the Knee: Surgical Technique

Intraosseous injections of bone marrow aspirate concentrate have shown promise in the treatment of bone marrow lesions (BMLs) in the knee. With the wide-awake limited anesthesia no tourniquet (WALANT) technique, intraosseous injections can be performed with the patient under local anesthesia in the procedure room or operating room setting. This article describes 2 techniques to access the BML of interest. The "decompression route" involves drilling through the nearest cortex, and the "biologic route" involves drilling through healthy bone to promote bleeding and the introduction of healthy biologic tissue to the BML.

Combined Oral Fentanyl Citrate and Midazolam as Premedication for Bone Marrow Aspiration and Biopsy in Patients with Hematological Malignancies: A Randomized, Controlled and Patient-Blinded Clinical Trial

Bone marrow aspiration and biopsy (BMAB) is a painful procedure, and the routinely used local infiltration anesthesia (LIA) with lidocaine is unable to provide pain relief during the most uncomfortable phases. The primary endpoint of the present randomized, patient-blinded trial was to evaluate the efficacy of an opioid and benzodiazepine combination plus LIA (sedoanalgesia) in patients undergoing BMAB for hematological malignancies. The secondary endpoint was the safety of the procedure in an outpatient setting. Ancillary assessments were anticipatory anxiety related to pain recall in the event of re-biopsy, and adequacy of bone tissue harvested. Patients were randomly assigned to one of 2 arms to receive either sedoanalgesic placebo plus LIA (standard group) or oral fentanyl citrate 200 μg plus oral midazolam 5 mg plus LIA (combo group) during BMAB. Pre-procedural anxiety and procedural pain were assessed according to the Numerical Rating Scale (NRS: 0–10), dividing the time of the procedure into five intervals (T0, T1, T2a, T2b and T3) and evaluating the degree of discomfort at each time (T) in both groups. One hundred and sixteen patients were eligible for the study. At T2b (time of biopsy) and T3 (time after biopsy), a significantly lower perception of pain was registered in the combo group. Moreover, there were no significant sedoanalgesia-related side-effects. Finally, histological specimens were higher in quality in the combo group. Sedoanalgesia was highly effective in reducing pain during biopsy, diminished anticipatory anxiety in patients undergoing re-biopsy and led to fewer non-diagnostic specimens being harvested.

A Multivariate Analysis of Pain and Distress in Adults Undergoing BMAB

Clinicians routinely perform bone marrow aspiration and biopsy (BMAB) to diagnose cancer and evaluate disease status; however, few studies address pain and distress with BMAB. A prospective descriptive-correlational design examined patients' (N = 152) ratings of pain intensity (numeric rating scale, 0-10) and distress (distress thermometer) at baseline and 5 min and 1 hr postprocedure. Data were analyzed using descriptive statistics, chi-square, and linear regression models. Mean postprocedure pain intensity at 5 min was moderate, 5.56 (SD = 3.03), and opioid use was associated with decreased pain at 1 hr (p < .001). Preprocedure administration of anxiolytics had no significant effect on distress reduction (p = .88). Being female, first-time biopsy, and increased preprocedure pain were significant predictors of postprocedure distress (p < .001). Treating anxiety alone may not be sufficient to lessen pain and distress. Individualized plans of care should be based on patient risk and response to procedure.

Midazolam in conjunction with local anaesthesia is superior to Entonox in providing pain relief during bone marrow aspirate and trephine biopsy

AIM

To compare intravenous titrated midazolam 5-10 mg and inhaled Entonox in addition to local anaesthesia in order to identify which agent provides optimum pain relief.

METHODS

Randomised, controlled trial. 49 patients were recruited, of which 46 were evaluable. 24 and 22 patients were recruited into the Entonox and midazolam arms, respectively. Patient experiences as well as staff observations were recorded with questionnaires after recovery from the procedure and 24 hours later.

RESULTS

45% and 59% of the patients in the midazolam arm could recollect the procedure after 15 minutes and 24 hours, respectively, compared to 96% and 88% who received Entonox. Midazolam provided a more comfortable experience (p<0.01) and improved pain relief (p = 0.01) compared to Entonox immediately after the procedure; this further improved when recalled 24 hours later. Nausea, dizziness and hallucinations were observed with both treatments, but dizziness was significantly more frequent with Entonox (p = 0.048). Clinically relevant respiratory depression (O(2) saturation <90%) occurred in 19% of patients in the midazolam arm; sedation was reversed with flumazenil.

CONCLUSION

Midazolam in conjunction with local anaesthesia provides rapid and reversible sedation as well as effective pain relief during bone marrow biopsy, and is superior to Entonox; however, care must be taken to monitor respiratory function.

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.

Pain related to cancer treatments and diagnostic procedures: a no man's land?

BACKGROUND

While guidelines are available for the management of cancer-related pain, little attention is given to the assessment and treatment of pain caused by treatments and diagnostic procedures in cancer patients.

METHODS

We evaluated the literature on pain related to cancer treatment and diagnostic procedures within a critical analysis.

RESULTS

The data available are sparse, suggesting that little attention has been directed at this important aspect of oncology. This points to potentially suboptimal patient management.

CONCLUSIONS

Appropriate studies are necessary in order to understand the incidence and appropriate management of pain, both during and/or after oncological treatments and diagnostic procedures. At the same time, Health Care Professionals should have heightened awareness of the causes and treatment of pain with the aim of anticipating and managing pain most appropriately for each individual patient. This is clearly an important component of holistic patient care before, during, and after oncological treatment.

Comparison between 1-needle technique versus 2-needle technique for bone marrow aspiration and biopsy procedures

CONTEXT

Bone marrow examination is essential for diagnosis and staging of hematologic disorders. Traditionally, the bone marrow biopsy and aspirate are obtained with 2 needles at 2 separate sites. This approach is associated with significant discomfort, procedural time, and occasionally, morbidity. Although previous observations had suggested that a single-needle technique at one site is a simpler and less-painful procedure, there had been concern that the 1-needle technique may yield a suboptimal biopsy for diagnosis.

OBJECTIVE

To conduct a systematic comparison of multiple parameters of bone marrow biopsy specimens obtained by the traditional 2-needle technique versus the 1-needle technique for bone marrow collection.

DESIGN

We retrospectively evaluated 20 biopsy specimens obtained by each of the 2 mentioned techniques by comparing the morphologic quality of the biopsy, biopsy length, and biopsy cellularity.

RESULTS

We found that the 1-needle technique yielded an adequate biopsy for diagnosis. The measured parameters of the samples obtained by the 1-needle versus 2-needle techniques were similar.

CONCLUSION

This study suggests that the 1-needle technique may be preferred for bone marrow aspirate and biopsy.

Applications of nitrous oxide for procedural sedation in the pediatric population

OBJECTIVE

The objective of this review was to provide a general descriptive account of the physical properties, end-organ effects, therapeutic applications, and delivery techniques of nitrous oxide (N2O) as used in the arena of procedural sedation.

DATA SOURCE

A computerized bibliographic search regarding the applications of nitrous for provision of sedation and analgesia during procedures with an emphasis on the pediatric population was performed.

RESULTS

The end-organ effects of N2O have been well described in the operating room setting. Aside from its effects on the central nervous system of sedation and analgesia, N2O may alter intracerebral dynamics and alter cerebral blood flow and intracranial pressure especially in patients with altered intracranial compliance. Effects on ventilation include a dose-related depression of ventilatory function and control of upper airway patency. These effects are generally limited in the absence of comorbid diseases and potentiated by other sedative and analgesic agents. The more clinically significant respiratory effect of N2O on ventilatory function is a dose-dependent depression of the ventilatory response to hypoxemia. Hemodynamic effects include a mild direct depressant effect on myocardial function, which in the absence of comorbid cardiac disease is generally compensated by stimulation of the sympathetic nervous system. Nitrous oxide may potentially aggravate pulmonary hypertension. Additional physiologic effects on neurologic and hematologic function may result in inactivation of the enzyme, methionine synthetase. Recent concern has also been raised regarding the potential effects of N2O on immune function and its relationship to perioperative surgical site infections. Given differences in the solubility, N2O will diffuse into and significantly expand gas-filled cavities. Chronic exposure of health care works to N2O is also a concern. Although there are limited data in the literature to clearly substantiate concerns regarding the reproductive toxicity of occupational exposure to N2O, appropriate scavenging and use of other techniques are mandatory. Nitrous oxide has been shown to be effective for a variety of minor surgical procedures such as venipuncture, intravenous cannula placement, lumbar puncture, bone marrow aspiration, laceration repair, dental care, and minor dermatologic procedures. It is generally as effective as midazolam, with several studies demonstrating it to be more effective. However, its utility is not as great in severely painful procedures such as fracture reduction. Demonstrated advantages to parenteral sedation include a more rapid onset and a shorter recovery time with the majority of patients preferring it to over other agents or agreeing to its use for subsequent procedures. The literature also suggests increased success rates with simple procedures such as intravenous cannula placement when compared with placebo. In general, life-threatening adverse events have not been reported. Most common adverse effects include dysphoria and vomiting. For more painful procedures, combination with another agent may be used, and in all cases, topical or infiltrative local anesthesia is recommended.

CONCLUSIONS

In general, N2O is a useful adjunct for procedural sedation. Given the variety of procedures performed in the pediatric patient, ongoing research is required to identify the most appropriate and effective use of this agent. This may be particularly relevant when evaluating its use for procedures associated with significant pain. In these scenarios, the combination of N2O with other agents needs to be evaluated. Given the potential for adverse effects, strict adherence to published guidelines regarding procedural sedation and monitoring is suggested.

Strategies of pain reduction during the bone marrow biopsy

Examination of the bone marrow biopsy and aspirate allows diagnosis and assessment of various conditions such as primary hematologic and metastatic neoplasms, as well as nonmalignant disorders. Despite being performed for many years, according to many different protocols, the procedure still remains painful for the majority of patients. This paper summarizes the current knowledge of pain reduction measures in the bone marrow biopsy and aspiration.

Anxiety and pain during bone marrow aspiration and biopsy

Background

Previously we found that pre-procedural nervousness and tension (translated into English as “anxiety”), assessed on a non-validated five-point scale, correlated with pain intensity of the various stages of bone marrow aspiration and biopsy (BMAB). The fewer the previous BMAB procedures the stronger the pain from a repeated procedure. The primary purpose of the present observational study is to evaluate the state of anxiety just before BMAB and to find out whether it affects the pain experiences during the various stages of the BMAB procedure. We also examined whether first-timers differ from patients with previous BMAB experience in the degree of anxiety and intensity of BMAB procedural pain.

Methods

A total of 166 adult outpatients undergoing the BMAB from the Helsinki University Hospital were enrolled, 48 of them being first-timers. The level of anxiety was measured with State-Trait Anxiety Inventory (STAI) and the pain experiences associated with the various stages of the procedure were evaluated on the NRS-scale (Numeral Rating Scale 0-10) and using the Finnish pain vocabulary. BMAB was planned to be performed under lidocaine infiltration anaesthesia but, on request, patients were allowed to receive premedication with diazepam orally or alfentanil i.m. If, in spite of supplemental local anaesthetic the patient still felt pain from the sampling needle tip, i.m. alfentanil was administered.

Results

There was a clear association between anxiety and pain during all stages of the procedure, except during biopsy. The NRS scores varied from 0 to 10 in all the various stages of BMAB. The first-timers did not differ from the more experienced patients with regard to pain experiences; only the pain felt during the local anaesthetic infiltration was milder (P = 0.007) in first-timers than in the others. Procedural pain in those who were given analgesic or sedative premedication was similar (P < 0.05) to that in the non-premedicated patients. The words characterizing the pain of the various stages belonged to a major extent (76-90%) to the sensory class of words.

Conclusion

Pre-procedural anxiety had a major impact on the pain ratings. The first-timers and patients with previous experience of BMAB had a similar degree of pre-procedural anxiety, as well as of the intensity of procedural pain, except that infiltration of local anaesthetic was less painful in the first-timers.

Implications

Identification of anxious (fearful) patients prior to BMAB, and premedicating them individually may improve satisfaction in both patient and caregiver.

Pain and anxiety during bone marrow aspiration/biopsy: Comparison of ratings among patients versus health-care professionals

PURPOSE

To assess pain and anxiety during bone marrow aspiration/biopsy (BMA) among patients versus health-care professionals (HCPs).

METHOD

235 adult hematologic patients undergoing BMA were included. BMA was performed by 16 physicians aided by nine registered nurses (RNs). Questionnaires were used to obtain patients and HCPs ratings of patients' pain and anxiety during BMA. Patterns of ratings for pain and anxiety among patients HCPs were estimated with proportions of agreement P(A), Cohen's kappa coefficient (κ), and single-measure intra-class correlation (ICC). We also explored if associations of ratings were influenced by age, sex, type and duration of BMA.

RESULTS

The P(A) for occurrence of rated pain during BMA was 73% between patients and RNs, and 70% between patients and physicians, the corresponding κ was graded as fair (0.37 and 0.33). Agreement between patients and HCPs regarding intensity of pain was moderate (ICC=0.44 and 0.42). Severe pain (VAS>54) was identified by RNs and physicians in 34% and 35% of cases, respectively. Anxiety about BMA outcome and needle insertion was underestimated by HCPs. P(A) between patients and RNs and patients and physicians regarding anxiety ranged from 53% to 59%. The corresponding κ was slight to fair (0.10-0.21). ICC showed poor agreement between patients and HCPs regarding intensity of anxiety (0.13-0.36).

CONCLUSIONS

We found a better congruence between patients and HCPs in pain ratings than in anxiety ratings, where the agreement was low. RNs and physicians underestimated severe pain as well as anxiety about BMA outcome and needle insertion.

A review of pain management interventions in bone marrow biopsy

AIMS

This review was designed to evaluate the evidence relating to pain management interventions for patients having bone marrow biopsy.

BACKGROUND

Bone marrow biopsy is an invasive procedure causing considerable pain and anxiety for adult patients, yet there are no guidelines to inform effective nursing care. Although this is an under-researched area, a range of pain interventions have been tested on this patient group, but this evidence has not been synthesised.

DESIGN

Structured evidence review.

METHOD

The Cochrane Library and databases Medline, Scopus and Cinahl were searched for original research reports. Reference lists of retrieved papers were hand-searched and researchers in the field were contacted. Retrieved papers were analysed using the CASP framework. A narrative data synthesis considered the strengths and limitations of included studies and findings were collated and interpreted.

RESULTS

No systematic reviews of evidence have been undertaken and the search strategy identified twelve research studies eligible for inclusion in the review. Hand-searching did not identify any additional studies, and emails to researchers confirmed this is an under-researched field. Analysis shows three main interventions, intravenous midazolam, premedication with analgesia and/or anxiolysis and the use of Entonox™ are used to manage the pain experience for patients undergoing a bone marrow biopsy.

CONCLUSIONS

Evidence is inconclusive and provides little guidance for practice. There is an urgent need for research into effective interventions for pain management in bone marrow biopsy and in understanding the patient experience.

RELEVANCE TO CLINICAL PRACTICE

Nurses have a central role to play in the assessment and management of the pain and anxiety associated with bone marrow biopsy. There is little evidence to guide this aspect of care, but it is important that nurses involved with bone marrow biopsy are aware of the best evidence to facilitate the most effective management of their patients' pain.

Procedure-related pain among adult patients with hematologic malignancies

BACKGROUND

Cancer patients undergo numerous invasive diagnostic procedures. However, there are only sparse data on the characteristics and determinants for procedure-related pain among adult cancer patients.

METHODS

In this prospective study, we evaluated the characteristics and determinants of procedure-related pain in 235 consecutive hematologic patients (M/F:126/109; median age 62 years, range 20-89 years) undergoing a bone marrow aspiration/biopsy (BMA) under local anesthesia. Questionnaires were used to assess patients before-, 10 min and 1-7 days post BMA. Using logistic regression models, we calculated odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

165/235 (70%) patients reported pain during BMA; 92 (56%), 53 (32%) and 5 (3%) of these indicated moderate [visual analogue scale (VAS)>or=30 mm], severe (VAS>54 mm) and worst possible pain (VAS=100 mm), respectively. On multivariate analyses, pre-existing pain (OR=2.60 95% CI 1.26-5.36), anxiety about the diagnostic outcome of BMA (OR=3.17 95% CI 1.54-6.52), anxiety about needle-insertion (OR=2.49 95% CI 1.22-5.10) and low employment status (sick-leave/unemployed) (OR=3.14 95% CI 1.31-7.55) were independently associated with an increased risk of pain during BMA. At follow-up 10 min after BMA, 40/235 (17%) patients reported pain. At 1, 3, 6 and 7 days post BMA, pain was present in 137 (64%), 90 (42%), 43 (20%) and 25 (12%) patients, respectively.

CONCLUSIONS

We found that 3/4 of hematologic patients who underwent BMA reported procedural pain; one third of these patients indicated severe pain. Pre-existing pain, anxiety about the diagnostic outcome of BMA or needle-insertion, and low employment status were independent risk factors.