Attitudes of children with leukemia toward repeated deep sedations with propofol

Procedural sedation is generally recommended for children requiring repeated painful diagnostic or therapeutic procedures. A child with leukemia undergoes an average of 20 procedures such as lumbar puncture and bone marrow aspiration through the course of illness. No data are currently available about the psychological impact of repeated sedations on children. The objective of this study was to evaluate the attitudes of patients with leukemia toward repeated deep sedations using propofol. A questionnaire addressing sedation-related distress was given to 30 children with leukemia. Procedure-related distress was evaluated using the Amended Observational Scale of Behavioural Distress. Another questionnaire concerning the same issues was given to an historical group of 39 children who had undergone painful procedures without sedation in previous years. Fear and distress were significantly reduced in the sedation group compared with the historical one. Fear of sedation was reported by 17% of children of this group. Distressed behavior was observed in 27%. In conclusion, sedation-related distress was observed in a subgroup of patients; in these cases, specific strategies could be considered to reduce sedation-related distress.

Propofol or propofol--alfentanil anesthesia for painful procedures in the pediatric oncology ward

BACKGROUND

For children with cancer receiving curative treatment, the pain of diagnostic and therapeutic procedures is often worse than that of the disease itself. In order to evaluate if light propofol anesthesia in the pediatric oncology ward (POW) could improve the management of procedure pain and anxiety, a questionnaire was developed.

METHODS

After prolonged EMLA application, 65 propofol anesthetics were performed successfully in 28 children during lumbar puncture and/or bone marrow aspiration in the POW, with short recovery time and without major adverse events. The questionnaire was mailed to the parents of the 28 children who were included in the survey.

RESULTS

The return of questionnaire compliance was 89% (25 of 28), 12 females and 13 males, mean age was 7 years (range 2-16). Among those who replied, the diagnoses were acute lymphatic leukemia in 21, lymphoma in two and tumor in the other two. In the questionnaire, all parents/patients reported advantages with anesthesia in the POW compared with the operating room. In the list of stated advantages, 88% marked 'familiar nurses and doctors', 84% 'familiar environment', 80% 'closer to own room', 68% 'the child more calm', 72% 'shorter waiting-time', 60% 'faster recovery', 44% 'shorter fasting-time' and 44% 'parents more calm', as benefits. For future procedures requiring anesthesia to reduce pain, discomfort and/or anxiety, 92% of the parents/patients preferred anesthesia in the POW.

CONCLUSIONS

If anesthesia is chosen for invasive procedures, this study suggest that propofol anesthesia in the POW is preferred by parents and children.

Painful procedures in pediatric cancer. A comparison of interventions

Different interventions (i.e., cognitive-behavioral, pharmacological) and their combination were examined and compared to assist pediatric patients with cancer to manage distress during painful procedures. Findings revealed that cognitive protocols are effective in relieving procedural distress for a significant number of children. Pharmacological therapies were found to be relatively safe and effective when carefully administered and monitored by medical personnel. Data from combined cognitive therapies and pharmacological interventions, particularly those more recent pharmacological interventions, reveal generally mixed results, with both types of interventions yielding distinct benefits and disadvantages. Recommendations are made for future studies that match interventions to specific characteristics of the children for whom they are intended, as well as additional studies that combine pharmacological approaches together with cognitive techniques.

Prospective evaluation of propofol anesthesia in the pediatric intensive care unit for elective oncology procedures in ambulatory and hospitalized children

OBJECTIVES

To evaluate our experience with propofol anesthesia delivered by pediatric intensivists in the pediatric intensive care unit (PICU) to facilitate elective oncology procedures in children performed by pediatric oncologists.

METHODS

Elective oncology procedures performed with propofol anesthesia in our multidisciplinary, university-affiliated PICU were prospectively evaluated over a 7-month period. Ambulatory and hospitalized children were prescheduled for their procedure, underwent a medical evaluation, and met fasting requirements before the start of anesthesia. Continuous cardiorespiratory and neurologic monitoring was performed by a pediatric intensivist and a PICU nurse, while the procedure was performed by a pediatric oncologist. Propofol was delivered in intermittent boluses to achieve the desired level of anesthesia. Information studied included patient demographics, procedures performed, induction and total doses of propofol used, the duration of the different phases of the patient's PICU stay, the occurrence of side effects, the need for therapeutic interventions, and the incidence of recall of the procedure.

RESULTS

Fifty procedures in 28 children (mean age: 7.5 +/- 4.3 years) were evaluated. Sixty-one percent of patients had established diagnoses. Fifty-four percent of procedures were lumbar puncture with intrathecal chemotherapy administration and 26% of procedures were bone marrow aspirations with biopsy. Induction propofol doses were 2. 0 +/-.8 mg/kg for ambulatory and hospitalized patients, while total propofol doses were 6.6 +/- 2.3 mg/kg and 7.9 +/- 2.4 mg/kg for ambulatory and hospitalized patients, respectively. Induction time was 1.5 +/-.7 minutes, recovery time was 23.4 +/- 11.5 minutes, and total PICU time was 88.8 +/- 27.7 minutes. Transient decreases in systolic blood pressure less than the fifth percentile for age occurred in 64% of procedures, with a mean decrease of 25% +/- 10%. Intravenous fluids were administered in 31% of these cases. Hypotension was more common in ambulatory patients but was not predicted by propofol dose, anesthesia time, or age. Partial airway obstruction was noted in 12% of procedures while apnea requiring bag-valve-mask ventilation occurred in 2% of procedures. Neither was associated with age, propofol dose, or the duration of anesthesia. All procedures were successfully completed and there were no incidences of recall of the procedure.

CONCLUSIONS

Propofol anesthesia is effective in achieving patient comfort and amnesia, while optimizing conditions for elective oncology procedures in children. Although transient hypotension and respiratory depression may occur, propofol anesthesia seems to be safe to use for these procedures in the PICU setting. Recovery from anesthesia was rapid and total stay was brief. Under the proper conditions, propofol anesthesia delivered by pediatric intensivists in the PICU is a reasonable option available to facilitate invasive oncology procedures in children.

Parent coping and child distress behaviors during invasive procedures for childhood cancer

This study examines what parents identified as their primary stressor before their child's invasive procedure, what coping strategies were used to manage the stress, what level of distress their children experienced during each phase of the procedure, and whether parents' coping modes were associated with their children's distress. Twenty children with cancer from 3 to 11 years of age and the parent present during the procedure participated in the study. Parents' primary stressors were identified as uncertainty about parent role and anticipating the child's distress during the procedure. Although parents used both emotion-focused and problem-focused strategies for coping with their primary stressors, they primarily relied on emotion-focused strategies. Children experienced the most behavioral distress during the procedural phase, and girls exhibited more distress than boys. The parents' coping modes were not associated with their children's distress, but children of parents whose primary stressor was uncertainty about parent role had higher distress than children of parents whose primary stressor was anticipating the child's distress. The findings related to parents' stressors, their coping strategies, and their children's distress were consistent with previous research. Directions for future research and suggestions for dealing with invasive procedures for childhood cancer are described.

Pharmacologic and psychologic interventions for procedural pain

OBJECTIVE

This study evaluated a combined pharmacologic and psychologic intervention (combined intervention, CI) relative to a pharmacologic-only (PO) intervention in reducing child distress during invasive procedures in childhood leukemia. Predictors of child distress included age, group (CI, PO), and procedural variables (medications and doses, technical difficulty, number of needles required).

METHODOLOGY

This was a randomized, controlled prospective study that compared the PO (n = 45) and CI arms (n = 47), at 1, 6, and >12 months after diagnosis. A cross-sectional control group consisted of parents of 70 patients in first remission before the prospective study. Parent questionnaires, staff and parent ratings, and data on medications administered, technical difficulty of the procedure, and needle insertions were obtained for each procedure. This article reports on the final data point for the project (>12 months).

RESULTS

Mothers and nurses reported lower levels of child distress in the CI than the PO group. The CI and PO groups showed lower levels of child and parent distress than the cross-sectional control group. Distress decreased throughout the time, and child age was inversely related to distress (younger children had more distress) regardless of group. Child distress was associated with staff perceptions of the technical difficulty of the procedure and with child age, but not with medications administered.

CONCLUSIONS

The data showed that pharmacologic and psychologic interventions for procedural distress were effective in reducing child and parent distress and support integration of the two approaches. Younger children experienced more distress and warranted additional consideration. Staff perceptions of the technical difficulty of procedures were complex and potentially helpful in designing intervention protocols.

The Perception of Procedures Questionnaire: psychometric properties of a brief parent report measure of procedural distress

Reported the reliability and validity of the Perception of Procedures Questionnaire (PPQ), a 19-item parent-report measure developed to assess child and parent distress related to lumbar punctures and bone marrow aspirates in the diagnosis and treatment of childhood cancer. PPQ data from 140 mothers and 96 fathers of children and adolescents with leukemia in a first remission were analyzed separately. Factor analyses yielded five factors for mothers and fathers: Parent Satisfaction; Child Distress: During; Child Distress: Before; Parent Distress; and Parent Involvement. Internal consistency (Cronbach's alpha) was high for the total score and the five factor scores as were interrater reliabilities between mothers and fathers. Validity was determined using the Parenting Stress Index-Short Form, the Pediatric Oncology Quality of Life Scale, and parent and nurse ratings during procedures. Factors 2 and 3, assessing child distress, show strong associations with the validation measures and support the distinction between distress before and during procedures. This developing scale is recommended for use in the assessment and evaluation of child and parent procedure-related distress in pediatric oncology.

Physician and parent behavior during invasive pediatric cancer procedures: relationships to child behavioral distress

Observed 51 children with cancer, their parents, and their physicians during routine bone marrow aspirations and lumbar punctures. Child distress was measured via the Observational Scale of Behavioral Distress (OSBD); adult behaviors were coded via the Child Adult Medical Procedure Interaction Scale (CAMPIS). In general, physicians were less verbally interactive than parents both before and during the procedure. As expected, several parent behaviors were positively related to child distress. However, physician behaviors were uniformly negatively related to child distress. Findings are discussed in terms of the physician-patient relationship and the possible role of physicians as change agents in reducing child distress during invasive procedures.

Parenting and child distress during cancer procedures: a multidimensional assessment

We examined the relationship between children's distress during invasive cancer procedures and parent anxiety, parent disciplinary attitudes, and parent behavior during the medical procedure. Sixty-six children with cancer and their parents were evaluated during a routine bone marrow aspiration. Significantly higher levels of distress were obtained for young (under age 8) versus older children. Patterns of relationships with parent variables also varied by age. Anxious parents of young children reported relying on less effective discipline strategies. They also were less reassuring prior to to medical procedure. Age differences in the correlations between child distress and parenting are discussed in terms of developmental differences in children's dependence on caregivers for emotional regulation and control. Implications for clinical distress reduction programs are also discussed.

Primary and secondary control among children undergoing medical procedures: adjustment as a function of coping style

The literature suggests that optimal adjustment to relatively uncontrollable stressors may require adjusting oneself to the stressors rather than trying to alter them. This possibility was explored, for low-controllability stressors (e.g., painful medical procedures) associated with leukemia. Children's reports of coping strategies and goals were classified as primary control coping (attempts to alter objective conditions), secondary control coping (attempts to adjust oneself to objective conditions), or relinquished control (no attempt to cope). Secondary control coping was positively associated with (a) general behavioral adjustment assessed by the Child Behavior Checklist and (b) illness-specific adjustment assessed by children's own distress ratings and by behavioral observations during painful procedures. All significant group differences showed better adjustment among secondary control children than among the primary or relinquished groups.

Differences between high and low coping children and between parent and staff behaviors during painful medical procedures

Coded behaviors of pediatric oncology patients undergoing bone marrow aspirations and lumbar punctures, parents, and medical staff using the Child-Adult Medical Procedure Interaction Scale. Children were grouped into high and low coping groups for three analyses. Results indicated that adults with the high coping children engaged in more coping-promoting behaviors than adults with the low coping children. Further, high coping children were more likely to respond with coping to coping-promoting prompts. However, both groups of children were more likely to respond by coping following coping-promoting antecedents than following distress-promoting or adult neutral antecedents. Both groups were more likely to respond with distress following distress-promoting antecedents. When interacting with children, staff engaged in a higher proportions of giving control to the child and apologies than did parents. Also, children were more likely to display coping than distress following staff's and parents' nonprocedural talk (distraction).

An investigation of cognitive-behavior therapy combined with oral valium for children undergoing painful medical procedures

In previous research, a cognitive-behavioral therapy (CBT) package was found to be effective in reducing children's distress associated with the painful medical procedures of bone marrow aspirations (BMAs) and lumbar punctures (LPs). Orally administered Valium demonstrated less effectiveness but was helpful in reducing behavioral distress before the medical procedure. In the present study, we investigated whether the combination of oral Valium and CBT would result in increased efficacy of the CBT. Eighty-three subjects were randomly assigned to receive either CBT or CBT plus Valium while undergoing either a BMA or an LP. Dependent variables included observed behavioral distress, self-reported fear and pain, and pulse rate. Results failed to support the value of such a combination but did provide additional evidence in regard to the effectiveness of the CBT. The need for more potent medical interventions for some children is discussed.