Local Anesthesia With General Anesthesia for Pediatric Bone Marrow Procedures

Abstract

Background: Pediatric patients with cancer undergo repeated painful procedures, including bone marrow aspirations and biopsies (BMABs). Optimal management of procedure-related pain can reduce discomfort, anxiety, and distress.

Methods: Children with neuroblastoma were randomly assigned to 1 of 2 arms on a prospective, single-blind, crossover trial conducted at Memorial Sloan Kettering Cancer Center from October 2016 to January 2018 (www.clinicaltrials.gov, identifier NCT02924324). Participants underwent 2 sequential BMABs: one with general anesthesia (GA) alone, the other with GA plus local anesthesia (LA) (GA + LA). The objective was to assess procedure-related pain and its interference with quality of life (QoL) with GA versus GA + LA. Primary outcome was percentage of participants requiring postprocedural opioids. Secondary outcomes were total opioid and nonopioid analgesics, pain scores, time to first analgesic, QoL, and toxicity. Management of postprocedural pain was standardized.

Results: Of 56 participants randomly assigned (3-16.5 years old), 46 completed both procedures. There was no significant difference in percentage of participants requiring opioids with GA versus GA + LA (24% vs 20%, P = .5). Pain scores in the recovery room were significantly lower for GA + LA versus GA (median [IQR]: 0 [0-2] vs 2 [0-4], P = .002). There were no statistically significant differences in total opioid or nonopioid analgesic, 6- and 24-hour pain scores, median time to first analgesic, or pain interference. No adverse events occurred.

Conclusions: LA was associated with significant improvement in pain scores in the immediate recovery period. LA did not reduce postprocedural opioid use, nor did it improve QoL for patients undergoing BMAB with GA.

FIGURE 1

CONSORT diagram of participant flow. ^a Disease progression and painful procedures prior to BMAB. ^b Deviation from postprocedure algorithm, replacement procedure not scheduled before study closure (n = 1); patient death before replacement procedure (n = 1). CONSORT, consolidated standards of reporting trials.

FIGURE 2

Postprocedure pain scores with or without LA. Each diamond (♦) represents an individual pain score (GA [n = 50], GA + LA [n = 51]). Red lines represent median pain scores. Distribution of RR pain scores was significantly lower for GA + LA than GA (median [IQR]: 0 [0–2] vs 2 [0–4], P = .002). No difference was observed 6 or 24 hours postprocedure. ^a Indicates a statistically significant difference between pain score distributions. A, RR. B, 6 hours postprocedure. C, 24 hours postprocedure.

FIGURE 3

Pain interference on QoL within 24 hours of BMAB. Pain interference with sleep, physical activity (“run”), social recovery (“have fun”), and emotional recovery (“get along with others”) on a Likert scale (1 = strongly disagree [that pain interfered], 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = strongly agree). Major interference is a score of 4 or 5.