The Road Leading to Children’s Hem/Onc/BMT Propofol Clinic

from Caring For Our Future, Spring 2004

By Ellen Servetar, BSN, RN, Clinical Director, Hem/Onc/BMT Clinic

For many people, the words pediatric oncology create a distinct image of children, possibly in pain, struggling for survival. It was not until the 1970s that chemotherapy was first recognized as a modality to improve survivorship. By the early 1980s, approximately 50 percent of children with cancer were being cured, and today that number is well over 75 percent. While cure has always been the driving force in therapy at The Children's Hospital Hematology/Oncology/Bone Marrow Transplant (Hem/Onc/BMT) clinic, it has been delivered hand-in-hand with the recognition of the importance of quality of life. Today, diminishing long-term side effects has become yet another part of our vision.

Pain and the fear of pain are often in the forefront of our patientsí minds. Prior to clinic visits or hospitalizations, some patients develop anticipatory nausea and vomiting, and many may not sleep as worries of painful procedures haunt their dreams. Patients with leukemia, the most common pediatric oncology diagnosis, face numerous injections or pokes during their illnesses. Typically, these patients have ports (internally placed central venous catheters), that are accessed with a special needle. In addition to countless injections through their ports, these children sometimes require intramuscular and subcutaneous injections for therapy, and over the course of their two- to three-year treatments, they may also receive numerous bone marrow aspirations and lumbar punctures. Although patients with leukemia receive the majority of the bone marrow aspirations and lumbar punctures, children who are being initially evaluated for hematology problems, brain tumors, solid tumors and bone marrow transplants may also require these invasive procedures.

Early Comfort Measures

Hem/Onc/BMT clinic staff always has been aware of the need to prepare patients for painful procedures. The primary nurse, physician or advanced practice nurse and the family work together to develop a plan of care. In the past, most patients were supported through their procedures with non-pharmacologic measures such as play therapy and distraction techniques. Parents were offered the opportunity to be in the room with their child, and many chose to do so. Historically, patients requiring bilateral bone marrow aspirations and those who could not tolerate the pain of the procedures while awake were scheduled in the operating room with general anesthesia for their procedures.

Over the years, as reports on the use and safety of sedatives and analgesics in children became more readily available, these medications were added to the care plans. Initially, various oral sedatives such as chloral hydrate, diazepam (Valium), lorazepam (Ativan), and later midazolam hydrochloride (Versed) were used during painful procedures with varying degrees of success. Later, intravenous analgesics such as meperidine hydrochloride (Demerol) and morphine were added. The effective combination of sedatives and analgesics led to the Hem/Onc/BMT clinicís current conscious sedation plan of Versed and Fentanyl. EMLA, a topical anesthetic cream, was introduced to reduce the pain of the initial injection.

A New Problem and Solution

Despite great advances in anxiety and pain control, it became clear through discussions with our increasing numbers of cancer survivors that the memory of the pain and trauma of their procedures was still difficult for them to deal with. For many, it had created severe needle phobia and impeded their ability to return for routine medical care. Fortunately, as we were recognizing the need to provide our patients with different options during their procedures, an anesthetic agent called propofol was becoming more widely used in pediatric patients.

Propofol is a short-acting intravenous anesthetic in the anxiolytic-sedative-hypnotic category. Advantages include a rapid onset of action, deep sedation with total amnesia, and reduction of post-anesthesia nausea/vomiting and agitation. It has a short half-life, allowing for a short recovery time for patients, who often wake with a clear head, ready to eat and drink. Propofol needs to be administered by an anesthesiologist in a controlled setting since it produces respiratory depression; however, the airway can be managed by the anesthesiologist without intubation. Propofolís benefits versus its side effects has made it a safe, effective and popular anesthetic agent.

In the Hem/Onc/BMT clinic, the initial approach toward introducing propofol was to develop a relationship with the day surgery department. A patient checked in and had his or her pre-procedure workups in the Hem/Onc/BMT clinic, and then was brought down to day surgery, where the procedure was performed by the oncologist, with operating room nurses and an anesthesiologist present. Recovery was initiated in the day surgery PACU and then the patient was transferred back to the Hem/Onc/BMT clinic for discharge. This approach marked a positive step toward decreasing memory of procedural pain, but patients began expressing their anxiety about transferring to a different department and staff.

To address this new anxiety, Edythe Albano, MD, Clinical Director of Oncology, met with Geoff Lane, MD , pediatric anesthesiologist, to propose performing procedures with propofol in the Hem/Onc/BMT clinic. The concept was both exciting and intimidating. To create a safe and effective outcome, the details of the procedures were discussed with the Hem/Onc/BMT staff, clinic schedulers, insurance personnel, risk management specialists, pharmacists and the OR staff.

The Propofol Clinic is Born

We decided to start slowly and use our experience as a barometer for what we would be able to provide. We held our first Hem/Onc/BMT propofol clinic in March of 1998. Propofol clinic was scheduled for two half-days a month, with four patients in each clinic. A small team of anesthesiologists and clinic nurses participated in the pilot, along with the patientís primary Hem/Onc/BMT care provider.

The first few months of clinics went well, and within a short period of time we realized there was enough demand to hold the clinics to every week. Now, six years later, the propofol clinic takes place twice a week, on Tuesdays for a half a day (six patients) and on Wednesdays for a full day clinic (12 patients). Patients are scheduled just 30 minutes apart, creating a fast-paced clinic where cooperation and timeliness are imperative. Cooperation and support from the anesthesiologists has been key in helping us determine how to best meet the needs of patients and staff.

As our propofol clinic became more structured, guidelines were developed to help the clinic run smoothly. Families are given explicit NPO guidelines prior to the childís procedure and they are advised to place EMLA on the procedure site(s) one hour before the procedure. EMLA provides enough analgesia to decrease the pain of the initial injections and reduces the need for increased amounts of propofol. Exclusion criteria for the outpatient clinic were developed, so all patients need to be medically stable and weigh less than 90 kg. If a patient has a need for additional infection control precautions, we have the ability to schedule isolation at the end of each session.

Fine-Tuning and Details

As the propofol clinic has expanded, our attention to detail has grown. Working in cooperation with the anesthesia department, we can now allow new patients to fall asleep with an inhalation anesthetic prior to having their port accessed. Once the port is accessed, the propofol can be given and the procedure started. This process gives patients a gentler adaptation to their pokes. The clinic treats patients with many types of illnesses. Patients may undergo bone marrow aspirations or biopsies, lumbar punctures, intramuscular injections, dressing changes and/or skin biopsies. If a patient is in pain prior to the procedure or is having a number of procedures, the anesthesiologist may choose to add nitrous oxide, an inhalation anesthetic, or other medications to the care plan to provide increased pain relief. After the first two months of intensive therapy and numerous procedures, some patients and their families may choose to transition to a simpler course of conscious sedation for the remainder of their treatments.

In 1997, 106 bone marrow and lumbar puncture procedures were performed in The Childrenís Hospital operating rooms using general anesthesia. From March through December of 1998, 116 of the same procedures were performed in the Hem/Onc/BMT clinic using propofol. In 2003, 620 procedures took place in the propofol clinic. This recent number represents more than 80 percent of our patientsí total procedures. Complications during procedures have been minimal and manageable. Families of patients express a high degree of satisfaction with this program, and the staff is very committed to the continuing improvement of patient care.

The biggest fans of the propofol clinic are the patients themselves. One of the first patients to try the clinic was a 4-year-old boy with leukemia. This boy had had several past procedures, and he was consistently worried and anxious despite using conscious sedation during the procedures. His first procedure in the propofol clinic went well and the family went home happy. It was not until his return visit that we were able to realize the impact this new propofol clinic had. As he entered the clinic, he walked by the procedure room, pointed and announced for all to hear, I love that room!

Through ingenuity and a multidisciplinary team effort, the Hem/Onc/BMT propofol clinic has been able to create a positive change for our patients and their families. In addition to increasing survival rates among patients with childhood cancers, we have improved supportive care measures and decreased procedural pain and anxiety in our practice, thereby improving our patientsí quality of life and diminishing some of the long-term side effects of therapy.

Bibliography

Clark, Lyda. Propofol: Diprivan by Stuart Pharmaceuticals. 1990.

Jayabose, S., Levendoglu-Tugal, O, et al. (2001). Intravenous anesthesia with propofol for painful procedures in children with cancer Journal of Pediatric Hematology/Oncology, 23, 290-293.