4. Discussion
As pediatric cancer outcomes have improved over the decades, focus has
shifted toward avoiding harmful side effects of treatment. This is
especially true of cancers with high rates of survival, such as
pediatric ALL. While procedural sedation has been routinely utilized for
LPs in pediatric patients with ALL for decades, emerging evidence
regarding the deleterious neurocognitive effects of repeated propofol
exposure raises concerns about what is best for the long-term health of
the patient.
The COVID-19 pandemic brought many challenges to health care
institutions, but also provided opportunities for reevaluation and
optimization of many processes. The burden of clinic visits on
consecutive days for COVID-19 testing prior to procedures became yet
another stressor for families already contending with the complex care
of a child with leukemia.
At our institution, we began offering unsedated LPs to most of our
pediatric patients with ALL and were able to achieve our goal of
reducing the number of post-Induction sedated LPs by over 50%.
Secondarily, we found that unsedated LPs improved the patient/family
experience and reduced expenditures while also improving cost
opportunity. Most importantly, the conversion to unsedated LPs could
potentially address one of the significant late effects of ALL
treatment, neurocognitive decline. Further studies aimed specifically at
comparing neurocognition in ALL survivors treated with unsedated vs
sedated LPs are needed to support this hypothesis.
One potential problem observed for our unsedated LPs was an increased
incidence of CSF samples containing blood. Importantly, there were no
failed procedures with the unsedated approach. Of the five
blood-containing CSF specimens, three came from a single patient who was
later converted back to sedated LPs and continued to have
blood-containing specimens on occasion. Another came from a child who
previously had blood in a sedated CSF sample. While there are no known
risks of introducing blood into the CSF for patients with ALL in
remission, inferior outcomes of patients with traumatic LPs at diagnosis
are well-described.6,7 The increased incidence of
traumatic LPs without sedation supports our reasoning to avoid this
technique at diagnosis. Given this experience, additional proven
strategies to improve LP techniques such as ultrasound guidance are
being explored at our institution to enhance technique
efficiency8.
With regards to patient and family preferences, the majority responded
very strongly in favor of the unsedated approach. A significant
percentage of patients and families indicated that mandatory COVID-19
testing did not strongly influence this preference. Other benefits of
unsedated LPs noted by patients and families include lack of NPO
requirements, shorter hospital visit time, and allowance of caregiver
presence in the room during the procedure. While not the motivating
force behind our study, our analyses also suggest a potentially
significant financial benefit of unsedated LPs, both to payers and
treating institutions. An estimated decrease in patient charges of
$5,700 per procedure visit is substantial considering they will receive
at least 20 during their therapy. Last-minute cancellations for sedated
LPs in ALL patients are a regular part of practice that create a burden
for institutional sedation services. In our study, during the 3-month
post intervention period, 30% of sedated LPs were cancelled with 24
hours of the procedure, providing inadequate time to utilize the
scheduled sedation resources to maximal capacity. Depending on the size
of the treating institution, decreasing opportunity cost and improving
access for all patients in need of sedation could be substantial
benefits associated with the intervention described in this report.
Our results are assumed to be generalizable, as unique institutional and
contextual factors during the intervention period may have affected our
findings. Fewer patients may have been willing to convert to unsedated
LPs without a COVID-19 testing mandate, and the requirement of hospital
visits on consecutive days may have been less problematic at
institutions with a smaller geographic catchment area. In addition, the
individualized approach to patient/family counseling as well as the
significant procedural experience among our medical staff may not be
available at some institutions.
Our findings suggest that performing LPs without sedation in pediatric
patients with ALL offers several key benefits, including improving the
patient and family experience as well as decreasing health care
expenditures. This is in addition to prior evidence that minimizing
exposure to propofol sedation could reduce long-term neurocognitive side
effects. Increasing the number of unsedated LPs performed in pediatric
patients with ALL provides an opportunity to deliver better care in a
more streamlined, cost-effective manner, warranting consideration of
implementing such a strategy on a wider scale.