Paediatric oncological patients
Our patients are mostly those with either a blood cancer or a tumor. Whenever we have to treat children with cancer, the first thing we do is to perform a biopsy (bone marrow or organ).
A biopsy is an unpleasant procedure in which a small piece of the cancer or tumor is extracted through a needle. Children who have cancer require multiple invasive procedures during the course of their treatment i.e. lumbar punctures for intrathecal chemotherapy, bone marrow aspiration and biopsies, PICC line insertion etc which can be safe if procedural sedation is provided to them.
During a lumbar puncture, we take a tiny sample of the fluid around the spinal cord or cerebrospinal fluid, and this is obtained by introducing a needle into the spine of the child. Intrathecal chemotherapy is given particulary for patients with blood cancers. For this purpose, we require them to be consciously sedated, and this minimizes the possible pain, discomfort and fear.
Conscious sedation makes the child unaware of the trauma and pain and also reduces the parents’ anxiety. The children usually wake up within a few minutes and come back to their original state within 10 to 15 minutes. Unfortunately, children with cancer require these painful procedures multiple times. This is why we feel it is very important to ensure they don't experience pain and trauma.
Sedation procedure with Chemotherapy
Chemotherapy is like any other medication, which is generally either given through a cannula or through a PICC line (peripherally inserted central catheter) for the safe institution of the chemotherapy without risk of extravasation and burns which is common around cannulation sites. Most of the time parents abandon treatments because they don't want their children to go through this pain.
For long-term medications like chemotherapy or when multiple cannulations make it difficult to find a vein, children may need a PICC line or peripherally inserted central catheter. Once a PICC line is placed, the patient does not need a cannula for months, since it delivers all kinds of medications.
In order to put in a PICC line, an Interventional radiologist has to puncture a small vessel. To accomplish this, we sedate the patient, because the window of the vessel is very narrow and we can mis-puncture or miss the vein, especially if the patient is moving. Usually, there is no such complication in a PICC line insertion, except where it is placed; a local hematoma may form or there may be blood clotting. This is common and spontaneously resolves within 24 hours.
We perform sedation through the IV cannula. The benefit is that the children are sedated immediately, within a few minutes. In this way, one actual invasive procedure may take 10 to 15 minutes. When their children are getting treatment under sedation they do not have any memory or emotional trauma and this increases the compliance of our treatment.
Sedation for the MRI, CT scan, US guided biopsies, abdominal or chest drains insertion
MRI is a cross-sectional imaging, which can take up to 30 to 45 minutes and some times even more. It is not possible for small children to have an MRI without moving. They have to stay still. This is why sedation is crucial.
Sometimes children get hydronephrosis i.e. urine collection within kidneys due to obstruction or other reasons. The treatment is to puncture a needle in the kidney and insert a PCN (percutaneous nephrostomy tube) to drain the urine. This is a reliable treatment for hydronephrosis, however, it can be a very difficult procedure and its failure rate can be very high if the patient is not sedated.
Other procedures that can be easily done under procedural sedation included CT scans, US guided renal, liver or other organ biopsies, skin biopsies, PICC line insertion, US guided chest or abdominal drains insertion, or insertion of the drains for a liver abscess.
Minor surgical procedures
Minor surgical procedures such as laceration repairs (face, scalp), incision and drainage of a superficial abscess, ingrown nails, surgical dressing changes, which are usually very painful especially in burns or graft-related or orthopedic surgeries can benefit from sedation.
How is Procedural Sedation undertaken?
For babies, the sedation criteria is that they must be 6 months old and weigh over 6kg. For children, sedation can be provided to anyone between 6 and 18 years of age. In a situation where a child is 5 months old, or even 6kg, we advise the parents on the risk. If they are still willing to take the risk, we proceed after written consent is granted.
A sedation nurse assesses the child for any high-risk conditions, and counsels the parents in detail about the drugs and timings. The Nothing Per Oral instruction, for example, means the child should have an empty stomach during the entire sedation process. The child is then cannulated and prepared for the procedural sedation.
After sedation, the child is monitored in recovery or at the hospital bed where the child is admitted for 1 to 2 hours. We make sure the child returns to his or her baseline, is fully awake, and taking orally well before they can be discharged.
Risks and side effects of procedural sedation
Individuals with a history of cardiac arrest or congenital heart disease are not advised to be sedated, instead, general anesthesia is advised. For instance, general anaesthesia is recommended for children with a higher risk, such as those who are younger than 6 months.
General anaesthesia is also advised when children need to have their breathing stopped during procedures such as abdominal or cardiac MRIs so that the anesthesia can control their breathing. This can be an expensive procedure, and the cost of sedation is almost a third of GA.
Vomiting is a frequent adverse effect of sedation. For this reason, we keep the child in recovery and make sure they don't vomit after being sedated. To ensure that they are digesting, we provide them with food and liquids. Infants are evaluated for 1-2 hours before being let out of recovery.
Our team performs almost 1,500 procedural sedations a year with a failure rate of zero percent.
