Pharmacologic Management of Painful Oncology Procedures in Pediatrics

Abstract

Children with cancer often cite procedural pain as the most distressing part of their disease. Pharmacologic interventions that decrease the pain and anxiety of invasive procedures have been shown to be beneficial, particularly when these interventions are a routine part of every procedure. However, despite the known benefits of analgesia and sedation, guidelines for the management of pediatric pain and stress during oncology procedures have not been established. Thus, children may not be receiving optimal pain relief. Various drugs have been investigated in pediatric populations to provide local anesthesia, systemic analgesia, conscious sedation, deep sedation, and general anesthesia. These agents include lidocaine-prilocaine, amethocaine, lidocaine, methohexital, propofol, midazolam, meperidine, nitrous oxide, fentanyl, ketamine, and diazepam. Local anesthesia with lidocaine-prilocaine and amethocaine decreases pain from accessing centrally placed venous devices (ports) and venipuncture; however, neither, is sufficient as a sole intervention for bone marrow aspirations (BMA), bone marrow biopsies (BMB) or lumbar punctures (LP). Transient local skin reactions are common with the use of lidocaine-prilocaine and amethocaine. Deep sedation or general anesthesia can be achieved with a variety of agents and are ideal interventions if pain and movement are to be prevented during more invasive procedures such as LP, BMA, and BMB. Titration of doses and monitoring to detect early adverse effects increase the safety of these interventions. Systemic analgesia with fentanyl or nitrous oxide in combination with local anesthesia may be appropriate for older children more comfortable and familiar with these procedures; conscious sedation may also be an option for these children, but deep sedation and general anesthesia should always be made available if it is the child’s preferred method of pain relief.