Safe and efficacious use of procedural sedation and analgesia by non-anesthesiologists in a pediatric hematology-oncology unit.

BACKGROUND: Children often require relief of pain and anxiety while undergoing diagnostic and therapeutic procedures. Procedural sedation and analgesia (PSA) is the safe and effective control of pain, anxiety and motion so as to allow a necessary procedure to be performed and to provide an appropriate degree of memory loss or decreased awareness. OBJECTIVE: To prospectively describe procedural sedation and analgesia as performed in the pediatric oncology unit and to report the success of sedation and the incidence of complications. METHODS: IV Midazolam and IV Ketamine were used for PSA in pediatric oncology patients undergoing painful procedures. RESULTS: Between June 2004 and December 2004, 55 diagnostic and therapeutic procedures were performed using PSA in 16 children. There were 9 boys and 7 girls with a median age of 11 years. Twelve patients had hematolymphoid malignancies and 4 patients had solid tumors. The indication for PSA were bone marrow aspiration and or biopsy in 7 patients, therapeutic lumbar puncture in 43 patients, bone marrow aspiration and lumbar puncture in 4 patients and skin biopsy in 1 patient. All 55 procedures were successfully completed. Adverse events occurred in 15 (27%) episodes and included transient drop in oxygen saturation, vomiting, dizziness and disinhibition with crying spells. Average time to arousable state and full recovery was 22 minutes and 31 minutes respectively. None of the patients complained of post procedure pain nor recalled the procedure at the follow up visit. CONCLUSION: Procedural sedation and analgesia using midazolam and ketamine is a safe and efficient method of limiting anxiety and procedure related pain and can be successfully administered by non-anaesthesiologists. The complication rate is low and can be easily managed.

Successful allogeneic stem cell transplantation with fludarabine-based conditioning regimen in severe aplastic anemia.

Graft failure is a problem in HLA-identical sibling transplants for patients with refractory severe aplastic anaemia (SAA). Intensification efforts includes addition of radiation or biologic agents such as antithymocyte globulin (ATG), procarbazine or cyclophosphamide has often been advocated to combat this problem. With this approach engraftment rate has improved. However the incidence of transplant related complications are also increased, resulting in little change in the overall outcome. We therefore investigated the use of combination of fludarabine and cyclophosphamide as a non-myeloablative conditioning regimen in a patient who was refractory to multiple immunosuppressive agents and transfusions. He received peripheral blood stem cells from his HLA-identical sibling donor. With a follow up of eighteen months, the patient is alive with complete and durable hematopoietic engraftment. Fludarabine-based conditioning regimen therefore has the potential to be successfully and safely used in patients with SAA undergoing transplant.