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.