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How Much Sedation is Enough for Kids?

General anesthesia used less in U.S. than Europe for bone marrow surgery

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HealthDay Reporter

SATURDAY, Aug. 11, 2001 (HealthDayNews) -- The excruciating pain caused by invasive bone marrow procedures is so legendary that many doctors argue children should be given general anesthesia for such surgery.

That happens far more frequently in Europe, it seems, than in North America, reports a new study comparing treatment at an international mix of hospitals.

Nearly a third of the 52 North American hospitals surveyed - which included 46 from the United States and six from Canada -- did not use general anesthesia or deep sedation for the majority of their bone marrow procedures, the study says.

A significant minority of North American hospitals considered a lighter approach to be sufficient: combining a local anesthetic with a drug that relieves anxiety, known as an anxiolytic, the study says. But only 6 percent of the 18 European hospitals did so. Details appear in the July issue of the Archives of Disease in Childhood.

The procedures involved are bone marrow aspirates or biopsies, which usually are performed on children with cancer or leukemia. And they're notoriously painful, says lead researcher Dr. Richard Hain, a senior lecturer in pediatric palliative care at the University of Wales College of Medicine in England.

"These are two of the most unpleasant procedures children with cancer have to undergo," Hain says. "It is difficult, if not impossible, to administer enough local anesthetic to render this procedure pain free."

"Even if it were, the attendant anxiety and discomfort could not be adequately managed," he adds.

But not everyone agrees.

Dr. Lynne Maxwell, a pediatric anesthesiologist at Johns Hopkins Hospital in Baltimore, argues that the study errs in its view of so-called "conscious sedation," which is a method many U.S. hospitals use.

"A lot of the conclusions of this study are based on the assumptions that unconsciousness is better than consciousness, and that conscious sedation means the patient is conscious, which is not always true," Maxwell says.

In fact, she adds, the term "conscious sedation" is being phased out in the medical community because, in children, the state achieved is more like moderate sedation.

"You cannot achieve a state where children are conscious and responsive to command and do the procedures," she notes.

Not only are children on "conscious sedation" not really very conscious at all, but they usually don't remember any pain they may have been experienced, she says.

"Looking at this situation [from afar], one would assume that having a patient who is completely asleep and doesn't move at all when something painful is done is better off than one who has some kind of verbal response or moves during the procedure," Maxwell says.

"But in fact there are many procedures done in operating rooms in this country with IV or a local anesthetic in which the patient may move in the procedure, but they don't remember it or have any pain afterwards," she says.

It's still unknown, she says, whether the pain that patients experience but don't remember afterwards has any real impact.

To Hain, however, that's not good enough.

"I am not convinced that the fact children can be made to forget the trauma afterwards means it is OK for them to have the experience in the first place," he says.

"I remember what writer Sylvia Plath said after watching a woman in labor: 'How typical of a man to develop a drug that does not prevent a woman having pain but makes her forget about it afterwards,' " he says. "I deny the slur on my sex, but her point was very well made."

"From a more pragmatic point of view," Hain notes, "for a child to be sedated so heavily that he or she is nearly unconscious has just the same safety implications as full anesthesia, so why not use the latter?"

Maxwell says there are a number of reasons.

"There are practical difficulties in obtaining anesthetic support," she says. "Frequently, hospitals have anesthesiologists in numbers sufficient to provide anesthesia in the operation room, but they don't have enough personnel to provide to patients outside of the operating room."

"So it's easier for pediatric oncologists or pediatricians to sedate their own patients for these procedures," she adds.

What To Do

To learn more about children and anesthesiology, visit the American Society of Anesthesiologists online. For more on conscious sedation, check out information from the American Association of Nurse Anesthetists.

And, for information on bone marrow transplants, take a look at an article from the FDA Consumer magazine.

SOURCES: Interviews with Richard Hain, M.D., senior lecturer in pediatric palliative care, University of Wales College of Medicine, Cardiff, England; and Lynne Maxwell, M.D., pediatric anesthesiologist, Johns Hopkins Hospital, Baltimore; July 2001 Archives of Disease in Childhood

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