Pain and Distress from Bone Marrow Aspirations and Lumbar Punctures

OBJECTIVE To compare the efficacy of 3 different pharmacologic regimens to relieve pain and distress in children with cancer undergoing bone marrow aspirations (BMAs) and lumbar punctures (LPs). DESIGN Retrospective cohort study with crossovers for some patients. PATIENTS AND METHODS The pain and distress ratings of patients undergoing BMAs (n = 73) and LPs (n = 105) were examined in a comparison of 3 different interventions: (1) a topical eutectic mixture of lidocaine and prilocaine (EMLA cream), (2) oral midazolam and EMLA cream, or (3) propofol/fentanyl general anesthesia. The choice of the intervention depended on patient/parent request. A validated faces pain scale was completed by the child or parent following each BMA or LP. The faces pain scale includes ratings of the severity of pain (from 0 = none to 5 = severe) and ratings of how frightened (from 0 = not scared to 5 = scared) the child was prior to each procedure. Comparisons of the pain and distress ratings were made among all patients for their first procedure and also within individual patients who had received >1 of the 3 interventions. Independent comparisons between the first treatments received by each patient were analyzed using Kruskal–Wallis tests. Comparisons of different crossover treatments received by individual patients were analyzed using Wilcoxon tests. RESULTS For all first procedures, mean ± SD pain and distress ratings during LPs were significantly lower when propofol/fentanyl was used (n = 43; 0.4 ± 1.0 and 1.4 ± 1.7) versus either EMLA (n = 29; 2.4 ± 1.7 and 2.9 ± 1.9) or midazolam/EMLA (n = 33; 2.4 ± 1.8 and 2.7 ± 1.8), respectively. Pain and distress ratings during BMAs were also significantly lower with propofol/fentanyl (n = 29; 0.5 ± 1.0 and 1.2 ± 1.7) versus EMLA (n = 21; 3.5 ± 1.6 and 3.3 ± 1.8) or midazolam/EMLA (n = 23; 3.3 ± 1.5 and 3.0 ± 1.9), respectively. When data were analyzed within each patient, these differences were also present. CONCLUSIONS Children receiving propofol/fentanyl general anesthesia experienced significantly less procedure-related pain and distress than did those receiving either EMLA or oral midazolam/EMLA.