Bone Marrow Biopsies – A New Avenue To ‘Act Local’?

Bone marrow aspiration biopsies are a frequently performed procedure on the pediatric oncology service, with the sedation and anesthesia being provided by a variety of divisions including pediatric anesthesia and critical care. Many of these patients undergo this procedure multiple times and may develop anxiety or stress related to the procedure, in addition to the physical pain during the procedure and the recovery itself. Zarnegar-Lumley et al (10.1542/peds.2018-3829), in a study being early released this week in our journal, report their findings from a cross-over design clinical trial comparing the additional benefit of local anesthesia in combination with the general anesthesia already provided for this procedure. With each patient being their own control, they looked for differences in opioid and non-opioid analgesic requirement after the procedure, in the effect of pain on quality of life after the procedure, and in previously validated self-reported pain scale scores. Interestingly, only a minority of patients in their study needed opioids after the procedure, hence potentially limiting the ability to attain statistical significance for their outcomes. They did find a longer time to opioid and non-opioid analgesic administration in the encounters when patients received additional local anesthesia, although the p-values did not turn out to be statistically significant. They also noted a significantly improved short-term self-reported pain score during the immediate recovery from the procedure. They also performed an interesting sub-analysis, comparing the requirements for opioid analgesics in patients younger than 8 years of age versus older children. They found that a higher percentage of patients in the older cohort required opioid analgesia after the procedure, regardless of whether they received additional local anesthesia for the procedure itself. While they did not describe at what time point after the procedure these opioids were required, this could potentially be due to their greater muscle mass and bone density. As a physician in the pediatric intensive care unit who often provides monitored anesthesia care for this group of patients, the findings from this study are food for thought. It may be reasonable to consider additional local anesthesia to allow a more comfortable acute recovery from a bone marrow biopsy. The older patients may require special consideration with a more elaborate anxiolysis and pain management plan.