Original article

Propofol/alfentanil and propofol/ketamine procedural sedation in children with acute lymphoblastic leukaemia: safety, efcacy and their correlation with pain neuromediator expression
A. CHIARETTI, md, Paediatric Intensive Care Unit, A. Gemelli Hospital, Catholic University of Rome, Rome, A. RUGGIERO, md, Division of Paediatric Oncology, A. Gemelli Hospital, Catholic University of Rome, Rome, G. BARONE, md, Division of Paediatric Oncology, A. Gemelli Hospital, Catholic University of Rome, Rome, A. ANTONELLI, phd, professor, Paediatric Intensive Care Unit, A. Gemelli Hospital, Catholic University of Rome, Rome, I. LAZZARESCHI, md, Division of Paediatric Oncology, A. Gemelli Hospital, Catholic University of Rome, Rome, O. GENOVESE, md, Paediatric Intensive Care Unit, A. Gemelli Hospital, Catholic University of Rome, Rome, S. PAIANO, md, Division of Paediatric Oncology, A. Gemelli Hospital, Catholic University of Rome, Rome, M. SAMMARTINO, md, Department of Anaesthesia, A. Gemelli Hospital, Catholic University of Rome, Rome, P. MAURIZI, md, Division of Paediatric Oncology, A. Gemelli Hospital, Catholic University of Rome, Rome, & R. RICCARDI, md, professor, Division of Paediatric Oncology, A. Gemelli Hospital, Catholic University of Rome, Rome, Italy CHIARETTI A., RUGGIERO A., BARONE G., ANTONELLI A., LAZZARESCHI I., GENOVESE O., PAIANO S., SAMMARTINO M., MAURIZI P. & RICCARDI R. (2010) European Journal of Cancer Care 19, 212220 Propofol/alfentanil and propofol/ketamine procedural sedation in children with acute lymphoblastic leukaemia: safety, efcacy and their correlation with pain neuromediator expression Invasive procedures, such as the lumbar puncture, can cause anxiety and pain in children undergoing treatment for acute lymphoblastic leukaemia (ALL). We investigated the safety and efcacy of two different protocols for analgo-sedation in 20 children with ALL undergoing lumbar puncture. We have conducted a prospective, cross-over study. Protocol A was composed of an association between propofol and alfentanil. Protocol B consisted in the combination of propofol and ketamine. We also evaluated the levels of nerve growth factor, substance P and enkephalins in the cerebrospinal uid of these patients. All patients showed a satisfactory sedation and analgesia. We found a statistically signicant difference of vital parameters between protocol A and protocol B, while there were no signicant differences between sedation scores and the other parameters evaluated. Patients in protocol A showed a higher incidence of major side effects, such as respiratory depression. Pain neuromediator levels did not show any statistical difference between the two groups. This study shows that both protocols are effective to obtain a good sedation and analgesia in children with ALL undergoing lumbar puncture, but the association between propofol and ketamine appears to be safer due to the lower incidence of side effects.

Keywords: procedural sedation, lumbar puncture, pain neuromediators, acute lymphoblastic leukaemia.
Correspondence address: Antonio Ruggiero, Division of Paediatric Oncology, A. Gemelli Hospital, Catholic University of Rome, Rome, Italy (e-mail: ruggiero@rm.unicatt.it).

Accepted 23 June 2008

DOI: 10.1111/j.1365-2354.2008.01006.x European Journal of Cancer Care, 2010, 19, 212220

2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd

Procedural sedation in children with ALL

IN T R O D U C T I O N About 50% of children with cancer experience pain as a result of tumour progression, mucositis, chemotherapic treatment or needle medical procedures. Despite effective drugs for pain relief and the detrimental effects cancer pain can have on the childs health status, it is often inadequately assessed and treated (Yeh et al. 1999; Alexander & Manno et al. 2003). Sedative-hypnotics and opioids are the most common drugs for pain relief or analgo-sedation in children with cancer who experience moderate or severe pain due to medical procedures and/or tumour progression (Anderson et al. 1993; Litman 1999; Krauss & Green 2000; Litman 2000; Keidan et al. 2001). These drugs require to be safe, short-acting and effective in order to obtain an adequate analgo-sedation outside the operating room, where the painful procedures are often carried out. Up to date, many compounds such as propofol, alfentanil, remifentanil and ketamine have been assessed to provide analgesia and sedation in children (Foubert et al. 2002; Hostetler et al. 2002). Propofol is an ultra-short acting sedative agent with rapid onset, substantial potency, extremely short recovery and high satisfaction to patients due to its anti-emetic and euphoric properties. However, when used alone a relatively large dose may be required to provide satisfactory comfort and such high doses may be responsible of cardiovascular and respiratory depression (Wehrmann et al. 1999; Green & Krauss 2003). Alfentanil is a synthetic opioid, chemically related to fentanyl, with a rapid onset and short elimination half-life used for short-time paediatric painful procedures, such as bone marrow aspiration (Bailey & Stanley 1994; Antmen et al. 2005). Ketamine is a shortacting analgesic and anaesthetic drug that has been extensively used for paediatric procedures in and out of the operating room. It provides effective analgesia and sedation with a low incidence of side effects (Kim et al. 2003). Nevertheless, not many trials have been performed in children to assess what drugs, or combination of these, should be considered as safe and effective for an adequate analgesia and sedation during painful procedures, such as lumbar puncture. Lumbar puncture is one of the most common painful procedures that children with acute lymphoblastic leukaemia (ALL) undergo and generally local anaesthesia is not sufcient to prevent pain. Moreover, it is well known that pain determines neurological and chemical adaptive processes within neuron networks located at various levels of the central nervous system (CNS). The effects of pain on neurons are mediated by different neuropeptides, such as nerve growth factor (NGF), substance P and enkephalins. Nerve growth factor 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd

has a key role in the generation of pain and hyperalgesia in several acute and chronic pain states. The expression of NGF is high in injured tissues and increased levels of endogenous NGF result in a facilitation of ring of nociceptive neurons (Aloe et al. 1992; Woolf et al. 1994). Nerve growth factor also enhances the expression of several endogenous proteins, such as the substance P. Substance P is a short chain peptide that belongs to the family of tachykinins. It is considered as a key neuropeptide mediating nociceptive message transmission from peripheral afferents to sensory neurons located in the dorsal horn of the spinal cord (Mazario & Basbaum 2007). Noxius stimuli also enhance the expression of other mediators of pain, such as enkephalins, endorphins and dynorphins, with analgesic and physiologic properties similar to morphine. These neuropeptides, binding to opioids receptors, perform similar biological effects modulating perception and transmission of sensitivity to pain (Jacob & Ramabadran 1983). Based on these clinical and molecular aspects of pain, we aim to describe our experience on using two different protocols for procedural sedation, reporting on their safety and efcacy, in children with ALL undergoing a therapeutic lumbar puncture outside the operating room and to evaluate the levels of pain neuromediators in the CerebroSpinal Fluid (CSF) of these patients, in order to consider if any change in their expression was modied by administered drugs.

P A TI E NTS A ND ME THODS From January to September 2006 we have conducted a prospective, cross-over study in children with ALL, which required analgesia and sedation for the execution of lumbar puncture, to evaluate the safety and efcacy of two different protocols (protocol A and protocol B). To minimize any bias due to the individual responses to the administered drugs, both of the protocols were administered to all patients enrolled in the study, according to the cross-over method. All patients had a central venous catheter for delivering sedative and analgesic drugs during the procedure. Patients had to take neither central nor peripheral opioid drugs nor sedative compounds for 7 days before procedure. On the day of sedation, all children had to have normal laboratory values and a normal electrocardiogram. Patients were not eligible for the study if they were ASA 4 grade (dened by the American Society of Anaesthesiologist as patients with severe systemic disease that is a constant threat to life), were suffering from central apnoea or respiratory failure, cystic brosis, renal failure, liver 213

CHIARETTI et al.

diseases, endocranial hypertension and haemodynamic or cardiac dysfunction. Protocol A was composed of a starting dose of propofol (2 mg/kg), followed from a single dose of alfentanil (20 mg/ kg). Protocol B consisted in a starting dose of propofol (2 mg/kg), followed from a single dose of ketamine (1 mg/ kg). If sedation was inadequate (i.e. if the patients level of sedation was not sufcient to allow execution of the lumbar puncture), patients received a repeated dose of sedative agent (propofol 1 mg/kg), in order to compare how the analgesic drug (alfentanil or ketamine) inuenced the number of propofol boluses throughout the procedure. All drugs were administered as an intravenous bolus in 1 min. Lumbar puncture was performed 2 min after the administration of the analgesic drug and 1 mL of CSF was collected and stored at -70C until analysis of NGF, substance P, beta-endorphin and leu-enkephalin. Safety and depth of sedation of the single protocol was evaluated by monitoring vital parameters, such as heart rate (HR), respiratory rate (RR) and pulse oximetry (O2Sat), at different times during the procedure: T0 before sedation started, T1 immediately after the administration of propofol and analgesic drug, T2 as the oncologist was performing the spinal puncture, T3 5 min after the end of the procedure. At these times were checked closely also the drug side effects, such as bradycardia, hypotension, hypoxia, apnoea, nausea and vomiting. Bradycardia was dened as a HR lower than the third percentile for the age, hypotension as a blood pressure lower than the third percentile for the age, and hypoxia as a O2Sat < 92% at room air. If bradycardia or apnoea occurred, the sedation was stopped, patient was aroused from sleep and, if necessary, atropine was administered. If patient experienced hypoxia in room air, O2 was administered by facial mask until O2Sat > 95% was recovered. The efcacy of the single protocol was evaluated using Ramsay and CHEOPS scales, depending on the patient age and general clinical conditions, and with a questionnaire administered to the children at the time of awaking in order to assess patients compliance and satisfaction. Time to awakening was determined by measuring the time between the initial administration of drugs and the time that patients opened their eyes and talked. Ramsay sedation scale is a suitable way to evaluate the depth of the sedation state after drug infusion and during the sedation (see Table 1). On the other hand, CHEOPS scale (Childrens Hospital Eastern Ontario Pain Scale) was administered at the moment of the awakening and it is useful to evaluate intensity of post-procedural pain. Other parameters considered for the evaluation of the efcacy of two protocols were immobilization degree and 214

Table 1. Ramsay sedation scale 1. 2. 3. 4. Patient is anxious and agitated or restless, or both. Patient is cooperative, oriented and tranquil. Patient responds to commands only. Patient exhibits brisk response to light glabellar tap or loud auditory stimulus. 5. Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus. 6. Patient exhibits no response.

number of attempt required to perform lumbar puncture, time and quality of the awaking after each protocol, time to discharge from the sedation room, time to which the child was permitted to eat or drink something, and, nally, time to discharge from the ward or Day-Hospital rooms. Moreover, all children older than 3 years were requested to complete a questionnaire of their grade of satisfaction before and after the procedure in order to evaluate the previous experience of painful procedures and the satisfaction degree of the current analgesia. The Ethical Committee of the hospital approved the study and the parents of all patients involved provided written informed consent.

Pain neuromediator assays Nerve growth factor The levels of NGF in the CSF were measured by a highly sensitive two-site immunoenzymatic assay which recognizes human NGF (R&D Systems, Minneapolis, MN, USA) following the instruction of the manufacturer. The cross-reactivity with other molecules of the NGF family such as BDNF, NT-3, NT-4/5 was less than 0.3%. Data were represented as pg/mL and all assays were performed in triplicate.

Substance P The CSF levels of substance P were found using an immunoenzymatic assay which recognizes human substance P (R&D System, Minneapolis, MN, USA) following the instruction of the manufacturer. This assay is based on the competitive binding technique in which substance P present in a sample competes with a xed amount of horseradish peroxidase (HRP)-labelled substance P for sites on a mouse monoclonal antibody. During the incubation, the monoclonal antibody becomes bound to the goat anti-mouse antibody coated onto the microplate. Following a wash to remove excess conjugate and unbound sample, a substrate solution is added to the wells to determine the bound enzyme activity. The colour development 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd

Procedural sedation in children with ALL

is stopped and the absorbance is read at 450 nm. The intensity of the colour is inversely proportional to the concentration of substance P in the sample. Data were represented as pg/mL and all assays were performed in triplicate.

Leucine-enkephalin The CSF levels of leucine-enkephalin were found using an immunoenzymatic assay which recognizes human leucine-enkephalin (MD Biosciences, St. Paul, MN, USA) following the instruction of the manufacturer. In detail, immunoplate in this kit is pre-coated with secondary antibody and the non-specic binding sites are blocked. The secondary antibody can bind to the Fc fragment of the primary antibody whose Fab fragment will be competitively bound by both biotinylated peptide and peptide standard or targeted peptide in sample. The biotinylated peptide is able to interact with streptavidin-horseradish peroxidase (SA-HRP) which catalyses the substrate solution composed of 3,3,5,5-tetramethylbenzidine (TMB) and hydrogen peroxide to produce a blue coloured solution. The enzyme-substrate reaction is stopped by hydrogen chloride (HCl) and the solution turns to yellow. The intensity of the yellow is directly proportional to the amount of biotinylated peptideSA-HRP complex but inversely proportional to the amount of the peptide in standard solutions or samples. This is due to the competitive binding of the biotinylated peptide and the peptide in standard solutions or samples to the peptide antibody (primary antibody). A standard curve of a peptide with known concentration can be established accordingly. The peptide with unknown concentration in samples can be determined by extrapolation to this standard curve. The crossreactivity with other molecules such as MET-Enkephalin, MET-Enkephalin-Arg-Gly-Leu, Leu-Enkephalin-Arg, BetaEndorphin is 0. Data were represented as pg/mL and all assays were performed in triplicate.

peptide is able to interact with SA-HRP which catalyses the substrate solution composed of TMB and hydrogen peroxide to produce a blue coloured solution. The enzyme-substrate reaction is stopped by HCl and the solution turns to yellow. A standard curve of a peptide with known concentration can be established accordingly. The peptide with unknown concentration in samples can be determined by extrapolation to this standard curve. The cross-reactivity with other molecules such as METEnkephalin, Leu-Enkephalin, Alpha-Endorphin, LeuEnkephalin-Arg, Gamma-Endorphin is 0. Data were represented as pg/mL and all assays were performed in triplicate.

Statistical analysis Data are reported as mean standard deviation. Statistical analyses were performed with spss version 13.0 for Windows (SPSS Inc., Chicago, IL, USA). Neuromediators levels and vital parameters such as HR, RR and O2Sat were analysed using two-tailed t-test. KolmogorovSmirnov test was applied to establish if these data showed normal distribution. All of the remaining parameters were analysed using Wilcoxons ranked sum test. Adverse effects were analysed using Fischers exact test. We considered P < 0.05 to indicate statistical signicance. RE SUL TS Twenty patients with low-risk ALL undergoing therapeutic lumbar punctures were enrolled in the study. The median age of these patients was 7 years (range: 215). All patients experienced analgo-sedation with both protocols according to the cross-over method. In all, the procedures counted 40 lumbar punctures, 20 for each protocol. All patients were in the maintaining phase of therapy and were receiving chemotherapy for their consolidation treatment which consisted of intravenous high-dose metrotrexate, intrathecal methotrexate and oral 6mercaptopurine. In Figure 1 we report the variations of vital parameters recorded during the procedures when sedation was obtained using propofol plus alfentanil (protocol A) or propofol plus ketamine (protocol B). The gure shows a statistically signicant difference of HR and RR values between protocol A and protocol B at times T1 and T2. Regarding the O2Sat evaluation, alfentanil brought signicantly on deeper O2Sat reduction at time T2 compared with ketamine (P = 0.02), while no signicant differences were found among the other times (Fig. 2). Nine children belonging to alfentanil group who had experienced respiratory depression required supplemental oxygen by facial 215

Beta-endorphin The CSF levels of beta-endorphin were found using an immunoenzymatic assay which recognizes human leucine-enkephalin (MD Biosciences, St. Paul, MN, USA) following the instruction of the manufacturer. The immunoplate in this kit is pre-coated with secondary antibody and the non-specic binding sites are blocked. The secondary antibody can bind to the Fc fragment of the primary antibody whose Fab fragment will be competitively bound by both biotinylated peptide and peptide standard or targeted peptide in sample. The biotinylated 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd

CHIARETTI et al.

Figure 1. Heart rate (HR) and respiratory rate (RR) variations during drug administration. At time T0 starting values of HR were similar in both groups without any statistical difference (P = 0.9). At times T1 and T2 HR decreased signicantly in protocol A respect to protocol B (P = 0.009 and P = 0.008 respectively). No differences were noted during the remaining time of observation. RR also showed a signicantly greater reduction in protocol A respect to protocol B at times T1 and T2 (P = 0.03). No differences were found during the remaining time of observation. The error bars indicate standard deviations (SD).

Figure 2. O2Sat variations during drug administration. Protocol A caused a signicantly deeper O2Sat reduction at time T2 respect to protocol B (87% vs. 95% respectively) (P = 0.02). No statistically signicant differences were found among the other times. The error bars indicate standard deviations (SD).

mask, even though neither transient bag-valve-mask ventilation nor endotracheal intubation was necessary. In particular, oxygen desaturation events occurred in 11 out of 20 children who received alfentanil (protocol A) and only in three out of 20 in those who received ketamine (protocol B). In all patients satisfactory sedation was obtained and there was no statistical difference between sedation scores of the two groups during and after the painful procedure. In particular, in protocol A the mean CHEOPS score was 5.25 0.6, while in protocol B the mean CHEOPS score was 5.5 0.5 (P > 0.05). The mean Ramsay score was 6.08 1.2 in protocol A compared with 6.15 1.1 in protocol B (P > 0.05). The number of 216

attempts requested to perform lumbar puncture was only one for both protocols. The mean of time to awakening was 20.72 10.7 min in protocol A and 25.85 13.1 min in protocol B. The time to discharge from sedation room was about 30 min for both protocols, and the time to which children were permitted to eat or drink something was 130.2 45.2 min in protocol A and 134.4 25.9 min in protocol B. The time to discharge from the ward or Day-Hospital rooms was 182.3 45.2 min in protocol A and 184.5 38.9 in protocol B. All these parameters did not show any statistical difference between the two protocols. Sedation efcacy was also assessed as immobilization degree and as need of additional propofol boluses to obtain an adequate analgesia during the lumbar puncture. In this regard, both children who received alfentanil as part of sedation schedule, and those whom ketamine was administered to, required some supplemental bolus of propofol (1 mg/kg). Overall number of propofol boluses was of 15 in the alfentanil group (protocol A) and only ve in the ketamines (protocol B). We have also analysed the answers to the questionnaire that was lled in by children older than 3 years. After awakening no children reported that they had felt pain during the procedure. Ninety per cent of children in protocol A had felt pleasant sensations when they awoke, and three children in protocol B reported pleasant dreaming. All of children sedated with ketamine were not afraid at the moment of awakening while 20% of children belonging to alfentanil group felt little fear. Regarding the minor side effects related to the drugs utilized, one child each protocol showed rash and two children belonging to the ketamine 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd

Procedural sedation in children with ALL

NGF and SP (pg/mL) 140 120 100 80 60 40 20 0 Protocol A Protocol B NGF 13.35 10.25 SP 123.58 129.62

Protocol A Protocol B

Leu-enkephalin and Beta-endorphin (pg/mL) 25 20 15 10 5 0 Protocol A Protocol B

Leu-enkephalin Beta-endorphin

Protocol A Protocol B

8.38 21.93

1.195 0.714

Figure 3. Nerve growth factor (NGF) and substance P (SP) levels in the Cerebro-Spinal Fluid of children enrolled in the study. In both protocols there was not any signicant difference between the levels of these neuromediators.

Figure 4. Leu-enkephalin and beta-endorphin levels in the Cerebro-Spinal Fluid of patients enrolled in the study. Leuendorphin and beta-endorphin levels were 8.38 1.85 pg/mL and 1.2 0.4 pg/mL in the alfentanil group and 21.9 8.3 pg/mL and 0.7 0.3 pg/mL in the ketamine group respectively.

group complained of nausea and diplopia respectively when they awoke. Assessment for the neuromediators of pain in the CSF did not show any statistical difference between the two groups. The NGF concentration was 13.3 2.4 pg/mL in patients who received alfentanil (protocol A) and 10.2 1.4 pg/mL in those who were sedated by ketamine (protocol B). Similarly, the substance P concentration was 123.6 14.1 pg/mL when protocol A was employed and 129.6 10.4 pg/mL when protocol B was prompted (Fig. 3). Also for leu-endorphin and betaendorphin CSF levels, there was no signicant difference between the two protocols (Fig. 4).

D I SC U SSI O N Intrathecal prophylaxis by lumbar puncture plays a central role in the management of haematological and oncological disorders in children as well. As lumbar puncture causes a moderate to severe pain and anxiety, an adequate analgesia and sedation is required when the procedure is planned. Our study shows that both protocols were effective in prompting an appropriate degree of sedation and analgesia during the procedures. All enrolled children showed a satisfactory grade of immobilization that ensured to perform the lumbar puncture on the rst attempt and to collect the liquoral samples with no difculty. All patients showed a long-standing haemodynamic stability with some important differences between the two protocols. In protocol A (propofol plus alfentanil) statistically signicant differences were noted regarding the 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd

HR, RR and O2Sat values, as compared with protocol B (propofol plus ketamine). These differences were more evident at time T1 and T2, probably due to the extremely rapid effects of alfentanil on the cardio-respiratory system. The greater number of apnoeas and oxygen desaturation events in this group required oxygen supplementation by facial mask for about 50% of these, even though neither bag-valve-mask ventilation nor endotracheal intubation was necessary. Respiratory depression observed in protocol A may be due to the link between alfentanil and type m opioid receptors, which are responsible for both the pharmacological and early side effects (times T1 and T2 of our study). So, physicians should take into account this potential adverse effect when they plan to perform procedural sedation outside the operating room by using alfentanil. Recently, the use of alfentanil in paediatric procedural sedation has been evaluated by several studies. Antmen et al. (2005) investigated the efcacy and safety of alfentanil alone, or in association with midazolam, in providing analgo-sedation in children who underwent a diagnostic bone marrow aspiration, stating that both of these schedules are effective (Antmen et al. 2005). Our results are in keeping with this study, conrming that the use of alfentanil, in association with propofol, is safe and effective for pain relief in children with ALL, even though a particular attention must be taken on its important side effects. On the other hand, the most frequent adverse reaction related to ketamine is hallucinations and occurs more commonly when this drug is administered alone. 217

CHIARETTI et al.

Moreover, it has been known that combination of ketamine with propofol reduces this unfavourable effect (Guit et al. 1991). Our study conrms these data as only three out of 20 patients reported on their own dreams during sedation with propofol and ketamine. In addition, post-anaesthetic agitation and hallucinations associated with the use of ketamine, as well as diplopia and nystagmus, are much less frequent after propofol anaesthesia. In the experts opinion, the combination of these drugs is the most effective and safety scheme in the paediatric and neonatal procedural sedation due to their synergistic effect and the stability of haemodynamic parameters of their concurrent administration (Golden 2001; Ostreikov et al. 2002). Our results are consistent with those ndings because the number of additional propofol boluses, needed to obtain an adequate analgo-sedation during the lumbar puncture, was lower when propofol was administered in association with ketamine (protocol B) respect to protocol A (propofol plus alfentanil). Efcacy of administered drugs was also conrmed by assessing the behavioural parameters, such as CHEOPS and Ramsay scales. During and after the execution of the lumbar puncture both scores showed a satisfactory degree of sedation and analgesia, without any signicant difference between the two protocols. Nevertheless, statistically signicant differences were noted neither in the time to awakening nor in sedations length. Children were early discharged from the sedations room and could be in their own beds after 30 min since the end of the procedure and could speak with their parents or watch television. They were, moreover, permitted to eat after about 2 h to lumbar puncture, obtaining a very good degree of satisfaction, especially for younger children. Time to discharge from the ward or Day-Hospital rooms was of about 3 h since the ending of the sedation with both protocols. The optimal timing of discharge from the sedation room after paediatric procedural sedation has not been yet well established. A recent study stated that serious adverse effects such as hypoxia, stridor or hypotension rarely occurred after 25 min from the drug administration (Newman et al. 2003). Our results are in keeping with this study, conrming that discharge from the sedation room may be safe at approximately 30 min after the end of sedation as no side effects were reported by the children or their parents during this observational time. Short timing of hospitalization represents a signicant advantage of procedural sedation performed outside the operating room, since children spend little time in the hospital without any alterations in their own ordinary life. About the answers to the questionnaire all children did not show any forewarned fear, anxiety or apprehension at the time of the following procedure, 218

demonstrating the good degree of amnesia too. Moreover, all patients stated that they had not felt any pain, irrespective of the administered drugs, conrming further the good degree of analgesia. Moreover, in our study we wanted to investigate the expression of some neuromediators of pain, such as NGF, substance P and enkephalins, in the CSF of these patients. Recent studies suggest that these neuromediators exert a key role on biological mechanisms of hyperalgesia (Lowe et al. 1997). Peripheral inammatory or traumatic insult might result in the alteration of neuronal development in the nociceptive circuits (Dyck et al. 1997). Nerve growth factor plays an important role in sensory nerve innervation in the CNS and inammatory insults determine molecular changes of this neurotrophin in the process of neuronal development and plasticity in primary afferent neurons (Woolf et al. 1994; Chien et al. 2007). In injured and inamed tissues the concentration of endogenous NGF-mRNA increases massively within a few hours of a lesion and this NFG up-regulation on nociceptive neurons triggers and strengthens pain signalling (Aloe et al. 1992; Chien et al. 2007). Nerve growth factor up-regulation enhances the expression of other mediator of pain, such as substance P, that further sensitizes these neurons and facilitates the activation of second-order nociceptive neurons in the CNS. In particular, elevated concentrations of substance P in the CSF are involved in both depression states or post-traumatic stress disorders that often characterize the clinical course of children with ALL (Geracioti et al. 2006). Substance P up-regulation in the CSF during and after pain stimuli implicates CNS release of this protein in the mechanism of acute pain that also enhances the expression of enkephalins in the CNS (Geracioti et al. 2006). These neuropeptides may take part in the neurochemical mechanisms of human pain and exert an important role as immunomodulatory substances in the development of pain and anxiety in children with acute and chronic pain states, such as children with ALL (Sardelli et al. 1986; Constantopoulos et al. 1995). In our study, assessment for the levels of these neuromediators did not show any statistical difference between the two protocols. However, important limitations of our study are related both to the limited number of patients examined and to the fact that CSF could be collected just when lumbar puncture was performed for the therapeutic purpose. Further sampling of CSF was not permitted for obvious ethic reasons and, so, we were not able to know how the expression of these neuromediators changed in time in response to painful stimuli or if the administered drugs could affect their levels. Further prospective studies, which include a larger number of patients, will be 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd

Procedural sedation in children with ALL

necessary to correctly evaluate the levels of these factors in the CSF of children with ALL, but dening the relationships between their expression and the pathophysiology of pain may help to shed light on the clinical manifestations of hyperalgesia in these subset of patients to nd new drugs and strategies for the treatment of cancer pain. In conclusion, our study reports that the using of a sedative drug, such as propofol, in association with an analgesic one, such as alfentanil or ketamine, is safe and effective schedule to obtain a good procedural sedation and analgesia in children with ALL undergoing lumbar puncture. Both of the protocols are effective, but the association between propofol and ketamine results in a safer schedule due to the lower incidence of side effects respect to the combination between propofol and alfentanil.

A C K N O W L E D G E M E NT S This study was supported by the project on Neurotrophic factors and oxidative injury markers in infants and children with traumatic and non-traumatic brain injury (Grant R-05-48) from the Fondazione Mariani, Milano, Italy. All authors declare that there are not conicts of interest.

REF E R E N C E S
Alexander J. & Manno M. (2003) Underuse of analgesia in very young patients with isolated painful injures. Annals of Emergency Medicine 41, 617622. Aloe L., Tuveri M.A., Carcassi U. & Levi-Montalcini R. (1992) Nerve growth factor in the synovial uid of patients with chronic arthritis. Arthritis and Rheumatism 35, 351355. Anderson C.T.M., Zeltzer L.K. & Fanurik D. (1993) Procedural pain. In: Pain in Infants, Children and Adolescents (eds Schechter N.L., Berde C.B. & Yaster M.), pp. 435458. Williams & Wilkins, Baltimore, MD, USA. Antmen B., Sasmaz I., Birbicer H., Ozbek H., Burgut R., Isik G. & Kilin Y. (2005) Safe and effective sedation and analgesia for bone marrow aspiration procedures in children with alfentanil, remifentanil and combination with midazolam. Paediatric Anaesthesia 15, 214219. Bailey P.L. & Stanley T.H. (1994) Intravenous opioid anesthetics. In: Basics of Anesthesia, 4th edn (eds Stoelting R.K. & Miller R.D.), pp. 291387. Churchill Livingstone, New York, USA. Chien C.C., Fu W.M., Huang H.I., Lai Y.H., Tsai Y.F., Guo S.L., Wu T.J. & Ling Q.D. (2007) Expression of neurotrophic factors in neonatal rats after peripheral inammation. The Journal of Pain 8, 161167. Constantopoulos A., Papadaki-Papandreou U. & Papaconstantinou E. (1995) Increased beta-endorphin but not Leu-enkephalin in plasma due to preoperative stress. Experientia 51, 1618. Dyck P.J., Peroutka S., Rask C., Burton E., Baker M.K., Lehman K.A., Gillen D.A., Hokanson J.L. & OBrien P.C. (1997) Intradermal recombinant human nerve growth factor induces

pressure allodynia and lowered heat-pain threshold in humans. Neurology 48, 501505. Foubert L., Reyntjens K., De Wolf D., Suys B., Moerman A. & Mortier E. (2002) Remifentanil infusion for cardiac catheterization in children with congenital heart disease. Acta Anaesthesiologica Scandinavica 46, 355360. Geracioti T.D., Jr, Carpenter L.L., Owens M.J., Baker D.G., Ekhator N.N., Horn P.S., Strawn J.R., Sanacora G., Kinkead B., Price L.H. & Nemeroff C.B. (2006) Elevated cerebrospinal uid substance p concentrations in posttraumatic stress disorder and major depression. The American Journal of Psychiatry 163, 637643. Golden S. (2001) Combination propofol-ketamine anaesthesia in sick neonates. Paediatric Anaesthesia 11, 119122. Green S.M. & Krauss B. (2003) Propofol in emergency medicine: pushing the sedation frontier. Annals of Emergency Medicine 42, 773782. Guit J.B., Koning H.M., Coster M.L., Niemeijer R.P. & Mackie D.P. (1991) Ketamine as analgesic for total intravenous anaesthesia with propofol. Anaesthesia 46, 2427. Hostetler M.A., Auinger P. & Szilagyi P.G. (2002) Parenteral analgesic and sedative use among ED patients in the United States: combined results from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 19921997. The American Journal of Emergency Medicine 20, 139143. Jacob J.J.C. & Ramabadran K. (1983) Role of opiate receptors and endogenous ligands in nociception. In: Pain and Its Management (eds Williams N.E. & Wilson H.), pp. 1332. Pergamon Press, Oxford, UK. Keidan I., Berkenstadt H., Sidi A. & Perel A. (2001) Propofol/ remifentanil versus propofol alone for bone marrow aspiration in paediatric haemato-oncological patients. Paediatric Anaesthesia 11, 297301. Kim G., Green S.M., Denmark T.K. & Krauss B. (2003) Ventilatory response during dissociative sedation in children: a pilot study. Academic Emergency Medicine 10, 140145. Krauss B. & Green S.M. (2000) Sedation and analgesia for procedures in children. The New England Journal of Medicine 342, 938945. Litman R.S. (1999) Conscious sedation with remifentanil and midazolam during brief painful procedures in children. Archives of Pediatrics and Adolescent Medicine 153, 1085 1088. Litman R.S. (2000) Conscious sedation with remifentanil during medical procedures. Journal of Pain and Symptom Management 19, 468471. Lowe E.M., Anand P., Terenghi G., Williams-Chestnut R.E., Sinicropi D.V. & Osborne J.L. (1997) Increased nerve growth factor levels in the urinary bladder of women with idiopathic sensory urgency and interstitial cystitis. British Journal of Urology 79, 572757. Mazario J. & Basbaum A.I. (2007) Contribution of substance P and neurokinin A to the differential injury-induced thermal and mechanical responsiveness of lamina I and V neurons. The Journal of Neuroscience 27, 762770. Newman D.H., Azer M.M., Pitetti R.D. & Singh S. (2003) When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations. Annals of Emergency Medicine 42, 627635. Ostreikov I.F., Milenin V.V., Vasilev IaI, Mishustin V.V. & Cherdantsev S.V. (2002) Central hemodynamics conditions of combined intravenous anesthesia using propofol and ketamine in pediatric ophthalmology. Anesteziologiia i Reanimatologiia 11, 2224. Sardelli S., Petraglia F., Massolo F., Messori A., Santoro V., Facchinetti F. & Genazzani A.R. (1986) Changes in

2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd

219

CHIARETTI et al.

immunoreactive beta-endorphin, methionine-enkephalin and ACTH in bone marrow cells and uid from leukemic children. Clinical Immunology and Immunopathology 41, 247 253. Wehrmann T., Kokabpick S., Lembcke B., Caspary W.F. & Seifert H. (1999) Efcacy and safety of intravenous propofol sedation during routine ERCP: a prospective, controlled study. Gastrointestinal Endoscopy 49, 677683.

Woolf C.J., Saeh-Garabedian B., Ma Q.P., Ma Q.P., Crilly P. & Winter J. (1994) Nerve growth factor contributes to the generation of inammatory sensory hypersensitivity. Neuroscience 62, 327331. Yeh C.H., Lin C.F., Tsai J.L., Lai Y.M. & Ku H.C. (1999) Determinants of parental decisions on drop out from cancer treatment for childhood cancer patients. Journal of Advanced Nursing 30, 193199.

220

2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd

Copyright of European Journal of Cancer Care is the property of Blackwell Publishing Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.