Paediatric Anaesthesia 2003 13: 375–383

Review article
Considerations for anaesthesia in children
with haematological malignancy undergoing
short procedures
V A L E R I E C U LS H A W F R C A * , M U R R A Y Y U L E MRCPaed†
AND ROS LAWSON FRCA‡
*Department of Anaesthesia, Victoria Infirmary, Glasgow, †Medical Advisor )
Oncology ⁄ Haematology, Eisai Ltd, London and ‡Department of Anaesthesia,
Royal Hospital for Sick Children, Glasgow, UK

Summary
As a result of increased use of risk-directed treatment regimes, there is
a regular requirement for short-lasting but painful procedures to be
performed on children to aid in diagnosis or treatment. The aim of any
anaesthetic technique is to provide analgesia and amnesia with
minimal side-effects and early return to former activity levels. We
review the implications of haematological malignancy in children
with regard to anaesthesia and the consequences arising from both the
disease and ensuing treatment. We outline some of the current
anaesthetic techniques in use and review the advantages and
disadvantages of each.

Keywords: haematology; malignancy; anaesthesia; children

invasive procedures, particularly bone marrow as-

Introduction
In the UK, cancer affects one in every six hundred
children prior to their sixteenth birthday. The most
common paediatric malignancy is acute leukaemia,
which has a peak incidence between 2–5 years of age.
Intracranial tumours are the most frequent nonhaem-
atological malignancy followed by neuroblastoma,
Wilm’s tumour, non-Hodgkin’s Lymphoma (NHL)
and various bone and soft tissue sarcomas. During
the last two decades, the development of centralized
care facilities, national treatment protocols and
multidisciplinary therapies has produced overall
5-year survival rates in excess of 60% (1). This has
been achieved at the expense of a wider use of
Correspondence to: Valerie Culshaw, Department of Anaesthesia,
Victoria Infirmary, Langside Road, Glasgow G42 9TY, UK (email:
rcunningham@bun.com).
pirates and lumbar punctures for the administration
of intrathecal chemotherapy. Parental preference and
an increased awareness of the limitations of sedation
have led to many of these investigations being
performed under general anaesthesia. The wide-
spread use of intrathecal methotrexate as central
nervous system prophylaxis in preference to cranial
irradiation has considerably increased the number of
children receiving repeated lumbar punctures dur-
ing therapy. In addition, treatment strategies have
become increasingly
risk-directed in an effort to
individualize therapy to patients and their disease
(2). This approach requires multiple marrow aspir-
ates during treatment in order to assess ongoing
response upon which subsequent chemotherapy
decisions are based. These changes have produced
an increasing number of children requiring short and

 2003 Blackwell Publishing Ltd 375

376 V. CULSHAW ET AL.
repeated anaesthetics for invasive procedures. For-
tunately, most of these investigations are performed
electively and can be postponed in the face of
intercurrent illness. The most common exceptions
to this are the newly presenting patient in whom a
tissue diagnosis is often paramount in order to start
treatment and children with an ongoing central
venous line infection requiring urgent removal.
The aim of this review is to identify suitable
techniques for children with haematological malig-
nancy who require anaesthesia and to highlight
some of the potential hazards presented by this
group of patients.
Disease and treatment factors influencing
anaesthesia
Airway obstruction
The most common cause of airway obstruction in
children with cancer is the presence of a mediastinal
mass, which is most often found at presentation
Figure 1
Chest X-ray of a 3-year-old girl with T-cell acute lymphoblastic
leukaemia who presented with respiratory distress as a result of
an extensive mediastinal mass.
 2003 Blackwell Publishing Ltd, Paediatric Anaesthesia, 13, 375–383
(Figure 1). Patients at particular risk are those with
acute lymphoblastic leukaemia (especially those with
a T-cell phenotype and a high white cell count), NHL,
Hodgkin’s disease, neuroblastoma and, more rarely,
intrathoracic germ cell tumours. In these cases, it is
well documented that anaesthesia may cause sudden
and potentially fatal respiratory embarrassment as
resting airway muscle tone is abolished (3,4).
Computed tomagraphy (CT) is often advocated in
the initial assessment of the severity of the obstruc-
tion (5). In the small child, however, anaesthesia may
still be required to obtain adequate CT imaging.
Careful preoperative assessment is essential to elu-
cidate the potential risks, although the severity of a
lesion may not become apparent until loss of
consciousness has ensued (Figure 2).
In such cases, full provision for a potentially
obstructed airway must be in place. This usually
means the presence of an ENT surgeon capable of
inserting a rigid bronchoscope and some centres
even advocate the availability of cardiopulmonary
bypass (6). An inhalational induction with the main-
tenance of spontaneous respiration is recommended
Figure 2
CT scan of an 11-year-old boy with NHL who presented with a
mediastinal mass, following treatment with steroids demonstra-
ting patency of the major airways.
 A N A E S T H E S I A IN C H I L D R E N WI T H H A E M A T O L O G I C A L M A L I G N A N C Y
because this minimizes the loss of airway tone and
thus compression of the airway. This may best be
performed with the patient in a semisitting position.
In a proportion of patients, the diagnosis may have
to be made from cells obtained from an accompany-
ing pleural effusion or a marrow aspirate performed
under local anaesthesia. In an emergency situation
where no diagnostic procedures are without risk,
lymphoid malignancies may be identified by their
location as an anterior mediastinal mass and their
rapid response to corticosteroids.
Coagulopathy
Thrombocytopaenia is an invariable consequence of
most cytotoxic drugs and should be screened for
preoperatively. In order to reduce the risk of
paraspinal haematoma formation, it is our practice
only to perform lumbar punctures in the presence of
a normal coagulation screen and a platelet count of
at least 50 · 109Æl)1. Children who have received
multiple platelet transfusions may become refractory
to random donor platelets and, in such cases, single-
donor or human leukocyte antigen-matched plate-
lets may be required (7). It is prudent to confirm an
adequate increment immediately following platelet
transfusion in multiply transfused children prior to
invasive procedures. The consequences of local
bleeding following marrow aspiration are less severe
and this technique can performed safely by an
experienced operator in the presence of a platelet
count as low as 20 · 109Æl)1. Several groups of
children are at particular risk from ongoing coagul-
opathy, especially patients with active infection,
acute promyelocytic leukaemia and disseminated
neuroblastoma (8,9). Where possible, deranged
coagulation parameters should be corrected preop-
eratively using group-matched fresh frozen plasma
or cryoprecipitate (if plasma fibrinogen is less than
1.5 gÆl)1) using increments of 20 mlÆkg)1.
Tumour lysis syndrome
Patients with a large tumour bulk at presentation,
usually those with acute leukaemia or NHL, may
experience the rapid death of large numbers of
malignant cells following induction chemotherapy.
This tumour lysis leads to progressive renal impair-
ment from urate nephropathy and phosphate preci-
 2003 Blackwell Publishing Ltd, Paediatric Anaesthesia, 13, 375–383
377
pitation with a rapidly rising serum potassium.
Increased serum phosphate concentrations may be
accompanied by hypocalcaemic seizures. Haemofil-
tration can be avoided in the majority of cases by
prophylactic allopurinol and hyperhydration.
Patients considered to be at high risk of urate
nephropathy are often alkalinized with sodium
bicarbonate, which may result in problematic carbon
dioxide retention (10,11). Red cell transfusion may
be inappropriate in children with acute leukaemia
who present with peripheral blast counts of greater
than 100 · 109Æl)1 because of the risk of precipitating
the hyperviscosity syndrome.
Infection
The intensification of paediatric chemotherapy reg-
imens has resulted in periods of prolonged neutro-
paenia accompanied by bacterial and fungal sepsis
(12). In many cases, the risk of infection is heigh-
tened by the presence of an indwelling central
venous catheter which may necessitate urgent atten-
tion. Although it is possible to control florid sepsis
prior to surgery in the majority of cases, often by
ceasing to use an infected central line, a small
number of patients may not respond to antibiotics
prior to its removal. In these circumstances, it may
be unavoidable to administer a general anaesthetic
to a febrile septic patient. It is wise to avoid using a
central line which is known to be infected. Other
indications for surgery in infected neutropaenic
patients are rare but include gastrointestinal com-
plications of treatment, such as volvulus and
appendicitis. Whilst bacterial pneumonias are com-
mon, particular care should also be taken in children
with Streptococcal septicaemias because these are
often accompanied by more subtle respiratory
embarrassment (13). Children with neutropaenic
sepsis may have a subclinical coagulopathy that
should be corrected prior to theatre. Furthermore,
they are frequently affected by electrolyte distur-
bances, particularly hypokalaemia, following treat-
ment with diuretics, aminoglycoside antibiotics and
amphotericin B.
Complications of therapy
Most currently used cytotoxic agents produce
varying degrees of dose-dependent bone marrow
378 V. CULSHAW ET AL.

suppression and, in particular, some are associated
with severe mucositis (cytarabine, melphalan, anth-
racyclines). Several categories of drugs pose further
hazards to anaesthesia, as outlined in Table 1.
Refractory emesis is now rare following the intro-
duction of 5-hydroxytryptamine antagonists.
Despite the widespread use of corticosteroids for
their lymphocytoxic, antiemetic and immunosup-
pressive properties, the incidence of steroid-induced
adrenal crisis in children receiving chemotherapy is
very low. We were unable to find a single docu-
mented report of this in the literature. This may
reflect their use in short courses lasting up to 1 week.
Routine hydrocortisone supplementation is not
given prior to a short procedure.
Ideally, children undergoing elective procedures
should not arrive in theatre with infusions of
cytotoxic drugs or hydration regimens still running
because it is often unclear as to whether these can be
interrupted to provide venous access or whether
individual drugs are compatible with anaesthetic
agents. The literature is scarce regarding the com-
patibility of individual cytotoxic agents with anaes-
thetic agents and it is prudent to avoid any form of
drug mixing. At present, the most commonly
encountered situations are children receiving pro-
longed infusions of
high-dose methotrexate for the
treatment of acute leukaemia or NHL. Although the
methotrexate infusion must be completed prior to
the patient’s arrival in theatre (see below), it is
necessary to continue with intravenous bicarbonate
hydration for at least 72 h in order to increase renal
elimination of methotrexate. All patients undergoing
such therapy will have a double-lumen central
venous line in situ and, whilst the bicarbonate
infusion should not be discontinued, the uninvolved
lumen may be used for the administration of
anaesthetic drugs. It is also imperative to flush any
anaesthetic agents through the line deadspace after
administration. Anthracyline infusions (most com-
monly involving daunorubicin or doxorubicin)
should be discontinued prior to theatre because of
their cardiodepressant property (14).
A minority of patients, usually those with bone
and soft tissue sarcomas, will have received prior
radiotherapy. Although severe mucositis may occur
as an acute complication, the long-term effects of
localized radiotherapy are unlikely to increase

Table 1
Potential anaesthetic hazards of commonly used cytotoxic drugs

Cytotoxic drug Common usage Early complications of therapy Long-term hazards

Vincristine ALL SIADH Peripheral neuropathy

Anthracyclines (daunorubicin, Acute leukaemia, STS, NHL, Cardiomyopathy, Cardiac failurea
doxorubicin, epirubicin, bone tumours, Wilms’ tumour, cardiac arrhythmias
mitozantrone) neuroblastoma, Hodgkin’s disease
Cyclophosphamide NHL, BMT, STS, neuroblastoma Cardiomypathyb, Pulmonary fibrosis
cardiac arrhythmiasb
Ifosfamide NHL, STS, bone tumours Fanconi’s syndrome, Fanconi’s syndrome,
renal failure renal failure
Cisplatin Germ cell tumours, Seizures, hypomagnesaemia, Hypomagnesaemia,
neuroblastoma, renal failure renal failure
bone tumours
Nitrosoureas Intracranial tumours None Pulmonary fibrosis,
(carmustine, lomustine) renal failure
Bleomycin Germ cell tumours, Allergic reactions Pulmonary fibrosisc,
Hodgkin’s disease Raynauds phenomenon
L-Asparaginase ALL Coagulopathy, hepatitis, None
pancreatitis, allergic reactions
Actinomycin D Wilms’ tumour, STS Coagulopathy, liver failure, RDS None
Busulphan BMT Hepatic veno-occlusive disease, None
seizures
a
Girls, patients treated under the age of 5 years and children who have received high cumulative doses (> 240 mgÆm2 of daunorubicin or
doxorubicin) are at particular risk. bFollowing high-dose therapy, such as that employed as conditioning for bone marrow transplantation
only. cFibrosis may be progressive and oxygen exposure may precipitate respiratory failure. ALL, acute lymphoblastic leukaemia; SIADH,
syndrome of inappropriate antidiuretic hormone secretion; NHL, non-Hodgkin’s lymphoma; BMT, bone marrow transplant; STS, soft
tissue sarcoma; RDS, respiratory distress syndrome.

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 A N A E S T H E S I A IN C H I L D R E N WI T H H A E M A T O L O G I C A L M A L I G N A N C Y
the risk of subsequent anaesthesia unless prior
treatment has altered head and neck anatomy. The
widespread use of bone marrow transplantation has
produced an increasing number of long-term survi-
vors who received total body irradiation as condi-
tioning prior to transplant. Many of these patients
have restrictive defects in pulmonary function that
require monitoring perioperatively (15).
Anaesthetic techniques
General preparation
Regardless of the proposed technique, normal fast-
ing regimes and minimal monitoring standards
should apply throughout the perioperative period.
Many children may be on complicated treatment
protocols and the timing of the procedure may need
to be based on adherence to a specific protocol. Full
resuscitation facilities, anaesthetic personnel and
skilled assistance should be available for all proce-
dures where anaesthesia is administered. Documen-
tation of vital signs and the technique used is
mandatory until the child has fully recovered
(16,17).
In our unit, patients are assessed 24 h prior to
anaesthesia. Past medical history, progress of dis-
ease and previous anaesthetic history are evaluated.
Routine measurements of serum biochemistry, hae-
matology and coagulation are made to allow correc-
tion of abnormal indices as far as possible and
preordering of blood products for the following day.
Fit children are then discharged, to return fasted the
following morning.
Topical analgesia
In those children undergoing intensive therapy,
there will be an indwelling tunnelled line obviating
the need for repeated venepuncture (18). Lumens
should be patent and show no evidence of infection.
They should be flushed with heparinized saline
prior to anaesthesia, and again subsequent to the
procedure, paying particular attention to an aseptic
technique. In our unit, it is common practice to use a
clean but not sterile technique in uncomplicated
cases with no neutropaenia or suspicion of sepsis. It
is regarded as a standard of care to use topical local
analgesia, such as EMLA cream or amethocaine gel,
 2003 Blackwell Publishing Ltd, Paediatric Anaesthesia, 13, 375–383
379
if intravenous cannulation is required (19). These
agents also have a useful place in the provision of
surface anaesthesia when applied to bone marrow or
lumbar puncture sites preoperatively (20).
Sedation or anaesthesia?
Sedation and anaesthesia have been differentiated
by the fact that verbal contact is supposed to be
maintained during sedation but lost during anaes-
thesia (17). This is an arbitrary definition and has
little application in paediatric practice. Moreover,
there is a continuous spectrum between the sedated
child and the anaesthetized child and it is difficult to
predict the degree of sedation or anaesthesia that
will ensue when the patient is given a particular
agent. For this reason, the term anaesthesia is used
when describing pharmacological regimes and we
advocate the presence of an anaesthetist during all
procedures.
However, a protocol driven sedation regime using
chloral hydrate has recently been described with
regard to the management of children undergoing
magnetic resonance imaging (MRI) (21).
Intravenous techniques
The most frequently used agents administered
intravenously to provide short-acting anaesthesia
with or without analgesia are propofol, ketamine and
midazolam. These drugs are often used in various
combinations and dosage regimes but are also used
as the sole anaesthetic agent by some operators.
Propofol can be used successfully as a single agent
given as an infusion (TIVA) (22–24) or more simply
in increments by the anaesthetist. TIVA compared
favourably with a thiopentone and isoflurane tech-
nique (25). The use of an infusion pump, providing a
controlled rate of infusion, is cited as being inher-
ently safer than bolus dosing (22). However, from a
practical point of view with a rapid turnover of
patients, anaesthetist administered boluses of prop-
ofol can be used efficiently and safely. An initial
dose of 4 mgÆkg)1 is often required with subsequent
increments of 1 mgÆkg)1 to maintain anaesthesia
depending on the stimulus and duration of the
procedure. The documented antiemetic effect of
propofol, when used without nitrous oxide, has
an advantage in this patient population (24). As
380 V. CULSHAW ET AL.
apnoea can occur initially, it is imperative that an
anaesthetist is present to maintain and secure the
airway if required. Supplemental oxygen is often
necessary. The combination of propofol and the ultra
short-acting opioid remifentanil has been evaluated
for use in short painful procedures and this further
increases the risk of apnoea, albeit improving con-
ditions and reducing the amount of propofol
required (26,27).
Pain on injection when propofol is given into a
peripheral vein is commonly experienced. If a
peripheral line is being used, it is important to add
lidocaine (0.2 mgÆkg)1) to the syringe to attempt to
attenuate the discomfort. This complication is obvi-
ously avoided if given centrally, although the speed
of injection may influence how comfortable the child
finds the induction. A slow induction may avoid
unpleasant sensations.
The phencyclidine derivative ketamine has both
analgesic and anaesthetic properties, making it a
useful agent for this type of procedure. It also usually
preserves airway reflexes, respiration and cardiovas-
cular stability. An initial bolus of 2 mgÆkg)1 will
provide good analgesia for 5–10 min and the drug
can easily be given in increments to prolong anaes-
thesia. Ketamine would appear to potentially have a
major role as the main agent in these procedures.
However, it use is limited by the complication of
emergence dreams and hallucinations, making a
quiet recovery environment and perhaps the use of
a benzodiazepine imperative. In addition, excessive
salivation and hypertension can occur and an anti-
sialogogue is recommended. Using a combination of
drugs may mean that the child takes longer to
recover than when a single agent is used and this
may be less acceptable if early discharge and return
to
street-fitness is desired. The use of ketamine is not
recommended in intracranial malignancy due to the
consequent effect on intracranial pressure.
The short-acting, water-soluble benzodiazepine,
midazolam, has a rapid onset and short duration of
action and a role in the provision of anxiolysis and
amnesia (28,29). It may be usefully employed in
combination with a short-acting opioid or ketamine
(30,31). Adverse effects are few, but will obviously
increase if given with other sedative agents. The
recommended dose is up to 0.1 mgÆkg)1, although
this should be titrated to effect with careful evalu-
ation of physical health and concomitant medication.
 2003 Blackwell Publishing Ltd, Paediatric Anaesthesia, 13, 375–383
Midazolam may be used in abating emergence
phenomena when ketamine is used (29).
Ketamine has been studied in combination with
midazolam. Pellier et al. successfully used ketamine
doses of 1–2 mgÆkg)1 along with 0.025 mgÆkg)1 of
midazolam. The advantages were reported to be a
reduced dose of midazolam, and hence more rapid
recovery times, and a reduced incidence of dysphor-
ic reactions (31). In the study of Parker et al., no
respiratory support or reversal of sedation was
claimed to be necessary using a combined keta-
mine ⁄ midazolam technique (30).
Methohexitone and etomidate have also been
described in techniques for paediatric oncology
procedure management but appear to confer little
advantage over existing newer agents (32).
Stress and anxiety may affect anaesthetic require-
ment and supplementation of an intravenous tech-
nique with volatile agent during the procedure may
be required.
Inhalational agents
Induction with an intravenous induction agent and
maintenance with a volatile agent is frequently used
but, if intravenous access is not preexisting, it is
often simpler to perform a gaseous induction on a
suitably prepared child. With the introduction of
sevoflurane, this can be well tolerated with an
extremely rapid induction due to the the low blood
gas solubility and acceptable odour of the agent.
Recovery from a short procedure is also rapid for the
same reason. There is an observed incidence of
excitement following sevoflurane anaesthesia but
adequate analgesia postprocedure may minimize
this (33). Studies using the other volatile agents
have been described but there appears to be little
advantage over sevoflurane other than cost. Recent
studies have tended to concentrate on intravenous
techniques. Prior to the introduction of sevoflurane,
Fisher et al. studied 60 children, comparing isoflura-
ne, enflurane and halothane, and concluded that
rapid recovery times and minimal airway related
complications made halothane an excellent agent for
short procedures (34). In their study, isoflurane
showed the greatest incidence of laryngospasm
and coughing. Enflurane had the most rapid recov-
ery times. There was no difference in nausea or
vomiting.
 A N A E S T H E S I A IN C H I L D R E N WI T H H A E M A T O L O G I C A L M A L I G N A N C Y
The issue of adequate anaesthetic gas scavenging
arises if these procedures are not being performed in
the operating department environment, and this is
particularly relevant with respect to the use of
nitrous oxide.
The use of nitrous oxide
Nitrous oxide with oxygen in the form of Entonox
has been advocated as the sole method of anaesthe-
sia in older children with some success (35).
However, nitrous oxide impairs methionine syn-
thetase activity, disturbing folate metabolism and
thus vitamin B12 metabolism. Bone marrow sup-
pression is more likely to occur when exposure to
the agent is prolonged but, theoretically, this can still
occur with short periods of administration. In
patients receiving methotrexate, which also acts by
impairing folate metabolism and with additional
causes for bone marrow suppression, it would
appear that the use of nitrous oxide as an adjunct
to anaesthesia should be applied with caution. It is
also conceivable that nitrous oxide may reduce the
therapeutic benefit and increase the side-effects of
methotrexate therapy (36,37).
Alternative routes of administration
The oral, transmucosal and rectal routes of drug
administration have also been utilized in the anaes-
thetic management of short procedures using mid-
azolam, ketamine and fentanyl (38–40). However,
the induction may be less predictable and unsuited
to longer or more technically difficult procedures.
An alternative to intramuscular injection is always
preferable.
Midazolam is available only as the bitter-tasting
i.v. preparation in the UK. For oral use, it can be
disguised in a small amount of sweetened juice or
paracetamol syrup. This should be administered
30 min before performing the procedure and has a

window of full effect of approximately 30 min.
The fentanyl lollipop for transmucosal adminis-
tration as a premedicant or adjunct to anaesthesia
has been studied. The main side-effect is a signifi-
cant incidence of vomiting. Usual doses are 15–
20 lgÆkg)1. Vital signs remain stable and it has been
shown to reduce the pain of minor procedures in
older children (39). At present, it is not widely used.
 2003 Blackwell Publishing Ltd, Paediatric Anaesthesia, 13, 375–383
381
Midazolam and S-(+)-ketamine have been used in
combination rectally for anaesthesia during MRI (38).
Adjuvant techniques
There have been attempts to analyse individual
patient response to these procedures (41). Beha-
vioural technique training has been used in addition
(42). There is little evidence that children as a group
habituate to multiple procedures. This may be due to
the fact that there is no static stimulus and that there
is a tendency for inconsistencies. For example, there
may be a different operator or anaesthetist on
several occasions. The number of previous vene-
punctures or the presence of scarring from previous
operations also have a role in the stress response.
Factors described that influence the response of
the child, and which may be manipulated, include
the behaviour of the personnel in the immediate
theatre environment, overreassurance, criticism of
the child and parental anxiety (42). Coping tech-
niques for parents are available.
Postprocedure complications
As already emphasized, a full recovery area with
trained staff is mandatory.
Postoperative nausea and vomiting (PONV)
Nausea and vomiting should be treated early. Those
children who have had a prolonged fast and who
vomit may require intravenous rehydration. Using a
single agent technique without nitrous oxide, the
incidence of PONV is very low (24).
Pain
In our experience, children do not experience signi-
ficant discomfort following a single bone marrow
aspirate. Our practice is to infiltrate local anaesthetic
only following multiple aspirates and trephine
biopsies.
Postdural puncture headache (PDPH)
The incidence of PDPH in children has not been
studied extensively. This may be the result of under
reporting or a failure to recognize the less-well
382 V. CULSHAW ET AL.
defined symptoms of this type of headache in the
younger child. Reported incidences range from
8–50% and vary with age (43,44). However, a recent
study has shown that age bears no relation to
whether a child experiences a headache after lumbar
puncture (45).
As with adults, the factors influencing PDPH are
gauge and type of spinal needle and its orientation
to dural fibres when lumbar puncture is performed.
In addition, the volume of cerebrospinal fluid
drained for sampling, relative to a chemotherapeutic
agent injected, may be of relevance.
Children who experience prolonged vomiting
after lumbar puncture may be experiencing PDPH
symptoms. There has been one reported case of
successful blood patch use in a child (46), although
injecting into the epidural space in the potentially
pancytopaenic patient should be viewed with
caution.
Personal practice
We operate a weekly theatre list for routine proce-
dures such as lumbar punctures, bone marrow
aspirates or trephine biopsies and the elective
removal of central lines. Because of the lethal toxicity
of vincristine when given intrathecally, this drug is
not permitted within the theatre suite (47). Child-
rens’ cancer centres within the UK employ a wide
variety of protocols for the handling of central lines
(18). As the benefit of individual protocols remains
unproven, we use a clean, rather than sterile,
technique for handling an indwelling central line.
Historically, patients with chemotherapy-induced
neutropaenia have been treated in isolation cubicles
rather than in open wards. Unsurprisingly, given
that the majority of infections are endogenous in
origin or central venous line related, there is no
convincing evidence that this practice is associated
with an improved outcome. Patients undergoing
bone marrow transplantion often experience a pro-
longed period of severe neutropaenia making them
susceptible to airbourne fungal infection, typically
with aspergillus fumigatus. In order to reduce the
incidence of infection, many units maintain patients
in high efficiency particulate arresting (HEPA) air
filtration and ⁄ or laminar airflow units until their
neutropaenia resolves. While there have been no
randomized comparisons of different air filtration
 2003 Blackwell Publishing Ltd, Paediatric Anaesthesia, 13, 375–383
and isolation techniques, one retrospective analysis
reported an improved survival in adults undergoing
allogeneic bone marrow transplantation nursed in
laminar air flow or HEPA rather than a side room
(48). On a practical level, bedside anaesthesia is
usually rendered impossible by the lack of space
within air filtration units and there is no alternative
to using a ward side room or the theatre suite. In the
absence of evidence to the contrary, it is our practice
to transfer patients to the theatre suite where all
appropriate equipment is readily available, at the
same time ensuring that no unnecessary delays
occur.
References
1 Stiller CA, Bunch KJ. Trends in survival of childhood cancer in
Britain. Br J Cancer 1990; 62: 806–815.
2 Pui CH, Evans WE. Acute lymphoblastic leuemia. N Engl J Med
1998; 339: 605–615.
3 Ferrari LR, Bedford RF. General anesthesia prior to treatment
of anterior mediastinal masses in children. Anesthesiology 1990;
72: 991–995.
4 Dilworth KE, McHugh K, Stacey S et al. Mediastinal mass
obscured by a large pericardial effusion in a child: a potential
cause of serious anaesthetic morbidity. Paed Anaesth 2001; 11:
479–482.
5 Shamberger SC, Holzman RS, Griscom NT et al. CT quantita-
tion of tracheal cross sectional area as a guide to surgical and
anesthetic management of children with anterior mediastinal
masses. J Pediatric Surg 1991; 26: 138–142.
6 Goh MH, Lui XY, Goh YS. Anterior mediastinal masses ) an
anaesthetic challenge. Anaesthesia, 1999; 54: 670–674.
7 Murphy MF, Waters AH. Platelet transfusions: the problem
with refractoriness. Blood Rev 1990; 4: 16–24.
8 Scott JP, Morgan E. Coagulopathy of disseminated neurobla-
stoma. J Pediatr 1983; 103: 219–222.
9 Tallman MS, Kwaan HC. Reassessing hemostatic disorder
associated with acute promyelocytic leukemia. Blood 1992; 79:
543–553.
10 Stapleton FB, Strother DR, Roy S et al. Acute renal failure at
onset of therapy for advanced stage Burkitts’ lymphoma and
acute B cell lymphoblastic leukemia. Pediatrics 1988; 82: 863–
869.
11 Ten Harkel AD, Kirst-Van Holte JE, Van Weel W et al.
Alkalinisation and the tumour lysis syndrome. Med Ped Oncol
1998; 31: 27–28.
12 Albano EA, Pizzo PA. Infectious complications in childhood
acute leukemias. Pediatr Clin Am 1988; 35: 873–901.
13 Martino R, Subira MR, Manteiga R et al. Viridans streptococcal
bacteremia and viridans streptococcal shock syndrome in
neutropenic patients; comparison between children and adults
receiving chemotherapy or undergoing bone marrow trans-
plantation. Clin Infect Dis 1995; 20: 476–477.
14 Hale JP, Lewis IJ. Anthracyclines; cardiotoxicity and its
prevention. Arch Dis Child 1994; 71: 457–462.
15 Makiperbaa A, Heino M, Laitinen LA et al. Lung function
following treatment of malignant tumour with surgery,
 A N A E S T H E S I A IN C H I L D R E N WI T H H A E M A T O L O G I C A L M A L I G N A N C Y
radiotherapy or cyclophosphamide in childhood. a follow up
study after 11–27 years. Cancer 1989; 63: 625–630.
16 Morton N, Oomen GJ. Development of a selection and
monitoring protocol for safe sedation of children. Paed Anaesth
1998; 8: 65–68.
17 American Academy of Pediatrics. Guidelines for monitoring
and management of pediatric patients during and after
sedation for diagnostic procedures. Pediatrics 1989; 89: 1110–
1115.
18 Tweedle DA, Windebank KP, Barrett AM et al., on behalf of the
UK Childrens Cancer Study Group and the Paediatric Oncol-
ogy Nursing Forum. Central venous catheter use in UKCCSG
oncology centres. Arch Dis Childhood 1997; 77: 58–59.
19 Gall O, Annequin D, Revault N et al. Relative effectiveness of
lignocaine prilocaine emulsion and nitrous oxide inhalation
for routine preoperative laboratory testing. Paed Anaesth 1999;
9: 305–310.
20 Kapelushnik J, Koren G, Solh H et al. Evaluating the efficacy of
EMLA cream in alleviating the pain associated with lumbar
puncture: comparison of open and double protocols in
children. Pain 1990; 42: 31–34.
21 Keengwe NI, Hedge S, Dearlove O et al. Structured sedation
programme for magnetic resonance imaging examination in
children. Anaesthesia 1999; 54: 1069–1072.
22 Scheiberf G, Ribeiro FC. Deep sedation with propofol in
children undergoing radiation therapy. Paed Anaesth 1996; 6:
209–213.
23 Gonzalez-Arrieta ML, Juarez-Mendelez J, Silva-Hernandez J
et al. Total intravenous anaesthesia with propofol vs. propo-
fol ⁄ midazolam in oncology patients. Arch Med Res 1999; 26:
75–78.
24 Mcdowal RH, Scher CS, Barst SM. Total intravenous anesthe-
sia for children undergoing brief diagnostic procedures. J Clin
Anesth 1995; 7: 273–280.
25 Harlington DW, Harrison DA, Dorman T et al. Comparison of
thiopentone-isoflurane anaesthesia versus propofol infusion in
children having repeat minor haematological procedures. Paed
Anaesth 1997; 7: 19–26.
26 Keidan I, Berkenstadt H, Sidi A et al. Propofol ⁄ remifentanil
versus propofol alone for bone marrow aspiration in paediat-
ric haemato-oncological patients. Paed Anaesth 2001; 11: 297–
301.
27 Duce D, Glaisyer H, Sury M. An evaluation of propofol
combined with remifentanil: a new intravenous anaesthetic
technique for short painful procedures in children. Paed
Anaesth 2000; 10: 689–690.
28 Rosen DA, Rosen KR. Intravenous conscious sedation with
midazolam in paediatric patients. Int J Clin Pract 1998; 52: 46–
50.
29 Seivers TD, Yee JD, Foley ME et al. Midazolam for conscious
sedation during pediatric oncology procedures; safety and
recovery parameters. Pediatrics 1991; 88: 1172–1179.
30 Parker RI, Mahan RA, Giugliano D et al. Efficacy and safety of
intravenous midazolam and ketamine as sedation for thera-
peutic and diagnostic procedures in children. Pediatrics 1997;
99: 427–431.
 2003 Blackwell Publishing Ltd, Paediatric Anaesthesia, 13, 375–383
383
31 Pellier I, Monrigal JP, Moine P et al. Use of intravenous
ketamine–midazolam association for pain procedures in
children with cancer. A prospective study. Paed Anaesth 1999;
9: 61–68.
32 Freyera DR, Swanda E. Intravenous methohexital for brief
sedation of pediatric oncology out patients: physiologic
behavioral responses. Pediatrics 1997; 99: E8.
33 Lapin SL, Auden S, Goldsmith J et al. Effects of sevoflurane on
recovery in children: a comparison with halothane. Paed
Anaesth 1999; 9: 229–304.
34 Fisher DM, Robinson SR, Brett C et al. Comparison of enflurane
halothane and isoflurane for diagnostic and therapeutic pro-
cedures in children. Anesthesiology 1985; 63: 647–650.
35 Miser A et al. Use of a patient controlled device for nitrous
oxide administration to control procedure related pain in
children and young adults with cancer. Clin J Pain 1988; 4: 5–10.
36 Ueland P, Refsum H, Wesenberg F et al. Methotrexate therapy
and nitrous oxide anesthesia. N Engl J Med 1986; 314: 1514.
37 Wyatt SS. An absolute contraindication to nitrous oxide.
Anaesthesia 1999; 54: 307.
38 Haeseler G, Zuzan O, Kohn G et al. Anaesthesia with
midazolam and S-(+)-ketamine in spontaneously breathing
patients during magnetic resonance imaging. Paed Anaesth
2000; 10: 513–519.
39 Schechter NL, Weisman J, Rosenblum M et al. The use of
transmucosal fentanyl citrate for painful procedures in chil-
dren. Pediatrics 1995; 95: 335–339.
40 Tobias JD, Phipps S, Smith B et al. Oral ketamine premedica-
tion to alleviate the distress of invasive procedures in pediatric
oncology patients. Pediatrics 1992; 90: 537–541.
41 Slifer KJ, Babbit RL, Cataldo MD. Simulation and countercon-
ditioning as adjuncts to pharmacotherapy for invasive pedi-
atric procedures. Dev Behav Paediatr 1995; 16: 133–141.
42 Blount RL, Powers SW, Cotter MW et al. Making the system
work. Training paediatric oncology patients to cope and their
parents to coach them. Behav Modif 1994; 18: 6–31.
43 Wee LH. The incidence of postdural puncture headache in
children. Anaesthesia 1996; 51: 1164–1166.
44 Ramamoorthy C, Geiduschek JM, Bratton SL et al. Postdural
puncture headache in pediatric oncology patients. Clin Pediatr
1998; 37: 247–251.
45 Kokki H, Salonvaara M, Herrgard E et al. Postdural puncture
headache is not an age related symptom in children. Paed
Anaesth 1999; 9: 429–434.
46 Robbins KB, Prentiss JE. Prolonged headache after lumbar
puncture. Clin Pediatr 1990; 29: 350–352.
47 Williams ME, Walker AM, Bracikowsk JP et al. Ascending
myeloencephalography due to intrathecal vincristine sulphate:
a fatal chemotherapeutic error. Cancer 1983; 51: 2041–2047.
48 Passweg JR, Rowlings PA, Atkinson KA et al. Influence of
protective isolation on outcome of allogeneic bone marrow
transplantation for leukemia. Bone Marrow Transpl 1998; 21:
1231–1238.
Accepted 16 April 2002