Case Report Intravenous Anesthesia for Total Body Irradiation in a Child without Oxygen Support: Case Report
by Anna Lúcia Calaça Rivoli1, Luiz Eduardo Imbelloni2*, Sylvio Valença de Lemos Neto3, Patrícia L Procópio Lara4, Ana Cristina Pinho5, Pedro Henrique Souza Kelly6, Renata Pra7, Norma Sueli Pinheiro Módolo8, Geraldo Borges de Morais Filho9
1Anesthesiologist at the National Cancer Institute (INCA), Brazil
2National Cancer Institute (INCA), Senior Researcher, Rio de Janeiro, RJ, Brazil
3INCA Anesthesiologist, Responsible for the CET-SBA of the National Cancer Institute, Rio de Janeiro, RJ, Brazil
4Anesthesiologist at the National Cancer Institute (INCA), Brazil
5INCA Anesthesiologist, Co-Responsible for the CET-SBA of the National Cancer Institute, Rio de Janeiro, RJ, Brazil
6Anesthesiologist Resident of CET-SBA of the National Cancer Institute, Rio de Janeiro, RJ, Brazil
7Anesthesiologist at the National Cancer Institute – HC2 (INCA), Brazil
8Professor of the Department of Surgical Specialties and Anesthesiology at Faculty of Medicine of Botucatu - Unesp, Botucatu, SP, Brazil
9Master in Labour Economics, UFPB, João Pessoa-PB. Statistician of the Complexo Hospitalar Mangabeira, João Pessoa-PB, Brazil
*Corresponding author: Luiz Eduardo Imbelloni, National Cancer Institute (INCA), Senior Researcher, Av. Epitácio Pessoa, 2356/203, Lagoa, 22411-072- Rio de Janeiro, RJ - Brazil
Received Date: 20 March, 2024
Accepted Date: 27 March, 2024
Published Date: 29 March, 2024
Citation: Rivoli ALC, Imbelloni LE, de Lemos Neto SV, Lara PLP, Pinho AC, et al. (2024) Intravenous Anesthesia for Total Body Irradiation in a Child without Oxygen Support: Case Report. J Community Med Public Health 8: 425. https://doi.org/10.29011/25772228.100425
Abstract
Background: Total body irradiation twice daily for three consecutive days followed by chemotherapy for conditioning pediatric patients with acute lymphoid leukemia before bone marrow transplantation is superior to chemo conditioning alone. In children, this procedure must be performed with anesthesia, which can be inhaled or intravenous. Case report: The patient was a four-year-old child, weighing 18 kg, with a diagnosis of B-cell acute lymphoblastic leukemia and planned for stem cell transplantation. Parents’ consent form was signed to perform repeated anesthesia (twice/day) for three consecutive days. After monitoring and review of the venoclysis, it was intravenous sedation was performed for the procedure with administration of midazolam 3 mg, ketamine 10 mg (0.5 mg/kg) and dexmethedomidine (0.5 mg/kg). During the procedure, oxygen saturation remained between 94-100%, and at the end, the patient was under observation but without the need for hemodynamic and ventilatory support. Conclusion: Every year the number of procedures performed by interventional radiology in children with cancer increases, thus new anesthetic techniques are used, such as in this case the use of intravenous medication without the need for intubation or laryngeal mask airway, and without the use of supplemental oxygen, without hypoxemia or cardiorespiratory complications occur.
Keywords: Anesthesia; Children; Total body irradiation; Risks; Sedation
Introduction
In recent years, the complexity of patients undergoing interventional radiology has increased, thus also increasing the demand for anesthetic support with all types of anesthesia [1]. Total Body Irradiation (TBI) is a type or radiation therapy is a treatment that delivers small doses of irradiation to your entire body. TBI is used in several types of cancer, such as leukemias, lymphomas, multiple myeloma, and some solid tumors [2]. The TBI treatment is usually delivered twice a day for three to four consecutive days [3]. In pediatric patients, anesthesia or sedation is required to conduct this very crucial treatment effectively.
Most of the articles consulted on the various search sites addressed the form of TBI, and few articles on the anesthetic technique most used in children, and few case reports. However, the provision of sedation and analgesia for children undergoing TBI is now routine and the standard of care. Many pediatric patients may require anxiolysis to have CT or MRI imaging, ultrasound, or echocardiography to ensure adequate imaging is obtained and minimize patient stress [4]. Due to children’s wide age differences and developmental levels, sedation of infants and children is associated with unique challenges for anesthesiologists.
Pediatric procedural sedation refers to techniques and medications used to minimize anxiety and pain associated with unpleasant procedures. The objective of this case report is a 4-year-old child, submitted to two TBI procedures per day, on three consecutive days, using intravenous drugs, without intubation or laryngeal mask airway and without oxygen supply.
Case Report
We recently created a protocol to study the use of radiotherapy in children, having been registered in Plataforma Brazil (CAAE: 91507318.1.0000.5274) and was approved by the Ethics Committee at National Cancer Institute (INCA) with number 2,762,022. A preoperative anesthesia assessment was done, and the informed consent form was signed by one of the children’s parents.
Male patient, requesting together with his parents not to use a mask, as he was panicking, 4 years old, 18 kg, diagnosed with type B acute lymphoblastic leukemia. Eligible for treatment with allogeneic bone marrow transplant, the donor being the father, underwent preparation consisting of TBI carried out by the Clinac CS Linear Accelerator device, Varian Medical Systems (Figure 1), and high doses of chemotherapy with vincristine sulfate (1.5 mg/ kg), daunorubicin (30 mg/m2), asparaginase (5,000 IU/m2). The TBI program consisted of six sessions, twice a day with a 6-hour break between them and lasting one hour, under anesthesia. As part of the routine for performing TBI, the six procedures were performed by different anesthetists, but with the same protocol.
Figure 1: Clinac CS Linear Accelerator device, Varian brand.
For the first treatment session of each day, nothing per oral period was six hours for solid and semi-solid food. In the second treatment session of each day, clear liquid was allowed up to two hours prior to the second anesthesia induction of the day. Standard monitoring for pediatric TBI patients, including electrocardiogram, and oxygen saturation. The anesthetic technique performed was intravenous after revision of the venous access Broviac®/ Hickman® central venous line semi-implantable double lumen 7 French, with the following drugs and doses: midazolam 3 mg (0.15 mg/kg), ketamine 10 mg (0.5 mg/kg), dexmedetomidine (0.5 mg/ kg), and if necessary, propofol (10 mg). In one session in the morning and two in the evening, supplementation with propofol 10mg was necessary, so he could leave his mother and be taken to the TBI room. The monitoring control used was through the closedcircuit camera in the radiotherapy room. There were no changes in heart rate (Figure 2), no respiratory problems and oxygen saturation ranged from 94 to 100% in all sessions (Figure 3). In one session in the morning and another in the evening, midazolam needed to be reversed with flumazenil. In the other children anesthetized in the morning, flumazenil was not used to reverse midazolam, at the mother’s request, as the child would undergo the second treatment at night, and would remain drowsy, which was woken up by the anesthetist (Table 1).
Figure 2: Heart rate from arrival in the operating room to PACU.