Published online February 5, 2007
PEDIATRICS Vol. 119 No. 3 March 2007, pp. e631-e636 (doi:10.1542/peds.2006-0727)
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ARTICLE

Pediatric and Emergency Medicine Residents' Attitudes and Practices for Analgesia and Sedation During Lumbar Puncture in Pediatric Patients

Vicky R. Breakey, MDa, Jonathan Pirie, MDb,c and Ran D. Goldman, MDb,c

a Divisions of Hematology and Oncology
b Pediatric Emergency Medicine
c Pediatric Research in Emergency Therapeutics (PRETx) Program, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. Analgesia and sedation for painful procedures in children are safe and effective, yet our experience is that pain management during lumbar puncture is suboptimal. We aim to document factors that influence residents' decisions to use analgesia and sedation during lumbar puncture and to compare pediatric and emergency medicine residents' practices.

METHODS. A survey was developed and sent to pediatric and emergency medicine residents from across Canada that inquired about clinical practices, learning experiences, current use of analgesia and sedation for lumbar puncture, and their clinical reasoning for using or abstaining from using analgesia and sedation. The Student's t and {chi}2 tests were used to compare the 2 resident groups.

RESULTS. Of the 374 residents to whom the survey was sent, 245 completed the survey. Pediatric residents reported performing lumbar punctures with no local anesthetic much more frequently. Pediatric residents used EMLA (AstraZeneca, Wilmington, DE) more frequently and injectable lidocaine less frequently. Pediatric residents used sedation for lumbar puncture at least once, more frequently than emergency medicine residents, and used mostly benzodiazepines. Both groups used ketamine at a similar rate. Pediatric residents reported that they witnessed adverse events of sedation more frequently. Although pediatric residents were responsible for teaching trainees the lumbar-puncture procedure significantly more frequently, they reported less educational opportunities during residency themselves and that they were less likely to recommend the use of local anesthetic during lumbar puncture when teaching the procedure.

CONCLUSIONS. Several significant differences exist between the pediatric residents and emergency medicine residents we surveyed. Pediatric residents were using less injectable local anesthesia for lumbar puncture in children and more sedation for the procedure and have had notably less training in the use of sedation. Pediatric residents have more teaching responsibilities than their emergency medicine residents colleagues and are inconsistently recommending the use of local anesthetics for lumbar puncture.

Key Words: lumbar puncture • residents • pediatric • emergency department • pain • sedation • analgesia

Abbreviations: LP—lumbar puncture • PR—pediatric resident • ER—emergency medicine resident • PGY—postgraduate year

Lumbar puncture (LP) is one of the most commonly encountered painful procedures in pediatric medicine. Despite evidence to suggest that analgesia and sedation are both efficacious and safe in children,1 clinical practices do not adhere to these data.2 Although the LP method is well described in pediatric textbooks, the use of local anesthetics for this procedure remains controversial,3,4 and adequate use of analgesia during this painful procedure is limited.2 A recent report, which used logistic regression analysis, found that LPs performed with local anesthetic by residents and medical students were twice as likely to be successful.5

Currently, there are no data on residents' use of analgesia for painful procedures in children. Procedural skills are taught early in training on an individual basis by a variety of teachers, primarily senior housestaff who are still mastering these skills themselves.6 Learning to be competent at LP and other procedures is often based on the principle "see one, do one, teach one," and bad habits may be passed from instructor to learner.6

The objectives of our survey were to document and compare the attitudes of pediatric residents (PRs) and emergency medicine residents (ERs) toward the use of analgesics and anesthetics for LPs in children and to describe the current practice as reported by residents across Canada. In addition, we evaluated residents' education in this area and their LP-teaching methodology.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
We surveyed residents in accredited training programs in pediatric and emergency medicine across Canada. By contacting the chief residents of each training program, we generated a list of 374 residents from a total of 12 programs. Residents and fellows in pediatric subspecialty programs were excluded because of their variable previous clinical exposure.

We developed a survey that included questions about clinical practices, learning experiences, use of analgesia and sedation for LP, and clinical reasoning for using or abstaining from using analgesia and sedation. We conducted a focus group with fourth-year PRs at the Hospital for Sick Children in Toronto, Canada, to identify key issues. In addition, a pilot study of 10 residents ensured completeness and comprehension of the survey before distribution.

We mailed the survey up to 3 times to each resident between December 1, 2003, and June 1, 2004. To maximize the response rate, envelops were number-coded to determine nonresponders, and second and third surveys were mailed out to nonresponders only. Self-addressed, stamped envelopes were sent to each resident to promote easy return.

Data were collected in Microsoft Excel 2003 (Microsoft Corporation, Redmond, WA). Descriptive analysis of means and SDs for normally distributed continuous variables and skewed continuous data were summarized with medians and interquartile ranges; categorical data were summarized with percentages. The {chi}2 and Student's t tests were used for comparison of the 2 resident groups by using SPSS 10.0 for Windows (SPSS Inc, Chicago, IL). P values of <.05 were considered significant.

The study was approved by the Hospital for Sick Children's institutional research ethics board.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Of 374 residents, 245 (67%) completed and returned the survey; 173 (71%) were enrolled in a pediatrics residency, and 72 (29%) were enrolled in either a 5-year Royal College emergency medicine residency program (50) or a 1-year College of Family Physicians of Canada emergency medicine residency program (20). There was representation from all postgraduate years (PGYs) of training: 48 (20%) in PGY1, 59 (24%) in PGY2, 80 (33%) in PGY3, 43 (18%) in PGY4, and 15 (6%) in PGY5 or above. Of the residents surveyed, 231 (94%) had performed at least 1 LP in the preceding 6 months, and 119 (49%) performed between 1 and 4 LPs in the preceding 6 months.

Perception of Pain
Overall, 83 (34%) residents felt that pain was equal among neonates, toddlers, children, and teens undergoing the procedure when asked to estimate the "average pain experienced during LP with no analgesia, anesthesia, or sedation." The trend, however, showed that the residents surveyed felt the pain during LP to be least in neonates and greatest in children aged 4 to 12 years (Fig 1).


Figure 1
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  		FIGURE 1 Residents' estimation of the average pain experienced during LP with no analgesia, anesthesia, or sedation on a scale of 1 to 5 (1, painless; 5, excruciating pain) for different age groups.

 
Local Anesthesia
When asked to describe the frequency of using various methods of local anesthesia for LP, 81 (33%) residents responded that they never perform the procedure without some form of local anesthetic. Comparison of PRs and ERs showed that 57% of PRs frequently, almost always, or always perform the procedure with no local anesthesia versus only 1% of ERs. PRs used EMLA (AstraZeneca, Wilmington, DE) more often than ERs, and the converse was true for lidocaine use (Fig 2).


Figure 2
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  		FIGURE 2 Frequency of various methods of local anesthesia used by residents for LP reported as percent of total respondents, excluding those who declined to answer (N = 173 [PRs] and 72 [ERs]).

 
Factors that discouraged residents from using injectable local anesthesia during LP are presented in Table 1. Age of the patient, pain of injection, and prolongation of procedure were considered significantly more by PRs than by ERs as deterrents to using local anesthetics.


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  		TABLE 1 Factors That Discourage the Use of Injectable Local Anesthesia and Sedation According to Residents Performing an LP on a Pediatric Patient

 
Ten residents (4.1%) reported encountering adverse effects of injectable local anesthesia during LPs. Adverse effects cited included obscured landmarks (3), pain (2), increased anxiety that resulted in increased difficulty of the procedure (2), and local bleeding (1); 2 of these residents did not specify the adverse effect they encountered. There was no significant difference in the frequency of adverse effects from local anesthetic during LPs as reported by PRs and ERs (P = .386).

Sedation
Of the residents, 176 (72%) reported that they had used sedation during LPs in children in the past. PRs used sedation more often than the ERs. Of the PRs, 135 (78%) reported frequently, almost always, or always using sedation, compared with 43 (60%) ERs (P = .004). Benzodiazepines were the preferred method of sedation, used frequently or more often by 54 (31%) of the PRs and 12 (17%) of the ERs (Fig 3).


Figure 3
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  		FIGURE 3 Frequency of various methods of sedation used by residents for LP reported as percent of total respondents, excluding those who declined to answer (N = 173 [PRs] and 72 [ERs]).

 
Factors that residents reported as discouraging against the use of sedation during LPs are presented in Table 1. Significantly more PRs were deterred from using sedation because of concerns of respiratory depression and the age of the child undergoing the LP than the ERs (P < .005).

Of all residents surveyed, 35 (14%) had encountered adverse effects when using sedation. PRs reported more adverse effects than ERs (19% vs 5%; P = .006). Adverse effects cited by respondents included paradoxical reaction to midazolam (10), respiratory depression/apnea (9), hypotension (3), prolonged sedation (3), psychosis from propofol (2), patient's inability to protect the airway (1), increased secretions (1), "ineffectiveness" (1), and seizure (1); 4 residents did not list the adverse effects that they encountered.

Teaching
Of the respondents, 108 (44%) confirmed that they had been educated about the use of sedation in pediatric patients. PRs received less training than ERs (39% vs 57%; P = .008). Of the residents who reported no training, 114 (85%) suggested that formal training would be useful.

As many as 161 (66%) of those surveyed had taught medical students or other residents the procedure, with a mean of 4.5 trainees per resident-teacher. The PRs reported more teaching responsibilities, with 75% teaching trainees, compared with only 44% of the ERs. Overall, residents reported a significant difference in their teaching recommendations for LP in neonates as compared with LP in children. For neonates, 50% of the residents coach trainees to use local anesthetic, and 12% recommend sedation; for children, 67% teach trainees to use local anesthetic, and 63% recommend sedation.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
This is the first report of residents' experiences using analgesia and sedation for LP in children. We chose to compare PRs and ERs on the basis of our hypothesis that training primarily in pediatrics versus adult-based medicine affects decisions in pain management for children. A previous study examined the practices of attending physicians and showed that only 5% (15 of 198) of the pediatric subjects received local anesthesia for LP in a pediatric emergency department, whereas 93% of pediatric patients in a community emergency department were given lidocaine by nonpediatricians.2 A recent prospective observational study showed that local anesthesia was used in 74% of the infants during LP by medical students and residents and, along with stylet techniques, was associated with a higher LP success rate (defined as cerebrospinal fluid containing <1000 red blood cells per mL).5

Our results indicate several significant differences between the PRs and the ERs surveyed. First, it is clear that PRs are using injectable local anesthesia less often for LP in children. Although the use of subcutaneous lidocaine is routine for LP in adults,4 its use is still debated in children. Lidocaine injections have been shown not to obscure landmarks or hinder the procedure,7 and the use of injected lidocaine does not reduce the success rate of the procedure, increase the number of attempts, or result in additional trauma.7,8 In our study, PRs indicated concern that injected lidocaine is painful, despite evidence that suggests otherwise. Also, PRs cited patient age as a deterrent from the use of local anesthesia, suggesting that neonates' pain during LP is the most poorly treated of all. However, it has been shown that local lidocaine injection decreases struggling during an LP, which suggests a higher level of comfort for newborns.8 The use of lidocaine in sick and premature neonates does not increase physiologic instability, and there are no documented disadvantages or adverse effects.8 One possible reason that ERs are more comfortable using lidocaine is its' routine use in the adult setting.

PRs, however, use EMLA, a topical anesthetic, more commonly than do ERs for pediatric LPs. EMLA is associated with diminished pain as reported by children during LP and has been shown to be an effective alternative to lidocaine infiltration.9–15

Children can benefit from sedation for painful procedures.16–20 Midazolam decreases pain-related and anxiety-related behaviors in children before and after LPs, as observed by both parents and physicians.18 It also improves pain scores, induces amnesia of the procedure, and decreases anxiety for future procedures.18 In our study, PRs reported using significantly more sedation for the procedure than did ERs. The reasons for this difference are unclear. It is possible that the fast-paced work in the emergency department decreases the use of sedation for LPs. PRs indicated a significantly higher rate of adverse effects, which may be a result of their lack of training compared with their ER colleagues.

Finally, we found that PRs have more teaching responsibilities than their ER colleagues and are inconsistently recommending the use of injectable local anesthesia for LPs. This raises the concern that procedural training for residents is inadequate. Given the results of this survey, we advocate for the development of more formalized procedural training in pediatric residency programs with training in the use of local anesthetics and sedation for pediatric patients to improve patient care.

There were several limitations to our study. Because no previously validated survey tool exists on this subject, our survey tool was novel. We tried to ensure that the survey was clear and comprehensive by piloting and revising the tool before distribution. Although the response rate was only 67%, it included an adequate sample of residents from all years of training, across the country, and should be generalizable. As with all surveys, there is the possibility of recall bias, and residents may have succumbed to a social-desirability bias and overestimated their attitudes and practices.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
We have documented that incorrect perceptions of pediatric pain persist among residents today. Our results highlight some of the differences that exist in the practices of PRs and ERs. PRs are using less injectable local anesthesia for LP in children, are using more sedation for the procedure, and have less training in the use of sedation. PRs have more teaching responsibilities than their ER colleagues and are inconsistently recommending the use of local anesthetics for LP. The lack of PR education in the use of analgesia and sedation likely contribute to both underuse and misuse, and we recommend pediatric training programs to enhance procedural education to improve care for our pediatric patients.


   ACKNOWLEDGMENTS
 
This study was supported by the Canadian Association of Emergency Physicians Resident Research Grant and the Hospital for Sick Children Trainee Start-up Fund.


   FOOTNOTES
 
Accepted Sep 20, 2006.

Address correspondence to Ran D. Goldman, MD, Pediatric Research in Emergency Therapeutics Program, Division of Pediatric Emergency Medicine, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8. E-mail: ran.goldman{at}sickkids.ca

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
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 ABSTRACT
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 REFERENCES
 

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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics




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