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Discov Oncol
Discov Oncol
Discover Oncology
2730-6011
Springer US New York

39244740
1209
10.1007/s12672-024-01209-4
Comment
Addressing the critical gap: conscious sedation for pediatric oncology patients in LMICs
Bukhari Syed Ibrahim 1
Arega Gashaw gashaw.arega@aau.edu.et

2
Altaf Sadaf 1
1 https://ror.org/03gd0dm95 grid.7147.5 0000 0001 0633 6224 Department of Oncology, Aga Khan University, Karachi, Pakistan
2 https://ror.org/038b8e254 grid.7123.7 0000 0001 1250 5688 Division of Hematology Oncology, Department of Pediatrics & Child Health, Addis Ababa University, Addis Ababa, Ethiopia
8 9 2024
8 9 2024
12 2024
15 41528 5 2024
30 7 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Most newly diagnosed pediatric cancer patients reside in LMICs. These countries face challenges in providing quality treatment, particularly with procedures requiring stillness or causing pain. Conscious sedation (CS) is underutilized in LMICs due, causing treatment delays and adverse outcomes. Advocacy for CS teams, training, and policy support is essential to improve outcomes.

Keywords

Conscious Sedation
Treatment Delays
Need of Training
LMICs
issue-copyright-statement© Springer Science+Business Media, LLC 2024
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pmcIntroduction

Approximately 416 500 pediatric cancer patients are diagnosed each year globally. Majority of these children reside in low- and middle-income countries (LMICs) [1]. LMICs have challenges in maintaining the quality of treatment due to resource and expertise constraints.

In the treatment of oncology patients, numerous procedures demand either prolonged stillness or inflict pain or trauma on the patient. These include frequent lumbar punctures (LPs) for intrathecal chemotherapy delivery, bone marrow aspirations and biopsies, therapeutic radiation, and radiological scans. Maintaining stillness is crucial during radiological scans and radiation therapy to ensure accurate results and prevent harm to the patient. Conversely, LPs and bone marrow biopsies can be intensely painful, causing significant distress to patients and their families when performed while awake. These procedures often necessitate either conscious participation or administration of general anesthesia (GA) to children, which is burdensome, time-consuming, resource-intensive, and carries inherent risks.

In high-income countries (HICs), conscious sedation (CS) or moderate sedation/analgesia, which entails being in a state of moderate sedation and analgesia that allows children to remain responsive while maintaining protective airway reflexes, is used for procedures. In this state, children are unaware of their surroundings and can undergo procedures without experiencing fear and pain [2]. Importantly, they can be easily awakened within minutes after the procedure is completed. This method is favored by both patients and practitioners, as it enables smooth and swift completion of procedures without causing distress. Unlike general anesthesia (GA), conscious sedation minimizes time consumption and spares patients from potential adverse effects. Various drugs such as midazolam, chloral hydrate, fentanyl, morphine, and ketamine can be employed for this purpose, reflecting the widespread adoption of this approach in HICs.

In contrast, many LMICs lack the resources and expertise required for CS. Consequently, they encounter significant challenges in performing these procedures, leading to delays and deferrals that ultimately impede the treatment process. Lack of CS causes significant emotional trauma to both children and their parents, where they associate their treatment journey with fear and pain especially with various procedures. Interruptions in treatment are strongly linked to unfavorable outcomes and increased risk of cancer relapse among patients [3, 4].

However, this approach has its own set of advantages and disadvantages. Patients undergoing CS may experience adverse effects such as vomiting, desaturation, prolonged sedation, and apneic events, all of which can pose life-threatening risks [5]. Therefore, physicians administering CS must be certified for this procedure, fully informed about its potential side effects, and prepared to manage any adverse events that may arise.

We conducted a Google Forms survey across tertiary care centers in Ethiopia and Pakistan, specifically focusing on pediatric cancer patients. We received 33 responses from 15 prominent centers, with 40% originating from Ethiopia and 60% from Pakistan. Approximately 51.5% of respondents indicated that their patients required interventions other than conscious sedation for procedures (Fig. 1). Furthermore, 27% reported lacking a dedicated conscious sedation team (Fig. 2). For those facilities that do have such a team, there is a shortage of trained physicians within it to adequately manage the high patient turnover. Consequently, 51.5% of respondents highlighted experiencing procedural delays due to the unavailability of these teams (Fig. 3 & 4). There are obvious limitations to this preliminary survey, including a small number of respondents and the inclusion of only a limited number of cancer treatment centers from two LMICs. Nonetheless, these findings underscore a concerning reality: a substantial number of patients experience delays in procedures, ultimately impacting their treatment timelines and, consequently, their overall outcomes.Fig. 1 Answer of ‘How do you perform the procedures?’

Fig. 2 Answer of ‘Do you have a dedicated team to provide conscious sedation?’

Fig. 3 Answers regarding issues of procedural delays due to non-availability of conscious sedation teams

Fig. 4 Average procedure delays per month

Conclusion

There needs to be advocacy by pediatric oncologists in LMICs for establishing teams for CS. Certification courses for CS must be incorporated in both physician and nursing training programs. Hospital administrations must create policies and regulations against children getting procedures without conscious sedation. As the certification process and guidelines take time to establish, particularly in LMICs, specific guidelines and timelines must be formulated for each hospital based on their capacity to train and create a team of adequately certified personnel to administer CS. Once the team is established, hospital protocols must be developed to make the use of CS mandatory for every procedure. Additionally, governmental involvement is essential to provide support to public hospitals and encouraging policies for implementation of safe conscious sedation in all centers where children are being treated for cancers. By collectively addressing this issue, we can eliminate a significant barrier to childhood cancer care and ultimately enhance outcomes for these resilient patients.

Abbreviations

LMICs Low- and Middle-Income Countries

HICs High-Income Countries

CS Conscious Sedation

LP Lumbar Punctures

GA General Anesthesia

Acknowledgements

Not applicable

Author contributions

SIB contributed to conception and design as well as drafted the work. GA contributed to acquisition of data and wrote the manuscript. SA was the project supervisor and revised it. All authors reviewed the manuscript and have agreed to be personally accountable for their contributions.

Funding

Not applicable.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Human Ethics and Consent to Participate declarations: not applicable.The study was conducted in accordance with the WMA Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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