Child's Play: Avoiding Anesthesia in Pediatric Radiation Patients

Danielle Crump, BSN, RN

Danielle Crump, BSN, RN

Going for radiation therapy can be scary for any patient with cancer, even more so for a pediatric patient who might not understand the process or machines involved. Often, the answer to that fear and anxiety is treating the child with anesthesia beforehand. This solution is time-consuming, and whether it comes with long-term side effects is yet unknown.

Instead of relying on anesthesia, Danielle Crump, BSN, RN, worked to develop the Pediatric Training Program within the Radiation Department of Johns Hopkins Hospital. This initiative saves time and money while avoiding any risks or complications that might come from administering anesthesia to a pediatric patient.

Oncology Nursing News: Why is it important to avoid anesthesia, especially in children?

Crump: What we found was that we had no standard; we were just basically signing kids up for anesthesia because they were anxious, because of the unknowns. We had complications happen under anesthesia and radiation. Another component was that it was taking up a lot of time. Now, with this program, we can avoid the risk and complications that come along with anesthesia as well as give back that precious time to the family. Kids get stressed staying in radiation too long.

The other thing is, if a child gets anesthesia over the course of 6 weeks, we don't really know what the long-term effects of that are.

What is the training program that you’ve developed, in place of anesthesia?

Instead of anesthesia we go through a pediatric training program where we acclimate the patient and the family to our department so they can see what's going on in the department, so they can become familiar with what we do. We don't really cause pain—what we do is the “Mannequin Challenge,” this is, staying still. Anybody can do that if you train them. It's really acclimating the patient and family: This is what we do, these are the tools we use, these are our machines. Just to get them comfortable.

What are some specific things you do with the child, during the program?

We have a simulation room, where we create the immobilization devices. If we're treating a child with brain cancer, we will make a hand-mold first, to slow things down. We're not going to make a mask immediately. We'll do a little play, we'll show them everything that's in the room, we'll show them our hot-water bath, where we put our beginning mold into the bath and they can see how that changes. And then we'll make a hand-mold, so they can feel the sensation on their skin. Sometimes, they're not ready for it, and there's no rush. If this is going to be successful, we need to be patient. When we get to the point where we're ready to try it on their face, we explain what we’re doing the whole time. It can be really warm and wet, so we'll take cold towels and help to dry the mask quicker, and cool it down, so they're not so anxious.

How important is it to have the family there with the patient?

We really are focused on the patient- and family-centered care model, where we have families come into the room with the patient when we get them ready for the radiation session. We have a planning session where we create that immobilization device for their treatment. Sometimes siblings can model for us, and kids are more apt to do it, because they see that their sibling is doing it and that there's no pain, that the sibling isn't afraid. And it's nice because you do have the encouragement of the family right there throughout the whole process.

How long is a child typically in the program?

Every child is different. The simulation sessions are 1 hour, but if we see they need more time, we can schedule more time. The longest I've done with a patient is maybe 2 hours.

We never want to push anybody to the point where they're feeling upset about it and they're completely stressed out. We also will send home 1 of the masks, and they can do some home training. Parents are open to this, because they know it will benefit their child by avoiding complications. And it's going to free up some of their time. If their child needs anesthesia, they're going to spend 2 to 3 hours with me, Monday through Friday over 6 weeks. That motivates them.

What are some of the outcomes of this program?

When we started in 2011—and we were just experimenting with some idea—that year we had 60% of our children, aged 3 to 12, were able to do radiation without anesthesia; so, for 40%, we still had to give anesthesia. And then in 2012, we treated 90% of the patients without anesthesia. So only 10% each year, up until 2016. In 2016 we had no anesthesia. That's a huge drop. I plan to keep that going with our Child Life Specialist.

I really press to get all the kids treated without anesthesia. There's a joke they say to me, “If you could get a 6-month-old to do it, you would.” I'm not that crazy, but I would try, if I could.

What advice do you have for a center trying to implement a program like this?

I would say that you have to reach out to a child life specialist. You have to do some reading; you have to find out what's out there. You want to think about the milestones that the child is going through: Have they even met this developmental milestone? Does this machine look like a huge creature to them?

And you have to be patient—that's the number one thing. These are children you're working with. We all have, in nursing, these times that we have to get things done. We're task-oriented. That kind of falls off when you're working with children. It's all about patients and asking, “What's the safest way we can do this?”

What would you say is the main takeaway of this program?

I think it’s knowing that this is a time-saving initiative, it's cost-effective, and it also helps the family and lets them feel a sense of autonomy and accomplishment. They're doing this. This is huge. And we do celebrate this at the end of every treatment—we have a huge party, we have a bell-ringing. I just think that it's the way to do it if you can.