Reducing the Risk of Sedation for Adult Bone Marrow Biopsy Patients: Establishing a New Protocol to Support Pain Control and Anxiolysis

Background: Prior to May 2015, our Adult BMT Clinic's premedication approach for a bone marrow biopsy (BMBX) procedure consisted of an opioid and lorazepam intravenous (IV) push. This practice did not meet our hospital credentialing or institutional policies for procedural sedation. The predominant concern was the potential risk of unintended over-sedation vs. the intended goal of anxiolysis. While there were no cases of respiratory depression or life-threatening side effects, a few patients required extended time in clinic due to the sedating effects of the drug combination. The Sedation Committee met with the BMT clinical team and recommended the use of midazolam alone. Methods: The team established a new premedication regimen with midazolam for anxiolysis and lidocaine for procedural pain. Regimen used prior to transition: Morphine, hydromorphone or fentanyl in low doses with or without lorazepam. A new regimen of midazolam plus lidocaine 1% replaced the former regimen. The BMT clinical team was educated and patients were informed of the change. Data from May through September, 2015 was reviewed and presented to the BMT teams. Data included number of BMBXs, age, sex, and patient complaints. Changes in processes were made based on data and an audit plan was defined. Results: There were 369 BMBXs reviewed May-September, 2015, of which 229 (62%) received some form of anxiolysis. Patient age range was 22-79 with 218 (59%) male and 151 (41%) females. A range of complaints from 4% to 19% of patients who received midazolam plus lidocaine compared to 3%-14% who received an opioid plus lorazepam plus lidocaine. Conclusions: BMBXs with the new regimen have been tolerated well with similar rates of patient complaints. Midazolam is an acceptable approach for patients who require anxiolysis. Further statistical results will be analyzed and shared. Additional opportunities identified: Pre-BMBX assessment to identify those requiring moderate sedation, midazolam dosing revisions, additional integrative therapies to promote procedural comfort, and a BMT-specific process for utilizing the sedation procedure area (Table 1).Table 1Month# BMBX# (%)Pt Complaints Prior to New Regimen (Opioid + Lorazepam + Lidocaine)# (%)Pt Complaints after New Regimen (Midazolam + Lidocaine)May751 (3%)4 (19%)June915 (14%)4 (10%)July720%7 (12%)Aug58(N/A) Hard stop on use2 (4%)Sept73(N/A) Hard stop on use4 (7%) Open table in a new tab