Precision sedation puts kids in control of their lumbar punctures

Butterflies, playrooms, crafts, bracelets with her name on them, glass elevators and getting better. These are a few things that seven-year-old Avery thinks of when she thinks of The Hospital for Sick Children (SickKids). These everyday memories outweigh some tougher moments of her cancer journey, in part because her care team is rethinking one of the most routine but daunting procedures in leukemia treatment: lumbar punctures.

At age 4, Avery was diagnosed with Acute Lymphoblastic Leukemia (ALL) after her parents started to notice she was more tired than usual. It took a few investigative appointments before she was finally diagnosed and rushed down to SickKids.

“It all happened very quickly,” says Lauren, Avery’s mom. “She needed blood transfusions and quickly started a treatment regimen. We spent a lot of time at SickKids after that.”

As Avery settled into routine treatment, her care team raised a new possibility: what if they took a more precise approach to her sedation plan for lumbar punctures, one made just for her. It was a meaningful shift that reflects Precision Child Health at SickKids, a movement where teams continually look for opportunities to individualize care to each child’s specific needs and preferences.

Lumbar punctures are part of a standardized treatment plan for leukemia and lymphoma patients. It’s a procedure that involves putting a needle into the spinal canal to either take a sample of fluid to be analyzed and/or deliver a specific kind of chemotherapy.

Most patients typically receive 20 to 30 over the course of their treatment. Because it requires an exact approach to accurately place the needle in the spine, younger kids receive a general anesthetic to keep them still for the procedure. But with ALL, studies have shown an increased exposure to anesthesia may correlate with reduced reaction times, slower process speeds, and other neurocognitive deficits later in life.

“We started to think about how we can change our approach, instead of broadly giving anesthesia to everyone,” says Dr. Karen Arane, Pediatric Hematology/Oncology Fellow. “If we could offer the choice for kids to stay awake with their preferred sedative and distraction method, then it’s beneficial for everyone. Typically, we’ve only offered this to older teenagers, who we know might more easily tolerate the stillness required for the procedure.”

In 2023, a multi-disciplinary team from Anesthesia, led by Drs. Tobias Everett and Daphne Li, alongside Oncology and Child Life launched a quality improvement project to assess whether offering a more tailored approach was feasible for kids ages 5 to 18. It’s not the first time Anesthesia has supported teams in rethinking their sedation methods to improve patient care, including most recently in the Ophthalmology Clinic. 

Minimizing stress, maximizing safety  

To the team, trialing a new approach involved striking a delicate balance between minimizing anesthesia exposure and ensuring that a reduction in sedation did not cause unnecessary distress or discomfort. 

In practice, that means taking a more individualized approach by offering a menu of options that support a patient’s choice in their experience. 

For example, if they choose to stay awake, they can make decisions around who they want in the room, what distraction methods they prefer (like a tablet, virtual reality, music, guided imagery, or games), what level of sedation they want, and whether they want the room quiet or prefer to be talked through the procedure.  

With resources like information sheets for caregivers and checklists to help patients create their own ‘game plan’, the team found that many kids — even as young as five — were comfortable staying awake for their lumbar puncture.  

For Avery, who was one of the youngest patients to participate, the big benefit was not having to fast, a requirement before going under general anesthetic. 

“A side effect of one of her medications was extreme hunger, and on lumbar puncture days it was really hard to explain to her why we couldn’t give her food,” says Lauren. “Being able to wake up and have breakfast before heading down to SickKids was a big bonus, and having the options laid out for her in an age-appropriate way helped her to get behind staying awake.” 

“Now when she reflects on going to SickKids, she mentions her bravery beads, crafting and getting prizes. She never talks about the procedures.” 

In May 2025, Avery rang the bell in the Haematology/Oncology unit, in celebration of being in remission from cancer.