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Background: Spine surgery may be associated with severe acute postoperative pain. Compared with systemic analgesia alone, epidural analgesia may offer better pain control. However, epidural analgesia has sometimes been associated with rare but serious complications. Therefore, it is critical to quantify the real benefits of epidural analgesia over other modes of pain treatment., Objectives: To assess the effectiveness and safety of epidural analgesia compared with systemic analgesia for acute postoperative pain control after thoraco-lumbar spine surgery in children., Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature on 14 November 2018, together with the references lists of related reviews and retained trials, and two trials registers., Selection Criteria: We included all randomized controlled trials performed in children undergoing any type of thoraco-lumbar spine surgery comparing epidural analgesia with systemic analgesia for postoperative pain. We applied no language or publication status restriction., Data Collection and Analysis: We assessed risk of bias of included trials using the Cochrane tool. We analysed data using random-effects models. We rated the quality of the evidence according to the GRADE scale., Main Results: We included 11 trials (559 participants) in the review, and seven trials (249 participants) in the analysis: 140 participants received epidural analgesia and 109 received systemic analgesia.Most studies included adolescents. Three trials included in the analysis contained some participants older than 18 years. The types of surgery were posterior spinal fusion for idiopathic scoliosis (nine trials), anterior correction for idiopathic scoliosis (one trial), or selective dorsal rhizotomy in children with cerebral palsy (one trial). The mean numbers of vertebrae operated on were between nine and 14.5 and the mean numbers of spinal levels were between three and four and a half. The length of surgery varied between three and six and a half hours.Compared with systemic analgesia, epidural analgesia reduced pain at rest at all time points. At six to eight hours, the mean pain score on a 0 to 10 scale with systemic analgesia was 3.1 (standard deviation 0.7) and with epidural analgesia was -1.32 points (95% confidence interval (CI) -1.83 to -0.82; 4 studies, 116 participants; moderate-quality evidence). At 72 hours, the mean pain score with epidural analgesia was equivalent to a -0.8 point reduction on a 0 to 10 scale (standardized mean difference (SMD) -0.65, 95% CI -1.19 to -0.10; 5 studies, 157 participants; moderate-quality evidence).Return of gastrointestinal functionThere was no difference for nausea and vomiting between groups (risk ratio (RR) 0.87, 95% CI 0.58 to 1.30; 6 studies, 215 participants; low-quality evidence). One study found epidural analgesia with local anaesthetics may have increased the number of participants who had their first flatus within 48 hours (RR 1.63, 95% CI 1.08 to 2.47; 30 participants; very low-quality evidence). Two studies found epidural analgesia with local anaesthetics may have increased the number of participants in whom first bowel movement occurred within 48 hours (RR 11.52, 95% CI 2.36 to 56.26; 60 participants; low-quality evidence). It was uncertain whether epidural analgesia reduced the time to first bowel movement (MD 0.09 days, 95% CI -0.32 to 0.50; 1 study, 60 participants; very low-quality evidence) and time to first liquid ingestion following epidural infusion of an opioid alone or a local anaesthetic plus an opioid (mean difference (MD) -5.02 hours, 95% CI -13.15 to 3.10; 2 studies, 56 participants; very low-quality evidence). Epidural analgesia with local anaesthetics may have increased the risk of having first solid food ingestion within 48 hours (RR 7.00, 95% CI 1.91 to 25.62; 1 study, 30 participants; very low-quality evidence).Secondary outcomesIt was uncertain whether there was a difference in time to ambulate (MD 0.08 days, 95% CI -0.24 to 0.39; 1 study, 60 participants; very low-quality evidence) and hospital length of stay (MD -0.29 days, 95% CI -0.69 to 0.10; 2 studies, 89 participants; very low-quality evidence). Two studies found participants were more satisfied when treated with epidural analgesia (MD 1.62 on a scale from 0 to 10, 95% CI 1.26 to 1.97; 60 participants; very low-quality evidence). It was unclear whether there was a difference in parent satisfaction for epidural analgesia with an opioid alone (MD 0.60, 95% CI -0.81 to 2.01; 1 trial, 27 participants; very low-quality evidence).ComplicationsIt was uncertain whether there was a difference in the risk of complications such as: respiratory depression (risk difference (RD) -0.05, 95% CI -0.16 to 0.05; 4 studies, 126 participants; very low-quality evidence); wound infection (RD 0.01, 95% CI -0.05 to 0.08; 2 trials, 93 participants; very low-quality evidence); epidural abscess (RD 0, 95% CI -0.05 to 0.05; 3 trials, 120 participants; very low-quality evidence); and neurological complications (RD 0.01, 95% CI -0.04 to 0.06; 4 studies, 151 participants; very low-quality evidence)., Authors' Conclusions: There is moderate- and low-quality evidence that there may be a small additional reduction in pain up to 72 hours after surgery with epidural analgesia compared with systemic analgesia. Two very small studies showed epidural analgesia with local anaesthetic alone may accelerate the return of gastrointestinal function. The safety of this technique in children undergoing thoraco-lumbar surgery is uncertain due to the very low-quality of the evidence. The study in 'Studies awaiting classification' may alter the conclusions of the review once assessed.

Despite being the mainstay of pain management, opioids are limited in their clinical utility by adverse effects, such as tolerance and paradoxical hyperalgesia. Research of the past 15 years has extended beyond neurons, to implicate central nervous system immune signaling in these adverse effects. This article will provide an overview of these central immune mechanisms in opioid tolerance and paradoxical hyperalgesia, including those mediated by Toll-like receptor 4, purinergic, ceramide, and chemokine signaling. Challenges for the future, as well as new lines of investigation will be highlighted., (© 2015 American Headache Society.)

Objectives: Although 50% nitrous oxide (N(2) O) and oxygen is a widely used treatment, its efficacy had never been evaluated in the prehospital setting. The objective of this study was to demonstrate the efficacy of premixed N(2) O and oxygen in patients with out-of-hospital moderate traumatic acute pain., Methods: This prospective, randomized, multicenter, double-blind trial enrolled patients with acute moderate pain (numeric rating scale [NRS] score between 4 and 6 out of 10) caused by trauma. Patients were assigned to receive either 50/50 N(2) O and oxygen 9 L/min (N(2) O group) or medical air (MA) 9 L/min (MA group), in ambulances from two nurse-staffed fire department centers. After the first 15 minutes, every patient received N(2) O and oxygen. The primary endpoint was pain relief at 15 minutes (T15), defined as a NRS ≤ 3 of 10. The NRS was measured every 5 minutes. Secondary endpoints were treatment safety and adverse events, time to analgesia, and patient and investigator satisfaction with analgesia., Results: Sixty patients were included with no differences between groups in age (median = 34 years, interquartile range [IQR] = 23 to 53 years), sex (37 males, 66%), and initial median NRS of 6 (IQR = 5 to 6). At T15, 67% of the patients in the N(2) O group had an NRS score of 3 or lower versus 27% of those in the MA group (delta = 40%, 95% confidence interval [CI] = 17% to 63%; p < 0.001). The median pain scores were lower in the N(2) O group at T15, 2 (IQR = 1 to 4) versus 5 (IQR = 3 to 6). There was a difference at 5 minutes that persisted at all subsequent time points. Four patients (one in the N(2) O group) experienced adverse events (nausea) during the protocol., Conclusions: This study demonstrates the efficacy of N(2) O for the treatment of pain from acute trauma in adults in the prehospital setting., (© 2013 by the Society for Academic Emergency Medicine.)

Background: Colonoscopy is the gold standard investigation for large bowel disease. With the increase in demand, pressure is on clinics to shorten lengths of time per procedure in addition to maintaining high levels of patient safety. Analgesia has always been the mainstay of adequate pain relief, but it leads to prolonged recovery and lengths of hospital stay, in addition to increased risk of cardio-respiratory side effects. N2O/O2 mixtures have been used for its effective analgesic effect and short half life and provides an alternative method of sedation for colonoscopy procedures., Objectives: The primary objective was to compare the overall effectiveness of nitrous oxide mixtures to other types of pain relief used during colonoscopy procedures to provide adequate pain/discomfort relief.The secondary objective was to compare between nitrous oxide and other types of pain relief with respect to hospitalisation/recovery time, side effects, patients and endoscopists satisfaction, and colonoscopy completion rates., Search Strategy: The following electronic databases were searched: Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, MEDLINE (1966- present), EMBASE (1980 - present), and the Internet (Google Scholar)., Selection Criteria: Randomised controlled trials which compared nitrous oxide to placebo or active comparators for patients undergoing elective colonoscopic procedures. Patients with known underlying causes of pain/discomfort were excluded. , Data Collection and Analysis: Seven randomised trials were included. Each trial compared a nitrous oxide/oxygen mixture to a placebo or sedation +- other analgesic drugs on patients undergoing elective colonoscopic procedures. The results of these studies were analysed and discussed., Main Results: There were a total of 547 patients included.There were 257 patients randomised to receive the N2O/O2 mixture (7 studies), while 225 patients received some form of sedation with or without other analgesia (6 studies), and 65 patients received a placebo (3 studies).Four studies showed that N2O/O2 is as good in controlling pain/discomfort as conventional methods, while one showed sedation was better and another study showed N2O/O2 was better.Six of the studies showed that N2O/O2 groups had quicker recovery times and shorter lengths of hospital stays while one study showed that there was no difference between the two groups.Two studies showed that N2O/O2 was safer while one reported that sedation was safer., Authors' Conclusions: Nitrous oxide is as efficient and safer than various pain relief methods used during colonoscopy procedures, but further trials are necessary.

Objectives: The objectives were to explore the tolerance of pediatric emergency medicine (PEM) physicians for risk in choosing when to perform procedural sedation and analgesia (PSA) and to describe adherence to preprocedural fasting guidelines and factors affecting the physicians' decisions., Methods: A survey of Canadian PEM physicians who perform PSA was conducted. Respondents were asked about their PSA practices. Risk tolerance was assessed using an economics-based stated preference elicitation method called a discrete choice experiment (DCE). Using a hypothetical clinical situation of a healthy child needing PSA, three fasting scenarios (ingestion of full meal < 2 hours ago, full meal between 2 and 4 hours ago, liquids less than 1 hour ago) were created. For each fasting scenario, 16-choice questions with varying numeric risks of major and minor adverse events were presented and respondents were asked whether they would administer PSA now or wait for guidelines to be met. In this exploratory study, choice data were analyzed using multivariate regression analysis, and preliminary inferential statistics are presented., Results: A total of 114 (63.6%) completed surveys were returned. Respondents were 54% male, were in practice for a median of 6-10 years, and reported following fasting guidelines 53% of the time. Most had institutional fasting policies (70%), used ketamine (in 78% of PSA by 95% of users), and identified patient variables (prolonged pain, parental concern) as more important than environmental variables (patient flow, use of resources) in deciding when to administer PSA. Both major and minor risks of adverse events affected the choice of whether to do immediate PSA or wait until fasting guidelines were met. A 0.1-percentage-point increase in the probability of a major adverse event reduced physician likelihood of performing immediate PSA before meeting fasting guidelines by 17.6 percentage points. In comparison, a 10-percentage-point increase in the probability of a minor adverse event reduced physician likelihood of performing immediate PSA by 17.2%. Respondents were less likely to perform PSA immediately if a child had a full meal < 2 hours ago versus 2-4 hours ago or liquids < 1 hour ago. Sex, highest level of postgraduate training, frequency of performing PSA, and experience with a prior adverse event did not affect the choice to do immediate PSA. Years in practice affected the decision, with those in practice for 6-10 years more likely to perform immediate PSA than those in practice for shorter or longer. Those who reported having an institutional fasting policy were less likely to perform immediate PSA., Conclusions: These results suggest that fasting guidelines are not strictly adhered to in Canadian pediatric emergency departments (EDs) currently, and there is some willingness of physicians to change their sedation practice in light of evidence from hypothetical surveillance data about risks. On the other hand, some physicians suggest that they will follow guidelines regardless of how low the estimated risk is from surveillance data. An understanding of how physicians respond to evidence about small risks and how the information is best understood by this population is interesting for knowledge translation if evidence-based practice guidelines for procedural sedation in the ED are developed in the future., (© 2010 by the Society for Academic Emergency Medicine.)

Background: Oocyte retrieval for in vitro fertilization (IVF) is one of the most common minor surgical procedures., Objectives: To give an update on anesthesia practices used currently in the United States and Europe in assisted reproductive technology, and discuss the safety or the potential risks for oocyte and embryo quality., Search Strategy: Electronic search of MEDLINE for literature published between 1972 and 2008., Selection Criteria: Relevant studies on the types of anesthesia used for oocyte retrieval and the impact on oocyte and embryo quality., Data Collection and Analysis: Relevant studies were reviewed by the authors and the ones of significant scientific merit, based on methodology, were included., Main Results: Types of anesthesia that may be used for transvaginal follicular aspiration and oocyte retrieval include: general anesthesia, neuraxial anesthesia, conscious sedation, injection of local anesthetic agents into the cervix or the vaginal wall, or any combination of the above. Conscious sedation is most commonly used in IVF because it is relatively safe and does not require the presence of an anesthesiologist when opioids or benzodiazepines are used. Propofol is the preferred anesthetic agent, but should be used by specially trained personnel., Conclusion: Conscious sedation is the most popular method of anesthesia used in IVF. Presently, a combination of propofol, fentanyl, and midazolam is used frequently. It is easy to administer in cooperative and motivated patients and is safe in healthy individuals; it has a relatively low risk for adverse effects on oocyte and embryo quality and pregnancy rates.

Objectives: The aim was to compare the rate of procedural sedation-related adverse events of pediatric residents with specific training in "patient safety during sedation" and pediatric emergency physicians (PEPs) who completed the same course or were teaching faculty for it., Methods: This prospective single-blinded, nonrandomized study was conducted in two university-affiliated pediatric emergency departments (PEDs) in Israel. Pediatric residents who were authorized to perform unsupervised sedations had previously completed a course in patient safety during sedation. Unsupervised sedations by residents were defined as sedations where the entire procedure was performed independently. Study subjects had autonomy in choosing medications for sedation. Adverse events were defined as transient hypoxia (oxygen saturation < or = 90%) or apnea. Adverse outcomes were situations where intubation or hospitalization directly related to sedation complications would occur. Sedations over 12 consecutive months were recorded, and rates of adverse events in each group were compared., Results: A total of 984 eligible sedations were recorded, 635 by unsupervised residents and 349 by PEPs. A total of 512 (80.6%) sedations were performed by residents when attending physicians were not in the ED. The total adverse event rate was 24/984 (2.44%). When the two groups used a similar type drugs, residents had 8/635 (1.26%) events, compared to 11/328 (3.35%) by PEPs. There was no statistically significant difference in the rates of hypoxia or apnea between the two groups (p = 0.29 and p = 0.18, respectively). Adverse outcomes did not occur., Conclusions: Unsupervised pediatric residents with training in patient safety during sedation performed procedural sedations with a rate of adverse events similar to that of PEPs.

Millimetre wave therapy (MWT) is a promising complementary method for pain relief, however rigorous investigations of its effectiveness are needed. The purpose of this study was to examine if MWT can reduce opioid requirement compared to sham procedure applied for relief of acute pain in patients after total knee arthroplasty (TKA). Eighty patients undergoing TKA were randomly assigned to receive MWT or sham procedure. Patients and evaluators were blinded to the group allocation. MWT consisted of six sessions, each session of 30 min duration. During each session the knee wound was exposed to electromagnetic waves with frequency 50-75 GHz and power density 4.2 mW/cm(2). Postoperative analgesia with piritramide, a weak opioid with 0.7 potency of morphine delivered via patient-controlled analgesia pump, was directed to achieve pain intensity of less than 40 on a 100 mm visual analogue scale (VAS). The primary outcome measure was postoperative piritramide requirement for three days after surgery. Secondary outcome measures were: total ibuprofen requirement from the fourth postoperative day to discharge; success of patients' blinding; patients' satisfaction with pain relief; incidence of analgesia-related side effects; heart rate and blood pressure. Piritramide requirement was similar in both groups whereby all patients reported adequate pain relief measured on a VAS. Secondary outcome measures were also comparable in both groups. The majority of patients in both groups believed they had received true MWT and wanted to repeat it in future. Millimetre waves applied to surfaces of surgical wounds did not reduce opioid requirement compared to the sham procedure after TKA.

Epidural analgesia is regarded as the gold method for controlling post-thoracotomy pain. Intercostal nerve cryoanalgesia can also produce satisfactory analgesic effects, but is suspected to increase the incidence of chronic pain. However, randomized controlled trials comparing these two methods for post-thoracotomy acute pain analgesic effects and chronic pain incidents have not been conducted previously. We studied 107 adult patients, allocated randomly to thoracic epidural bupivacaine and morphine or intercostal nerve cryoanalgesia. Acute pain scores and opioid-related side effects were evaluated for three postoperative days. Chronic pain information, including the incidence, severity, and allodynia-like pain, was acquired on the first, third, sixth and twelfth months postoperatively. There was no significant difference on numeral rating scales (NRS) at rest or on motion between the two groups during the three postoperative days. The patient satisfaction results were also similar between the groups. The side effects, especially mild pruritus, were reported more often in the epidural group. Both groups showed high incidence of chronic pain (42.1-72.1%), and no significance between the groups. The incidence of allodynia-like pain reported in cryo group was higher than that in Epidural group on any postoperative month, with significance on the sixth and the twelfth months postoperatively (P<0.05). More patients rated their chronic pain intensity on moderate and severe in cryo group and interfered with daily life (P<0.05). Both thoracic epidural analgesia and intercostal nerve cryoanalgesia showed satisfactory analgesia for post-thoracotomy acute pain. The incidence of post-thoracotomy chronic pain is high. Cryoanalgesia may be a factor that increases the incidence of neuropathic pain.

Background: Cardioversion (CV), a painful procedure, requires sedation and analgesia. Although several sedation agents currently are in use for CV, data on age-specific efficacy and side effects of midazolam and propofol have been limited., Objectives: To compare the efficacy and side effects of midazolam and propofol in patients of two different age groups, younger than 65 years and 65 years and over, who were going through CV., Methods: Seventy consented patients with CV indications caused by atrial fibrillation were included in this clinical trial. The participants were placed into four groups by using a stratified randomization method: patients aged younger than 65 years who were receiving midazolam (n = 12) or propofol (n = 11) and patients 65 years and over who were receiving midazolam (n = 25) or propofol (n = 22). Medications were administered by slow intermittent bolus injections. During CV, time to reach Ramsay Sedation Scale level 5 (RSS-5; induction time); time to reach RSS-2 (recovery time); and side effects including desaturation, apnea, and changes in hemodynamic parameters were recorded by a person blinded to the patient treatment allocation., Results: Mean induction time was similar in all four groups. Mean recovery time (min +/- SD) was shorter in both propofol groups when compared with both midazolam groups: 18.8 (+/- 4.06) and 40.33 (+/- 20.8) in the group younger than 65 years and 18.2 (+/- 5.12) and 54.2 (+/- 20.85) in the group 65 years or older, respectively (p < 0.001). Older participants in each medication group needed less medication than younger patients. There were no hemodynamic differences between the groups. Desaturation was higher in both midazolam groups as compared with individuals in the age-matched propofol groups (both p < 0.05). Patient reactions were less in propofol groups with similar joules during CV procedures than were those in the midazolam groups., Conclusions: Propofol appears to be a better choice for CV sedation in elders because of its short recovery time, fewer side effects, and its more comfortable sedative effect.

Objectives: To compare the frequency and severity of adverse events associated with parenteral drugs commonly used for procedural sedation and analgesia (PSA) in a pediatric emergency department., Methods: A database of consecutive patients receiving parenteral PSA was prospectively generated with the intent of monitoring safety in the emergency department. Data were logged onto a dedicated sedation sheet. A retrospective analysis was performed; comparisons were made based on sedation drugs used., Results: A total of 2,609 patients from June 1, 1996, to September 16, 2003, received PSA by emergency physicians. Patients who received PSA nonparenterally (n = 109) were excluded. A total of 2,500 patients (2,279, intravenous; 221, intramuscular) remained for analysis. Age range was 19 days to 32 years (median, 6.7 years). A total of 1,511 (60.4%) were male. Four major drug combinations were identified: ketamine alone (n = 1,492; 59.7%), ketamine/midazolam (n = 299; 12.0%), midazolam/fentanyl (n = 336; 13.4%), and midazolam alone (n = 260; 10.4%). A total of 113 patients (4.5%) received various other combinations of drugs. A total of 458 adverse events were observed in 426 patients (17%). Respiratory adverse events occurred as follows: ketamine alone, 91 patients (6.1%); ketamine/midazolam, 30 patients (10%); midazolam/fentanyl, 65 patients (19.3%); midazolam alone, 15 patients (5.8%). Vomiting occurred as follows: ketamine alone, 151 patients (10.1%); ketamine/midazolam, 16 patients (5.4%); midazolam/fentanyl, six patients (1.8%); midazolam alone, two patients (0.8%)., Conclusions: Drug types used in pediatric PSA are associated with different adverse event profiles. Patients receiving ketamine with or without midazolam experienced fewer respiratory adverse events but more vomiting than the commonly used combination of midazolam and fentanyl. Adverse events may occur in any patient receiving parenteral PSA.

Peripheral nerve blocks are used as part of a preemptive and multimodal analgesic technique to provide safe and effective postoperative pain management with minimal side effects. They are used for a variety of surgical procedures in both inpatient and outpatient settings. Peripheral nerve blocks have resulted in shorter recovery times, decreased anesthesia-related complications, and better postoperative pain management. Peripheral nerve blocks, as part of a multimodal analgesic regimen, have decreased recovery times by lessening side effects (e.g., nausea, vomiting, drowsiness). Nerve blocks have allowed procedures previously performed only in hospitals to be performed on an outpatient basis by providing extended surgical area analgesia. The use of peripheral nerve blocks, however, requires skilled and knowledgeable clinicians. This article discusses the mechanism of action and the role of peripheral nerve blocks in multimodal analgesia, as well as perioperative nursing implications and management for upper and lower extremity peripheral nerve blocks.