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Pharmacological prevention of sevoflurane- and desflurane-related emergence agitation in children: a meta-analysis of published studies

The review found that prophylactic propofol, ketamine, fentanyl and perioperative analgesia appeared to reduce sevoflurane and desflurane-related emergence agitation in children. The review was well conducted in many respects, but in view of the incomplete retrieval of eligible studies, heterogeneity between the studies and lack of information on some aspects of their quality, some caution in interpretation may be advisable.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2010

Sedation and Anesthesia Options for Diagnostic Procedures: A Review of Clinical Effectiveness and Guidelines [Internet]

The purpose of this rapid review was to assess the available evidence regarding the clinical effectiveness of sedation and/or anesthesia options in patients undergoing diagnostic procedures who are required to be still. Furthermore, guidelines on sedation and anesthesia in patients undergoing diagnostic procedures were identified and assessed.

Rapid Response Report: Summary with Critical Appraisal - Canadian Agency for Drugs and Technologies in Health.

Version: May 8, 2015
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Delirium: Screening, Prevention, and Diagnosis – A Systematic Review of the Evidence [Internet]

Delirium is a common syndrome in hospitalized or institutionalized adults. It is characterized by the acute onset of altered mental status, hallmarked by difficulty sustaining attention and a fluctuating course. Delirium frequently causes patients, families, and health care providers considerable distress. The incidence varies widely based on patient population, setting, and intensity of diagnostic ascertainment with reported values of 10% to over 80%. Delirium is associated with multiple serious outcomes including increased morbidity, length of hospital stay, healthcare costs, institutionalization, and mortality. In surgical settings, older adults and those with multiple medical conditions are at increased risk for postoperative delirium. Delirium may be under-recognized by healthcare providers and it can be difficult to resolve. Several brief “bedside” questionnaires and checklists exist that can help detect delirium earlier and among those with milder symptoms. Additionally, efforts to prevent the development of delirium in those at risk have been advocated. Medications (including sedatives, narcotics, and anticholinergic drugs), diseases and intercurrent illnesses (e.g., stroke, infection, shock, anemia), surgical procedures (especially orthopedic and cardiac surgery), and environmental factors (e.g., use of a bladder catheter, pain, and emotional stress) are all associated with delirium. Therefore, identifying and implementing effective strategies to prevent and detect delirium could improve clinical outcomes and resource utilization. Suggested strategies to prevent delirium include avoidance of psychoactive medications, pharmacologic interventions to decrease risk, and single- or multi-component non-pharmacologic interventions (including use of music, mobilization, fluid and nutrition management, and orientation and cognitive stimulation).

Evidence-based Synthesis Program - Department of Veterans Affairs (US).

Version: September 2011
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The Management of Inadvertent Perioperative Hypothermia in Adults [Internet]

Inadvertent perioperative hypothermia is a common but preventable complication of perioperative procedures, which is associated with poor outcomes for patients. Inadvertent perioperative hypothermia should be distinguished from the deliberate induction of hypothermia for medical reasons, which is not covered by this guideline.

NICE Clinical Guidelines - National Collaborating Centre for Nursing and Supportive Care (UK).

Version: April 2008
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Comparison of propofol (an anaesthetic drug) with other drug options for sedating people undergoing painful procedures in emergency departments

Propofol is a drug frequently used as a general anaesthetic to sedate (calm) people for surgery in the operating theatre. It is administered into a vein. There is increasing evidence that propofol can be used outside of the operating theatre to sedate people undergoing painful procedures (e.g. when relocating a joint that is out of its normal position because of an injury) in the emergency department (ED) setting.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Drugs to treat phantom limb pain in those with missing limbs

Various medications have been tried in phantom limb pain but good treatment continues to be unsatisfactory. Whether opioids, N‐methyl D‐aspartate (NMDA) receptor antagonists (e.g. ketamine, memantine, dextromethorphan), anticonvulsants, antidepressants, calcitonin and anaesthetics are effective in improving outcomes that include pain, function, mood sleep, quality of life, satisfaction and safety, in the short‐ and long‐term, remains uncertain. Morphine, gabapentin, and ketamine provided short‐term pain relief but the findings were based mostly on small studies. The results for calcitonin and anaesthetics were variable. Considerable differences in the drugs, methods, designs, outcomes, outcome measures, follow‐ups, analyses, and reporting/presenting of findings made it difficult to combine results for the interventions and outcomes. Results must be interpreted with caution as these relied on a few studies with small numbers of study participants and lacked long‐term efficacy and safety data. Good quality studies with sufficient sample size, longer follow‐ups and with outcomes that are important to patients are needed to make firmer recommendations to enable good advice on the best pain relief for this patient population.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Systemic drugs for the prevention of chronic pain after surgery

Pain associated with surgery generally resolves within one to two weeks, however in some situations surgical patients are left with longstanding pain for months or even years after the surgical procedure. Researchers have studied the ability of various drug treatments to prevent the development of chronic pain after surgery and this systematic review evaluated published studies in this field. Available studies suggest a modest effect of ketamine, compared to placebo, for prevention of chronic pain after surgery, however small study size could lead to an overestimation of this effect. Studies of other drugs such as gabapentin and pregabalin did not suggest the same preventative effect. Additional large studies using improved research methods are necessary to more clearly identify treatments that are beneficial for preventing chronic postsurgical pain.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Analgesia for forceps delivery

Forceps are instruments designed to aid in the delivery of the baby by gripping the head. Many different types of forceps have been developed. Forceps may be used when the baby fails to progress to delivery or to help to shorten labour for the mother when there is a need, for example when the mother is exhausted in the second stage of labour, if there is suspected distress of the fetus, or when the mother has a medical condition such as a cardiac, respiratory or neurologic condition that may prevent her from pushing. A woman who requires forceps to be used to assist her baby's birth needs effective pain relief (analgesia) so that she can remain comfortable to help the doctor perform the procedure safely.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Agitation in children after sevoflurane anaesthesia

We reviewed the evidence looking at how often children wake up agitated after a sevoflurane general anaesthetic compared with other general anaesthetics. We also reviewed evidence looking at the effects of other treatments (e.g. a medication given during the anaesthetic, the presence of a parent when a child wakes up) on how often children wake up agitated after receiving a sevoflurane anaesthetic.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Major Trauma: Assessment and Initial Management

This guideline provides guidance on the assessment and management of major trauma, including resuscitation following major blood loss associated with trauma. For the purposes of this guideline, major trauma is defined as an injury or a combination of injuries that are life-threatening and could be life changing because it may result in long-term disability. This guideline covers both the pre-hospital and immediate hospital care of major trauma patients but does not include any management after definitive lifesaving intervention. It has been developed for health practitioners and professionals, patients and carers and commissioners of health services.

NICE Guideline - National Clinical Guideline Centre (UK).

Version: February 2016
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Local anaesthetic wound infiltration and abdominal nerves block during caesarean section for postoperative pain relief

Childbirth by caesarean section is becoming more frequent. Caesarean section requires an anaesthetic, either spinal, spinal epidural, epidural block or general anaesthesia. Postoperative pain is managed with a combination of an opioid such as morphine or pethidine and other analgesics. Opioids cause sedation and they can transfer to breast milk, also sedating the newborn infant. Childbirth is a deeply emotional experience and involves bonding with the newborn and starting breastfeeding. Improvements in pain relief that make the postanaesthesia period less uncomfortable are important. During the operation, local anaesthetic can be injected to block the nerves before cutting the skin or after closing the skin at the end of the operation (abdominal nerve block) or the wound can be irrigated or infiltrated with local anaesthetic solution to reduce postoperative pain (pre‐emptive wound analgesia).

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

Neuromodulators for pain management in rheumatoid arthritis

This summary of a Cochrane review presents what we know from research about the effect of neuromodulators on pain in patients with rheumatoid arthritis.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Midazolam for sedation before procedures

We wanted to find out whether midazolam makes medical procedures more comfortable for children and adults, as well as whether it makes the procedure easier to perform.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2016

Assessment and Management of Acute Pain in Adult Medical Inpatients: A Systematic Review [Internet]

Poor pain management in surgical settings is known to be associated with slower recovery, greater morbidity, longer lengths of stay, lower patient satisfaction, and higher costs of care, suggesting that optimal pain care in these settings is of utmost importance in promoting acute illness management, recovery, and adaptation. VA/DoD Clinical Practice Guidelines have been developed for the management of acute post-operative pain, although the basis for many of the recommendations was by expert consensus rather than empirical evidence.

Evidence-based Synthesis Program - Department of Veterans Affairs (US).

Version: April 2008
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Dexmedetomidine for Sedation in the ICU or PICU: A Review of Cost-Effectiveness and Guidelines [Internet]

Sedation of ICU patients is often essential for ICU patients to maximize survival, reduce ICU and hospital stay, and facilitate mechanical ventilation. The standard of care for sedation includes benzodiazepine sedatives and propofol. These sedatives (notably benzodiazepines) are associated with an increased risk of agitation and delirium. It has been hypothesized that dexmedetomidine would be an appropriate alternative to traditional sedatives for maintaining light to moderate sedation. Dexmedetomidine is an alpha2-adrenergic agonist, and it is approved in Canada for intensive care unit sedation and conscious sedation. In January 2014, the Canadian Agency for Drugs and Technologies in Health (CADTH) reviewed the evidence on the clinical effectiveness of using dexmedetomidine for sedation in intensive-care unit. Based on the CADTH review, dexmedetomidine was found to be associated with decreased ICU stay and decreased time on mechanical ventilation. However, it was associated with higher rates of bradycardia than comparators.

Rapid Response Report: Summary with Critical Appraisal - Canadian Agency for Drugs and Technologies in Health.

Version: December 17, 2014
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Capnography for Monitoring End-Tidal CO2 in Hospital and Pre-hospital Settings: A Health Technology Assessment [Internet]

Anesthesiologists have been using capnography for decades to monitor end-tidal carbon dioxide (ETCO2) in patients receiving general anesthesia. ETCO2 monitoring using capnography devices has application across several hospital and pre-hospital settings, including monitoring the effectiveness of cardiopulmonary resuscitation (CPR), continuous monitoring of patients in the emergency room or intensive care unit (ICU), during ambulatory transport, to confirm the correct placement of an endotracheal tube (ETT), and monitoring post-operative patients with a history of sleep apnea or who have received high doses of opioids. Depending on the clinical area, the technology is at various stages of adoption.

CADTH Health Technology Assessment - Canadian Agency for Drugs and Technologies in Health.

Version: March 2016
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Dexmedetomidine for Sedation of Patients in the ICU or PICU: Review of Clinical Effectiveness and Safety [Internet]

Sedation of ICU patients is often essential for ICU patients to maximize survival, reduce ICU and hospital stay, and facilitate mechanical ventilation. The standard of care for sedation include benzodiazepine sedatives and propofol. Some drawbacks of the available sedative agents include patients’ agitation and delirium. To overcome these drawbacks, it has been suggested that dexmedetomidine can be an appropriate alternative to traditional sedatives for maintaining light to moderate sedation. However, the Health Canada approved label for dexmedetomidine provides warnings that the drug is associated with hypotension, clinically significant episodes of bradycardia, and sinus arrest.

Rapid Response Report: Summary with Critical Appraisal - Canadian Agency for Drugs and Technologies in Health.

Version: January 16, 2014
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Cancer Pain (PDQ®): Health Professional Version

Expert-reviewed information summary about pain as a complication of cancer or its treatment. Approaches to the management and treatment of cancer-associated pain are discussed.

PDQ Cancer Information Summaries [Internet] - National Cancer Institute (US).

Version: June 22, 2016

Interventions for Atypical Facial Pain: A Review of Clinical Effectiveness and Guidelines [Internet]

The purpose of this report is to review the available published literature relating to pharmacological and non-pharmacological interventions for the treatment of atypical facial pain (AFP) in adults.

Rapid Response Report: Summary with Critical Appraisal - Canadian Agency for Drugs and Technologies in Health.

Version: April 1, 2016
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Sufentanil for Palliative Pain Relief: A Review of the Clinical Effectiveness, Cost-Effectiveness and Guidelines [Internet]

An evaluation of the evidence behind the use of sufentanil in palliative pain relief is warranted given the proposed and observed off-label use in palliative care, and the mention of sufentanil within palliative care guidelines. Further, the relatively high cost of sufentanil necessitates an evaluation of resource implications. This report will review the evidence on clinical effectiveness and cost-effectiveness, as well as evidence-based guidelines regarding sufentanil for pain relief specifically in the context of palliative care.

Rapid Response Report: Summary with Critical Appraisal - Canadian Agency for Drugs and Technologies in Health.

Version: November 18, 2015
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