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Analgesia for amniocentesis

In addition to concerns about the risks of miscarriage after amniocentesis, women are also concerned about pain during and after the procedure. Currently, approaches for analgesia can be categorised in two broad categories ‐ non‐pharmacological and pharmacological agents. Their effect, or lack of it, is most commonly evaluated with visual analogue scale (VAS).

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

Version: 2011

Pain relief for neonatal circumcision

Circumcision is a painful procedure frequently performed on newborn baby boys without using pain relief. Available treatments include dorsal penile nerve block (DPNB), which involves injecting anesthetic at the base of the penis. Ring block is another form of penile block. Locally applied anesthetic creams include EMLA, a water‐based cream including lidocaine and prilocaine. Based on 35 clinical trials involving 1,997 newborns, it can be concluded that DPNB and EMLA do not eliminate circumcision pain, but are both more effective than placebo or no treatment in diminishing it. Compared head to head, DPNB is substantially more effective than EMLA cream. Ring block and lidocaine creams other than EMLA also reduced pain but did not eliminate it. Trials of oral acetaminophen, sugar solutions, pacifiers, music, and other environmental modifications to reduce circumcision pain did not prove them effective. DPNB can cause minor bruising, bleeding, or swelling at the injection site. EMLA and other lidocaine creams can cause skin color changes or local skin irritation. There is a rare risk with lidocaine creams of causing methaemoglobinaemia (blue‐baby syndrome, where the baby's blood lacks sufficient oxygen). However, two trials of EMLA for circumcision pain relief measured methaemoglobin levels and found them normal. The circumcision procedure itself, especially without pain relief, can cause short term effects such as choking, gagging, and vomiting. Long term effects of circumcision without pain relief are not well understood. Strict comparability between trials was rare. Trials used a variety of indicators to measure baby's pain. Crying time, facial expression, and sweating palms can indicate infant pain, as can increased heart rate, breathing rate, and blood pressure. Levels of chemical indicators that can be part of a pain or stress response and are present in the blood or saliva are another gauge of pain levels. Also, procedures were not generally performed in just the same way in different trials. Type of clamp used (8sing a Mogen clamp can shorten the duration of the procedure), length of wait time after injection or application of anesthetic and procedure techniques varied.

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

Version: 2009

Topical agents or dressings for reducing pain in venous leg ulcers

Venous leg ulcers are often painful, both during and between dressing changes, and during surgical removal of dead tissue (debridement). Dressings, topical creams and lotions have been promoted to reduce the pain of ulcers. Two trials tested a dressing containing ibuprofen, however, the pain measures and time frames reported were different. One trial indicated that pain relief achieved over 5 days with ibuprofen dressings could represent a clinically relevant reduction in pain. The other trial found no significant difference in the chance of pain relief, measured on the first night of treatment, for ibuprofen dressings compared with foam dressings. This trial, however, was small and participants were only followed for a few weeks, which may not be long enough to assess whether the dressing affects healing. There was evidence from five trials that a local anaesthetic cream (EMLA 5%) reduces the post‐procedural pain of debriding leg ulcers but there was insufficient evidence regarding any side effects of this cream and its impact on healing.

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

Version: 2012

Analgesia for infants' circumcision

Male circumcision (MC) is one of the oldest and most common operations performed all over the world. It can be performed at different ages, using different surgical techniques, for different religious, cultural and medical reasons.Our aim is to examine and compare the various methods of analgesia and different surgical procedures reported in literature that are applied in infant MC. We performed a PubMed, MEDLINE, EMBASE and Cochrane search in the papers published since 2000: 14 studies met the inclusion criteria, most of them showing that a combined pharmacological and non-pharmacological intervention is the best analgesic option, in particular when the dorsal penile nerve block is combined with other treatments. The Mogen surgical procedure seems to be the less painful surgical intervention, when compared with Gomco clamp or PlastiBell device. Only 3 papers studied groups of at least 20 babies each with the use of validated pain scales. Data show a dramatic decrease of pain with dorsal penile nerve block, plus acetaminophen associated to oral sucrose or topic analgesic cream. However, no procedure has been found to definetively eliminate pain; the gold standard procedure to make MC totally painfree has not yet been established.

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

Version: 2013

Sedation in Children and Young People: Sedation for Diagnostic and Therapeutic Procedures in Children and Young People [Internet]

Many children present to hospitals and dental clinics needing effective sedation or anaesthesia for painful or distressing diagnostic or therapeutic procedures. There are many sedation techniques available but there is insufficient guidance on which techniques are effective and what resources are required to deliver them safely. Sedation is not always effective enough and will occasionally require the procedure to be delayed until the child can be anaesthetised perhaps in another healthcare setting or on another day. Consequently sedation failure is both distressing for the child and has major NHS cost implications. Excessive doses of sedation can cause unintended loss of consciousness and dangerous hypoxia. In comparison, planned anaesthesia is effective, but may have resource implications. The need for sedation or anaesthesia will depend upon the type of procedure. Some types of procedures are very common and healthcare providers and practitioners need to understand whether sedation or anaesthesia is the most cost effective method of managing them

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: December 2010
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Pain Management Interventions for Hip Fracture [Internet]

To review and synthesize the evidence on pain management interventions in nonpathological hip fracture patients following low-energy trauma. Outcomes include pain management (short and long term), mortality, functional status, pain medication use, mental status, health-related quality of life, quality of sleep, ability to participate in rehabilitation, return to pre-fracture living arrangements, health services utilization, and adverse effects.

Comparative Effectiveness Reviews - Agency for Healthcare Research and Quality (US).

Version: May 2011
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Clonidine as an adjuvant to intrathecal local anesthetics for surgery: systematic review of randomized trials

The authors concluded that adding clonidine to intrathecal local anaesthetic had beneficial effects on some, but not all measures of motor and sensory block. Adding clonidine reduced intra-operative pain but increased the risk of arterial hypotension. Given the low quality of the included studies and the possibility of publication bias, the reliability of the results is questionable.

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

Version: 2008

Temporary pain in the lower extremities following spinal anaesthesia with lidocaine compared to other local anaesthetics

Lidocaine is the drug of choice for inducing spinal anaesthesia in ambulatory surgery because of its rapid onset of action, intense nerve blockade, and short duration of action. The possible side effects of spinal anaesthesia in adults, which develop after recovery, are backache, post‐dural puncture headache, and transient neurologic symptoms that are characterized by slight to severe pain in the buttocks and legs. TNS symptoms develop within a few hours and up to 24 hours after anaesthesia. They last, in most cases, up to two days. The present review shows that lidocaine is more likely to cause transient neurologic symptoms than bupivacaine, prilocaine, and procaine. However, these drugs produce prolonged local anaesthetic effects and therefore are not desirable for ambulatory patients. It is possible that the reintroduction of 2‐chloroprocaine will solve this lack of a suitable intrathecal local anaesthetic; confirmatory studies are needed.

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

Version: 2009

Pain relief for women with pre‐cancerous changes of the cervix (cervical intraepithelial neoplasia (CIN)) undergoing outpatient treatment

Treatment for CIN is usually undertaken in an outpatient colposcopy clinic to remove the pre‐cancerous cells from the cervix (lower part of the womb). It commonly involves lifting the cells off the cervix with electrically heated wire (diathermy) or laser, or destroying the abnormal cells with freezing methods (cryotherapy). This is potentially a painful procedure.

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

Version: 2016

Methods to reduce pain with insertion of intrauterine contraception

Fear of pain with insertion of intrauterine contraception (IUC) may cause women to avoid using this very effective method of birth control. IUC includes devices with copper and with the hormone levonorgestrel. Researchers have studied many ways of reducing pain with IUC insertion. These include drugs that lessen uterine cramps, soften and open the cervix (uterus opening), or numb the cervix.

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

Version: 2015

Fractures (Non-Complex): Assessment and Management

Two of the five guidelines in the NICE trauma suite relate to fractures. These are titled non-complex and complex fractures. In broad terms, non-complex fractures are those likely to be treated at the receiving hospital, whereas complex fractures require transfer or the consideration of transfer of the injured person to a specialist.

NICE Guideline - National Clinical Guideline Centre (UK).

Version: February 2016
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Anaesthesia for treating distal radial fracture in adults

Wrist fractures (breaks) are very common, especially in women with osteoporosis. Bone fragments may need to be put back into place. Anaesthesia is used to prevent pain during treatment and several methods are in common use. General anaesthesia involves a loss of consciousness. Regional anaesthesia involves an injection (either into a vein or into tissue surrounding nerves) to numb the injured arm. Local anaesthesia is an injection directly into the fracture site. Sedation usually involves a drug to allay anxiety and promote sleepiness. The review found there was not enough evidence from randomised trials to decide which is the best method.

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

Version: 2009

What is the clinical effectiveness and cost-effectiveness of conservative interventions for tendinopathy? An overview of systematic reviews of clinical effectiveness and systematic review of economic evaluations

This study aims to summarise the evidence concerning the clinical effectiveness and cost-effectiveness of conservative interventions for lateral elbow tendinopathy (LET). Clinical effectiveness evidence continues to suggest uncertainty as to the effectiveness of many conservative interventions for the treatment of LET. Although new randomised controlled trial (RCT) evidence has been identified with either placebo or active controls, there is uncertainty as to the size of effects reported within them owing to small sample size. Conclusions regarding cost-effectiveness are also unclear. Future work should be on conducting large scale, good-quality clinical trials using a core set of outcome measures (for defined time points) and appropriate follow-up. Subgroup analysis of existing RCT data may be beneficial to ascertain whether or not certain patient groups are more likely to respond to treatments.

Health Technology Assessment - NIHR Journals Library.

Version: January 2015
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The Clinical Effectiveness and Cost-Effectiveness of Management Strategies for Sciatica: Systematic Review and Economic Model

Sciatica is a symptom characterised by well-localised leg pain with a sharp, shooting or burning quality that radiates down the back of the leg and normally to the foot or ankle. It is often associated with numbness or altered sensation in the leg.

Health Technology Assessment - NIHR Journals Library.

Version: November 2011
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Sweet‐tasting solutions for needle‐related pain in infants up to one year of age

The use of needles that break the skin and cause pain is a common practice around the world with babies aged between one month and 12 months (Appendix 4). In this review we were interested in whether giving babies sugar‐based solutions to taste when the needle breaks the skin will help reduce their pain.  We found 14 separate studies that had asked this question. However, the differences between the studies were often too great to let us combine their findings.  Overall, the studies show that different types of sugar‐based solutions were effective but we were not able to confidently assert that there is strong evidence for this treatment in reducing pain.  We did find some evidence that babies may not cry for as long if given sugar‐based solutions. This review is broadly in agreement with two other reviews, one asking this question in younger children, and one in older children. There is a need for better studies in this field.

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

Version: 2013

Interventions to treat premature ejaculation: a systematic review short report

The study aimed to systematically review evidence for clinical effectiveness of behavioural, topical and systemic treatments for premature ejaculation. Several interventions significantly improved intravaginal ejaculatory latency time, and many also improved sexual satisfaction and other outcomes. However, assessment of longer-term safety and effectiveness is required to evaluate whether or not initial treatment effects are maintained long-term, whether or not dose escalation is required, how soon treatment effects end following treatment cessation and whether or not treatments can be stopped and resumed at a later time. In addition, assessment of the adverse effects associated with long-term treatment and whether or not different doses have differing adverse effect profiles is required.

Health Technology Assessment - NIHR Journals Library.

Version: March 2015
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Intravenous regional anesthesia: a review of common local anesthetic options and the use of opioids and muscle relaxants as adjuncts

This review found that ropivacaine was effective for intravenous regional anaesthesia and the addition of muscle relaxants and fentanyl could reduce the local anaesthetic requirements. Insufficient information on the size of the effects, means that the reliability of the authors' conclusions is unclear.

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

Version: 2011

A systematic review of measures for reducing injection pain during adult immunization

This review of interventions to reduce injection pain during immunisation in adults concluded that there was only limited evidence that lidocaine-prilocaine, vapo-coolant spray Fluori-Methane and manual pressure reduced pain, and that jet injectors increased pain. The conclusions and recommendations for further research from this well-conducted review appear reliable.

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

Version: 2010

Trigger point injections for chronic non-malignant musculoskeletal pain: a systematic review

This review concluded that trigger point injections to treat patients with chronic non-malignant musculoskeletal pain were relatively safe, but there was no clear evidence of either benefit or ineffectiveness of this approach. Despite some methodological limitations, the review conclusions broadly followed from the presented evidence and the detailed recommendations for future research seemed appropriate.

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

Version: 2009

Sedation and analgesia for pediatric fracture reduction in the emergency department: a systematic review

The review concluded that ketamine hydrochloride-midazolam hydrochloride was associated with less distress and significantly fewer airway interventions during paediatric fracture reduction than fentanyl citrate-midazolam or propofol-fentanyl. Data comparing other forms of sedation or analgesia were limited. The authors' conclusions reflect the evidence presented, but their reliability is uncertain due to potential language bias and small sample sizes for some studies.

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

Version: 2006

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