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Resources in Evidence Repository and Individual Compendia

Bottom Line Recommendations

Bottom Line Recommendations: Procedural Sedation

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Evered L, Bhatt M & TREKK Network

Bottom line recommendations for pediatric procedural sedation. Published online: March 2018.

UNDER REVIEW Bottom Line Recommendations: Procedural Pain

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Ali, S, Drendel A & TREKK Network

Bottom line recommendations for the treatment and management of procedural pain. Published online: November 2016.

Recommandations de Base: La Sédation Procédurale

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Evered L, Bhatt M & TREKK Network

Bottom line recommendations for the procedural sedation - French. Published online: March 2018.

Bottom Line: Sucrose as a procedural analgesic for infants up to 12 monts of age

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BC Children's Hospital

Purpose: Oral sucrose and other sweet tasting solutions have been used for management of pain in infants for centuries. Studies done since the early 1990's have demonstrated that the administration of sucrose and non-nutritive sucking are effective non-pharmacological interventions for relief of procedural pain in neonates and infants and may help reduce pain in infants up to 12 months of age. Sucrose and non-nutritive sucking are thought to elevate pain thresholds via endogenous opioid pathways.

Bottom Line: Acute Procedural Pain: Paediatric Recommendations and Implementation Toolkits

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The Canadian Association of Paediatric Health Centres, Knowledge Exchange Net...

Objective: This overview is intended to summarize the systematic reviews of interventions studied to decrease paediatric pain that are currently available in the Cochrane Library. Given their unique physiology, research relevant to the management of newborns in the first month of life is not reviewed here. Four reviews relevant to the management of childrens pain are currently available

Bottom Line: An Evidence-Based Approach to Minimizing Acute Procedural Pain in the Emergency Department and Beyond. Pediatr Emerg Care 2016;32(1):36-42.

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Ali S, McGrath T, Drendel AL

Objective: This review article aims to provide a summary of several strategies, which are supported by definitive and systematically reviewed evidence, that can be implemented alone or in combination to reduce procedural pain and anxiety for children in the ED and beyond.

UNDER REVIEW: Recommandations de Base: Douleur procdurale

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French Bottom line recommendations for the treatment and management of procedural pain. Published online: March 2017.

Clinical guidelines

Video: Procedural sedation and analgesia in children

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Krauss BS, Krauss BA, Green SM.

This video describe procedural sedation and analgesia for children. Published: April 2014.

Clinical Guideline: Sedation in children and young people: Sedation for diagnostic and therapeutic procedures in children and young people

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NICE National Institute for Health and Care Excellence

This clinical guideline covers the assessment, preparation, training and monitoring needed when using sedation in people under the age of 19. The aim is to help healthcare professionals decide when sedation is the most clinically and cost effective option for reducing pain and anxiety during operations for children and young people.

Clinical Guideline: Clinical policy: procedural sedation and analgesia in the emergency department

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Godwin SA, Burton JH, Gerardo CJ, Hatten BW, Mace SE, Silvers SM, Fesmire FM,...

This clinical policy from the American College of Emergency Physicians is the revision of a 2005 clinical policy evaluating critical questions related to procedural sedation in the emergency department.

Video: Managing Procedural Anxiety in Children

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Krauss BS, Krauss BA, Green SM.

This video describes the signs of acute anxiety in children and demonstrates approaches to interacting with children that minimize anxiety and maximize cooperation. Published: April 2016.

Clinical Practice Guideline: Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update

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American Academy of Pediatrics, American Academy of Pediatric Dentistry, Cot ...

This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Clinical Guideline: Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update

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Green SM, Roback MG, Kennedy RM, Krauss B

This update of an evidence-based clinical practice guideline critically discusses indications, contrindications, personnel requirements, monitoring, dosing, coadministered medications, recovery issues, and future research questions for ketamine dissociative sedation.

Clinical Guideline: Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

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Cot CJ, Wilson S, American Academy of Pediatrics, American Academy of Pediatr...

This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Clinical Practice Guideline: Good practice in postoperative and procedural pain management

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Association of Paediatric Anaesthetists of Great Britain and Ireland

This themed issue starts with an outstanding review of the history of Pediatric Regional Anesthesia (PRA), written by an equally outstanding second-wave pioneer and promoter of this particular facet of pediatric anesthesia, Professor Emeritus Kester Brown.

Clinical Practice Guideline: Pain-Less Practice: Techniques to Reduce Procedural Pain and Anxiety in Pediatric Acute Care

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Olsen, K, Weinberg, E

Purpose: This article introduces the concept of a PainLESS Practicean evidence-based, tiered approach to procedural pain and anxiety management in acute care

Clincal Practice Guideline: Prevention and Management of Procedural Pain in the Neonate: An Update

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Committee on Fetus and Newborn and Section on Anesthesiology and Pain Medicine

Purpose: This statement updates previous recommendations with new evidence on the prevention, assessment, and treatment of neonatal procedural pain.

Summaries of systematic reviews

Cochrane Summary: Psychological interventions for needle-related procedural pain and distress in children and adolescents

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Birnie KA, Noel M, Chambers CT, Uman LS, Parker JA

To assess the efficacy of psychological interventions for needlerelated procedural pain and distress in children and adolescents.

Cochrane Summary: Breastfeeding or breast milk for procedural pain in neonates

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Shah PS, Herbozo C, Aliwalas LL, Shah VS

Breastfeeding provides pain relief for newborn babies undergoing painful procedures. Medicine for pain relief is commonly given for major painful procedures, but may not be given for minor painful procedures such as blood sampling (by heel prick orvenepuncture). There are different forms of non-pharmacological strategies that may be used to reduce pain in babies, such as holding, swaddling them, sucking on a pacifier, or giving sweet solutions (such as sucrose or glucose). Different studies done in babies have shown that breastfeeding is a good way to reduce the pain babies feel when subjected to minor painful procedures. These studies have been done in full-term babies and they have shown that breastfeeding is effective by demonstrating that it reduces babies' crying time and reduces different pain scores that have been validated for babies. Breast milk given by syringe has not shown the sameefficacyas breastfeeding itself. No studies have been done in premature babies, and so new studies are needed to determine if the use of supplemental breast milk in these small babies is effective in reducing their pain.

Cochrane Summary: Skin-to-skin care with newborns cuts down procedural pain

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Johnston C, Campbell-Yeo M, Disher T, Benoit B, Fernandes A, Streiner D, Ingl...

The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and to determine the effects of the amount of SSC (duration in minutes), method of administration (e.g. who provided the SSC) of SSC in reducing pain from medical or nursing procedures in neonates

Cochrane Overview: The Cochrane Library and procedural pain in children: an overview of reviews

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Curtis S, Wingert A, Ali S

Objective: To summarize Cochrane reviews assessing the effects of various interventions used for pain in non-neonatal children undergoing painful medical procedures.

Cochrane Summary: Nonpharmacological management of infant and young child procedural pain

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Pillai Riddell RR, Racine NM, Gennis HG, Turcotte K, Uman LS, Horton RE, Ahol...

We examined 13 different types of commonly investigated non-pharmacological treatments (excluding breastmilk, sucrose, and music) to determine theirefficacyfor pain reactions after an acutely painful procedure (right after the needle ('pain reactivity') and less immediate pain reactions ('immediate pain-related regulation').Fifty-onerandomizedcontrolled trials were included involving 3396 participants. For preterm infants, there was sufficient evidence to recommend kangaroo care, sucking-related interventions, and swaddling/facilitated tucking interventions for both pain reactivity and immediate pain-related regulation. For neonates, there was sufficient evidence to recommend sucking-related interventions as an effective treatment for pain reactivity and immediate pain-related regulation.Rocking/holding was also found to be efficacious for neonatal immediate pain-related regulation.For older infants, there were no treatments reviewed that demonstrated sufficient evidence. Due to significant differences in the magnitude of treatment effects among studies (heterogeneity), some analyses that found a lack of treatment effect need to be interpreted with caution.

Overviews of systematic reviews

Overview of Systematic Reviews: What works and what's safe in pediatric emergency procedural sedation: an overview of reviews

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Hartling L, Milne A, Foisy M, Lang E, Sinclair D, Klassen TP, Evered L

This overview of systematic reviews examines the safety and efficacy of sedative agents commonly used for procedural sedation (propofol, ketamine, nitrous oxide, midazolam) in children in the ED or similar settings.

Systematic reviews

Systematic Review: Intravenous vs intramuscular ketamine for pediatric procedural sedation by emergency medicine specialists: a review

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Deasy C, Babl FE

This review investigated existing evidence to determine whether ketamine should be best administered intravenously or intramuscularly.

Systematic Review: Professional skills and competence for safe and effective procedural sedation in children: recommendations based on a systematic review of the literature

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Leroy PL, Schipper DM, Knape HJ

This review investigated which skills and competence were imperative to assure optimal effectiveness and safety of procedural sedation (PS) in children and analyzed the underlying levels of evidence.

Systematic Review: Intranasal ketamine for procedural sedation and analgesia in children

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Poonai N, Canton K, Ali S, Hendrikx S, Shah A, Miller M, Joubert G, Rieder M,...

Evidence suggests ketamine can be administered intranasally. This study reviews the evidence for intranasal ketamine for procedural sedation and analgesia in children.

Review: Update on pharmacological management of procedural sedation in children

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Roback MG, Carlson DW, Babl FE, Kennedy RM

This review provides an update on pharmacological techniques for procedural sedation for children outside the operating room.

Systematic Review: Hematoma block or procedural sedation and analgesia, which is the most effective method of anesthesia in reduction of displaced distal radius fracture?

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Tseng, PT, Leu, TH, Chen, YW and Chen, YP

The aim of this study was to compare HB and PSA for adult and pediatric patients during reduction of displaced distal radius fracture to identify the level of pain relief, frequency of adverse effects (AEs), and reduction failure.

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

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Migita RT, Klein EJ, Garrison MM

This review assessed the safety and efficacy of various forms of analgesia and sedation for fracture reduction in pediatric patients in the emergency department, as observed in randomized controlled trials in pediatric populations.

Systematic Review: Predictors of emesis and recovery agitation with emergency department ketamine sedation: an individual-patient data meta-analysis of 8,282 children

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Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D, McKee M, Weiss...

Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies.

Systematic Review: Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children

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Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D, McKee M, Weiss...

Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events.

Systematic Review: Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department

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Mace SE, Barata IA, Cravero JP, Dalsey WC, Godwin SA, Kennedy RM, Malley KC, ...

This document is a clinical policy on pediatric procedural sedation.

Systematic Review: Pain management and sedation for children in the emergency department

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Atkinson P, Chesters A, Heinz P

We provide an overview of published evidence to help clinicians assess, manage, and minimise pain in children presenting to hospital.

Cochrane Systematic Review: Non-pharmacological management of infant and young child procedural pain

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Pillai Riddell RR, Racine NM, Turcotte K, Uman LS, Horton RE, Din Osmun L, A...

OBJECTIVES: To assess the efficacy of non-pharmacological interventions for infant and child (up to three years) acute pain, excluding breastmilk, sucrose, and music. Analyses accounted for infant age (preterm, neonate, older) and pain response (pain reactivity, pain-related regulation).

Cochrane Systematic Review: Sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age

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Kassab M, Foster JP, Foureur M, Fowler C

OBJECTIVES: To determine the effectiveness of sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age compared with no treatment, placebo, other sweet-tasting solutions, or pharmacological or other non-pharmacological pain-relieving methods.

Systematic Review: Pediatric clinical practice guidelines for acute procedural pain: a systematic review

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Lee GY, Yamada J, Kyololo O, Shorkey A, Stevens B

Objective: To systematically review the quality of existing practice guidelines for acute procedural pain in children and provide recommendations for their use.

Cochrane Systematic Review: Sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age

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Kassab M, Foster JP, Foureur M, Fowler C

Objectives: To determine the effectiveness of sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age compared with no treatment, placebo, other sweet-tasting solutions, or pharmacological or other non-pharmacological pain-relieving methods.

Cochrane Systematic Review: Breastfeeding or breast milk for procedural pain in neonates

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Shah PS, Herbozo C, Aliwalas LL, Shah VS

Objectives: The primary objective was to evaluate the effectiveness of breastfeeding or supplemental breast milk in reducing procedural pain in neonates. The secondary objective was to conduct subgroup analyses based on the type of control intervention, gestational age and the amount of supplemental breast milk given.

Cochrane Systematic Review: Sweet tasting solutions for reduction of needle-related procedural pain in children aged one to 16 years

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Harrison D, Yamada J, Adams-Webber T, Ohlsson A, Beyene J, Stevens B

Objectives: To determine the efficacy of sweet tasting solutions or substances for reducing needle-related procedural pain in children beyond one year of age.

Cochrane Systematic Review: Non-pharmacological management of infant and young child procedural pain

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Pillai Riddell RR, Racine NM, Turcotte K, Uman LS, Horton RE, Din Osmun L, Ah...

Objectives: To assess the efficacy of non-pharmacological interventions for infant and child (up to three years) acute pain, excluding breastmilk, sucrose, and music. Analyses accounted for infant age (preterm, neonate, older) and pain response (pain reactivity, pain-related regulation).

Cochrane Systematic Review: Psychological interventions for needlerelated procedural pain and distress in children and adolescents

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BirnieKA, NoelM, ChambersCT, UmanLS, ParkerJA

Objectives: To provide an update to our 2006 review assessing the efficacy of psychological interventions for needle-related procedural pain and distress in children and adolescents.

Systematic Review: Clinical efficacy of virtual reality for acute procedural pain management: A systematic review and meta-analysis

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Evelyn Chan, Samantha Foster , Ryan Sambell , Paul Leong

There is no comprehensive, high-quality systematic review that specifically assesses the efficacy of virtual reality on acutely painful healthcare interventions, nor has there been any quantitative data synthesis on this topic. We therefore conducted a systematic review and meta analysis to appraise the quality of published literature and to synthesize data for acute pain scores.

Systematic Review: Sweet Solutions to Reduce Procedural Pain in Neonates: AMeta-analysis

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Denise Harrison,Catherine Larocque,Mariana Bueno,Yehudis Stokes,Lucy Turner,B...

Objective: To review all trials evaluating sweet solutions for analgesia in neonates and to conduct cumulative meta-analyses (CMAs) on behavioral pain outcomes.

Cochrane Systematic Review: Breastfeeding for procedural pain in infants beyond the neonatal period

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Harrison D, Reszel J, Bueno M, et al.

Objectives:To determine the effect of breastfeeding on procedural pain in infants beyond the neonatal period (first 28 days of life) up to one year of age compared to no intervention, placebo, parental holding, skin-to-skin contact, expressed breast milk, formula milk, bottle feeding, sweet-tasting solutions (e.g. sucrose or glucose), distraction, or other interventions.

Cochrane Systematic Review: Nonpharmacological management of infant and young child procedural pain

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Pillai RiddellRR, RacineNM, GennisHG, TurcotteK, UmanLS, HortonRE, Ahola Kohu...

Objectives: To assess the efficacy of non-pharmacological interventions for infant and child (up to three years) acute pain, excluding breastmilk, sucrose, and music. Analyses accounted for infant age (preterm, neonate, older) and pain response (pain reactivity, pain-related regulation).

Cochrane Systematic Review: Local anaesthetics and regional anaesthesia for preventing chronic pain after surgery

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Andreae MH, Andreae DA

OBJECTIVES: To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of persistent pain six or 12 months after surgery.

Cochrane Systematic Review: Topical anaesthetics for repair of dermal laceration

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Eidelman A, Weiss JM, Baldwin CL, Enu IK, McNicol ED, Carr DB

OBJECTIVES: To compare the efficacy and safety of infiltrated local anaesthetics with those of topical local anaesthetics for repair of dermal lacerations and to evaluate the efficacy and safety of various single or multi-component topical anaesthetics to identify cocaine-free topically applied local anaesthetics that may provide equivalent analgesia to those containing cocaine.

Cochrane Systematic Review: EMLA and Amethocaine for reduction of children's pain associated with needle insertion

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Lander JA, Weltman BJ, So SS

OBJECTIVES: To compare the topical anaesthetics amethocaine and an eutectic mixture of local anaesthetics (EMLA) in terms of anaesthetic efficacy, ease of needle insertion and adverse events when used for intravenous cannulation and venipuncture in children.

Cochrane Systematic Review: Local anaesthetic sympathetic blockade for complex regional pain syndrome

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Stanton TR, Wand BM, Carr DB, Birklein F, Wasner GL, O'Connell NE

OBJECTIVES: To assess the efficacy of LASB for the treatment of pain in CRPS and to evaluate the incidence of adverse effects of the procedure.

Systematic Review: Nitrous oxide provides safe and effective analgesia for minor paediatric procedures--a systematic review

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Pedersen RS, Bayat A, Steen NP, Jacobsson ML

The aim of this review was to investigate the safety and efficacy of nitrous oxide during brief, but painful paediatric procedures and to compare nitrous oxide with some of the commonly used pharmacological and non-pharmacological treatments for relieving anxiety and mild to moderate pain in Denmark.

Key studies

Key Study: Physiologic monitoring practices during pediatric procedural sedation: a report from the Pediatric Sedation Research Consortium

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Langhan ML, Mallory M, Hertzog J, Lowrie L, Cravero J

This study aimed to describe the frequency of different physiologic monitoring modalities and combinations of modalities used during pediatric procedural sedation and to describe the variations of monitoring and whether or not sedations meet monitoring guidelines.

Key Study: The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium

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Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog JH,

This study aims to delineate the nature and frequency of adverse events associate with propofol-based sedation/anesthesia care using prospectively collected data on pediatric sedation/anesthesia outside the operating room (OR).

Key Study: Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium

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Cravero JP, Blike GT, Beach M, Gallagher SM, Hertzog JH, Havidich JE, Gelman B

The objective of this study was to use a large database of prospectively collected data on pediatric sedation and/or anesthesia for diagnostic and therapeutic procedures to delineate the nature and the frequency of adverse events that are associated with sedation/anesthesia care for procedures that are performed outside the operating room in children.

Key Study: Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia Outside the Operating Room: A Report of the Pediatric Sedation Research Consortium

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Beach ML, Cohen DM, Gallagher SM, Cravero JP

This study evaluated aspiration episodes and a combined outcome of major adverse events (aspiration, death, cardiac arrest, or unplanned hospital admission) with respect to NPO status, American Society of Anesthesiologists physical status, age, propofol use, procedure types, and urgency of the procedure.

Key Study: Etomidate versus midazolam for procedural sedation in pediatric outpatients: a randomized controlled trial

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Di Liddo L, D'Angelo A, Nguyen B, Bailey B, Amre D, Stanciu C

The objective of this study was to compare the efficacy of etomidate and midazolam for achieving procedural sedation and analgesia in children.

Key Study: Comparison of propofol/fentanyl versus ketamine/midazolam for brief orthopedic procedural sedation in a pediatric emergency department

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Godambe SA, Elliot V, Matheny D, Pershad J

This study compared the effectiveness of 2 medication regimens, propofol/fentanyl (P/F) and ketamine/midazolam (K/M), for brief orthopedic emergency department procedural sedation.

Key Study: Intravenous ketamine plus midazolam is superior to intranasal midazolam for emergency paediatric procedural sedation

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Acworth JP, Purdie D, Clark RC

This study compared intranasal midazolam (INM) with a combination of intravenous ketamine and intravenous midazolam (IVKM) for sedation of children requiring minor procedures in the emergency department.

Key Study: Safety and efficacy of propofol administered by paediatricians during procedural sedation in children

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Chiaretti A, Benini F, Pierri F, Vecchiato K, Ronfani L, Agosto C, Ventura A,...

The aim of this study was to determine the safety and the efficacy of paediatrician-administered propofol in children undergoing different painful procedures.

Key Study: A blinded, randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children

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Shah A, Mosdossy G, McLeod S, Lehnhardt K, Peddle M, Rieder M

This study compared total sedation time when ketamine/ propofol was used compared with ketamine alone for pediatric procedural sedation and analgesia.

Key Study: Characteristics of and Predictors for Apnea and Clinical Interventions During Procedural Sedation

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Krauss BS, Andolfatto G, Krauss BA, Mieloszyk RJ, Monuteaux MC

This study aims to describe the characteristics of and predictors for apnea and clinical interventions during emergency department (ED) procedural sedation.

Key Study: Procedural Sedation With Ketamine Versus Propofol for Closed Reduction of Pediatric Both Bone Forearm Fractures

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Morrison T, Carender C, Kilbane B, Liu RW

The current study was conducted to answer 2 questions for pediatric both bone forearm fractures treated with closed reduction with either ketamine or propofol procedural sedation : 1) Is there a difference in the rate of unacceptable alignment 4 weeks after reduction? 2) Is there a difference in the rates of major sedation-related complications?

Key Study: Desaturation in procedural sedation for children with long bone fractures: Does weight status matter?

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Hirsch, D G, Tyo, J and Wrotniak, B H

The objective of our study was to determine if overweight and obesity were associated with increased desaturations during procedural sedation compared with patients of healthy weight.

Key Study: Behavioral Changes in Children After Emergency Department Procedural Sedation

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Pearce, J I, Brousseau, D C, Yan, K, Hainsworth, K R, Hoffmann, R G and Drend...

The purpose of this study was to determine the proportion of children undergoing procedural sedation for fracture reduction in the emergency department (ED) observed to experience negative postdischarge behaviors. Predictors of negative behaviors were evaluated, including anxiety.

Key Study: Etomidate Versus Ketamine: Effective Use in Emergency Procedural Sedation for Pediatric Orthopedic Injuries

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Disel, N R, Yilmaz, H L, Sertdemir, Y, Yesilagac, H and Avci, A

The aim of this study was to compare the induction and recovery times, postsedation observation durations, and adverse effects of etomidate and ketamine in pediatric patients with fractures and/or dislocations requiring closed reduction in the emergency department.

Key Study: Liposomal lidocaine to improve procedural success rates and reduce procedural pain among children: a randomized controlled trial

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Taddio A, Soin HK, Schuh S, Koren G, Scolnik D

Historically, children have been undertreated for their pain, and they continue to undergo painful cutaneous procedures without analgesics. A new topical anesthetic, liposomal lidocaine 4% cream (Maxilene, RGR Pharma, Windsor, Ont.), has become available. It has pharmacologic properties that are superior to other topical anesthetics, including an onset of action of only 30 minutes. We sought to determine the success rate of cannulation, analgesic effectiveness, procedure duration and rate of adverse skin reactions when liposomal lidocaine is used before intravenous cannulation of children.

Key Study: The emerging use of ketamine for anesthesia and sedation in traumatic brain injuries

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Chang LC, Raty SR, Ortiz J, Bailard NS, Mathew SJ

This article reviews the current literature in regards to using ketamine inpatientswith traumatic brain injuries in different clinical settings associated with anesthesia, as well as reviews the potential mechanisms underlying the neuroprotective effects of ketamine.

Key Study: A randomized, controlled trial of i.v. versus i.m. ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures

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Roback MG, Wathen JE, MacKenzie T, Bajaj L

This study compared adverse events, efficacy, and length of sedation of intravenous (i.v.) versus intramuscular (i.m.) ketamine procedural sedation and analgesia for orthopedic procedures in the emergency department (ED).

Key Study: The Lancaster experience of 2.0 to 2.5 mg/kg intramuscular ketamine for paediatric sedation: 501 cases and analysis

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McGlone RG, Howes MC, Joshi M

The aims of this study were to report the experience of using intramuscular ketamine 2.0 or 2.5 mg/kg for minor painful procedures in children in a medium sized district general hospital accident and emergency department, and to demonstrate the safety and acceptability of ketamine and determine if the incidence of adverse effects is related to dose or other variables.

Key Study: Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomized, double-blind, placebo-controlled trial

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Sherwin TS, Green SM, Khan A, Chapman DS, Dannenberg B

This study characterized the nature and severity of recovery agitation after ketamine sedation in children treated in the emergency department and determined whether the addition of adjunctive midazolam reduced the magnitude of such recovery agitation.

Key Study: Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double-blind, randomized, controlled, emergency department trial

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Wathen JE, Roback MG, Mackenzie T, Bothner JP,

This study was conducted to investigate the frequency and severity of adverse effects, specifically emergence phenomena, experienced by patients receiving intravenous ketamine with or without midazolam for sedation in a pediatric emergency department.

Key Study: Effect of ondansetron on the incidence of vomiting associated with ketamine sedation in children: a double-blind, randomized, placebo-controlled trial

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Langston, WT, Wathen, JE, Roback, MG, Bajaj, L,

This study investigated the effect of ondansetron on the incidence of vomiting in children who received intravenous (IV) ketamine for procedural sedation and analgesia in the emergency department (ED).

Key Study: A randomized clinical trial of continuous-flow nitrous oxide and midazolam for sedation of young children during laceration repair

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Luhmann JD, Kennedy RM, Porter FL, Miller JP, Jaffe DM,

This study compared the efficacy and complication profile of oral midazolam therapy and continuous-flow 50% nitrous oxide in alleviating anxiety during laceration repair in children 2 to 6 years old.

Key Study: Success rate of pneumatic reduction of intussusception with and without sedation

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Feldman O, Weiser G, Hanna M, Devir O, Balla U, Johnson DW, Kozer E, Shavit I

The aim of this study was to evaluate the success rate of pneumatic reduction of intussusception with and without sedation.

Key Study: Effects of esketamine sedation compared to morphine analgesia on hydrostatic reduction of intussusception: A case-cohort comparison study

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van de Bunt JA, Veldhoen ES, Nievelstein RAJ, Hulsker CCC, Schouten ANJ, van ...

The aim of this study was to compare hydrostatic reduction using morphine analgesia compared to procedural sedation with eskatamine in terms of success rate, adverse events, and duration for reduction.

Key Study: Hematoma block versus sedation for the reduction of distal radius fractures in children

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Bear, DM, Friel, NA, Lupo, CL, Pitetti, R and Ward, WT

To determine which mode of anesthesia, hematoma block (HB) or procedural sedation (PS), was preferable for distal radius fracture (DRF) reduction in children.

Key Study: Conscious sedation and reduction of fractures in the paediatric population: an orthopaedic perspective

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Yang, B W and Waters, P M

This study describes the epidemiology and outcomes associated with fracture conscious sedation and reduction in a level I paediatric ED.

Key Study: Equimolar nitrous oxide/oxygen versus placebo for procedural pain in children: a randomized trial

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Reinoso-Barbero F, Pascual-Pascual SI, de Lucas R, Garca S, Billot C, Dequenn...

Objective: This randomized, single-dose, double-blind, Phase III study was designed to compare the level of procedural pain after use of premixed equimolar mixture of 50% oxygen and nitrous oxide (EMONO) or placebo (premixed 50% nitrogen and oxygen).

Key Study: Parent and provider perspectives on procedural care for children with autism spectrum disorders

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Davignon MN, Friedlaender E, Cronholm PF, Paciotti B, Levy SE

The aim of this study was to identify parent and provider perspectives on barriers and facilitators to procedural care for children with autism spectrum disorders.

Key Study: Pretreatment with intravenous ketamine reduces propofol injection pain

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Barbi E, Marchetti F, Gerarduzzi T, Neri E, Gagliardo A, Sarti A, Ventura A

The aim of the study was to investigate whether pretreatment with ketamine would reduce infusion line pain in propofol sedation in children.

Key Study: Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies

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Kennedy RM, Porter FL, Miller JP, Jaffe DM

Emergency management of pediatric fractures and dislocations requires effective analgesia, yet children's pain is often undertreated. This study compared the safety and efficacy of fentanyl- versus ketamine- based protocols.

Key Study: Administration of nitrous oxide to pediatric patients provides analgesia for venous cannulation

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Henderson JM, Spence DG, Komocar LM, Bonn GE, Stenstrom RJ

This study aimed to determine whether administration of nitrous oxide, 50% and 70%, could provide analgesia and anxiolysis during venous cannulation in pediatric patients.

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Emergency Medicine Cases Podcast: Pediatric Procedural Sedation (2016)

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Dr. Amy Drendel

Episode 76: Join Dr. Amy Drendel, a world leader in pediatric pain management and procedural sedation research, as she discusses how best to manage pain and anxiety in three situations in the ED: the child with a painful fracture, the child who requires imaging in the radiology department and the child who requires a lumbar puncture.

Published online: February 2016

Resource - Acute Procedural Pain Toolkits

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Canadian Association of Paediatric Health Centres Pain Community of Practice

These Toolkits are a resource for clinicians who work with children that may experience acute procedural pain and support moving best practice recommendations into practice. Based on the best research evidence and clinical practice, these Toolkits bring together a collection of evidence-based recommendations, clinical and family resources, policy examples, pre-populated power point templates, videos, and background articles with the purpose of making these recommendations easier to move into practice. 

There are eight toolkits to choose from: 

  • Assessment
  • Distraction
  • Intranasal fentanyl
  • Breast feeding, non-nutritive sucking, and positioning
  • Oral sucrose
  • Pain with suturing
  • Topical anesthetics (venipuncture)
  • Implementation strategies

Website: Pain Assessment and Management Initiative (PAMI)

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Pain Assessment and Management Initiative (PAMI) is an e-Learning and patient safety educational project funded through a grant by the Florida Medical Malpractice Joint Underwriting Association. The overall goal of PAMI is to improve the safety of patients of all ages by developing tools and learning modules for health care providers to recognize, assess, and manage acute and chronic pain in acute care settings such as the Emergency Department. The tools and resources developed are designed to be used, adapted and implemented by any health care facility or agency based on their specific needs. The PAMI site also includes pain related resourcesapps/podcasts and learning modules. PAMI learning modules and materials are developed by a state and national expert panel and are multidisciplinary, targeting physicians, nurses, PAs, pharmacists, paramedics, hospital patient safety officers, risk managers and other providers.

TREKK.ca Info Pages

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Podcast: Pediatric Procedural Sedation

Posted: Feb 09, 2016  | Announcement  | Team: News and Events 
Tags: Procedural Sedation, Procedural Pain



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New resources available on trekk.ca!

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New Bottom Line Recommendation: Procedural Pain

Posted: Nov 07, 2016  | Announcement  | Team: News and Events 



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2017 Pediatric Emergency Care Conference

Posted: Oct 19, 2017  | Announcement  | Team: News and Events 



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New bottom line recommendations for concussion on trekk.ca

Posted: Nov 05, 2014  | Announcement  | Team: News and Events 




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