Form Of Analgesia Research Articles

Cochrane Review: Nonsteroidal anti‐inflammatory drugs and perioperative bleeding in paediatric tonsillectomy

AbstractBackgroundNonsteroidal anti‐inflammatory drugs (NSAIDs) are used for pain relief following tonsillectomy in children. However, as they inhibit platelet aggregation and prolong bleeding time, they could cause increased perioperative bleeding. The overall risk remains unclear. This review was originally published in 2004 and was updated in 2010.ObjectivesThe primary objective of this review was to assess the effects of NSAIDs on bleeding with paediatric tonsillectomy. Our secondary outcome was to establish whether NSAIDs affect the incidence of other postoperative complications when compared to other forms of analgesia.Search methodsWe searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 6); MEDLINE (inception until May 2010); EMBASE (inception until May 2010); Current Problems (produced by the UK Medicines Control Agency), MedWatch (produced by the US Food and Drug Administration) and the Australian Adverse Drug Reactions Bulletins (to May 2010). The original search was performed in August 2004. We also contacted manufacturers and researchers in the field.Selection criteriaWe included randomized controlled trials assessing NSAIDs in children, up to and including 16 years of age, undergoing elective tonsillectomy or adenotonsillectomy.Data collection and analysisTwo authors independently assessed trial quality and extracted the data. We contacted study authors for additional information, where necessary.Main resultsWe included 15 trials that involved 1046 children in this updated review. This included one trial that was added as a result of updating our search and another trial that we had incorrectly excluded from our previous review. All included trials compared NSAIDs with other analgesics or placebo and looked at bleeding requiring surgical intervention. NSAIDs did not significantly alter the number of perioperative bleeding events requiring surgical intervention: Peto odds ratio (OR) 1.32 (95% confidence interval (CI) 0.47 to 3.70). Eight trials involving 532 children looked at bleeding not requiring surgical intervention. NSAIDs did not significantly alter the number of perioperative bleeding events not requiring surgical intervention: Peto OR 1.00 (95% CI 0.39 to 2.53). Twelve trials involving 928 children looked at postoperative nausea and vomiting. There was less nausea and vomiting when NSAIDs were used as part of the analgesic regime than when NSAIDs were not used: OR 0.49 (95% CI 0.29 to 0.83).Authors' conclusionsNSAIDs did not cause any increase in bleeding that required a return to theatre. There was significantly less nausea and vomiting when NSAIDs were used compared to alternative analgesics.Plain Language SummaryNonsteroidal anti‐inflammatory drugs (NSAIDs) do not significantly increase bleeding in children having their tonsils out, and there is less nausea and vomiting when NSAIDs are used.Nonsteroidal anti‐inflammatory drugs (NSAIDs) are used for pain relief following tonsillectomy in children. Bleeding is a recognised complication of this procedure but NSAIDs can interfere with blood clotting so there has been concern that these drugs will increase the risk of bleeding. If bleeding is severe this may result in the child being re‐admitted to hospital, having a blood transfusion or returning to theatre. It was therefore important to establish whether these drugs are safe to use in children having their tonsils out. The review focused on clinically significant bleeding that results in the child requiring additional treatment rather than measured blood loss.We also wanted to establish whether NSAIDs affect the incidence of other postoperative complications when compared to other forms of analgesia.The review found that NSAIDs did not significantly increase bleeding. There were insufficient data to compare the risk of bleeding with each individual type of NSAID. However, we were able to compare ketorolac, which has been perceived as having a greater risk of bleeding, with the other NSAIDs and found no increased risk of bleeding. There was less nausea and vomiting when NSAIDs were used as part of the analgesic regime than when NSAIDs were not used.The main limitation of our review is that bleeding following tonsillectomy is an uncommon event (occurring in 3% to 5% of children). We found all the data that are currently available (15 trials studying approximately 1000 children) but a very large number of participants are required to provide an adequate number of events to give a significant result. It is possible that the numbers of participants are too small to establish whether NSAIDs increase bleeding. However, currently there is no evidence to support withholding NSAIDs for paediatric tonsillectomy.

Significance of Preprocedure Ultrasound Scan in Ultrasound-guided Regional Anaesthesia

We would like to report our experience that highlights the significance of preprocedure ultrasound scan before successfully performing an ultrasound-guided supraclavicular brachial plexus block in a patient with previous major neck, chest and arm injuries. Our patient was a 30 year old male soldier who, 14 months prior to the scheduled surgery, suffered lifethreatening penetrating neck and chest injuries following the explosion of an improvised explosive device. The neck injuries included 2/3rd disruption of the left common carotid artery 3 cm below its bifurcation, total transection of left internal and external jugular veins and a perforation in the hyoid cartilage. Other injuries included blast injury to the left arm (which was ultimately treated with a split skin graft), left pneumothorax, left occipital cerebral infarct (secondary to the carotid injury) and left corneal injury. The carotid injury had been repaired using a saphenous vein graft, while the transected internal and external jugular veins had been tied off. He subsequently underwent a redo surgery to his left carotid artery following surgical problems relating to the graft. He was scheduled for serial excision of scar secondary to the split skin graft in the left arm (middle and lower 1/3) and removal of a fragment from the left index finger. It was felt that a brachial plexus block would provide excellent perioperative analgesia for the elective procedure in this young man who had already suffered from significant injuries in the past with ongoing pain issues. However, the nature of his previous injuries and repeated vascular procedures in the neck meant that a block could be technically difficult and risky due to altered anatomy or abnormal vascular proliferation. A decision was made to proceed with ultrasound examination of the supraclavicular region to delineate the anatomy before proceeding with a block. This was to be followed with a general anaesthetic. If the anatomy was abnormal to an extent that the risks outweigh the benefits of brachial plexus block, the plan was to provide alternate forms of analgesia. The anaesthetic plan was discussed with the patient and consent obtained. In the anaesthetic room, a thorough ultrasonographic assessment of the left supraclavicular area was done using Sonosite S-NerveTM. All the important structures relevant to performing a brachial plexus block were identified viz subclavian artery, subclavian vein, 1st rib, pleura and brachial plexus (Fig. 1). We could not identify any aberrant blood vessels in the area of interest. We repeated the scan with colour Doppler. Satisfied with the anatomy, we proceeded with real-time ultrasound-guided supraclavicular brachial plexus block using the in-plane technique. A 20G Locoplex insulated peripheral nerve block needle attached with nerve stimulator was used. Although no twitch was obtained at 0.3 mA, visual confirmation of correct position of the needle was confirmed. A total of 30 ml of 0.375% levobupivacaine was injected around the brachial plexus. Good local anaesthetic spread was confirmed by ultrasound. We then proceeded with a general anaesthetic as planned. The duration of surgery was 2 hours. Intraoperative course was uneventful with the patient requiring no supplemental analgesia. Postoperative assessment confirmed a good block that was effective for 24 hours. The postoperative course was uneventful and the patient was discharged from the hospital on the 3rd postoperative day.

English

Systemic opioids are widely used for the relief of labor pain. Self-administered nitrous oxide with concentration of 50% is a new form of analgesia. The aim of this study was to compare the analgesic efficacy and side effects of the patient controlled inhaled nitrous oxide (50% ‘‘Entonox’’) with systemic intramuscular pethidine, in reducing pain during normal vaginal labor in Iranian population. In a randomized controlled study, the analgesic efficacy of inhaled 50% nitrous oxide (Entonox) was evaluated as compared to intra muscular pethidine for reducing labor pain among 100 women undergoing normal vaginal delivery. Mean maternal age was 26.2 and 27.2 years in entonox and pethidine groups, respectively. Duration of first and second stages was significantly shorter in patients receiving nitrous oxide as analgesia as compared to pethidine group (P < 0.05). Pain severity according to visual analog scale (VAS) score was significantly lower in patient that received nitrous oxide (P = 0.0001). We also showed significantly higher satisfaction of pain reduction in nitrous oxide group during labor (P = 0.01). No significant difference was observed among the groups regarding neonatal complications. Although, nitrous oxide is certainly not a potent analgesic, we found that it has more beneficial effects than pethidine in parturient women which is yet to be cleared. Key words: Entonox, labor pain, pethidine, nitrous oxide.

An alternative analgesic agent for intra-articular corticosteroid injections (IAI) in juvenile idiopathic arthritis (JIA) – a fentanyl lollipop

Background Intra articular injections are an effective and widely used technique that involes the direct application of a corticosteroid compound such as triamcinalone hexacetonide into a joint with active synovitis. Local IAIs can avoid many of the unwanted adverse effects of sytemic steroids but in children younger than 11 years or those with a polyarticular presentation a general anaesthetic is typically required. Traditional local anaesthetic agents include topical agents such as lignocaine or gaseous agents such as entonox (nitrous oxide). We have introduced an unique form of analgesia for this procedure since the establishment of our national unit in 2006 in form of fentanyl lollipops (Actiq). Aim To evaluate the efficacy & safety of fentanyl lollipops for children with JIA undergoing IAIs. Methods A total of 19 patients were studied . Pain scores an hour after the procedure were recorded using a 0–10 cm visual analogue scale (VAS). Parents and patients were reinterviewed at a later date regarding the effectiveness of the lollipops as a form of pain relief and whether they would consider this form of analgesia for their child again.

X-Ray Hysterosalphingography: The Most Painful Part in the Nigerian Woman.

Background: Hysterosalphingography (HSG) despite the accompanying pain still remains relevant in gynaecological practice. For effective analgesia, it is important to identify the most painful step of this procedure. Numerical Rating Scale (NRS) and the Categorical Pain Scale (CPS) were used to identify the most painful step of HSG procedure and to find out if age, parity and the degree of infertility affect pain perception in this group of patients. Patients and Methodology: Ninety Four women referred for HSG due to infertility were recruited into this study. Their background pain and perceived pain of each step of the procedure was graded using the NRS and the CPS. The data collected were statistically analysed. Results: Participant’s age ranged from 21 to 34 years with a mean of 33.3±4.8 years. Cervical traction with introduction of cannula and instillation of contrast was found to be the most painful step of the procedure both having a median score of 6 (range 0-10) based on the NRS and were rated to be moderate to worst possible pain based on the CPS. Almost 65% of the patients perceived the pain to be more than expected and nearly 100% would have preferred one form of analgesia or the other. Conclusion: The most painful step of HSG was found to be the same for the Nigerian women as in other parts of the world. These women should be offered effective analgesia for pain during HSG procedure. Key words: Hysterosalphingography, Pain Rating, Painful Step

Analgesia of Patients with Multiple Rib Fractures in Critical Care: A Survey of Healthcare Professionals in the UK.

ABSTRACTIntroductionGood analgesia has been shown to reduce the risk of pneumonia, chronic pain, and mortality in patients with multiple rib fractures (MRFs). This survey explores the current analgesic practice in the UK, protocol use, barriers to provision, and physician preferences.Materials and methodsA web-based survey was distributed nationally to an enriched cohort of clinicians working in UK trauma units with an interest in MRF management.ResultsSeventy-nine healthcare professionals responded. A third (31.4%) reported that their department had a rib fracture pain protocol, 52.9% did not, and 15.7% were unsure. Significantly more respondents reported adequate pain control when a hospital protocol was present compared to when not (χ2, p < 0.01). Inadequate analgesia, a poor cough, and inability to breathe deeply were the commonest complications reported by 81.4, 78.6, and 65.7%, respectively. Patient-controlled analgesia (PCA) was the most commonly used form of analgesia (38.6%) followed by thoracic epidural (TEA) (30.0%) and continuous opioid infusion (18.6%). However, TEA was the preferred method of analgesia among respondents (37.1%) followed by serratus block (21.4%), paravertebral block (17.1%), and PCA (14.3%).DiscussionThere is considerable variation among physicians in their current use of analgesic modalities, with opiate-based methods predominating despite a physician preference for regional techniques. Thoracic epidurals are preferred by physicians but of limited use as a result of contraindications, time pressures, and staff skill mix. Pain control is reported to be better handled when protocols are present. Further research focusing on currently utilized regional techniques is required in order to produce a validated standardized national protocol that is informed by the current practice, the evidence base, and limitations to service provision.Key messagesThere is considerable variation among physicians in their current use of analgesic modalities. Opiate-based methods dominate for thoracic trauma despite a physician preference for regional techniques, which can be challenging in this cohort due to contraindications, staff skill mix, and time pressures. Inadequate analgesia is common but is better managed when pain management protocols are available.How to cite this articleBeard L, Holt B, Snelson C, Parcha C, Smith FG, Veenith T. Analgesia of Patients with Multiple Rib Fractures in Critical Care: A Survey of Healthcare Professionals in the UK. Indian J Crit Care Med 2020;24(3):184–189.

Nitrous Oxide versus Pethidine with Promethasine for Reducing Labor Pain

Background: Systemic opioids are widely used for relief of labor pain. Self-administered nitrous oxide with concentration of 50% is a new form of analgesia. The aim of this study was to compare the analgesic efficacy and side effects of patient controlled, inhaled nitrous oxide 50% ‘‘Entonox’’ with systemic intramuscular pethidine, in reducing of pain during normal vaginal labor in Iranian population. Materials and Methods: In a randomized controlled study the analgesic efficacy of inhaled 50% nitrous oxide (Entonox) was evaluated compared to intra muscular pethidine for reducing labor pain among 100 women undergoing normal vaginal delivery. Results: Mean maternal age was 26.2 and 27.2 years in Entonox and Pethidine groups, respectively. Duration of first and second stages was significantly shorter in patients receiving nitrous oxide as analgesia, comparing to pethidine group (P<0.05). Pain severity according to VAS score was significantly lower in patient received nitrous oxide (P=0.0001). We also showed significantly higher satisfaction of pain reduction in nitrous oxide group during labor (P=0.01). No significant different was observed among the groups regarding infant complications. Conclusion: Although nitrous oxide is certainly not a potent analgesic, we found that it has more beneficial effects than pethidine in parturient women which remains to be cleared.

Pain as a Symptom in Patients Living With HIV/AIDS Seen at the Outpatient Clinic of a Nigerian Tertiary Hospital

Although the negative impact of pain on the quality of life of patients living with HIV has been documented in many Western studies, there is a paucity of data on pain in HIV-infected patients in Nigeria in spite of a large disease burden. We studied the frequency of pain as a symptom and determined the body regions often affected among our cohort of patients attending the antiretroviral (ARV) clinic. An interviewer-administered questionnaire was used to obtain information on presence of pain in the 2 weeks before the interview. Those with pain were further screened with the modified Brief Pain Inventory. There were 79 respondents-40.5% males, mean age 37.1 ± 8.6 years. Pain was present in 22 (27.8%) of the respondents. The major regions affected by pain were lower limbs (40.9%), head and neck (31.8%), and abdomen (31.8%). Only 40% of those with moderate to severe pain intensity reported being on any form of analgesia.

Neuraxial Morphine and Oral Herpes Reactivation in the Obstetric Population

Neuraxial morphine administration is a common strategy for providing postcesarean delivery analgesia. Morphine delivered via this route increases the risk of herpes labialis (oral herpes) reactivation, a disease common in women of childbearing age. A primary concern is risk of transmission to the neonate from maternal reactivation. The benefits to the mother of this form of analgesia outweigh the risk of neonatal herpes acquired postpartum from maternal recurrence because serious neonatal morbidity from recurrent herpes has not been described.

Labor Epidural Analgesia and Maternal Fever

Women in labor who receive epidural analgesia are more likely to experience hyperthermia and overt clinical fever. The gradual development of modest hyperthermia observed in laboring women with epidural analgesia is not seen in those electing other forms of analgesia or unmedicated labor. Clinical fever is also far more likely in women laboring with epidural analgesia. It is possible that the observed slow increase in mean temperature is an artifact of averaging the temperature curves of a small group of women who eventually develop fever with a larger group who remain afebrile throughout labor. Selection bias confounds the association between epidural analgesia and fever, because women at risk for fever-due to longer duration of ruptured membranes, longer labor, more frequent cervical examinations, and other interventions-are also more likely to select epidural analgesia. However, even randomized trials have confirmed a higher incidence of fever in epidural-exposed women, suggesting a causal relationship. The mechanisms of epidural-associated fever remain incompletely understood. Altered thermoregulation and an antipyretic effect of opioids given to women without epidural analgesia may explain part of the phenomenon, but the most likely etiology is inflammation, most commonly in the placenta and membranes (chorioamnionitis). The consequences of maternal fever are diverse. Obstetricians are more likely to intervene surgically in laboring women with fever, and neonatologists are more likely to evaluate neonates of febrile women for sepsis. More ominously, maternal inflammatory fever is associated with neonatal brain injury, manifest as cerebral palsy, encephalopathy, and learning deficits in later childhood. At present, there are no safe and effective means to inhibit epidural-associated fever. Future research should define the etiology of this fever and search for safe and effective interventions to prevent it and to inhibit its potential adverse effects on the neonatal brain.

Provision of Medical Acupuncture Service in General Practice under Practice-Based Commissioning

Acupuncture involves inserting small needles into various points in the body; the needles are normally stimulated by manual rotation or electrically. Western acupuncture uses the same needling technique as traditional Chinese acupuncture but is based on affecting nerve impulses and the central nervous system. A Western medical acupuncturist makes a medical clinical diagnosis in the conventional way, and uses acupuncture as a form of analgesia along with other drugs and other appropriate interventions, including surgery. Myofascial pain is an extremely common presenting complaint, and general practitioners (GPs) are normally the first point of contact. Studies have indicated that acupuncture helps in different musculoskeletal pain1,–,3 and migraine,4 and NICE has recommended the use of acupuncture in the management of low back pain. Acupuncture may be most effective in primary care to treat patients early and prevent deterioration in the patients' condition while on a waiting list. Charlton medical practice started to provide Western medical acupuncture for NHS patients registered with the practice in November 2008. The practice is situated in Telford, West Midlands with about 10 600 registered patients. Pain management is taken very seriously in our …

Pain relief through expectation supersedes descending inhibitory deficits in fibromyalgia patients

In healthy adults, expectations can modulate the activity of inhibitory bulbo-spinal projections, and can even block the analgesic properties of counter-irritation – a phenomenon that triggers descending inhibition. Since descending inhibition is known to be deficient in fibromyalgia (FM) patients, we tested the possibility that expectancy-mediated analgesia would improve, or even kick-start, the deficient inhibitory responses of FM patients. By measuring subjective pain ratings, spinal withdrawal reflexes, and somatosensory evoked potentials (SEP), it was possible to test whether or not expectancy-mediated analgesia involved descending inhibition in FM patients. Here, we show that expectations of analgesia radically change the subjective experience of pain, but do not eliminate evidence of spinal hyperexcitability in FM patients. We found that expectations of analgesia reduce subjective pain ratings and decrease SEP amplitudes, confirming that expectations influence thalamocortical processes. However, even when analgesia was experienced, the spinal activity of FM patients was abnormal, showing heightened reflex responses. This demonstrates that, unlike healthy subjects, the modulation of pain by expectations in FM fails to influence spinal activity. These results indicate that FMs are capable of expectancy-induced analgesia but that, for them, this form of analgesia does not depend on the recruitment of descending inhibitory projections.

Conservative management of gigantic splenic cyst during pregnancy; a differential diagnosis for chest pain caused by the forgotten organ

Splenic cyst is extremely rare in pregnancy. All the six cases that had been described in literatures were treated surgically. However, we report the first case of a huge splenic cyst during pregnancy managed by conservative approach in the form of analgesia, antibiotics and percutaneous aspiration.

Thoracic Paravertebral Block (Pvb) Analgesia

Paravertebral blockade is a safe and effective technique for intraoperative and postoperative management of acute surgical pain. The block may be performed as a single injection or a catheter may be inserted to allow for the continuous or bolus administration of a long acting local anaesthetic. This mode of analgesia is not considered to be a stand alone technique (in contrast to epidural analgesia) and most patients will require additional analgesia (usually parenteral patient controlled analgesia). Compared to epidural analgesia, the paravertebral administration of analgesia is considered to be safer in anti-coagulated patients, but the risk of local anaesthetic toxicity remains. There is little published about the care of patients receiving this form of analgesia. This article provides an overview of the technique of thoracic paravertebral analgesia, the choice of analgesics and side effects together with recommendations for patient care.

What’s new in the other journals?

What’s new in the other journals?

Spinal disease in the dog—from the perspective of a VN

As Veterinary Nurses, we provide comfort and care to our patients, whether that is in the form of analgesia, providing adequate bedding, exercise and physiotherapy or just good old tender loving care but all this is based on the history of the patient and a basic understanding of the illness or disorder from which the patient is suffering and the treatment it receives. This series of articles aims to give an insight into the reasons why dogs develop spinal disorders and understanding the approaches to their treatment.

Squamous Cell Carcinoma Occurring Within Incision of Recently Implanted Spinal Cord Stimulator

Spinal Cord Stimulation (SCS) is a treatment option for chronic pain patients. Spinal cord stimulation has been employed in the treatment of chronic pain for more than 30 years. The most common indication for SCS is the failed back syndrome with leg pain. Its indications have expanded beyond back and lower extremities pain to include axial low back pain, CRPS, mesenteric ischemia, peripheral neuropathy, limb ischemia, and refractory angina pectoris. The SCS has become a more versatile form of analgesia. The number of wound complications will surely rise in conjunction with the increasing number of devices being implanted. We describe a case of a well-differentiated squamous cell carcinoma occurring within the incision site of a recently implanted spinal cord stimulator early in the postoperative period. The patient developed a rapidly growing mass within the leads incision. The mass was confirmed to be squamous cell carcinoma by biopsy. The mass was excised under local anesthesia with appropriate margins. It was determined that the carcinoma did not extend below the dermis, and that there was no involvement of the underlying fascia. The device was tested for proper functioning, and the leads were thus left in place. While the development of skin malignancies in surgical wounds has been described in the literature, to our knowledge there have been no reports of a cutaneous neoplasm developing early in the postoperative period after spinal cord stimulator implantation. Key words: Spinal cord stimulator, CRPS type 1, squamous cell carcinoma

Sensorial Saturation for Neonatal Analgesia

Sensorial saturation (SS) is a procedure in which touch, massage, taste, voice, smell, and sight compete with pain, producing almost complete analgesia during heel prick in neonates. SS is an apparently complex maneuvre, but when correctly explained it is easily learnt. In the present paper, we studied its feasibility, assessing whether a long training is really needed to achieve good results. We enrolled 66 consecutive babies and divided them randomly into 3 groups which received the following forms of analgesia: glucose plus sucking (A), SS performed by nurses (B), SS performed by mothers (C). We did not use perfume on the caregivers' hands, so that babies could smell the natural scent of the hands. We assessed pain level by the ABC scale. Median scores of groups A, B, and C were: 1 (0 to 6), 0 (0 to 4), and 0 (0 to 6), respectively. Mean scores were: 0.6, 0.6, and 1.7 and standard errors were 0.38, 0.22, and 0.32, respectively. Scores of groups B and C were significantly lower than that of A (P=0.03 and 0.006, respectively). No significant difference was found between values of scores of groups B and C. Even without the use of perfume on the hands, SS was effective as an analgesic maneuvre. It made no difference whether SS was performed by mothers who applied it for the first time or experienced nurses. SS is rapid to learn and any caregiver (mother, pediatrician or nurse) can effectively use it.

Animal Welfare Aspects of Preventing Boar Taint

Introduction Since boar taint is connected to testicular hormones and sexual maturity, surgical castration has for centuries been the method employed to prevent taint in meat from male pigs, as well as to obtain more docile pigs. However, since the castration is performed without anaesthesia, it is painful for the pig and therefore poses a serious welfare problem. With growing focus on animal welfare in animal production, surgical castration without anaesthesia and some form of analgesia is now increasingly regarded as unacceptable.

Sedation and Analgesia for Pediatric Fracture Reduction in the Emergency Department

To assess 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. Cochrane Controlled Trials Register, CINAHL (Cumulative Index to Nursing & Allied Health Literature), and MEDLINE. The search terms "fractures," "manipulation, orthopedic," "an(a)esthetics," "analgesics," and "hypnotics and sedatives" were used. Studies were included if they were randomized controlled trials studying sedative and/or analgesic regimens for fracture reductions in pediatric patients in the emergency department. The search yielded 915 references. From these, 8 studies including 1086 patients were selected. Interventions studied included intravenous regional blocks (Bier blocks), nitrous oxide, and parenteral combinations. Data on measures of effectiveness and safety were extracted. Ketamine hydrochloride-midazolam hydrochloride was associated with less distress during reduction than fentanyl citrate-midazolam or propofol-fentanyl. Patients receiving ketamine-midazolam required significantly fewer airway interventions than those in whom either fentanyl-midazolam or propofol-fentanyl were used. Data comparing Bier blocks with systemic forms of sedation or analgesia were limited. Ketamine-midazolam seems to be more effective and have fewer adverse events than fentanyl-midazolam or propofol-fentanyl. Data on other forms of analgesia or sedation are too limited to make comparisons. More research is needed to define the regimen that maximizes safety, efficacy, and efficiency for fracture reduction in pediatric patients.