Index [assets.cambridge.org]assets.cambridge.org/97805218/74915/index/9780521874915... · 2009-05-19 · Index 681 patient-controlled epidural analgesia (PCEA) 3 step analgesic ladder

Index

Aaron, L. A., 43Aasboe, V., 381Abbott PCA machines, 204Abboud, T. K., 543abdominal surgery. See also colectomy;

postoperative bowel dysfunction(POBD)

bupivacaine for, 224buprenorphine for, 240catheter placement for, 221clonidine-fentanyl (epidural) mixture for,

232vs. dexmedetomidine, 176diclofenac for, 60epidural analgesia for, 180, 221, 467

continuous, 467–468for elderly patients, 529

EREM for lower abdominal surgery, 106,328

fentanyl infusions for, 233, 327hydromorphone (epidural) for, 237

with bupivacaine/ropivacaine, 238ketamine for, 93, 368, 370ketorolac for

with opioids, 60, 346preemptive use of, 345

local anesthetic injections for, 132magnesium (perioperative infusion) for,

179morphine for

epidural, 232, 234with ibuprofen, 345intrathecal, 230–232

oxycodone with ibuprofen for, 198oxymorphone (immediate release) for, 198parecoxib sodium for, 353parenteral/oral opioids for, 583pulmonary response to, 25remifentanil for, 122rofecoxib for, 350ropivacaine for, 224

with fentanyl, 105, 235

tenoxicam for, 346thoracic epidurals for, 241upper abdominal/thoracic, 28

and postoperative pain, 36acetaminophen (paracetamol), 54

for acute postoperative pain, 385for ambulatory surgery, 481analgesics for, effects of, 56, 59antipyretic effects of, 56classification of, 53–54clinical actions of, 58combinations

COX-2 inhibitors, 131hydrocodone, 197lidocaine, 383oxycodone, 193, 197, 238rofecoxib, for oral surgery, 350tramadol, 198–199

description, 334for emergency room use, 591–592intravenous (IV APAP), for ambulatory

surgery, 481mechanism of action, 58, 177–178for moderate/severe pain, 197for pediatric pain management, 493pharmacokinetics of, 58–59for postsurgical use, 356–358

intravenous (paracetamol), 358–359oral/rectal, 358

preventive multimodal analgesia with,177–178

for sickle cell disease, 554solubilized, in solution, 66

acetanilide, 54, 356acid-sensing ion channels (ASICs),

672–673Actiq R© oralet (oral transmucosal fentanyl),

194, 198, 572, 574acupressure, 392acupuncture, 384–385, 392–395

administered after naloxone, 394for ambulatory surgery, 482

FDA, NIH, WHO approval for, 393and Gate Control Theory, 394involvement of neural systems, 395meridian/acupuncture points, 393PET/fMRI studies, 395for postoperative pain, 395–396and release of endogenous opioids,

394–395Acute Pain Management: Scientific Evidence

(ANZCA), 630, 634Acute Pain Service (APS)/Acute Pain

Management Service (APMS), 227,425. See also community hospital/practice setting

communication needs, 436–437economic considerations, 439–440European criticism of U.S. APMS

organization, 435future considerations, 440goals and objectives development, 436governmental aspects, 440human resource management, 437–438introduction of PCA, 204operation and production management,

438–439organizational role in hospital settings,

433patient guide to PCA, 215–216quality assurance issues, 434respiratory depression monitoring, 417types of organizations, 433–436

anesthesiologists, 433–434hospitals/anesthesia groups, 435–436JCAHO, 433nurse practitioners, 434nurses, 434nursing education, 434pharmacists, 434–435psychological component, 434

acute respiratory distress syndrome (ARDS),25

adaptive purposes of pain, 3

679

© Cambridge University Press www.cambridge.org

Cambridge University Press978-0-521-87491-5 - Acute Pain ManagementEdited by Raymond S. Sinatra, Oscar A. de Leon-Cassasola, Brian Ginsberg, Eugene R. ViscusiIndexMore information

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680 Index

adjusted life-years (QALYs), 629. See alsoeconomic aspects of healthcare

advanced practice registered nurses(APRNs), 598–599

affective-motivation domain, McGill painquestionnaire assessment, 12

African-American patients. See also sickle celldisease

OUCHER scale for, 490, 552undertreatment for pain, 160women, PCA/ morphine consumption,

34Agency for Health Care Policy and Research

(AHCPR)acute pain management guidelines, 147,

659Patient Outcome Questionnaire, 664recommendation for multimodal

analgesia, 478Agency for Health Care Research and

Quality, 176aging, effect of, on nervous system, 515–516.

See also elderly patientsAlaris System PCA Module, 311alfentanil

for ambulatory surgery, 368, 479clinical trials, 103–105elderly sensitivity to, 521epidural administration, 103–104, 223and hypnosis, 402lipophilicity of, 105ODAC monitoring, 204for PCA/IV-PCA use, 305response variability, 35use, for ambulatory surgery, 368

Alford, J. W., 297Alfred, D. P., 566Ali, J., 25allodynia, 3, 6, 15, 102

from BDNF administration, 17defined, 21from IL-1-Beta elevation, 7from PGE2 application, 15

allyl-2, 5-dimethyl-1-piperazines, 412. Seealso DPI-3290

alpha-1-acid glycoprotein (AGP), 76alpha-2 adrenergic receptor agonists, 28,

132–133, 383–384. See alsoclonidine; dexmedetomidine(MPV-1440); epinephrine;tizanidine

dosages, 384intrathecal administration of, 383locations/subtypes, 383properties of,side effects, 383

alpha-2-adrenergic receptorsimmunologic effects of, 89interactions with other analgesics, 88–89and pain modulation, 82–84pharmacology of analgesia, under different

conditions, 84–85peripheral use of clonidine, 85postoperative pain condition, 85

pharmacology of clinically availableadrenergic agonists as analgesics,85–88

alpha-2 delta membrane stabilizers, 17alternate theories of pain

Gate Control Theory (Melzack and Wall),4–5, 41–42, 394

neuromatrix theory (Melzick), 42alvimopan

for minimization of opioid-relatedgastrointestinal distress, 613,672

for morphine-induced increased GI time,408

for POBD/POI, 586–587, 672postoperatively, for abdominal surgery,

408ambulatory surgery

economicsannual surgery statistics for U.S., 476health expenditure statistics, 476

pain control improvement, 478–483acetaminophen, 481adjuvant analgesics, 480–481

anticonvulsant type analgesics,480–481

IV acetaminophen, 481ketamine, 481

multimodal therapy, 478–479nonpharmacologic methods, 482–483

acupuncture, 482protocol based pain control, 483TENS, 482–483

NSAIDs, 479–480COX-2 inhibitors, 480

opioid analgesics, 479patient education, 478preoperative analgesia, 478regional blockade, 481–482

pain following, 476–478patient selection for, 287postsurgical milestone, 476sufentanil for, 574

ambulatory surgery, postoperative analgesiaankle block, 295axillary brachial plexus block, 292fascia iliaca block, 294femoral nerve block, 293–294ilioinguinal/iliohypogastric nerve block,

296infraclavicular brachial plexus blocks,

289–290intercostal nerve block, 296interscalene nerve block, 289–290intravenous boluses of fentanyl/

morphine/hydromorphone,196

lumbar plexus blocks, 293paravertebral nerve block, 295–296sciatic nerve blocks

distal, in popliteal fossa, 295proximal, 294–295

supraclavicular nerve block, 289–290wound infiltration for, 296–298

ambulatory surgery, regionalanesthesia/analgesia

local anesthetics/equipment for, 288patient selection for, 287

American Academy of Pain Medicine, 634American Academy of Pediatrics, 548American Academy of Sleep Medicine Task

Force, 422American College of Critical Care Medicine,

162American College of Emergency Physicians,

594American College of Obstetricians and

Gynecologists, 537American Pain Society (APS)

Brief Pain Inventory, 664concern about range order administration,

605–606“Pain as the 5th Vital Sign” slogan,

147–148Patient Barriers Questionnaire, 664Patient Outcome Questionnaire, 664–665Quality of Care Committee, 664–665quality/quality improvement issues

guidelines for evaluation of quality, 659recommendations for improvement,

665studies/evaluations, 665

recommendation against meperidine,612

“Recommendations for Improving theQuality of Acute and Cancer PainManagement,” 665

American Society for Pain ManagementNursing (ASPMN), 149, 163

concern about range order administration,605–606

guidelines for hierarchy of pain measuresdevelopment, 604

position statements, 167American Society of Anesthesiologists (ASA)

advocacy for multimodal analgesia, 176,478

outcome indicators for pain control, 476patient education section of website, 457Quality Management Template, 474

American Society of Health-SystemPharmacists, 162

American Society of Regional Anesthesia andPain Medicine (ASRA), 226, 239

guidelines for use of regional techniqueswith anticoagulants, 246

patient education section of website, 457amputation, 36

and chronic pain, 642, 675ketamine for, 372of lower extremity, 109–110and neuropathic pain, 116PNB anesthetics for, 529

analgesia. See also epidural analgesia;intravenous patient-controlledanalgesia (IV-PCA); neuraxialanalgesia; patient-controlledanalgesia (PCA);






Index 681

patient-controlled epiduralanalgesia (PCEA)

3 step analgesic ladder for cancer pain(WHO), 147

4-step analgesic ladder (Yale-New HavenHospital), 147

fading of, cold pressor pain model, 116peri-operative, and NSAIDs, 59pharmacology of, under different

conditions, 84–85peripheral use of clonidine, 85postoperative pain, 85

and postoperative cardiovascular functionin elderly, 526–527

and postoperative cognitive function inelderly, 523–526

and postoperative endocrine/immunefunction in elderly, 529–530

postoperative outcomes in elderly, 530–533and postoperative pulmonary function in

elderly, 527–529preventive, 175

analgesia, postoperative, in outpatientsankle block, 295axillary brachial plexus block, 292fascia iliaca block, 294femoral nerve block, 293–294ilioinguinal/iliohypogastric nerve block,






supraclavicular nerve block, 289–290analgesia, regional

administration options, 440economic considerations, 440epidural/continuous, for sleep

disturbances, 29and improved perioperative outcomes,

531interference with start of surgery, 438with local anesthetics, 179–181

for epidural block, 180for peripheral nerve block, 180for wound infiltration, 179–180

vs. opioid-based analgesia, 521–523patient controlled regional analgesia

(PCREA), 251for postoperative pain, 575use of COX-2 inhibitors/NSAIDs, 29

analgesic infusion pump technology, 308–310analgesics. See also acetaminophen

(paracetamol); COX-2(cyclo-oxygenase-2) inhibitors;epidural analgesia; morphine;

non-opioid analgesics; opioidanalgesics

activity sites/interactivity variability of, 377effects on prostaglandins, 35endogenous analgesics, 10–11future development of, 672–674and gender, 35interactions

with alpha-2-adrenergic agonists, 88–89with gabapentin/pregabalin, 96–97

new generations of, 17undermedication from, 3

analgesics, novel delivery systems. Seetransdermal therapeutic systems(TTS)

analgesics, oral dosing, 197–199fentanyl oralet (Actiq R©), 198future directions, 200–201hydrocodone/oxycodone, 197

with ibuprofen compounding, 198morphine, 197oxymorphone, 198short-acting agents, 199sustained release preparations, 198tramadol/acetaminophen, 198–199

analgesic tolerance, to opioidsacute opioid tolerance, 116–117after chronic administration, 117–118described, 116genetic approaches to, 121mechanisms of, 118–121

alterations in GTP binding proteincoupling, 119

cytokines and innate immunity,120–121

ion channels, 120NMDA receptor, 120protein kinase activation, 119–120receptor desensitization/tracking,

118–119anatomy

of brachial plexus, 247–248axillary level, 255–256below clavicle, 253

of elbow, 260of lumbo-sacral plexus, 266–267of respiration, 418–419of wrist, 264

anesthesia, orthopedic, success of peripheralnerve blocks, 180

anesthesia/anesthetics. See also epiduralanesthesia; localanesthesia/anesthetics; Nachannels; nerve blocks; regionalanesthesia; specific anestheticslisted in the index

balanced anesthesia, 133and cocaine, 70combined spinal plus epidural

(CSE/CSEA), 234dissociative anesthesia (from ketamine), 91as effect of alpha-2-AR usage, 88general anesthesia

for ambulatory surgery, 368

attenuation of remifentanilhyperalgesia, 386

cardio protective effects, 28vs. CBT, for children with leukemia,

47epidural infusion-light, 238vs. interscalene nerve blocks, 290with interscalene nerve blocks, 248with ketamine, 132light, for single-shot/continuous

peripheral blocks, 502with local-regional blocks, 174vs. lumbar plexus block with

mepivacaine, 267vs. lumbar plexus-sciatic nerve block,

293nerve injuries related to, 281vs. neuraxial anesthesia, 637–638, 642vs. paravertebral blocks, 295vs. preemptive analgesia, 36vs. regional anesthesia, 245, 281, 288,

469with sciatic block, lateral approach,

507vs. single-injection regional anesthesia,

132historical background, 70inhalational anesthesia, 174, 179, 369,

674limitations, for sympathetic

neuroendocrine/biochemicalresponses, 172

neuraxial anesthesia, 180and postoperative cognitive function in

elderly, 523–526and postoperative endocrine/immune

function in elderly, 529–530postoperative outcomes in elderly,

530–533and postoperative pulmonary function in

elderly, 527–529sensory anesthesia, 73–74, 88

anesthesia/hospital groups, in U.S., 435–436Anesthesia Patient Safety Foundation

(APSF), 213anesthesiologists. See also American Society

of Anesthesiologists; physicianscesarean section opioid choice, 537leadership of APMS in large centers,

433–434pain physiology/pathology knowledge of,

30regional, shortages of, 435–436relaxation training for patients by, 48and single bolus injection techniques,

132–133Angst, M., 104, 123ankle blocks, 260, 295anthranilic acids, pharmacokinetics of, 57antidopaminergics, for nausea and vomiting,

410anti-emetic treatment of nausea and

vomiting, 410–411antihistamines, for nausea/vomiting, 410






682 Index

anti-neuropathics, 382–383gabapentin and pregabalin (See also

gabapentin and pregabalin)lidocaine/mexilitine 383 (See also

lidocaine; mexilitine)anxiety. See also catastrophizing of pain;

cognitive-behavioral therapy(CBT); kinesiophobia;psychological aspects of pain

associated with hospital admission, 165burn-related anxiety, 43descending inhibition by, 14and fear, 43and pain, 42–43Pain Anxiety Symptoms Scale, 43predictive value of pain

postoperative, 42pre-surgical, 42–43

pre-surgical, predictiveness of, 42–43ANZCA. See Australian and New Zealand

College of Anesthetics (ANZCA)APMS. See Acute Pain Service (APS)/Acute

Pain Management Service (APMS)apnea. See sleep disturbancesAPRNs. See advanced practice registered

nurses (APRNs)APS. See Acute Pain Service (APS)/Acute

Pain Management Service (APMS)APS. See American Pain Society (APS)arachidonic acid (AA), conversion by COX-2,

5–6arcuate cingular cortex (ACC), and

acupuncture, 395Ashburn, M. A., 212Asian-American patients, 34aspirin (acetyl salicylate). See also salicylates

analgesic effects of, 59anti-inflammatory limitations, 55commonality with NSAIDs, 53comparisons

with acetaminophen, 59, 177, 493with celecoxib, 61

inhibition of COX by, 55for moderate/severe pain, 197pharmacokinetics of, 57and platelet clotting function, 64–65side effects of, 57, 63, 66

aspirin-sensitive asthma, 66hepatoxicity, 66peptic ulcers, 63

assessment of painin emergency department, 589historical background, 147–149patient barriers to, 165patient comfort and satisfaction, 159–160process of, 150–151

observer pain scores, 150–151self report scales, 151

types of pain, 149–150assessment of pain, special populations,

160–164addictive disorder patients, 163critically ill patients, 162–163elderly patients, 161

ethnic/racial minorities, 160–161pediatric patients, 163–164, 489–490 (See

also pediatric pain management,assessment/assessment tools)

assessment of pain, tools, 151–160adjunctive tools, 158–159

Leeds Assessment of NeuropathicSymptoms and Signs scale, 159

Neuropathic Pain Scale, 158–159behavioral/observational tools, 157–158

Behavioral Pain Scale, 158, 163Critical Care Pain Observation Tool,

157–158, 163Face, Legs, Activity, Cry and

Consolability tool, 157, 161Pain Assessment in Advanced Dementia

Scale, 157delirium assessment tools

Confusion Assessment Method for theICU, 162

Intensive Care Delirium ScreeningChecklist, 162

elderly assessment toolsChecklist of Nonverbal Pain Indicators,

161Pain Assessment in Advanced Dementia

Scale, 161in emergency department, 589

numerical rating scale/graphical ratingscale, 589

visual analog scale (VAS), 589multidimensional tools, 154–157

Brief Pain Inventory, 157Initial Pain Assessment Tool, 154McGill Pain Questionnaire, 12, 33, 111,

156–157OLD CART tool, 154–156Short-Form McGill Pain Questionnaire,

157Pain Anxiety Symptoms Scale, 43pediatric patients (See pediatric pain

management)Roland Disability Questionnaire, 44subjective sedation-assessment scales,

162Motor Activity Assessment Scale, 162Richmond Agitation-Sedation Scale,

162Riker Sedation-Agitation Scale, 162Vancouver Interaction and Calmness

Scale, 162Tampa Scale of Kinesiophobia, 43unidimensional pain rating scales, 151–154

Faces Pain Scale (FPS),Iowa Pain Thermometer (IPT), 154

Numeric Rating Scale (NRS), 151, 162Verbal Rating Scale (VRS), 151–153Visual Analog Scale (VAS), 153, 162Wong-Baker FACES Rating Scale, 154

AstromorphTM (morphine), 230attenuation of pain induced pathophysiology

cardiac surgery, 28cytokine response, 28–29persistent pain, 29–30

sleep disturbances/return to functionality,29

thoracic/upper abdominal surgery, 28thromboembolism, risk of, 28tissue breakdown/infection risk, 29vascular surgery, 28

Aubrun, F., 35Auroy, Y., 281, 289Austin, K. L., 303Australia, opioid trends study, 114Australian and New Zealand College of

Anesthetics (ANZCA), 630–631,634

Australian Pain Society, 634autonomic nervous system

aging’s effect on, 516fight or flight response, 567and opioid dependence, 400

AvinzaTM (sustained release morphine),565

axillary brachial plexus block, 255–259block techniques

nerve stimulation, 257–258paresthesia method,paresthesia/trans-arterial, 259ultrasound guidance, 258–259

complications, 259–260indications, 256pearls, 260pediatric patients, 505

continuous technique/dosage, 505single shot technique/dosage, 505

postoperative analgesia in outpatients,292

axon reflex, positive feedback loop from,102

back painabnormal brain chemistry in, 14auricular acupuncture for, 482epidural abscesses and, 226and kinesiophobia, 43lidocaine patch for, 324morphine study, 117Pain Anxiety Symptoms Scale (PASS)

measurement, 43and psychogenic pain disorder, 150QALYs measurement for, 629systemic opioids for, 130

Bailey, P. L., 420Ballantyne, J. C., 207Bamgbose, B. O., 382barriers to pain control, 164–166

of healthcare providers, 165–166overcoming, 166of patients, 165

Bartfield, J. M., 590Beauchemin, K. M., 50Beecher, H. K., 25, 41, 110Behavioral Pain Scale (BPS), 158behavioural based pain assessment scales,

pediatric patients, 490–493Children and Infants Postoperative Pain

Scale (CHIPPS), 490






Index 683

Children’s Hospital of Eastern OntarioPain Scale (CHEOPS), 164,491

Face, Legs, Activity, Cry and Consolability(FLACC) tool, 157, 492

Individualized Numeric Rating Scale(INRS), 493

Non-Communicating Children’s PainChecklist-Postoperative Version(NCCPC-PV), 492–493

objective pain scale (OPS), 492Pain Indicators for Communicatively

Impaired Children, 492Pediatric Pain Profile (PPP), 491

Bell, J. R., 114Benedetti, F., 110Bennett, G. J., 110benzocaine, 76, 78benzodiazepines, 57, 88

administration for anxiety, 575co-dependence on, 568and drug abuse, 391magnification of neuronal inhibition, 420pre-anesthesia administration, 368restriction in elderly patients, 239, 242, 521

Bernards, C. M., 103Bessler, H., 7betamethasone, 381Bier block (intravenous regional anesthesia),

293biofeedback, 14, 554biomedical model of pain, 41Birnbach, D. J., 538Bisgaard, T., 381–382Bispectral Index (BIS), for brain monitoring,

369Black Box Warning (of FDA)

against use of LMWH, 246against use of NSAIDs and COX-2Is, 355

bladder dysfunction, improvement frommethylnaltrexone, 411. See alsogenitourinary system, adverseeffects of opioids

Blount, R. I., 45–46Borgbjerg, F. M., 422Borgeat, A., 237, 281Boss, A. P., 297bowel dysfunction, from opioid use, 407–408brachial plexus. See also parascalene block

(brachial plexus), pediatricpatients; peripheral nerve blocks ofupper limb

anatomy of, 247–248axillary level, 255–256

axillary brachial plexus block, 255–259block techniques

nerve stimulation, 257–258paresthesia/trans-arterial, 259ultrasound guidance, 258–259

complications, 259–260indications, 256pearls, 260

infraclavicular brachial plexus blocks,253–255

block techniquesnerve stimulation, 254ultrasound guidance, 254

complications, 254–255brain derived neuropathic factor (BNDF),

17brain imaging studies, 44, 395brainstem (RVM), 14brain stem, opioid migration to, 104“breaking mechanism” in spinal cord, 10breast surgery

and chronic pain, 109, 134, 642dexamethasone for, 381ketamine for, 370and perioperative paravertebral block, 111and sentinel node biopsy, 111, 295

Brief Pain Inventory (BPI), 151, 157Brodsky, Jay B., 626Bromage, P. R., 23Brown, D. L., 251Brull, R., 290Buggy, D. J., 384Buntin-Mushock, C., 118bupivacaine, 72

as adjuvant, for postcesarean analgesia, 539cardiovascular system toxicity from, 77combinations with

epidural morphine, 234epinephrine, 75fentanyl infusion, 233morphine/morphine infusion, 234, 315

continuous infusions, 233epidural administration of, 72, 224for interscalene block, 249intrathecal administration, 232ketamine enhancement of, during wound

infiltration, 91lipophilicity of, 72onset of action, 72protein binding properties, 73selectivity for sensory fibers, 74use of, for motor block, 226

buprenorphine (partial mu receptor agonist),38

for abdominal surgery, 240avoidance of, with drug addicts, 570description, 196for epidural analgesia, 221

as adjuvant, 224glucoronidation of, 38intrathecal, for postcesarean delivery, 543for neuraxial analgesia, 239–240parenteral dosages of, 197and substance abuse, 565–566

sublingual formulations, 566Burnham, P. J., 255burn-related anxiety, 43butorphanol

avoidance of, with drug addicts, 570binding of kappa receptors (OPR2), 193description, 195for emergency room use, 592

Buvanendran, A., 183, 235, 350

calcitonin gene related protein (CGRP)enhancement of PGEs, 7mediated stimulation of, 6morphine’s effect on, 124release inhibition by opioid receptors, 102

calcium/calmodulin dependent kinase type 2(CaMKII), 119

calcium channel blockers, 382–383. See alsogabapentin and pregabalin

CaMKII. See calcium/calmodulin dependentkinase type 2 (CaMKII)

Campbell, James, 147–148Canadian Medical Association Journal, 396cannabinoids, 672. See also marijuana use;

9-tetrahydrocannabinol (THC)as adjuvant analgesic, 384, 673

Capdevila, X., 29, 268–269, 289, 481capnography, for monitoring intubated

patients, 424Capogna, G., 539capsaicin, 673carbonation (carbon dioxide) of anesthetics,

75cardiac surgery

aspirin-related risks, 64attenuation of pain induced

pathophysiology, 28background infusion following, 210and clonidine, 89CPOT validity/reliability for, 163and ketamine, 93PCA vs. nurse administered analgesia for,

205Cardiff Palliator pump (PCA system), 204,

303, 670–671cardiovascular system

effects of alpha-2-AR, 87effects of NSAIDs vs. COX-2s, 355–356Guidelines for Advanced Cardiac Life

Support, 78morbidity complication, 638–639side effects to

from bupivacaine, 77from NSAIDs, 63from opioids, 406

Carr, E.C.J., 165Casati, A., 271Cashman, J. N., 214, 417catabolism of prostaglandins (PGEs), 54–55catastrophizing of pain, 42, 44, 49catechol-O-methyltransferase (COMT) gene

influence of genetic variability onmorphine dosages, 192

and morphine requirements in cancerpatients, 37

Catley, D. M., 422caudal block, for pediatric patients, 498–500

complications, 500continuous technique, 499contraindications, 499drugs, 499indications, 498landmarks, 498materials, 498






684 Index

caudal block, for pediatric patients (cont.)single-shot technique, 498

CBT. See cognitive-behavioral therapy (CBT)CelebrexTM, 480celecoxib, 53, 235, 245

adjuvant use, 238affinity for COX-2, 58analgesic effects of, 61–62vs. aspirin, 61perioperative use, 676postoperative dosage recommendation,

480preemptive use, 361, 483with pregabalin, 182, 383, 481vs. rofecoxib, 350use of, in surgical pain, 347Yale-New Haven Hospital dosing

guidelines, 480Centers for Medicare and Medicaid Services

(CMS), 440central nervous system (CNS). See also

brainstem (RVM); periaqueductalgray (PAG) region (of CNS)

aging’s effect on, 515–516analgesic influences on, 377and central sensitization, 9–10, 15, 26functional imaging studies, 12of infants, 487, 496mu opioid receptor locations, 407NMDA receptor locations, 89, 120, 125nociceptive activation of,opioid inhibition of pain signals to, 102,

188pathophysiological pain response, 26–27plasticity of, 94, 172proinflammatory cytokines analgesic

effects on, 28and prostanoid synthesis, 15and secondary hyperalgesia, 4, 26side effects of local anesthetics, 77, 280–281toxicity of, from local anesthetics,

central sensitizationand CNS, 9–10, 15, 26, 173following peripheral inflammation, and

PGEs, 15importance of prostanoids for, 17physiology of, 172–173superoxides (SO) mediation of, 16transcription dependent, 10

Cepeda, M. S., 35cerebrospinal fluid (CSF), 103–104, 221–222cesarean delivery

diclofenac for,epidural hydromorphone for, 233, 235epidural/intrathecal fentanyl for, 122, 233

with dilute bupivacaine, 234epidural morphine for, 106, 230

epidural liposomal morphine, 223extended release (EREM), 328

and intravenous tenoxicam, 346and ketamine/local anesthetic/

bupivacaine, 91neuraxial vs. intravenous analgesia, 537and pain catastrophizing, 44

Chadwick, H. S., 543Chaplan, S. R., 234–235Chauvin, M., 105Chayen, D., 267Checklist of Nonverbal Pain Indicators

(CNPI), 161chemoreceptor trigger zone (CTZ)

mediation of nausea and vomiting,408–409

receptors found in, 409Chen, X., 120CHEOPS. See Children’s Hospital of Eastern

Ontario Pain Scale (CHEOPS)Chestnut, D. H., 233Chia, Y. Y., 35children. See pediatric pain management

index entriesChildren and Infants Postoperative Pain Scale

(CHIPPS), 490Children’s Comprehensive Pain

Questionnaire, 552Children’s Hospital of Eastern Ontario Pain

Scale (CHEOPS), 164, 491Chinese patients, 35chloroprocaine

lipophilicity of, 72onset of action, 72pKa properties, 72

cholecystokinin (CKK) peptidemediated stimulation of, 6upregulation following nerve injury, 17

chronic pain. See also central sensitization;McGill pain questionnaire;persistent pain; postoperative pain

acute pain transition to, xiii, 17, 26–27,109–110

amputation and, 642, 675analgesic undermedication as cause of, 3aspirin/NSAIDs used for, 66assessment tools (See assessment of pain,

tools)breast surgery and, 109, 134, 642and buprenorphine/norbuprenorphine, 38and CaMKII, 119classifications

neuropathic, 4, 17nociceptive, 4

definition, 3epidural analgesia and, 642epidural clonidine for, 88factors increasing susceptibility to, 30following surgical trauma, 25gabapentin/pregabalin for, 96, 182growing numbers of patients with, 166and inguinal hernia repair, 109morphine for, 193National Pain Foundation statistics, 166and NMDA receptor antagonists, 178observer scoring of, 150–151and pain catastrophizing, 44partner-assisted pain management for, 50PCA administration of analgesics, 199and perioperative pain interventions, 134predictors of, 110

prospective observational studies, 123self-report scales, 151surgeries associated with, 109and temporomandibular disorder (TMJ),

44from thoracotomies, 109, 111, 370, 642,

675and VAS scores, 27

chronic persistent pain, incidence of,post-surgery, 134

Chu, L. F., 115, 123City of Hope National Medical Center, PRN

program, 603classification of pain, 3–4, 149–150

hyperalgesia (See hyperalgesia)idiopathic pain, 149–150mixed pain, 149–150neuropathic pain (See neuropathic pain)nociceptive pain (See nociceptive pain)physiological pain, 3psychogenic pain, 149–150

clinical trialsappropriate conduction determination,

647author establishment of testability/clinical

relevance, 647Bonferroni Correction, 653Kaplan-Meier survival curves, 653Kruskal-Wallis one-way analysis of

variance, 653One-Way Analysis of Variance, 653primary efficacy variable definition,

647–651pain measurement, 649significant pain reduction, 649summary measures, 650–651

purpose of, 646–647Spearman’s Rank Correlation, 653Type I errors, 652Type II errors, 652–653Wilcoxon Signed Rank test, 653

ClinicalTrials.gov database, 647clonidine. See also DuraclonTM (injectable

clonidine)adjuvant use with children, 497

axillary block, 505caudal block, 499epidural block, 499–502fascia iliaca block, 506femoral block, 506ilioinguinal/iliohypogastric block, 509parascalene block, 504sciatic block (lateral approach), 507subgluteal approach, 508

alternative approach offered by, 28and cardiac surgery, 89and central neural blockade improvement,

233classification, 28combinations

bupivacaine-sufentanil, 370epidural morphine, 539, 544fentanyl, 232intrathecal morphine, 232






Index 685

local anesthetics, 75thoracic epidural morphine, 232

description/properties/uses, 85–86,176–177

for epidural analgesia, 84, 86, 221as adjuvant, 224

hemodynamic effects of, 87immune protective properties of, 89improvement of neuraxial analgesia, 238injury site direct administration of, 89interaction with analgesia, 88, 288intra-articular administration, 479intrathecal administration, 75, 85–86, 88

with morphine, 176, 232, 544lipophilicity of, 86–87mechanism of action, 224non analgesic effects, 87–88

cardiovascular/hemodynamic, 87hormonal influences, 88respiratory, 88sedation, anxiolysis, anesthesia, 88

OIH attenuation by, 133for opioid-dependent patients, 571partial agonist properties of, 383patches, for transdermal drug delivery, 324peripheral use of, 85pharmacology of, 85–86respiratory effects of, 88

coagulation-related morbidity, 641–642cocaine

anesthetic properties of, 70as racemic mixture, 72substance abuse, 565

Cochrane Database Review, chronic paindata, 111

codeine, 381–382with acetaminophen, 353, 358, 495for children, 494–495decreased use, in hepatic impairment, 38for dental/ENT surgeries, 198description, 195, 495, 613vs. fentanyl/sufentanil, 190mechanism of action, 587metabolism pathways, 193for sickle cell disease, 555

Coderre, T. J., 174cognitive-behavioral therapy (CBT), 45–46.

See also psychological aspects ofpain

for acute/persistent pain, 14general anesthesia vs., 47hypnosis, 47for sickle-cell pain, 553–554

cognitive-evaluative pain factors, 42Cohen, L. L., 46, 175cold pressor pain model, 116, 122colectomy

emerging therapies for, 586–587endogenous opioids, postsurgical release,

584exogenous opioids, administration of, 584

effects on bowel function, 584–585epidural analgesia, benefits of, 585peripheral opioid antagonists, 586–587

minimally invasive/laparoscopic surgery,584

NSAIDs/COX-2 inhibitors, 585–586opioid-associated POBD, 583–584

Collins, V. J., 251Coloma, M., 381combined spinal epidural anesthesia/

analgesia (CES/CSEA),234

Combunox R©, 193, 198, 479Community Epidemiologic Work Group

(CEWG), 565community hospital/practice setting. See also

Acute Pain Service (APS)/AcutePain Management Service (APMS)

creation of conducive environment,458

documentation, 470effective pain management preparations,

456–458interdisciplinary approach,

ancillary staff, 457nonsurgeon physicians, 457–458nurses/nursing extenders, 457public, 457surgeons, 458

leadership roles, 456–457follow-through, 470–474

complication management, 471for inpatients, 470–471for outpatients, 470quality improvement (QI), 471–474

pain management formulation/implementation, 458–470

management options,continuous epidural analgesia,

467–468continuous perineural analgesia,

468intravenous PCA, 466–467single-dose epidural opiates, 467single-dose intrathecal opiates, 467single-injection nerve blocks, 467

multimodal analgesia, 458–460realities of setting, 455–456

cultural issues, 456infrastructure challenges, 455–456personnel issues, 456

regional techniques, pragmatic approach,469–470

“comfort zone” operation, 469cost-consciousness, 469delay avoidance, 469–470progressive, logical learning, 469

complex regional pain syndrome (CRPS)ketorolac for, 65lidocaine patch for, 324multimodal therapy for, 183from orthopedic extremity surgery, 675perioperative regional anesthesia for, 134

Compton, P., 123COMT gene. See catechol-O-

methyltransferase (COMT)gene

conduction, described, 8Confusion Assessment Method for the ICU

(CAM-ICU), 162congenital indifference to pain (CIP)

condition, 674congestive heart failure, 38consequences of poorly controlled pain

cardiovascular pulmonaryfunction/maladaptive behaviors, 21

CONSORT (CONsolidated Standards OfReporting Trials), 632, 651. See alsoresearch in acute pain management

continuous epidural analgesia. See epiduralanalgesia, continuous

Continuous Quality Improvement (CQI),311

continuous quality improvement (CQI)plans, 603

Controlled Substances Act, 609Cook, P., 271Cornish, P. L., 608cortical reception and responses, 12–14Cortinez, L. I., 122“Cost Savings in the Operating Room” letter

to editor (Brodsky), 626Cottam, D. R., 36Coumadin, 241

for deep venous thromboses (DVT), 246vs. LMWH, 246

COX-2 (cyclo-oxygenase-2)and AA conversion, 5–6expression of, NF-kB upregulation, 15glucocorticoid inhibition of, 381IL-1-Beta induction of, 15induction of in CNS by IL-1-Beta

cytokine, 180intracellular Ca++ ion activation, 10mediation of excitotoxicity, 15relationship to coxibs, 53

COX-2 (cyclo-oxygenase-2) inhibitors, 17.See also celecoxib; etoricoxib;lumiracoxib; parecoxib; rofecoxib;tenoxicam; valdecoxib

with acetaminophen/NSAIDs, 178as adjuvant to opioid use, 131for ambulatory surgery, 480avoidance of, in renal patients, 356, 361Black Box Warning, against use of, 355cardiac morbidity concerns from use of,

166and colectomy, 585–586increased marketing of, 114intrathecal administration, 16and laparoscopic cholecystectomy, 182in multimodal analgesia, 245, 479, 570,

575vs. NSAIDs

bone/wound healing effects, 356gastrointestinal system, 356for postoperative pain, 178renal effects, 356

in perioperative pain, 346–347pre-incision administration, 478reduced PGE synthesis from, 29






686 Index

COX-2 (cyclo-oxygenase-2) (cont.)safety and tolerability of, 355for sickle cell disease, 554tainting of, with rofecoxib (scandal), 245use for opioid-dependent patients, 571

coxibsfor acute postoperative pain, 385with glucocorticoids, 382historical background, 53–54limitations of, 17pharmacokinetics of, 58preemptive/multimodal administration,

30relationship to cyclo-oxygenase-2, 53

Cozzi, L., 554Crile, L. W., 173, 179Critical Care Pain Observation Tool (CPOT),

157–158Crohn’s disease, 64Crone, L.A.L., 540“Crossing the Quality Chasm” report

(Institute of Medicine), 655culture or race. See also African-American

patients; Hispanic patientsimpact on pain management, 34–35issues in community practice setting, 456

cupping, 392Curlin Medical 4000 CMS (IV-PCA

multitherapy pump), 311, 317cytochrome P450 37 2D6 (CYP2D6),cytokines. See also Interleukin 1-Beta

(IL-1-Beta); Interleukin 6activation of transducer molecules, 7and development of persistent pain, 25and increased peripheral edema/allodynia,

21proinflammatory, analgesic effects on

CNS, 28release of, from superoxide mediated

injury, 16response of, 28–29

Dahan, A., 422Dahl, J. B., 234, 543Dahlstrom, B., 37Dampier, C. D., 551–552Das, D. A., 48Dauri, M., 297Davies, P. W., 540Decade of Pain Control and Research (law

provision, U.S. Congress), 114,149

Declaration of Helsinki, 646. See also researchin acute pain management

deep venous thrombosis (DVT), 25, 28, 246,641. See also Virchow’s triad

De Kock, M., 370delirium. See also postoperative cognitive

dysfunction (POCD)/postoperative delirium in elderlypatients

assessment toolsConfusion Assessment Method for the

ICU (CAM-ICU), 162

Intensive Care Delirium ScreeningChecklist, 162

from meperidine, 411Demanalg PCA system, 204, 670Demand Dropmaster PCA system, 204, 670dementia. See also postoperative cognitive

dysfunction (POCD)/postoperative delirium in elderlypatients

as barrier to pain assessment, 165pain assessment tools, 157–158, 161

DepoDurTM (prolonged duration epiduralmorphine), 240, 538

DepoFoamTM (extended release epiduralmorphine), 327

Descartes, Rene, 4, 172descending pathways of pain

described, 14modulation of pain perception, 102

design theoryof IV-PCA pumps, 302of patient-controlled epidural analgesia,

314of perineural ambulatory analgesia

systems, 318dexamethasone, 381–382

for nausea/vomiting, 410with rofecoxib, 382

dexmedetomidine (MPV-1440), 86–87FDA approval for sedative use in ICU, 383lipophilicity of, 86mechanisms of action, 176–177partial agonist properties of, 383

dextromethorphan. See also MorphiDex R©

administration methods, 132combinations

ketorolac, 345tenoxicam, 345

for OIH modulation, 128preventive multimodal effects, 179use in opioid tolerance reduction strategy,

120dextropropoxyphene, 38dezocine, avoidance of, with drug addicts,

570diabetic neuropathy, 4diclofenac

for abdominal surgery, 60analgesic effects of, 60for arthroscopic surgery, 60for children, 385efficacy of, in preemptive analgesic

therapy, 344evaluation for postoperative pain usage,

335–339postoperative use, 60, 346with prednisone, 382preemptive use of, 345topical patch for transdermal drug

delivery, 324–325transdermal delivery system, 324

differential sensory nerve blocks, 74Dilaudid R©, 194, 232–233Ding, E. L., 16

diphenhydramine, for pruritus, 237, 306Dirks, J., 480distal sciatic nerve block (in popliteal fossa),

295distal upper extremity nerve blocks,

292–293distraction (management strategy), 45–46

reassurance vs., 46topical anesthetics vs., 46

DNA scanning, 673documentation, for community

hospital/practice setting, 470Doering, S., 384Dolin, S. J., 214, 417Dolophine R©, 195dopamine

COMT inactivation of, 37and epidural clonidine, 87and opioid-induced euphoria, 115

dose escalation of opioids, analgesic paradoxof, 116

Doverty, M., 123DPI-125, and respiratory depression, 412DPI-3290, and respiratory depression, 412Drakeford, M. K., 232droperidol

adverse effects, 214for nausea/vomiting, 237, 242, 306, 410,

613for opioid-induced pruritus, 214

drug abuse/drug addiction. See opioiddependence/substance abuse

Drug Abuse Warning Network, 391Drug Addiction Treatment Act (DATA 2000),

565–566Drug Enforcement Administration (DEA),

609Dunbar, S. A., 121, 124DuraclonTM (injectable clonidine), 232DuragesicTM (fentanyl patch), 324, 574DuramorphTM (morphine), 230, 232dynorphins, 395

economic aspects of healthcarebusiness plans vs. economic studies, 623costs,costs/cost definitions

cost vs. charges, 625direct, indirect, intangible, 626explicit, implicit, total, 625fixed/variable, 626opportunity costs, 627–628total, average, marginal, 626–627

economic studiescost-benefit and cost-effective, 628–629cost minimization, 628

perspectivesevery day example, 624hospital example, 624and system thinking, 628

revenue,educational techniques, for sickle-cell pain,

553Egdahl, R. H., 23






Index 687

eicosanoid family, 54. See also prostaglandins(PGEs)

Eisenhower, Dwight D., 433elastomeric pumps (non-electric infusion

devices), 319–320elbow blocks, 260–262, 293

block techniquenerve stimulation, 260–262ultrasound guidance, 262

complications, 262elderly patients

alfentanil sensitivity, 521analgesia/anesthesia choice

and cardiovascular function(postoperative), 526–527

and cognitive function (postoperative),515, 523–526

and endocrine/immune function(postoperative), 529–530

postoperative outcomes, 530–533and pulmonary function

(postoperative), 527–529assessment tools

Checklist of Nonverbal Pain Indicators(CNPI), 161

Pain Assessment in Advanced DementiaScale (PANAID), 161

benzodiazepine restriction for, 239, 242,521

definition of, 514–515emergency department treatment, 590epidural infusion-light general anesthesia

for, 238and fentanyl PCEA, 235and IV-PCA, 166, 196

non-advisability of, 196methodology debates about, 514naloxone, for respiratory depression, 236nervous system and aging, 515–516neuroaxial regional anesthesia/peripheral

nerve blockade vs. opioid-basedanalgesia, 521–523

pain assessment considerations, 161, 521perioperative management development,

514pharmacodynamic alterations in, 520–521pharmacokinetic alterations in, 520postoperative cognitive dysfunction

(POCD), 515–517, 523–526recommendations for, 533sensitivity to alfentanil, 521

electropharmacology of local anesthesia, 71emergency department (ED)

assessment/prevalence of pain in, 589discharge diagnoses with pain complaint,

589illegitimate opioid procurement attempts,

590oligoanalgesia problem in, 589–590pain treatment/procedural sedation in,

590–591substance abuse visits, 565treatment (specific) modalities, 591–594

alternative delivery routes, 592

nonopiods, 591opioids, 591–592patient-controlled analgesia (PCA), 592procedural sedation and analgesia

(PSA), 592–594emergency physicians

assessment accuracy issues, 590as cause of pain, 589

endogenous opioids, 37, 584. See alsodynorphins; endorphins;enkephalin (ENK)

and acupuncture, 394–395description, 10–11mechanism of action, 14and TENS, 397

endorphins, 10–11, 37, 42, 188, 395, 410, 584Engbloom, D., 15enkephalin (ENK), 10–11, 188, 395, 584. See

also endogenous opioidsenoxaparin, 245environmental conduciveness, in community

practice setting, 458epidural analgesia

for abdominal surgery, 180choice of adjuvants, 224choice of agents (See epidural analgesia,

choice of agents)for colectomy, 585continuous administration, in community

practice setting, 467–468effect on postoperative outcomes (See also

under randomized controlledtrials)

background, 637cardiovascular morbidity, 638–639chronic pain, 642coagulation-related morbidity, 641–642cognitive decline/delirium, 642economic outcomes, 643

length of stay, 643multimodal therapy approach, 643

gastrointestinal morbidity, 640–641infectious/immune complications, 642major morbidity, 638mortality, 637–638patient-reported outcomes, 642–643

health-related quality of life, 643patient satisfaction, 643quality of recovery, 643

pulmonary morbidity, 639–640factors affecting efficacy of (See also

epidural analgesia, choice ofagents)

catheter location, 221cerebrospinal fluid, 222

improvements from, 29, 36vs. IV-PCA, 29preemptive analgesic effects of, 174–175risk factors of, 224–226

catheter problems, 224–226dural puncture, 225epidural hematoma, 225–226hypotension, 226infection, 226

motor block, 226respiratory depression, 226

single-dose administration, in communitypractice setting, 467

superiority following orthopedic surgery,180

for sympathetic hypertensive response, 28thoracic, 28

epidural analgesia, choice of agents, 221–224alfentanil, 223chloroprocaine/lidocaine, 73epidural morphine, 222fentanyl, 223hydromorphone, 222–223liposomal morphine, 223local anesthetics, 223–224

combined with opioids, 224opioids, 221–222sufentanil, 223

epidural analgesia, continuous, 233–235fentanyl infusions, 233–234hydromorphone infusions, 234–235,

237–239local anesthetic infusions, 233morphine infusions, 234spinal morphine plus epidural infusion,

234epidural anesthesia, 27

bupivacaine for, 72continuous, suppression of

sympatho-adrenal responses, 28vs. general anesthesia, followed by epidural

analgesia, 28thoracic

following CABG surgery, 28and improved pulmonary function, 28

epidural blocks, 29as adjuvant to opioid therapy, 133local anesthesia/regional analgesia for, 180in pediatric patients, 500–502

complications, 500–502continuous technique, 500–502contraindications, 499drugs, 499–502indications, 500landmarks, 500materials, 500single shot technique, 500

epidural bolus dosing, 232–233epidural hematoma

causes of, 225–226risk of, from LMWH, 239, 245

epidural infusion-light general anesthesia,238

epidural morphine. See also DepoDurTM

(prolonged duration epiduralmorphine); extended releaseepidural morphine (EREM)

age related reductions, 33clinical trials, 106–107combinations

bupivacaine, 234clonidine, 539, 544ketamine, 367, 370






688 Index

epidural morphine (cont.)local anesthetics, 538

description, 222vs. epidural fentanyl, 133, 539intrathecal administration, 230vs. intrathecal morphine, 543mechanism of action, 28vs. parenteral opioids, 232for postoperative pain management, 117and respiratory depression, 407, 540side effects

nausea/vomiting, 237, 409, 540pruritus, 237

single dose, vs. continuous infusion, 232epidural opioids

adverse effects associated with, 236–237nausea and vomiting, 237pruritus, 237, 495respiratory depression, 226, 236, 417urinary retention, 237

combinationsketamine, 179local anesthetics, 29, 133parenteral opioids, 179, 196

continuous infusion of, 233–235critical studies/clinical trials

alfentanil, 103–105fentanyl, 105–106morphine, extended, 106–107sufentanil, 106

following intraoperative ketamine, 92function at spinal level, 102as gold standard for pain management, 102intrathecal/single bolus administration,

230–233for patients on chronic opioid therapy vs.

opioid-naive patients, 133pharmacokinetics of, 103–105postadministration migration to brain

stem, 104safety factors, 239

epidural patient-controlled analgesia(Epi-PCA). See patient-controlledepidural analgesia (PCEA)

epinephrineas additive to local anesthetics, 75, 288COMT inactivation of, 37for epidural analgesia, 221

as adjuvant, 224, 539partial agonist properties of, 383post-surgical trauma increases, 23

EREM. See extended release epiduralmorphine (EREM)

Erikson, C. J., 554erythema, from opioid histamine release, 411Etches, R. C., 210, 421ethnic/racial minorities. See also

African-American patients;Hawaiian patients; Hispanicpatients

assessment considerations, 160–161healthcare provider perceptions of, 165

etidocaine, 72lipophilicity of, 72

onset of action, 72pKa properties, 72sensory/motor block, lack of separation, 74

Etienne, July, 248etomidate, for emergency room use, 592,

594etoricoxib, 346, 353–355E-trans fentanyl delivery system, 674evidence-based medicine (EMB)

in acute pain management, 634–635challenges of practitioners, 632–633defined/described, 630distinguishing features of, 630–631evidence recommendations

NHMRC of Australia, 633Scottish Intercollegiate Guidelines, 633

and expert-based opinion, 631guidelines development, 631limitations of, 633quality and validity issues, 632synthesizing medical evidence, 631–632

excitatory post synaptic potentiation (EPSP)phenomenon, 15

“exhaustion stage” (sympatho-adrenalresponse), 22

extended release epidural morphine (EREM).See also DepoDurTM (prolongedduration epidural morphine);DepoFoamTM (extended releaseepidural morphine)

for cesarean section, 328clinical trials, 106–107description, 327–329for hip arthroplasty/elective cesarean

delivery, 106length of analgesic effects, 106for lower abdominal surgery, 106

Face, Legs, Activity, Cry and Consolability(FLACC) tool, 157, 492

Faces Pain Scale (FPS), 154, 489facial expressions, of others in pain, 44–45failure mode and effects analysis (FMEA)

procedure, 614Farney, R. J., 422fascia iliaca block, 294Fassoulaki, A., 112Faymonville, M. E., 48fear

and pain-related anxiety, 43similarity to pain catastrophizing, 44

Feeney, S. L., 42femoral nerve block, 270–274

block techniquenerve stimulation, 271ultrasound guidance, 271–273

complications, 273pearls, 273postoperative analgesia in outpatients,

293–294fenbufen, efficacy of, in preemptive analgesic

therapy, 344fentanyl, 38. See also Actiq R© oralet;

DuragesicTM; FentoraTM;

IONSYSTM (fentanyliontophoretic transdermal system)

for abdominal surgery, 233, 327for ambulatory surgery, 479for arthroscopic surgery, 60clinical trials, 105–106vs. codeine, 190combinations

clonidine, 232ketamine, 370lidocaine, 543midazolam, 402, 593

continuous epidural infusion, 233–234combined with

bupivacaine/ropivacaine, 233description, 194diffusion into epidural fat, 222efficacy at mu receptors, 190elderly sensitivity to, 521for emergency room use, 592–593epidural administration, 223

for postcesarean delivery, 538–539, 542vs. epidural bupivacaine, 233–234E-trans fentanyl delivery system, 674heroin, fentanyl-laced, 565intrathecal administration, 122, 232, 328

with dilute bupivacaine, 234for IV-PCA use, 206, 305, 466–467limitations, as postoperative analgesic, 543lipophilicity of, 191, 194, 311, 316, 409,

538–539lockout interval investigations, 210mechanism of action, 587nonmedical usage, 565ODAC monitoring, 204parenteral dosages of, 197for PCEA use, 105, 235side effects of, 194, 391, 409, 571and substance abuse, 565tolerance to, 117transdermal delivery system, 197, 324–325,

466fentanyl, epidural, 223

clinical trials, 105–106combinations

clonidine/local anesthetic, 176, 232vs. epidural morphine, 133extending action of, 538vs. IV fentanyl infusions, 105for postcesarean delivery, 538–539, 542side effects of, 542

fentanyl iontophoretic transdermal system(Fentanyl ITS), 326–327

FentoraTM (rapidly disintegrating oralfentanyl), 572, 574

fibromyalgia, brain imaging studies for, 44“fight-flight reaction” (sympatho-adrenal

response), 22Filitz, N., 38Fillingim, R. B., 35Fishbain, D. A., 5665-HT4(a) agonist, 672FlectorTM Patch (diclofenac epolamine

topical patch), 324






Index 689

Flood, P., 384flurbiprofen, efficacy of, in preemptive

analgesic therapy, 344Folke, M., 422fondaparinux, 245–246Food and Drug Administration (FDA)

accidental injury warnings (MAUDE), 309approval of acupuncture, 393, 395approval of transdermal patches, 324warning against use of LMWH, 239, 246

France, C. R., 43Fuller, J. G., 538functional magnetic resonance imaging

(fMRI), 12–13facial expressions study, 45for fibromyalgia, 44

future of acute pain managementdelivery mechanisms development,

674–675outcomes influenced by uncontrolled pain,

675–677pain management in the future, 671–672pain management in the past, 670–671pharmaceutical development, 672

analgesic development, 672–674reduction of side effects, 672

gabapentinfor ambulatory surgery, 479–480limiting usage factor of, 245–246

gabapentin and pregabalin (calcium channelblockers), 382–383

as adjuvant to opioid therapy, 132anticonvulsants/voltage gated calcium

channels, 93–94description, 382–383immune modulatory effects, 97pharmacology of, 96

nonanalgesic effects/side effects, 96potency/mechanisms of action under

different pain conditions, 94–96for ambulatory surgery, 480peripheral use, 96postoperative pain condition, 94–96

preventive multimodal analgesia with, 182synergy with other analgesics, 96–97

Gagliese, L., 33, 161Galer, B. S., 118, 120, 128Gambling, D., 106gamma-aminobutyric acid (GABA) activate

opioid, 10–11mediation of spinal mechanisms

underlying NE antinociceptiveaction, 83

stimulated release by opioids, 102Gan, T. J., 480gastrointestinal system. See also colectomy;

postoperative bowel dysfunction(POBD); postoperative ileus (POI)

effects of opioids, 407–408morbidity complication, 640–641neural regulation (intrinsic/extrinsic) of,

584NSAIDs side effects, 63–64

vs. COX-2 inhibitors, 356enteropathy, 64

Gate Control Theory (Melzack and Wall),4–5, 41–42, 394

gender, impact on pain management, 35gene polymorphisms

impact on pain management, 37influence of, on opioid activity, 192and persistent pain, 21

general anesthesiafor ambulatory surgery, 368attenuation of remifentanil hyperalgesia,

386cardio protective effects, 28vs. CBT, for children with leukemia, 47epidural infusion-light, 238vs. interscalene block, 290with interscalene nerve blocks, 248with ketamine, 132light, for single-shot/continuous

peripheral blocks, 502with local-regional blocks, 174vs. lumbar plexus block with mepivacaine,

267vs. lumbar plexus-sciatic nerve block, 293nerve injuries related to, 281vs. neuraxial anesthesia, 637–638, 642vs. paravertebral blocks, 295vs. preemptive analgesia, 36vs. regional anesthesia, 245, 281, 288, 469with sciatic block, lateral approach, 507vs. single-injection regional anesthesia,

132genetic approaches, to analgesic tolerance of

opioids, 121genitourinary system, adverse effects of

opioids, 411Gibson, S. J., 161Giebler, R. M., 240Gieraerts, R., 540Gimbel, J. S., 479–480Ginsberg, B., 198, 210Glasson, J. C., 36glucocorticoids, 377–382

beneficial effects of, 382clinical actions of, 379–381, 385

analgesic, 381–382effect mechanisms, 378–379molecular actions of, 379overview, 377–378preemptive effects of, 385side effects of, 382

Gomoll, A. H., 298Gordon, D., 665Gottschalk, A., 297Govindarajan, R., 240Grachev, I. D., 14Graf, C., 162Green, C. R., 160Gross, R. T., 43GTP binding protein coupling, 119guanfacine, additive to local anesthetics, 75GuardrailsTM software (for Continuous

Quality Improvement), 311

Guidelines for Advanced Cardiac LifeSupport, 78

Guidelines for Good Clinical Practice (GCP)of the International Conference ofHarmonization (ICH), 646. Seealso research in acute painmanagement

Guignard, B., 122Gwirtz, K. H., 418gynecological surgery, 35, 42, 165

COX-2 inhibitors, pre-/postsurgery, 479intraoperative ketamine for, 368and opioid induced bowel dysfunction,

200preemptive use of sustained release

ibuprofen, 345

Hadzic, A., 290–291, 293hallucinogen abuse, 565Halsted, William Stewart, 70, 248. See also

interscalene nerve blockHandoll, H., 255Hansen, E. G., 122Harmon, T. M., 48Hartrick, C. T., 107, 206Harvard PCA system, 204Hawaiian patients, 34Hays, P., 50Health Care Financing Administration

(U.S.), 583healthcare providers, barriers to pain control,

165–166Health Related Quality of Life (HRQoL), 651Hebl, J. R., 268Helme, R. D., 161hematologic/cardiovascular effects of

NSAIDs vs. COX-2s, 355–356hemodynamic effects of clonidine, 87hepatic disease, 38herniorrhaphy, 36heroin

abuse of, 565and post-surgical pain, 37

herpes simplex virus labialis (HSVL), 540,542

Herpes Zoster, 4Herr, K., 158, 161Herrick, I. A., 206Herz, A., 222Hess, P. E., 538High-Alert Medications (of ISMP), 614–615Hill, H. F., 311Hispanic patients, 35. See also sickle cell

diseasecustomized OUCHER scale,undertreatment for pain, 160

historical backgroundof acute pain management, 670–671of anesthesia, 70

multimodal, 175of coxibs, 53–54of IV-PCA, 204, 302–303of local anesthetic epidural injections, 314of NSAIDs-description, 53






690 Index

historical background (cont.)of opioid use, 114of para-aminophenols, 54of PENS/TENS, 397of prostaglandin physiology, 54–55on quality improvement issues, 659of salicylates, 53of therapeutic touch (TT)/massage

therapy, 400Hodgkin, Sir Alan, 70Hoenecke, H.R.J., 297Hoffman, H. G., 48–49holistic medicine, 392. See also acupressure;

cupping; moxibustion;non-pharmacological therapy

acupuncture (See acupuncture)hypnosis (See hypnosis)magnet therapy, 399–400music therapy, 402–403osteopathic manipulation (OMT), 401TENS/PENS (See percutaneous electrical

nerve stimulation; transcutaneouselectrical nerve stimulation)

therapeutic touch/massage therapy,400–401

HolterTM roller pump, 302Hood, D. D., 123hormonal effects of clonidine, 88Hospira Gemstar (multitherapy PCA pump),

311–313, 317Huang Di Nei Jing (The Yellow Emperor’s

Classic of Internal Medicine), 392Hudcova, J., 207Hume, D. M., 23humoral mediators, 28Huxley, Sir Andrew, 70hydrocodone

description, 193–194mechanism of action, 587metabolism pathways, 193for moderate/severe pain, 197oral dosing of, 197

with ibuprofen compounding, 198plus ibuprofen, for short term

management, 198for sickle cell disease, 555and substance abuse, 564–565

hydromorphone (hydrophilic mu-1 selectiveopioid agonist), 103, 194

for abdominal surgery, 237for ambulatory surgery, 479continuous epidural infusions of, 234–235epidural administration (bolus dosing),

232–233co-administered with epidural

lidocaine, 233dosing guidelines, 238–239drug preparation/analgesic assessment,

239history and evolution, 237–238patient monitoring/safety, 239precautions/contraindications, 239

hydrophilicity of, 316intrathecal administration, 232

for IV-PCA use, 305parenteral dosages of, 196for PCEA use, 235–236for postcesarean analgesia, 539for sickle cell disease, 556and substance abuse, 565as therapeutic alternative for pain control,

196hydroxyzine, 306hyperalgesia, 102. See also opioid-induced

hyperalgesia (OIH); primaryhyperalgesia; secondaryhyperalgesia; thermal hyperalgesia

of chest wall/upper abdomen, 25classifications, 3–4M40403 prevention of, 16and NMDA activation “windup,” 9–10pathophysiological pain response, 21–22from PGE2 application, 15

hyperglycemia, 23hyperpathia, 3hypertension, post-surgical, 23, 28hypervolemia (stress-induced), 24hypnosis, 47–48, 401–402

cognitive-behavioral therapy vs., 47conscious sedation enhancement by, 47–48patient susceptibility to, 48PET/fMRI research on, 402pharmacological/nonpharmacological

methods, 402self-hypnosis, 47, 402for sickle-cell disease, 554

hypocarbia, 28hypotension, from opioid administration,

406hypoxia, 28hysterectomy, 34, 193, 205, 230, 384

low dose IV naloxone, 411preemptive rofecoxib, 350

ibuprofenanalgesic effects of, 59–60for children, 385compounded with

hydrocodone/oxycodone, 198for moderate/severe pain, 197vs. placebo, for post-surgical pain, 60plus hydrocodone, 198plus oxycodone, 198side effects, 64, 131sustained-release, preemptive use, with

morphine PCA, 345Ilfeld, B. M., 29, 290, 292ilioinguinal/iliohypogastric block, in

pediatric patients, 509imagery, facilitation descending pathways by,

14IMMPACT (Initiative on Methods,

Measurement, and PainAssessment in Clinical Trials), 651.See also research in acute painmanagement

immunologic effectsof alpha-2-AR agonists, 89

of clonidine, 89of gabapentin and pregabalin, 97of ketamine/NMDA receptor agonists, 93

Individualized Numeric Rating Scale (INRS),493

indomethacinefficacy of, in preemptive analgesic


335–339postoperative use, 346

inflammatory “triple response” (Lewis), 21infraclavicular brachial plexus blocks,

253–255block techniques

nerve stimulation, 254ultrasound guidance, 254

complications, 254–255pearls, 255postoperative analgesia in outpatients,

289–290ultrasound guidance, 254

inguinal hernia repair, and chronic pain, 109inhalational anesthesia, 174, 179, 369, 674Initial Pain Assessment Tool, 154Institute for Safe Medication Practices

(ISMP), 306, 614identification of epidural medication

errors, 614–615identification of PCA errors, 614

Institute of Medicine (IOM), 160, 655, 666Institution Review Board (IRB), 647. See also

research in acute pain managementintensity theory (Sydenham)Intensive Care Delirium Screening Checklist,

162Intention-to-Treat (ITT) analysis, 651. See

also randomized controlled trials(RCTs)

intercostal nerve block, 296Interleukin 1-Beta (IL-1-Beta)

and COX-2 induction in CNS fromperipheral inflammation, 180

elevated levels, and allodynia, 7, 21, 25,28

humoral induction of COX-2, 15Interleukin 6

elevated levels, and allodynia, 21, 25, 28post-surgical increase, 28

International Association for the Study ofPain (IASP)

on decision-making about opioids, 631endorsement of evidence-based medicine,

630pain, defined, 3, 149, 391

neuropathic pain, 4International Committee of Medical Journal

Editors (ICMJE), 647International Conference of Harmonization

(ICH), 646International Narcotics Control Boards, 631interscalene nerve block, 248–251. See also

Halsted, William Stewart; Winnie,Alon






Index 691

background information, 248–249block techniques

nerve stimulation technique, 249–250pearls, 251ultrasound guided technique, 250–251

complications of, 251indications for, 249postoperative analgesia in outpatients,

289–290side effects of, 290

intrathecal analgesiaadministration in children, 498dose determination, 467for postcesarean delivery, 543

intrathecal anesthesia/administrationadverse effects of, 236–237alpha-2 adrenergic receptor agonists,

383–384BDNF signaling molecule, 17bupivacaine, 75, 232, 234, 328buprenorphine, 543cholinesterase inhibitor, 83clonidine, 75, 83, 85–86, 88

with morphine, 176, 232, 544COX-2 inhibitors, 16dexmedetomidine, 87fentanyl, 122, 232, 328

with dilute bupivacaine, 234gabapentin, 94, 96glycine, 125guidelines for, 233hydromorphone, 232ibuprofen, 124ketamine, 92ketorolac with morphine, 121MK-80, 120morphine, 232, 407, 411, 417–418

with bupivacaine, 234with clonidine, 176, 232epidural, 230intrathecal vs. intravenous, 420

neostigmine, 384nitric oxide (NO), 16postcesarean analgesia, 543

adjunct therapy, 544single boluses of opioids, 230–233single-dose administration, in community

practice setting, 467intrathecal bolus dosing, 230–232intravenous patient-controlled analgesia

(IV-PCA), 28, 369–370. See alsopatient-controlled analgesia(PCA); patient-controlled epiduralanalgesia (PCEA)

advantages, 425in community practice setting, 466–467dosing requirements, 304–305for elderly/ill opioid-dependent patients,

166, 196historical background, 204, 302–303influence of ethnicity on prescribing, 35with intrathecal/epidural morphine,

230opioids for use with, 305–306

and parenteral opioid therapy, 196patient outcomes

postoperative morbidity, 207satisfaction, 207

for postcesarean analgesia, 538, 544–545vs. regional block/epidural analgesia for

knee flexion, 29risk factors of, 306safety issues, 306–308, 425study of bupivacaine/fentanyl, 106and systemic opioids, 28

intravenous patient-controlled analgesia(IV-PCA), analgesic efficacy of

comparisons with other analgesictechniques

conventional opioid analgesia, 205epidural analgesia, 205intranasal PCA, 205subcutaneous PCA, 205transdermal PCA, 206

opioids used with IV-PCA, comparison of,206

intravenous patient-controlled analgesia(IV-PCA), devices/systems. See alsoanalgesic infusion pumptechnology; Cardiff Palliator pump(PCA system); HolterTM rollerpump; On Demand AnalgesiaComputer; Prominject PCAinfusion pump

clinical management, 305–306commercially available systems, 311–314

Alaris System PCA Module, 311Curlin Medical 4000 CMS, 311Hospira Gemstar, 311–313Smith Medical CADD-Prizm PCS IITM,

313–314cost effectiveness, 308design theory, 303features/modes of operation, 304–305minimum effective analgesic

concentration (MEAC), 303, 308pharmacokinetic drug delivery systems,

310–311safety issues, 306–308

accidental purging protection, 306–307bar-code readers, 307computer-based pump programming,

307–308error-reduction features, 307overmedication, 306respiratory depression, 306

intravenous regional anesthesia (Bier block),293

ion channelsand analgesic tolerance to opioids, 120blocking agents, 17

IONSYSTM (fentanyl iontophoretictransdermal system), 197, 206,326–327

iontophoresis, analgesic delivery system,325–327, 674

Iowa Pain Thermometer (IPT), 151, 154Ishiyama, T., 235

ISMP. See Institute for Safe MedicationPractices (ISMP)

isoproterenol (beta 1/beta 2 receptor agonist)for epidural analgesia, 221

as adjuvant, 224IV-PCA. See intravenous patient-controlled

analgesia (IV-PCA)

Jay, S., 47Joint Commission on Accreditation of

Healthcare Organizations(JCAHO)

APMS education role, 433and assessment of pain, 589concern about range order administration,

605–606mandated evaluation of pain scores for all

patients, 148–149medication reconciliation, defined, 608pain management standards, 114, 175,

601, 604, 608, 659–660, 666patient medication safety goal, 608

Joly, V., 122, 127

Kaba, A., 383kappa receptors (OPR2)

butorphanol/nalbuphine binding of,193

mediation of spinal/visceral analgesia,189

for relief of visceral pain, 201Katz, J., 42–43, 175, 370Katz, Sir Bernard, 70Keeri-Szanto, M., 670Kehlet, H., 27, 29Kemper, P. M., 230ketamine (NMDA receptor agonist). See also

S(+)ketaminefor abdominal surgery, 93, 368adjuvant use with children, 497administration in perioperative period,

368–369adjunct to sedative during local

anesthesia, 369in ambulatory ENT surgery, 369ambulatory surgery (excluding ENT),

368postsurgical, 369

for ambulatory surgery, 481analgesic effects of, 366

preemptive, 366–367and cardiac surgery, 93combinations

bupivacaine, during wound infiltration,91

epidural morphine, 367, 370parenteral/epidural opioids,

for emergency room use, 592–593enhancement of opioid-induced analgesia,

367importance of opioid dose, 368

epidural administration, 221, 371–372as adjuvant, 224

lipophilicity of, 92






692 Index

ketamine (cont.)for major surgery

amputation, 372postoperative, abdominal surgery, 370postoperative, persistent pain

prevention, 370thoracic surgery, 370–371

and opioid combination, for PCA use, 206for opioid-dependent patients, 571and opioid-induced hyperalgesia,

125–127, 368and opioids, for PCA use, 206pharmacology/pharmacokinetics of,

91–92, 366postoperative infusion of, 367preemptive multimodal effects, 30, 385preventive effect in remifentanil-induced

hyperalgesia, 368–369preventive multimodal effects, 178–179side effects of, 366

ketamine and NMDA receptor agonistsNMDA receptors and pain modulation,

89–90immune modulatory effects, 93interaction with other analgesics, 92–93pharmacology under different pain

states, 90–91nonanalgesic effects, 92peripheral use of ketamine, 91postoperative pain conditions, 91

ketoprofen, 55efficacy of, in preemptive analgesic

therapy, 344pediatric use, 494postoperative use, 346preemptive IV, in laparoscopic

cholecystectomy, 345–346ketorolac

for ambulatory surgery, 479analgesic effects of, 60–61for complex regional pain syndrome, 65with dextromethorphan for

laparoscopic-assisted vaginalhysterectomy, 345

efficacy of, in preemptive analgesictherapy, 344

for emergency room use, 591evaluation for postoperative pain usage,

335–339with opioids, for abdominal surgery, 60postoperative use, 346preemptive use

in hip replacement surgery, 345in laparoscopic cholecystectomy, 345–346

reduction of thromboxane A2, 355for sickle cell disease, 554starting perioperative dosage, 385

kinesiophobia, 43–44Klaastad, O., 255Klein, S. M., 289, 293Koch, T., 119Koppert, W., 16, 123Koscielniak-Nelson, Z., 255Kotani, N., 395–396

Kotelko, D. M., 538

Lang, E. V., 45, 47Lao, L., 396laparoscopic surgery

cholecystectomyketoprofen, 345–346postoperative tenoxicam, 345

for colectomy, 182, 584dexamethasone following, 381ketamine, for gynecological surgery, 368piroxicam, for bilateral hernia repair, 345preoperative ketorolac/dextromethorphan,

345reduction of complications with, 584Roux-en-Y gastric bypass, use of ON-Q

bupivacaine pain pump, 36Lasagna, L., 110Lavand’homme, P., 370Lean methodology, for quality/quality

improvement, 658Lecht, C. H., 538Lee, L. H., 122Lee, Y., 381Leeds Assessment of Neuropathic Symptoms

and Signs (LANSS) scale, 159de Leon-Casasola, O. A., 117levobupivacaine, 72

epidural administration of, 224with morphine, 315

Lewis, T., 21Liang, D. Y., 124lidocaine

combinationsepinephrine, 75fentanyl, 543hydromorphone (epidural), 233paracetamol/NSAIDs, 383

description, 383iontophoresis, 327lipophilicity of, 72–73onset of action, 72patches, for transdermal drug delivery, 324protein binding properties, 73transdermal delivery system, 324

LidodermTM transdermal patch, 324LidositeTM Topical System (lidocaine

iontophoresis), 327lipophilicity

alfentanil, 105bupivacaine, 72chloroprocaine, 72clonidine, 86–87dexmedetomidine, 86–87etidocaine, 72fentanyl, 191, 194, 311, 316, 409, 538–539ketamine, 92lidocaine, 72–73mechanisms of action, 103, 316mepivacaine, 72–73procaine, 72sufentanil, 106, 133, 191, 409, 539tetracaine, 72

liposomal morphine, epidural, 223

Liu, S. S., 235–236, 288, 297, 381–382, 585Livingston, E. H., 583local anesthesia/anesthetics

for abdominal surgery, 132action at sites unrelated to Na

channels/nerve block, 71for ambulatory regional

anesthesia/analgesia, ambulatorylocal anesthetics/equipment for, 288

carbonation of, 75continuous epidural infusion, 233electropharmacology of, 71epidural administration, 223–224

combined with opioids, 224with epidural morphine, 538and equipment, for regional

anesthesia/analgesia, 288ketamine as adjuvant, 369maximum doses of, 73–74mechanisms of action, 496modification by vasodilators, 76for pediatric pain management, 496–497pharmacodynamics of, 73physiochemical properties of, 72–73preemptive analgesia with, 180–181racemic mixtures, 72with regional analgesia

for epidural blocks, 180for peripheral nerve blocks, 180for wound infiltration, 179–180

side effects (toxic) of, 76–78allergies, 78cardiovascular toxicity, 77–78central nervous system, 77, 280–281methemoglobinemia, 78treatment of, 78

single (S-) enantiomers, 72sodium bicarbonation of, 75structures of, 72use of additives with, 74–75

lockout intervalsof IV-PCA pumps, 105–106, 205, 210, 304for morphine, 304

long term potentiation (LTP)factors necessary for development of, 10,

15onset/reversibility of, 15

Lortab R©, 193low-molecular weight heparin (LMWH)

vs. Coumadin, 246for deep venous thromboses (DVT), 246growing use of, 673and risk of epidural hematoma, 226, 239,

245–246lumbar plexus blocks, 267–274, 293–294

fascia iliaca block, 294femoral nerve block, 270–274, 293–294ilioinguinal/iliohypogastric nerve block,

296paravertebral nerve block, 295–296postoperative analgesia in outpatients, 293psoas compartment block, 267–268

peripheral nerve stimulation, 268–269ultrasound guidance, 268–269






Index 693

lumiracoxib, 346analgesic effects of, 62

lungs, pathophysiological pain response,24–25

MacLaren, J. E., 46magnesium

as analgesic adjuvant, 384preventive multimodal effects of, 179

magnetism, 399–400magnet therapy, 399–400

application of, 399complex magnetic burst field applications,

400low frequency magnetic fields, 400

Manimala, M. R., 46Manne, S. L., 46Manufacturer and User Facility Device

Experience Database (MAUDE),309, 614

Marhoffer, P., 270–271marijuana use, 188, 565, 568. See also

cannabinoids;9-tetrahydrocannabinol(THC)

Marks, R. M., 302, 670massage therapy. See therapeutic touch

(TT)/massage therapymastectomy, 27, 36, 111, 480

chronic pain association, 675–677lidocaine patch for, 324persistent pain risk factors, 483

Matheny, J. M., 267Mayer, D. J., 119, 394, 397MC1R. See melanocortin-1-receptor

(MC1R)McCaffery, Margo, 149McCartney, C. J., 175, 292McCormack, J. P., 197McCracken, L. M., 43McGill Pain Questionnaire (MPQ), 12, 33,

111, 151, 156–157ratings of elderly patients, 161Short-Form McGill Pain Questionnaire

(SF-MPQ), 157MDMA (“Ecstasy”) abuse, 565Meadowsweet herb (Spirea ulmaria), 53. See

also salicylatesMeagher, L., 538mechanisms of action

acetaminophen, 58, 177–178agents with lipophilicity, 103alvimopan, 587clonidine, 85, 88of clonidine, 224codeine, 587endogenous opioids, 14epidural morphine, 28fentanyl, 587gabapentin, 96gabapentin/pregabalin, 94–96hydrocodone, 587local anesthetics, 496morphine, 587

naproxen, 60NMDA receptor antagonists, 92NSAIDs

on prostaglandin synthesis inhibition,53, 55

side effects, 62opioid analgesics, 88opioid-induced respiratory depression,

419–420oxycodone, 587prostaglandins (PGEs), 55–56, 63tissue injury from surgery, 366

medical report passport system, forsickle-cell disease, 554

Medical Society Patient Care AssessmentCommittee (Massachusetts),425–426

Medication Errors Reporting (MER)Program, 614

medication therapy management (MTM) bypharmacists, 607–608

definition, 607federal/state regulations, 607medication reconciliation, 607–608patient counseling, 607problems of, 607USP MEDMARX program, 608

Mehta, Y., 240melanocortin-1-receptor (MC1R), 37melatonin, 672–673Melzack, R., 156

Gate Control Theory,and acupuncture, 394

neuromatrix theory of pain, 42membrane stabilizing drugs:

anti-neuropathics, 382–383gabapentin/pregabalin (calcium channel

blockers), 382–383lidocaine/mexelitine (sodium channel

blockers), 383Mendell, L. M., 109Menigaux, C., 106meperidine

American Pain Society recommendationagainst, 612

delirium from, 411description, 195effect on cardiovascular system, 406effect on serotonin, 195for emergency room use, 592for IV-PCA use, 36, 206, 305for moderate/severe pain, 197ODAC monitoring, 204for postcesarean analgesia, 539, 543for sickle cell disease, 556as therapeutic alternative for pain control,

196meperidine PCA, 36–37, 103mepivacaine, 72

additive to epinephrine, 75lipophilicity of, 72–73onset of action, 72protein binding properties, 73

metabolic derangements, 4

methadonedescription, 194–195, 613during intraoperative/postoperative

period, 574and OIH, 121–122and opioid switching, for OIH

modulation, 127ora, for patients with high morphine

tolerance, 574parenteral dosages of, 197–199for postsurgical/medical related pain,

197for sickle cell disease, 556and substance abuse, 564–566

methadone maintenance therapy(MMT), 566–567

methohexital for emergency department use,593

methylnaltrexonefor blocking peripheral effects of opioids,

408for minimization of opioid-related

gastrointestinal distress, 613, 672for opioid-induced bladder dysfunction,

411for POBD/POI, 586–587

methylprednisone, 381metoclopramide, for nausea/vomiting, 210,

237, 242, 407, 613mexilitine, 383midazolam

for emergency room use, 592–593for epidural analgesia, 221

as adjuvant, 224Miguel, R., 106Milligan, K., 118minimally invasive surgery. See laparoscopic

surgeryminimum effective analgesic concentration

(MEAC), 303, 308Mitra, S., 576MK-801 NMDA (non-competitive)

antagonist, 120, 125Mogil, J. S., 37Moiniche, S., 174–175, 179–180Molke, J. F., 239Monitoring the Future Study (2006), 565Moore, P. A., 382MorphiDex R©, 128morphine

back pain study, 117cardiovascular system effects of, 406combinations

bupivacaine/levobupivacaine/ropicaine,315

with ibuprofen,with ketorolac, in ED, 591

description/uses of, 193dosing/dosage requirements

COMT gene’s genetic variability, 192epidural bolus dosing, 232–233intrathecal bolus dosing, 230–232

effect on calcitonin gene-related protein,124






694 Index

morphine (cont.)epidural administration, 28, 222–223

continuous epidural infusion, 234spinal, plus epidural infusion, 234

extended morphine, clinical trials,106–107

extended release epidural morphine(EREM), 327–329

glucoronidation of, 38hydrophilicity of, 316intramuscular, and sedation, 416–417intrathecal administration

in cesarean sections, 543with clonidine, 176, 232, 544and respiratory depression, 417–418

intravenous administrationfor elderly/pediatric patients, 33for emergency room use, 592vs. epidural administration, 370influence on sleep, 422vs. intramuscular morphine, 495vs. intrathecal administration, 407, 420

for IV-PCA use, 206, 305lockout intervals, 304

lockout interval investigations, 210mechanism of action, 587microdialysis delivery of, 421for moderate/severe pain, 197vs. nalbuphine, female response, 37oral dosing of, 197oral vs. intravenous, bioavailability of vs.

oral, 574for PCEA use, 235for postcesarean analgesia, 538pruritus from, 411for sickle cell disease, 556as standard parenteral opioid, 196and substance abuse, 564sustained release preparations, 198

morphine, epidural. See also DepoDurTM

(prolonged duration epiduralmorphine); extended releaseepidural morphine (EREM)

age related reductions, 33clinical trials, 106–107combinations

bupivacaine, 234clonidine, 539, 544ketamine, 367, 370local anesthetics, 538

description, 222vs. epidural fentanyl, 133, 539intrathecal administration, 230vs. intrathecal morphine, 543mechanism of action, 28vs. parenteral opioids, 232for postoperative pain management, 117and respiratory depression, 407, 540side effects

nausea/vomiting, 237, 409, 540pruritus, 237

single dose, vs. continuous infusion, 232morphine-3-glucuronide (M3G), 38, 127morphine-6-glucuronide (M6G), 37–38, 672

motivational-affective pain factors, 42moxibustion, 392MS Contin R© (controlled release morphine),

193, 198, 556Multicentre Australian Study of Epidural

Anesthesia (MASTER), 638multimodal analgesia, 245–246. See also

preemptive analgesia; preventivemultimodal analgesia

for ambulatory surgery, 478–479anesthesiologist initiation of, 30background/description, 175–176, 332,

335, 433and clinical outcomes, 182–183with clonidine, 479with COX-2 inhibitors, 479definition, 82with epidural bupivacaine, morphine,

ketamine, 372with gabapentin, 479goal/theme of, 361implementation in community practice

setting, 458–460NMDA antagonist/NSAIDs

administration, 182for opioid dependent drug addicts,

570–571for postcesarean delivery, 545

mu opioid receptors, 118actions/structure of, 11activation in medial thalamus, 12, 14binding of kappa receptors (OPR2), 193central/peripheral nervous system

locations, 407endocytosis of, 191mediation of TENS, 397polymorphism, 192, 304and sublingual buprenorphine, 196

Murphy, D. F., 239Muscoli, C., 16music therapy, 402–403

facilitation descending pathways by, 14myocardial ischemia (perioperative), 23–24,

172, 526

N-(4-hydroxyphenyl) acetamide, 54nabumetone (NSAID), 56, 342–344Na channels

anesthetic actions at unrelated sites, 71electrophysiology of, 70–71structure/function of, 70

nalbuphineavoidance of, with drug addicts, 570binding of kappa receptors (OPR2), 193for blunting respiratory depression, 407for emergency room use, 592intrathecal, for postcesarean section, 543vs. morphine, female response, 37for pruritus, 539–540

nalmefene, for nausea/vomiting, 411naloxone

and acupuncture, 394PENS/TENS, 397

for IV-PCA related pruritus, 306

for nausea and vomiting, 411, 540and opioid combination, for PCA use, 207for pruritus, 214, 237, 412, 540for reduction of opioid induced bowel

function, 586for respiratory depression, 236, 242, 407,

613reversal of intrathecal opiates, 174for urinary retention, 411

naltrexone, 193, 325, 407for reduction of opioid induced bowel

function, 586for reversing respiratory depression, 407

naphthylalkanones, 57–58naproxen

analgesic effects of, 60efficacy of, in preemptive analgesic


335–339postoperative use, 346preemptive use of, 345

Narcotic Addict Treatment Act (1974), 565narcotics (schedule II) management, by

pharmacists, 608–609Nasal Stadol R©, 195National Health and Medical Research

Council (NHMRC) of Australia,633

National Health Expenditure Accounts data,476

National Hospital Ambulatory Medical CareSurvey, 594

National Institutes of Health (NIH)approval of acupuncture, 393, 395National Library of Medicine database,

647National Pain Foundation, 166National Survey on Drug Use and Health

(NSDUH), 391, 565Naulty, J. S., 538–539nausea and vomiting

anti-emetic treatment of, 410–411CTZ mediation of, 408–409dexamethasone for, 410multimodal approach to, 409nalmefene for, 411naloxone for, 540ondansetron for, 237from opioids, 133, 199, 237, 332, 377,

408–411, 540from PCA/management of, 214, 306phenothiazines for, 613scopolamine patch for, 237, 410, 613serotonin for, 410, 613

negative affect (anxiety) and pain, 42negative-pressure pumps (non-electric

infusion devices), 321Negre, I., 230neonatal considerations, 545–548

meperidine absorption in gastrointestinaltract, 546

nursing mothers/medications, 537safety of acetaminophen, 58






Index 695

neostigmine (acetylcholinesterase inhibitor),83

for epidural analgesia, 221as adjuvant, 224, 384

nephrectomies, 36, 237nerve blocks. See also axillary brachial plexus

block; elbow blocks; interscalenenerve block; peripheral nerveblocks; supraclavicular nerveblock; wrist block

differential sensory nerve blocks, 74and Na channels, 70, 73peripheral, as adjuvant to opioid use,

132–133single-injection, in community practice

setting, 467volumes/concentrations of anesthetics

during, 73neural plasticity, 10, 14neuraxial analgesia

advantages of, 230adverse effects of spinal opioids, 236–237

nausea and vomiting, 237pruritus, 237respiratory depression, 236, 407urinary retention, 237

continuous epidural analgesia, 233–235buprenorphine, 239–240combined spinal morphine/epidural

infusion, 234fentanyl infusions, 233–234hydromorphone infusions, 234–235,

237–239local anesthetic infusions, 233morphine infusions, 234

patient-controlled epidural analgesia,235–236. (See alsopatient-controlled epiduralanalgesia)

for postcesarean delivery, 545for postoperative pain, in

opioid-dependent patients, 575single boluses of intrathecal/epidural

opioids, 230–233epidural bolus dosing, 232–233intrathecal bolus dosing, 230–232

neuraxial analgesia, patient controlledsystems

background information, 314clinical management, 315–316commercially available PCEA infusion

devicesCurlin Medical 4000 CMS, 317Hospira Gemstar, 317Smiths Medical CADD-Prizm PCS II,

317delivery variables/infusion rates, 314–315design theory, 314safety issues, 317systems, 316–317

neuromatrix theory of pain (Melzick), 42neuropathic pain, 16–17

allodynic/hyperpathic aspects of, 26associated disease states, 4

characteristics of, 4defined, 4description, 150mechanisms of development, 16nonadaptiveness of, 16research focus for, 16–17

neutrophil aggregation, prostaglandininhibition of, 55–56

Ng, K. F., 206, 270nicotine, 384, 568Nikolajsen, H. C., 5379-tetrahydrocannabinol (THC), 673nitric oxide synthetase (NOS), 10, 16, 26NMDA (N-methyl-d-aspartic acid) receptor

antagonists (NMDARA), 125. Seealso dextromethorphan; ketamine;MK-801 NMDA(non-competitive) antagonist

perioperative administration formultimodal analgesic effects, 182

preemptive analgesia with, 179preemptive analgesic with, 174–175preventive multimodal effects of, 178–179

NMDA (N-methyl-d-aspartic acid) receptorsand analgesic tolerance to opioids, 120and cAMP/protein kinases production, 15and clinical hyperalgesia, 9–10CNS locations, 89described, 9indirect reduction of opioid sensitivity, 17ketamine’s affinity for, 366locations of, 120for OIH modulation, 125overactivation of, and excitotoxicity, 15pharmacology under different pain states,

90–91postoperative pain conditions, 91

phosphorylation of, 15plasticity changes, 15and SOD activation, 16spinal/supraspinal, activation of, 15substrates of, 125

nociceptive pain. See also hyperalgesiadefined/subdivisions, 3, 149–150minimization by non-opioid

analgesics/adjuvants, 377NMDA receptors increase of, 366


non-opioid analgesics. See alsoacetaminophen; aspirin; COX-2(cyclo-oxygenase-2) inhibitors;ibuprofen; ketoprofen; naproxen

alpha-2 adrenergic receptor agonists,383–384

anti-neuropathicscalcium channel blockers, 382–383sodium channel blockers, 383

cannabinoids, 384glucocorticoids, 377–382. (See also

glucocorticoids)magnesium, 384neostigmine, 384

nicotine, 384principles of employment, 377for sickle cell disease, 554–555

non-opioid analgesics, clinical applicationsof, 385–387

acute post-operative pain, 385–386perioperative, early phase, 385–386postoperative

at home/without IV access at hospitalward, 386

in PACU/hospital, 386preoperative, 385

other pain types, 386–387non-pharmacological therapy, 384–385nonsteroidal anti-inflammatory drugs

(NSAIDs). See also COX-2(cyclo-oxygenase-2) inhibitors;diclofenac; fenbufen; flurbiprofen;indomethacin; ketoprofen;ketorolac; naproxen; piroxicam;tenoxicam

for acute postoperative pain, 385for ambulatory surgery, 479–480Black Box Warning, against use of, 355cardiac morbidity concerns from use of,

166and colectomy, 585–586combinations

with glucocorticoids, 382with lidocaine, 383with tramadol/acetaminophen, 198–199

vs. COX-2 inhibitorsbone/wound healing effects, 356gastrointestinal system, 356for postoperative pain, 178renal effects, 356

efficacy of, in preemptive analgesictherapy, 344

for emergency room use, 591hematological/cardiovascular effects, vs.

COX-2s, 355–356historical background

coxibs, 53–54NSAIDs-description, 53para-aminophenols, 54salicylates, 53

inhibition of COX by, 55inhibition of prostaglandin synthesis, 177limitations of, 17mechanisms of action, 335, 342for opioid-dependent patients, 571for pediatric pain management, 493–494perioperative administration for

multimodal analgesic effects, 182and peri-operative analgesia, 59pharmacokinetics of

of acetaminophen, 58–59acetic acids, 57anthranilic acids, 57aspirin, 57coxibs, 58general principles, 56–57naphthylalkanones, 57–58oxicams, 58






696 Index

nonsteroidal anti-inflammatory drugs (cont.)propionic acids, 57pyrazolones, 57

and platelet aggregation/risks of bleeding,355

for postcesarean delivery, 545preemptive analgesia with, 385preemptive/preventive/multimodal

administration, 30, 174–175,177–178

pre-incision administration, 478reduced PGE synthesis from, 29review of, for postoperative pain usage,

335–339safety and tolerability of, 355for sickle cell disease, 554, 558side effects of, 62–66

nonsteroidal anti-inflammatory drugs(NSAIDs), and surgical painmanagement

background information, 335–339perioperative use

COX-2 inhibitors, 346–347celecoxib,parecoxib, 350–353rofecoxib, 347–350valdecoxib, 350–353

postoperative use, 346acetaminophen,

intravenous (paracetamol), 358–359oral/rectal, 358

diclofenac, 346etoricoxib, 353–355indomethacin, 346ketoprofen, 346ketorolac, 346naproxen, 346propacetamol, 358rofecoxib,tenoxicam, 346tramadol, 346

pre-incisional use, 342–346diclofenac, 345ibuprofen, sustained-release, 345ketoprofen, 345–346ketorolac, 345naproxen sodium, 345piroxicam, 345tenoxicam, 345

nonsteroidal anti-inflammatory drugs(NSAIDs), side effects of, 62–66

aspiring-sensitive asthma, 66cardiovascular system, 63gastrointestinal system, 63–64

enteropathy, 64peptic ulcers, 63–64

hepatotoxicity, 66injection site damage, 66platelet clotting function, 64–65renal function, 65–66

norbuprenorphine, 38Nordberg, G., 104norepinephrine (NE), 10–12

acupuncture’s influence on, 395

COMT inactivation of, 37post-surgical trauma increases, 23role in descending pathway, 14spinal, antinociceptive effect of, 83tramadol’s inhibition of uptake of, 306,

495, 555, 591–592normeperidine

seizures from, 411toxicity, from PCA, 214–215

norpethidine, for IV-PCA use, 206novel analgesic drug delivery systems. See

transdermal therapeutic systems(TTS)

NSAIDs. See nonsteroidal anti-inflammatorydrugs (NSAIDs)

nSTT (lateral neo-spinothalamic tract), 12nuclear factor-kappa B (NF-kB), 15Number Needed to Treat/Harm

(NNT/NNH), 632. See alsoevidence-based medicine (EMB)

Numeric Rating Scale (NRS), 151, 162, 649NumorphanTM (oxymorphone), 305nurses. See also American Society for Pain

Management Nursing (ASPMN)ASPMN position statements, 167influences on pain assessment by, 165IV-PCA protocols, 208–209nurse-based pain programs, 604nursing issues

alternative agent-controlled analgesia,606

analgesia by catheter techniques, 605nonverbal patient assessment, 604–605patient monitoring, 605range order administration, 605–606

observer scoring of patient pain, 150–151pain resource nurse (PRN) programs for,

603–604role diversity of, 603role model programs/preceptorships for,

604nurses, as clinical coordinators, 597–598

characteristics of coordinators, 598–599advanced practice registered nurses

(APRNs), 598–599organization structure, 599responsibilities

clinical practice, 601–602continuous quality improvement (CQI),

603delineate responsibilities, 599–601establishment of policies/procedures,

601general responsibilities, 603multidisciplinary education, 602patient education, 603patient flow, 599

objective pain scale (OPS), 492obstructive sleep apnea (OSA)

from opioid use, 377, 421use of OCA without background infusion,

211Ochroch, E. A., 111

ODAC. See On Demand Analgesia Computer(ODACTM)

odds ratio (OR) method for analgesic efficacycomparisons, 650

OIH. See opioid-induced hyperalgesia (OIH)OLD CART assessment tool, 154–156oligoanalgesia (underuse of analgesics), in

emergency department, 589–590Olofsen, R., 35Olsen, Y., 114Olstad, O. A., 381Omnibus Budget Reconciliation Act (1990),

607ondansetron, for nausea/vomiting, 237On Demand Analgesia Computer

(ODACTM), 204, 303Ong, C. K., 175, 179, 181On-Q C-BlocTM Continuous Peripheral

Nerve Block System, 36, 319–320OPANA R© (immediate release

oxymorphone), 198Opana ER R©, 194, 198Opana Injectable R©, 194, 305Opana IR R©, 194opioid analgesics

adverse events related to use, 199–200for ambulatory surgery, 479annual sales statistics (U.S.), 564Australia, opioid trends study, 114benefits of, 377central/peripheral, and preventive

multimodal analgesia, 181–182classification of, 192–193dosage requirements, orthopedic

procedures, 36dose escalation, analgesic paradox of,

116and drug abuse, 391effects on bowel function, 584–585for emergency room use, 591–592genetic polymorphisms influence on, 192historical background, 114, 188increasing usage of, 114

clinical implications of, 114interactions with alpha-2 adrenoceptor

agonists, 88for IV-PCA use, 305–306lipophilicity of, 316mechanisms of action, 88multicompartment pharmacokinetics of,

310opioid disinhibition mechanism,parenteral, and vital capacity,and patient size, 36–37PCA consumption of, 117. (See also

patient-controlled analgesia,opioids for)

for pediatric patients, 494–496major, 495–496weak, 495

pharmacology ofpharmacokinetics, 190–191receptors, 188–190tolerance/hyperalgesia, 191–192






Index 697

physician prescribing patterns in U.S.(1992–2001), 114

preemptive analgesic effects of, 174–175,182

prolonged usage ofadaption to, 115adaptive mechanisms, 115

for sickle cell disease, 555–556systemic and cytokine response,U.S. opioid trends, 114

opioid analgesics, side effects, 199–200, 377,391

cardiovascular, 406constipation, 133, 199, 223, 332, 407–408dermatological, 411–412. (See also

pruritus)gastrointestinal, 407–408genitourinary, 411nausea/vomiting, 408–411neurological, 411respiratory, 406–407

opioid analgesics, tolerance to, 117–118,191–192

acute opioid tolerance, 116–117described, 116genetic approaches to, 121mechanisms of, 118–121

alterations in GTP binding proteincoupling, 119

cytokines and innate immunity,120–121

ion channels, 120NMDA receptor, 120protein kinase activation, 119–120receptor desensitization/tracking,

118–119and OIH, 115vs. opioid-induced hyperalgesia, 115–116,

121, 191–192opioid dependence/substance abuse

aspects of disorderopioid tolerance, 567physical dependence, 567

case management examples, 576–578cross addictions/poly-drug abuse, 568drug abuse statistics, 565Drug Addiction Treatment Act (DATA

2000), 565–566DSM-IV criteria, 565, 568emergency department (ED) visits, 565impact on pain management, 37methadone maintenance therapy (MMT),

566–567, 574Monitoring the Future Study (2006), 565Narcotic Addict Treatment Act/Opioid

Treatment Program (OTP), 565National Survey on Drug Use and Health

reports, 565need for knowledge about, 564opioid antagonist therapy (OAT), 566–567and pain management issues, 566–567patient management

assessment issues, 567–570goals and strategies, 570–571

multimodal analgesia approach,570–571

opioid medications, 571–572patient prescription increases, 564perioperative management

dose tapering, 575–576intraoperative period, 574postoperative period, 574–575

neuraxial analgesia, 575regional analgesia, 575

preoperative period, 574prescribed opioids, 565

and abuse of opioids, 566treatment with opioid agonists, 565–566

opioid dependence/substance use disorderaspects of disorder

criteria and definitions, 567opioid-induced hyperalgesia (OIH), 121–128

avoidance of dose escalation, 116as complication of opioid analgesics, 391defined, 114–115, 192distribution of opioids, 124–125mechanisms of, 123–124

peripheral effects, 123–124spinal effects, 124supraspinal effects, 124

multimodal therapy modulation of,125–128

dextromethorphan, 128ketamine, 125–127, 368methadone and opioid switching, 127NMDA receptors, 125

vs. opioid dosage, 121vs. opioid tolerance, 115–116, 121serotonin and, 124sufentanil’s impact on, 133therapeutic occurrences of, 121–123

methadone maintenance therapy,121–122

observational studies in chronic pain,123

perioperative opioid exposure, 122preemptive administration of

opioid/COX-2 inhibition, 182volunteers for experimental pain

methods, 122–123underlying pathways, 116very high doses, 125

opioid naive patients, perioperative therapymanagement, 133

balanced anesthesia, 133treatment of suspected OIH, 133

opioids, future challengesimpact of chronic persistent pain

post-surgery, 134lack of high quality evidence, 133–134optimal adjuvant use, 134usefulness of preoperative detoxification,

134opioids, patient use management, 128–133

adjuvant medications/treatmentsCOX inhibitors/paracetamol, 131epidural block, 133gabapentin, 132

infiltration/wound lavage, 132NMDA receptor antagonists, 131–132peripheral nerve block, 132–133regional anesthesia, 132

intraoperative considerations, 128–130perioperative considerations, 128postoperative considerations, 130preoperative considerations, 128

OPR2 receptors. See kappa receptors (OPR2)oral dosing of analgesics, 197–199

fentanyl oralet (Actiq R©), 198hydrocodone/oxycodone, 197

with ibuprofen compounding, 198morphine, 197oxymorphone, 198short-acting agents, 199sustained release preparations, 198

oral nutrition, 29organ impairment/failure, impact on pain

management, 37–38orthopedic surgery

acetaminophen/NSAIDs following, 178ambulatory infraclavicular block, 292celecoxib, postsurgical utilization, 347in children, continuous peripheral pump

vs. elastomeric pumps, 319CombunoxTM for, 479continuous peripheral nerve block, 289COX-2 inhibitors, 245epidural analgesia vs. peripheral nerve

block/PCA, 178epidural morphine, 230etoricoxib for, 353ketamine for, 369, 481ketorolac, preemptive, 345meloxicam for, 675and negative affect study, 42open surgeries, 36oxymorphone (IR) vs. oxycodone, 198paracetamol vs. propacetamol, 359pentazocine/piritramide/metamizol study,

106rofecoxib, perioperative use, 350sleep disturbances from, 27

osteopathic manipulation (OMT), 401OUCHER scales

for African-American/Hispanicself-assessment, 490, 552

for pediatric self-assessment, 163, 490outpatients. See ambulatory surgery index

entries; postoperative analgesia, inoutpatients

overmedicationIV-PCA incidents, 306of pediatric patients, 163

Oxford Pain Validity Scale (OPVS), 334oxicams, 53, 57–58oxycodone, 188

with acetaminophen, vs. valdecoxib, 353vs. codeine, 195description, 193extended-release, 460for IV-PCA use, 212mechanism of action, 587






698 Index

oxycodone (cont.)metabolism pathways, 193for moderate/severe pain, 197oral bioavailability of, 574oral dosing of, 197

with ibuprofen compounding, 198, 479immediate release (OPANA R©), 198, 479for sickle cell disease, 555–556

vs. rofecoxib, for oral surgery, 350and substance abuse, 564–565for visceral pain, 386

Oxycontin R©, 114, 193, 198, 556, 565, 574OxyIR R© (oxycodone elixir), 193oxymorphone. See also OPANA R©

(immediate release oxymorphone)description, 194for IV-PCA use, 305as pain control alternative, 196parenteral dosages of, 196–197as therapeutic alternative for pain control,

196

P450 enzymesCYP 37–38 2D6,CYP 38 3A4,

PAG. See periaqueductal gray (PAG)pain. See also chronic pain; chronic persistent

pain; pathophysiology of acutepain; perioperative pain; persistentpain; postoperative pain;preoperative pain

adaptive purposes of, 3ascending pathways, 12catastrophizing of, 42, 44, 49classification of, 3–4, 149–150conduction, 8cortical reception/responses, 12–14defined, 3, 109, 149, 391descending pathways, 14modulation, 10–12molecular level interactions, 102perception of, 4–5physiological pain, 3progression from acute to chronic,

109–110quality of life consequences of, 24, 27, 147,

151theories of

Gate control theory (Melzack/Wall), 4–5intensity theory (Sydenham),specificity theory (Descartes), 4of Woolf, 5

transduction, 5–7transmission, 8–10

Pain Anxiety Symptoms Scale (PASS), 43Pain Assessment in Advanced Dementia Scale

(PAINAD), 157“Pain as the 5th Vital Sign” slogan (APS),

147–148Pain Care 3000TM, 320–321 3200TM,

4200TM (spring-poweredpumps),

pain control,. See also holistic medicine;individual analgesia entries

barriers to, 164–166of healthcare providers, 165–166overcoming, 166of patients, 165

patient expectations from, 166pain-free injuries, 41Pain Indicators for Communicatively

Impaired Children, 492Pain Pump 1TM (negative-pressure pump),

321Pain Relief Scale, 649pain resource nurse (PRN) programs,

603–604Pain Standards by Joint Commission on

Accreditation of HealthcareOrganizations (JCAHO), 114, 175,601, 604, 608, 659–660, 666

Palmer, C. M., 538, 543p-aminobenzoic acid (PABA), 76papaveretum, 60para-aminophenols, 54paracetamol. See acetaminophenparascalene block (brachial plexus), pediatric

patients, 504continuous technique/dosages, 504–505dosages, 505single shot technique/dosages, 504

paravertebral nerve block, 295–296. See alsoperipheral nerve blocks

for breast cancer patients, 676perioperative, 111supplemental to interscalene block,

290parecoxib, 16, 56

for ambulatory surgery, 480analgesic effects of, 61, 350–353clinical trials in Europe, 346in epidural block, 180IV, for ambulatory surgery, 480postoperative use, 61starting preoperative dosage, 385

parenteral nutrition, 29parenteral opioid therapy, 196–197

for abdominal surgery, 583buprenorphine, 197vs. epidural morphine, 232fentanyl, 197future directions, 200–201hydromorphone, 196intravenous patient-controlled analgesia,

196ketamine,methadone, 197–199oxymorphone, 196–197and respiratory depression, 418risks of, postcesarean delivery, 545for sickle cell disease, 556vs. single dose epidural morphine, 232

parentsrelation to children’s pain, 45use of CBT during venipuncture

procedures, 46–47Parker, R. K., 34, 235–236Parkinson, S. K., 267

Pasero-McCaffery Opioid-induced SedationScale, 605

Passar, E. P., 583pathophysiology of acute pain

attenuation of pain inducedpathophysiology

cardiac surgery, 28cytokine response, 28–29persistent pain, 29–30sleep disturbances/return to

functionality, 29thoracic/upper abdominal surgery, 28thromboembolism, risk of, 28tissue breakdown/infection risk, 29vascular surgery, 28

hyperalgesia, 21–22. (See also hyperalgesia)key target organs

central nervous system, 26–27heart, 24hearth/lungs, 24–25injury site, 25–26vascular system, 25

neuroendocrine responses, 23–24in sickle cell disease, 550–551sympatho-adrenal responses, 22–23

patient-controlled analgesia (PCA). See alsointravenous patient-controlledanalgesia (IV-PCA);patient-controlled epiduralanalgesia (PCEA)

adverse events reports to MAUDEdatabase, 614

background infusion, with/without PCA,210–211

and body size of patients, 36–37devices used for, 204for emergency room use, 592and hypnosis, 47intravenous, vs. epidural analgesia, 29intravenous and cytokine response,neonatal manifestations, in breastfeeding

mothers, 545–546for opioid-dependent patients, 571opioids for

dosage requirements, 36drug combinations with, 206–207peak consumption levels, 117postoperative, 117

patient’s guide to (Royal AdelaideHospital), 215–216

by pediatric patients, 33–34pharmacists standardization of orders,

616respiratory depression from, 417for sickle cell disease, 556–557success limitations with IV-VC, 28unexpected deaths from, 425–426younger vs. older patients, 33

patient-controlled analgesia (PCA),complications, 212–215

equipment-related errors, 213nausea and vomiting/management of, 214normeperidine toxicity, 214–215operator errors, 212






Index 699

opioid-related, 213patient-related errors, 212–213pruritus/management of pruritus, 214respiratory depression, 213–214

patient-controlled analgesia (PCA),devices/systems. See intravenouspatient-controlled analgesia(IV-PCA), devices/systems

patient-controlled analgesia (PCA),safe/effective use requirements,207–212

background infusion, 210bolus dose, 209–210

duration of delivery, 210in opioid-tolerant patients, 210

dose limits, 211education

patients, 207–208staff, 208

loading dose, 209lockout interval, 210monitoring requirements, 209patient factors

comorbiditiesobstructive sleep apnea, 211renal impairment, 211–212

psychological, 211PCA prescription, 209standard orders/nursing procedure

protocols, 208–209patient-controlled epidural analgesia

(PCEA). See also intravenouspatient-controlled analgesia(IV-PCA); neuraxial analgesia,patient controlled systems;patient-controlled analgesia (PCA)

advantages of, 235with background infusion, 224fentanyl PCEA, 105, 235hydromorphone PCEA, 235–236morphine PCEA, 235for motor block, 226study of bupivacaine/fentanyl, 106University of Kentucky technique

evaluation, 235patient controlled regional analgesia

(PCREA), 251Patient Global Impression of Change Scale

(PGIC), 649patients. See also postoperative analgesia, in

outpatientsin chronic pain, growing numbers of, 166expectations from pain control, 166pain control barriers of, 165selection for ambulatory regional

anesthesia/analgesia, 287patients, opioid naive, perioperative therapy

management, 133balanced anesthesia, 133treatment of suspected OIH, 133

Patient Safety and Quality Improvement Act(2005), 666

patients consuming opioids, management of,128–133

adjuvant medications/treatmentsCOX inhibitors/paracetamol, 131epidural block, 133gabapentin, 132infiltration/wound lavage, 132NMDA receptor antagonists, 131–132peripheral nerve block, 132–133regional anesthesia, 132

intraoperative considerations, 128–130perioperative considerations, 128postoperative considerations, 130preoperative considerations, 128

patient variables (in pain management)age, 33–34anesthetic technique, 36culture or race, 34–35gender, 35gene polymorphisms, 37organ impairment/failure history,

37–38patient size/opioid pharmacokinetics,

36–37psychological factors, 35–36site/extent of surgery, 36warning patients of pain possibility, 45

Paul, J. E., 480Pautex, S., 161Pavlin, D. J., 44PCA. See patient-controlled analgesia (PCA)PCREA. See patient controlled regional

analgesia (PCREA)PDSA cycle, for quality/quality

improvement, 656–657pediatric pain management

background information, 487emergency department treatment, 590,

593local anesthetics, 496–497

adjuvantsclonidine (See clonidine, adjuvant

use with children)ketamine, 497

operative/post-traumatic pain, 488–489pharmacology, 493–496

acetaminophen, 493NSAIDs, 493–494opioids, 494–496

major, 495–496weak, 495

procedure-related pain, 487–488and use of PCA, 33–34

pediatric pain management,assessment/assessment tools,489

behavioural based scales,Children and Infants Postoperative Pain

Scale (CHIPPS), 490Children’s Hospital of Eastern Ontario

Pain Scale (CHEOPS), 164, 491Face, Legs, Activity, Cry and

Consolability (FLACC) tool, 157,492

Individualized Numeric Rating Scale(INRS), 493


objective pain scale (OPS), 492Pain Indicators for Communicatively

Impaired Children, 492Pediatric Pain Profile (PPP), 491

self-assessment, 489–490Children’s Comprehensive Pain

Questionnaire, 552Faces Pain Scale, 154, 489numeric scale, 490OUCHER scale, 163, 490Pain Descriptors, 490Poker Chip Tool (PCT), 490Varni-Thompson Pediatric Pain

Questionnaire, 552Word Graphic Rating Tool, 490

pediatric pain management, central blocks,497–502

caudal block,complications, 500continuous technique, 499contraindications, 499drugs, 499indications, 498landmarks, 498materials, 498single-shot technique, 498

epidural block, 500–502complications, 500–502continuous technique, 500–502contraindications, 499drugs, 499–502indications, 500landmarks, 500materials, 500single shot technique, 500

pediatric pain management, peripheral nerveblocks, 502–511

brachial plexus blocksaxillary block, 505parascalene block, 504

complications, 502–503contraindications, 502indications, 502lumbosacral plexus blocks

fascia iliaca block, 506–507femoral block, 505–506

materials, 503sacral plexus blocks, 507–509

ilioinguinal/iliohypogastric block, 509penile block, 509–511sciatic block

lateral approach, 507popliteal approach, 508–509subgluteal approach, 507–508

pediatric pain management, strategiesorthopedic surgery, continuous peripheral

pump vs. elastomeric pumps, 319pain management strategies

cognitive-behavioral therapy, 46–47distraction, 45–46reassurance, 46






700 Index

pediatric pain management, strategies (cont.)virtual reality, 48

pain of, relationship of parents to, 45and sickle cell pain, 551

assessments, 551–552Pediatric Pain Profile (PPP), 491Pendleton, J. M., 590penile block, in pediatric patients, 509–511PENS. See percutaneous electrical nerve

stimulation (PENS)pentazocine, avoidance of, with drug addicts,

570peptic ulcers, side effect of NSAIDs, 63–64Percocet R©, 193percutaneous electrical nerve stimulation

(PENS)(electroacupuncture), 392,397–399

historical background, 397and naloxone, 397research studies of, 398and serotonin, 397side effect reduction through, 399

periaqueductal gray (PAG) region (of CNS),12

actions of, 14and acupuncture, 395stimulation of serotonin release, 102

perineural ambulatory analgesia systemsbackground, 317–318basic considerations, 318–319clinical management/safety issues, 319commercially available non-electric

infusion deviceselastomeric pumps, 319–320negative-pressure pumps, 321spring-powered pumps, 320–321

continuous administration, in communitypractice setting, 468

cost effectiveness of, 319design theory, 318for outpatient orthopedic shoulder/foot

surgery, 481systems, 318

perioperative painaggravation of, via psychological factors,

118in elderly patients, management of, 521

ultrasound guided PNP placement, 531management considerations, 128multimodal analgesia strategy, 82, 245–246

blocking of NMDA receptor, 178COX-2 inhibitors, 333, 346–347NSAIDs, 59, 177

opioids/OIH, 122in opioid tolerant patients, management

of, 576paravertebral blockade for, 111

perioperative paravertebral block, 111peripheral kappa opioid agonists, 672peripheral nerve blocks

as adjuvant to opioid use, 132–133complications of, 280–281

cardiovascular toxicity, 281central nervous system toxicity, 281

local anesthetic toxicity, 280–281management of, 281

peripheral nerve injuries, 281–282enhancement by clonidine, 176equipment needed for performance of,

246–247increased uses of, 245local anesthesia/regional analgesia for,

180of lower limb, 266–274for orthopedic anesthesia, 180in pediatric patients (See pediatric pain

management, peripheral nerveblocks)

for postoperative analgesia in outpatients,288–296

use if indwelling nerve catheter, forextending benefits, 246

and use of LMWH, 246peripheral nerve blocks of lower limb,

ankle blocks, 295lumbar plexus blocks, 267–270, 293

fascia iliaca block, 294femoral nerve block, 270–274, 293–294ilioinguinal/iliohypogastric nerve block,

296paravertebral nerve block, 295–296psoas compartment block, 267–268

sacral plexus blocks, 274–280infragluteal sciatic nerve block, 276popliteal sciatic nerve block, 276–280sciatic nerve block, 274–276


peripheral nerve blocks of upper limb,247–248

axillary brachial plexus block, 255–259,292

distal upper extremity nerve blocks,292–293

elbow blocks, 260–262, 293infraclavicular brachial plexus blocks,

253–255, 289–290intercostal nerve block, 296interscalene nerve block, 248–251,

289–290supraclavicular brachial plexus nerve

block, 290–291wrist block, 262–266

peripheral nerve catheters, 245–246, 250,266, 436

peripheral sensitization, 5, 7, 89, 109,172–173

analgesic inhibition of, 335consequences of, 172mediation of, 15physiology of, 172–173and primary hyperalgesia, 91

persistent pain. See also chronic painallodynic/hyperpathic aspects of, 26attenuation of pain induced

pathophysiology, 29–30cognitive therapy for, 14defined, 109

developmental risk factors, 27development of, role of cytokines, 25following ambulatory surgery, 476–477following thoracotomy, 27gabapentin and, 132and genetic polymorphisms, 21from IL-1-Beta elevation, 7impact of primary/secondary analgesia,

22interventions for decreasing, 110–112ketamine and, 366–367, 370link with kinesiophobia, 43from nerve injury, 27and NMDA-mediated excitatory

neurotransmission, 89PASS assessment for, 43possible role of psychological

interventions, 42post-surgical, evidence of, 109risk factors linked to, 483role of limbic system, 12transition from acute pain, 3, 14–16,

109–111treatment crossover, with acute pain,

112use of perioperative paravertebral block,

111personnel issues, in community practice

setting, 456Pert, C. B., 670pethidine, 60, 206phantom body pains, 42Pharmaceutical Research and Manufacturers

of America (PhRMA), 647. See alsoresearch in acute pain management

pharmaceuticals, future use/development of,672

pharmacists. See also Institute for SafeMedication Practices (ISMP)

confrontations with physicians, overscheduled narcotics, 609

drug formulary management/policydevelopment

drug formularies, 609–610medication guidelines, 610therapeutic substitution programs, 610

drug selection, dosage, adverse effectsallergy identification, 613nonopioid analgesics, 612opioids, 612–614

infusion device selection considerations,610–611

intraspinal solution preparation, stability,sterility, 611–612

medication therapy management (MTM),607–608

definition, 607federal/state regulations, 607medication reconciliation, 607–608patient counseling, 607problems of, 607schedule II narcotics management,

608–609USP MEDMARX program, 608






Index 701

pain management education, 608reduction of pain medication errors,

614–615role in Acute Pain Management Services,

434–435route of administration considerations for

pain treatment, 611standard order set development, 615–617

epidural infusions, 616PCA orders, 616

pharmacodynamicsalterations of, in elderly patients, 520–521of local anesthesia, 73

pharmacokinetic drug (IV-PCA) deliverysystems, 310–311

pharmacokineticsacetaminophen, 58–59alterations of, in elderly patients, 520anthranilic acids, 57aspirin, 57coxibs, 58ketamine, 366naphthylalkanones, 57–58opioid analgesics, 310opioids, epidural, 103–105oxicams, 58propionic acids, 57pyrazolones, 57

phenacetin, 54phenothiazines, 613phenylephrine, 75, 78physicians. See also anesthesiologists;

emergency physiciansacceptance of inevitability of pain, 165compounding local anesthetics with

additives, 70confrontations with pharmacists, over

scheduled narcotics, 609influence of patient ethnicity on

prescriptions, 34–35observer scoring of patient pain, 150–151opioid prescribing patterns (1992–2001),

114and recent prominence of pain

management, 114piritramide, 106piroxicam, 58, 334

analgesic effects of, 61efficacy of, in preemptive analgesic


335–339half-life of, 58oral postoperative use of, 345sublingual, for inguinal hernia repair, 345

Pleym, O., 35Pluijms, W. A., 27POBD. See postoperative bowel dysfunction

(POBD)POI. See postoperative ileus (POI)Pomeranz, B., 397popliteal sciatic nerve block

complications, 280nerve stimulation technique, 276–277

pearls, 277, 280ultrasound guidance technique, 277–280

Portenoy, R. K., 118positive emission tomography (PET)

scanning, 12postcesarean analgesia

epidural analgesicsadjuvant therapy, 539, 542lipophilic opioids, 538–539

fentanyl, 538–539, 542hydromorphone, 539meperidine, 539sufentanil, 539

morphine, 538side effects, 539–542

intrathecal analgesics, 543adjunct therapy, 544

IV-PCA, 538, 544–545multimodal therapy, 545neonatal considerations, 545–548

posterior aspect of the anterior cingulategyrus (PAACG), 13–14

postoperative analgesia, in outpatientsankle block, 295axillary brachial plexus block, 292fascia iliaca block, 294femoral nerve block, 293–294ilioinguinal/iliohypogastric nerve block,






supraclavicular nerve block, 289–290wound infiltration for, 296–298

postoperative bowel dysfunction (POBD),583–584, 586–587. See alsocolectomy; postoperative ileus(POI)

postoperative cognitive dysfunction(POCD)/postoperative deliriumin elderly patients, 515–517,523–526

postoperative hypersensitivity state (“spinalwindup”), 172–173

postoperative ileus (POI)associated complaints, 583–584defined, 583emerging therapies for, 586–587

Postoperative Ileus Management Council,583

postoperative nausea and vomiting (PONV).See nausea and vomiting

postoperative pain. See also intravenouspatient-controlled analgesia(IV-PCA); patient-controlled

analgesia (PCA); individualanalgesics throughout the index

and alpha-2-adrenergic receptors, 85anxiety as predictor of, 42APMS management of, 435consequences of lack of relief, 172developmental factors for, 25and epidural morphine/local anesthetics,

117evidence of, 109future management of, 671–672goal (primary) for relief of, 172interventions for decreasing, 110–112and ketamine/NMDA receptor agonists, 91and NSAID use, 346and pain catastrophizing, 44in patients receiving IV/oral opioids, 29persistent, following thoracotomy, 27predictors of, 110use of paravertebral block, 111and use of PCA in children,

postsynaptic tyrosine kinase b (TrkB)receptors, 17

Powers, R. D., 556Practice Change Program (University of

Wisconsin at Madison), 604preemptive analgesia, 36, 173–175

with alpha-2 agonists, 177with alpha-2-delta ligands, 182with COX-2 inhibitors, 478–479with local anesthetics, 180–181with NMDA antagonists, 174–175, 179with NSAIDs, 178with opioids, 182

prefrontal cortex (PFC), and acupuncture,395

pregabalin. See also gabapentin andpregabalin

for ambulatory surgery, 481with celecoxib, 383linear kinetics of, 246

pre-incisional use of NSAIDS, for surgicalpain, 342–346

preoperative pain, and NSAIDs, 342–344preparation in community practice setting,

456–458interdisciplinary approach, 457–458

ancillary staff, 457nonsurgeon physicians, 457–458nurses/nursing extenders, 457public, 457surgeons, 458

preventive multimodal analgesia. See alsopreemptive analgesia

with acetaminophen/NSAIDs, 177–178with alpha-2 agonists, 176–177. (See also

clonidine; dexmedetomidine)with alpha-2-delta ligands, 182. (See also

gabapentin and pregabalin)benefits for knee surgery, 183with local anesthetics/regional anesthesia,

179–181epidural block, 180peripheral nerve block, 180






702 Index

preventive multimodal analgesia (cont.)wound infiltration, 179–180

with NMDA receptor antagonists, 179.(See also dextromethorphan;ketamine; magnesium)

with opioids (central/peripheral), 181–182prilocaine, 72

and methemoglobinemia, 78onset of action, 72

primary hyperalgesia. See also centralsensitization; opioid-inducedhyperalgesia (OIH); peripheralsensitization; secondaryhyperalgesia

described, 3–4, 6, 21and prostaglandins, 177role of NO, 16and spinal windup, 172–173

procaineadditive to epinephrine, 75lipophilicity of, 72metabolization to PABA, 76

procedural sedation and analgesia (PSA), forthe emergency department (ED),592–594

ProDalfganTM (intravenous acetaminophen),481

Prominject PCA infusion pump, 204,303

propionic acids, pharmacokinetics of, 57propofol

for ambulatory surgery, 368for emergency room use, 592–594

propoxyphene, for mild to moderate pain,612–613

PROSPECT (Europe) project, 483, 634–635prostaglandin endoperoxidase synthesis

(PEH), 54prostaglandins (PGEs)

AA conversion to, 5–6analgesic effects on CNS, 28and central sensitization, 15, 177CGRP enhancement of, 7exacerbated inflammatory responses from,

28and excitotoxicity, 15inhibition of synthesis by NSAIDs, 177mechanisms of action, 55–56, 63

analgesic effects, 56neutrophil aggregation, inhibition of,

55–56synthesis, inhibition of, 55

mediation of presynaptic/postsynapticplasticity changes, 15

physiology of, 54–55catabolism, 54–55synthesis, 54

and renal functionand blood flow, 65and NSAIDs, 65–66prostaglandin physiology, 65renin/vasopressin, interaction with, 65and tubular function, 65

and transcription dependent centralsensitization, 10

prostanoidsCNS synthesis control of, 15and GlyRa3 activation, 15importance in central sensitization, 17

protein kinase activation, and analgesictolerance to opioids, 119–120

proximal sciatic nerve block, 294–295pruritus

management of, from PCA use, 214, 306,412

nalbuphine for, 539–540naloxone for, 237, 412, 540from opioids, 133, 199, 223, 237, 332, 377,

407–408, 411, 539, 542psoas compartment block, 267–268

complications, 269pearls, 269–270peripheral nerve stimulation, 268–269ultrasound guidance, 269

pSTT (paleo neo-spinothalamic tract), 12psychological aspects of pain. See also

cognitive-behavioral therapy(CBT)

anxiety factor, 42–43and fear, 43

catastrophizing of pain, 44conceptual background, 41–42future directions, 49–50impact on pain management, 35–36social contexts, 44–45

psychological interventionscognitive-behavioral therapy (CBT),

46–47distraction, 45–46hypnosis, 47–48virtual reality, 48–49

psychological techniques for sickle-cell pain,553

psychoprophylaxis, 384Pud, D., 122pulmonary system. See also

respiration/respiratory rate;respiratory depression(opioid-induced)

postoperative pulmonary complications(PPC), 639–640

pulmonary embolism, 25, 641pulse oximetry

Alaris System PCA module, 311for monitoring

cesarean delivery, 543in emergency department, 593respiratory depression, 213, 416–417,

424with smart pump technology, 321

pyrazolones, pharmacokinetics of, 57

quality/quality improvement (QI). See alsoAcute Pain Service (APS)/AcutePain Management Service(APMS)

American Pain societyrecommendations for quality

improvement, 665studies/evaluations, 665

APMS/nurse practitioners, role of, 434clinician’s behavior, approaches for

changing, 667continuous programs for

development, 660–663implementation, 663–664maintenance, 664

Continuous Quality Improvement (CQI),311

definition, 148, 655epidural analgesia, benefits to, 29, 180femoral-sciatic nerve block, benefits to,

294GuardrailsTM software, 311historical background on initiatives, 659indicators and measures, 664–667

ambulatory settings, 666–667patient safety, 665–666

lack of clinical evidence, 133–134measurement of, in health care, 655–656methodology, 656–658

Lean methodology, 658PDSA cycle, 656–657Six Sigma process, 657–658

NSAIDs, for improved quality of recovery,311

Patient Safety and Quality ImprovementAct (2005), 666

perioperative treatments, long-termconsequences, 82

quality management (QM), 434Quality Management Template (ASA),

474and validity issues

Agency for Health Care Research andQuality, 176

in evidence-based medicine, 632for nurses, as clinical coordinators, 603

QUOROM (Quality Of Reporting OfMeta-analysis) statement, 632

Raimer, C., 268Ramsay score (RS), sedation scale, 425randomized controlled trials (RCTs)

cardiovascular morbidity, 639coagulation-related morbidity, 642CORTRA meta-analysis (neuraxial

anesthesia vs. general anesthesia),637–638

and evidence-based medicine, 631gastrointestinal morbidity, 641as “gold standard” of clinical trials, 651Multicentre Australian Study of Epidural

Anesthesia, 638on postoperative analgesia, 637on preemptive analgesia, 174–175on static magnetic therapy, 400Veterans Affairs Cooperative Studies

Program, 638Rapp, S. E., 117Rawal, N., 296–297, 538Ready, L. B., 232, 417, 543“Recommendations for Improving the

Quality of Acute and Cancer PainManagement” (APS), 665






Index 703

regional analgesiaadministration options, 440economic considerations, 440epidural/continuous, for sleep

disturbances, 29and improved perioperative outcomes,

531interference with start of surgery, 438and local anesthetics, 179–181with local anesthetics

for epidural block, 180for peripheral nerve block, 180for would infiltration, 179–180

vs. opioid-based analgesia, 521–523patient controlled regional analgesia

(PCREA), 251for postoperative pain, 575use of COX-2 inhibitors/NSAIDs, 29

regional anesthesia. See also axillary brachialplexus block; elbow blocks;infraclavicular brachial plexusblocks; interscalene nerve block;lumbar plexus blocks; multimodalanalgesia; peripheral nerve blocksof upper limb; postoperativeanalgesia, in outpatients; sacralplexus blocks; supraclavicularnerve block; wrist block

as adjuvant to opioid therapy, 132for cesarean delivery, 537chloroprocaine for, 72clonidine for, 75, 85, 176continuous, suppression of

sympatho-adrenal responses, 28deafferentation by, prior to surgery, 36decreased wake-up times with, 438as fastest growing subspecialty, 437vs. general anesthesia, 245and inhalational anesthesia, 174, 179integration into acute pain management,

436intraoperative considerations, 129local anesthesia/anesthetics with

for epidural blocks, 180for peripheral nerve blocks, 180for wound infiltration, 179–180

logistics/equipment needed forperformance of, 246–247

non-specific binding by nearbymembranes/tissues, 73

for patients on chronic opioid therapy, 132perioperative, and reduction of regional

pain syndrome, 134with postoperative COX-2 inhibitor, 183for postoperative pain, in

opioid-dependent patients, 575for sickle cell disease, 557single-injectional, 180ultrasound revolutionizing of, 440

regional cerebral blood flow (rCBF), 12remifentanil (mu-opioid agonist), 38, 116,

122, 368–369for abdominal surgery, 122for IV-PCA use, 206for PCA/IV-PCA use, 305

tolerance to, 117use, for ambulatory surgery, 368

renal functioneffects of NSAIDs vs. COX-2 inhibitors,

356side effects of NSAIDS, 65–66

prostaglandin physiology, 65renal blood and prostaglandins, 65renal tubular function and

prostaglandins, 65renin/vasopressin, interaction with, 65renin/vasopressin/interaction with, 65and tubular function, 65

research in acute pain managementbelievability of results, 651–653clinical trials

appropriate conduction determination,647

author establishment oftestability/clinical relevance, 647

Bonferroni Correction, 653Kaplan-Meier survival curves, 653Kruskal-Wallis one-way analysis of

variance, 653One-Way Analysis of Variance, 653primary efficacy variable definition,

647–651pain measurement, 649significant pain reduction, 649summary measures, 650–651

purpose of, 646–647Spearman’s Rank Correlation, 653Type I errors, 652Type II errors, 652–653Wilcoxon Signed Rank test, 653

study design influence on interpretation,651

“resistance stage” (sympatho-adrenalresponse), 22

respiration/respiratory rateanatomy/physiology of, 418–419fentanyl’s influence on, 192hydromorphone’s influence on, 232increase of, as response to pain, 25naloxone’s influence on, 236role in monitoring respiratory depression,

162–164, 209, 417respiratory depression (opioid-induced)

definition/incidence (in perioperativeperiod), 416, 418

effects of opioids, 332, 406–407measurement of, 420–421mechanisms of, 419–420monitoring, 422–424

capnography, 424guidelines, Acute Pain Services, 417by pharmacists, 613pulse oximetry, 424respiratory rate, 424

prediction of in postoperative setting,425–426

risk factorsepidural analgesia, 226, 236neuraxial opioid administration, 236,

407

parenteral opioids, 418PCA, 213–214, 417

sedation as early indicator, 411, 416–417sedation scores, role of,and sleep disturbances, influence on,

421–422treatment of, 241–242

DPI-125, 412DPI-3290, 412nalbuphine, 407naloxone, 236, 242, 407, 613naltrexone, 407

Reuben, S. S., 383, 478, 481, 676Richman, J. M., 289Riker Sedation-Agitation Scale, 162risk factors

of epidural analgesiacatheter problems, 224–226dural puncture, 225epidural hematoma, 225–226hypotension, 226infection, 226motor block, 226respiratory depression, 226, 417

of IV-PCA therapy, 306linked to development of persistent pain,

483for persistent pain development, 27

Robertson, K., 538Rodgers, A., 245Roe, B. B., 670rofecoxib, 53, 235. See also celecoxib

for abdominal surgery, 350affinity for COX-1, 58for colectomy, 585–586with dexamethasone, 382gastrointestinal (GI) outcome research

study (VIGOR), 355removal from market, 63, 235, 346,

480side effects of, 65in surgical pain, 347–350vs. valdecoxib, 353VIGOR research study, 355

Rogers, M. L., 110Roland Disability Questionnaire, 44Romberg, R., 37Romundstad, L., 379, 381ropivacaine, 72

as adjuvant, for postcesarean analgesia,539

for brachial plexus blocks, 73, 112combinations with

fentanyl infusion, 233morphine, 234, 315

continuous infusions, 233with fentanyl, 233with morphine, 234

epidural administration of, 224onset of action, 72selectivity for sensory fibers, 74use of, for motor block, 226

Rosen, M. A., 539Rosenberg, J., 422Ross, R., 539






704 Index

Rossbach, M., 121Royal College of Anesthesiologists, 634

Saarela, M. V., 45Sachar, E. J., 302, 670sacral plexus blocks, 274–280

infragluteal sciatic nerve block, 276popliteal sciatic nerve block, 276–280sciatic nerve block, 274–276

distal, in popliteal fossa, 295pediatric patients, 507–509proximal, 294–295

safety issuesAnesthesia Patient Safety Foundation

(APSF), 213COX-2 (cyclo-oxygenase-2) inhibitors, 355epidural opioids, 239hydromorphone, 239for IV-PCA therapy, 306–308

accidental purging protection, 306–307bar-code readers, 307computer-based pump programming,

307–308error-reduction features, 307overmedication, 306respiratory depression, 306

JCAHO goals, 608neonatal considerations/acetaminophen,

58neuraxial analgesia, patient controlled

systems, 317perineural ambulatory analgesia systems,

319salicylates

historical background, 53inhibition of prostaglandin synthesis, 591side effects, 57

Samad, T. A., 16Sanchez, B., 297Sandler, A., 105Sartain, J.B., 207schedule II narcotics management, by

pharmacists, 608–609Schug, S. A., 425sciatic nerve block, 274–276

distal, in popliteal fossa, 295pediatric patients, 507–509proximal, 294–295single-injections/techniques, 298

Scimeca, M. M., 566SCN9 gene mutation, 674scopolamine patch (transdermal), for

nausea/vomiting, 237, 410, 613Scott, D. A., 105Scott, J. S., 670Sechzar, P. H., 670Sechzer, Phillip, 302secondary hyperalgesia, 3–4, 102. See also

central sensitization;opioid-induced hyperalgesia(OIH); peripheral sensitization;primary hyperalgesia

defined/described, 4, 21–22, 370gabapentin and pregabalin for, 480

and peripheral/central sensitization,172–173, 370

and prostaglandins, 177role of nitric oxide, 16role of NO, 16and spinal windup, 172–173underlying spinal mechanisms, 91Woolf on, 5

secondary somatosensory cortex (SII),Sedlacek, K., 554Seib, R. K., 480selective serotonin reuptake inhibitors

(SSRIs), 17self-hypnosis, 47sentinel node biopsy, 111serotonin

acupuncture’s influence on, 395PENS/TENS, 397

agonists of, for pruritus treatment, 412ketamine (systemic) effect on, 91meperidine’s effect on, 195for nausea/vomiting, 410, 613and OIH, 124release of, stimulated by PAG/RVM, 102role in pain, 14sensitization of nociceptors, 21tramadol’s inhibition of uptake of, 306,

495, 555, 591–592Seventh American College of Chest

Physicians Consensus Conference,246

sevoflurane, for ambulatory surgery, 368Seyhan, T. O., 384Shapiro, B., 552, 557Shaw, I., 422Short-Form McGill Pain Questionnaire

(SF-MPQ), 157Sia, S., 255sickle cell disease

background/description, 550in children, 551

assessments, 551–552chronic pain in, 557medical management of, 552–553, 558

antibiotics, 553blood transfusions, 552–553oxygen, 552sickling inhibition compounds, 553

nonpharmacologic approaches, 553–554cognitive-behavioral techniques,

553–554educational/psychological techniques,

553hypnotherapy/biofeedback, 554medical report passport system, 554TENS/physical therapy, 554

pain assessment for, 551–552ethnicity of patients/providers, 552general considerations, 551–552sickle-cell specific considerations, 552

pathophysiology of, 550–551pharmacologic approaches, 554–557

adjuvants, 557nonopioid analgesics, 554–555

NSAIDs, 554, 558opioids, 555–556patient controlled analgesia, 556–557regional techniques, 557

treatment barriers, 557–558Sidebotham, D., 425side effects

of aspirin, 57, 63, 66aspirin-sensitive asthma, 66hepatoxicity, 66peptic ulcers, 63

of benzocaine, 78of cannabinoids, 384of codeine, 195of epidural opioids, 236–237

liposomal morphine, 223for postcesarean analgesia, 539–542

fentanyl, 194, 391, 409, 571of fentanyl, 194, 391of glucocorticoids, 382of hydromorphone, 194of interscalene nerve block, 290of ketamine, 366of local anesthetics, 76–78of meperidine, 195of methadone, 194–195of morphine, 193, 391of neostigmine, 384of NSAIDS, 62–66

cardiovascular system, 63gastrointestinal system, 63–64platelet clotting function, 64–65renal function, 65–66

of opioids/opioid-related adverse events,199–200, 377, 391, 406

cardiovascular, 406dermatological, 411–412gastrointestinal, 407–408genitourinary, 411nausea/vomiting, 408–411neurological, 411respiratory, 406–407

reduction of, as concern for future, 672salicylates, 57

Sinatra, R. S., 481, 576Singelyn, F. J., 297single (S-) enantiomers, 72single-injections/techniques

anesthesiologists and, 132–133of clonidine, 87dosages of long acting medications, 439,

467intrathecal administration of single

boluses of opioids, 230–233of ketamine, 366, 369of morphine

epidural, extended-release, 106with liposomes, 223

of peripheral nerve blocksaxillary brachial plexus, 292femoral nerve block, 294, 297, 467interscalene block, 290lower limb, 266lumbar plexus, 268






Index 705

for postoperative pain, 288sciatic nerve block, 298upper limb, 247

of regional anesthesia, 180single-voxel proton magnetic resonance

spectroscopy (H-MRS), 14Six Sigma process, for quality/quality

improvement, 657–658Sjostrom, S., 233–234S(+)ketamine, 91–92Slappendal, R., 342–344sleep disturbances, 27. See also American

Academy of Sleep Medicine TaskForce

apnea, defined, 422attenuation of pain induced

pathophysiology, 29improvements from epidural analgesia, 29obstructive sleep apnea (OSA)

from opioid use, 377, 421use of OCA without background

infusion, 211from opioid use, 377, 411and respiratory depression, 421–422

Smith Medical CADD-Prizm PCS IITM

(ambulatory pump), 313–314, 317social contexts of pain, 44–45

facial expressions of others in pain, 44–45parental relation to children’s pain, 45warning patients of pain, impact of, 45

Society of Critical Care Medicine (SCCM),162

Society of Obstetric Anesthesia andPerinatology (SOAP), 537

somatic nociceptive pain, 3Sparks, L., 45–46specificity theory (Descartes), 4SPID. See summed pain intensity difference

(SPID)spinal windup (postoperative

hypersensitivity state), 172–173spinothalamic tract (STT), 12spring-powered pumps (non-electric

infusion devices), 320–321Stadol R©, 195Stevens, R. D., 268Stone, Edward, 53stressors (psychological)

descending inhibition by, 14role in pain experience, 42. (See also

neuromatrix theory of pain)structures of local anesthetics, 72Strulov, L., 44subjective sedation-assessment scales, 162Suboxone R© (sublingual buprenorphine), 566substance abuse (by patients), impact on

pain management, 37Substance Abuse and Mental Health Services

Administration (SAMHSA), 391Substance-P (sP), 6substance use disorder (SUD), 564, 568

basic aspectscriteria/definitions, 567opioid tolerance, 567

patient assessment issues, 567–570physical dependence, 567

patient managementgoals/strategies, 570–571opioid medications, 571–572

perioperative managementdose tapering, 575–576intraoperative period, 574postoperative period, 574–575

neuraxial analgesia, 575regional analgesia, 575

preoperative period, 574Subutex R© (sublingual buprenorphine), 566sufentanil

for ambulatory surgery, 574clinical trials, 106description, 195–196diffusion into epidural fat, 222efficacy at mu receptors, 190elderly sensitivity to, 521epidural administration, 223, 370impact on OIH, 133lipophilicity of, 106, 133, 409, 539for PCA/IV-PCA use, 304–305for postcesarean delivery, 539

intrathecal administration, 543and preoperative methadone, 133

Sumerians, cultivation of opioids, 114summed pain intensity difference (SPID),

650superoxide dismutase (SOD)

description, 16and excitotoxicity, 15

superoxides (SO)mediation of central sensitization, 16and NMDA receptor activation, 16

supraclavicular nerve block, 251–253,290–291

block techniquesnerve stimulation technique, 251–252ultrasound guided technique, 252–253

complications of, 253postoperative analgesia in outpatients,

289–290Sweitzer, S. M., 124Swenson, J. D., 571Swinkels-Meewisse, I.E.J., 43sympathetic nervous system

alpha/beta receptor mediation of, 82morphine’s influence on, 406post surgical hypertension and, 514stimulation of, effect on gastrointestinal

tract, 584tonic inhibitory control of inflammation,

89sympatho-adrenal system

pathophysiological pain response, 22–23accelerated coagulation, 23diminished microcirculatory blood, 23increased peripheral vascular resistance,

23increased post-surgical hypertension, 23renal hypoperfusion, 23

synthesis of prostaglandins (PGEs), 54

Tampa Scale of Kinesiophobia, 43Tamsen, P., 36Task Force on Acute Pain Management

(American Society ofAnesthesiologists)

advocacy for multimodal analgesia, 176,478

Taylor, S., 421temporomandibular disorders (TMD), 44tenoxicam

for abdominal surgery, 346analgesic effects of, 61efficacy of, in preemptive analgesic

therapy, 344half-life of, 58intravenous, for cesarean section, 346peak synovial fluid concentrations, 62postoperative use, 345–346

TENS. See transcutaneous electrical nervestimulation (TENS)

Teoh, W. H., 234Teschemacher, H., 222tetracaine

for elective hip/knee arthroplasty, 232intrathecal administration, 234lipophilicity of, 72onset of action, 72pKa properties, 72prolongation of use via intrathecal

clonidine, 75tetrodotoxin (from Japanese Puffer fish), 383THC. See 9-tetrahydrocannabinol (THC)theories of pain

Gate control theory (Melzack/Wall), 4–5intensity theory (Sydenham),specificity theory (Descartes), 4of Woolf, 5

therapeutic touch (TT)/massage therapy,400–401, 488, 571

historic background, 400osteopathic manipulation (OMT), 401

thermal hyperalgesia, 3–4, 6–7Thomas, J. S., 43Thomas Jefferson University Hospital, 616thoracotomies, 23, 25, 36, 370

clinical trials/epidural analgesia, 111functional epidural catheter use, 241hydromorphone for, 237intrathecal morphine use, 232meperidine by PCA, 36osteopathic like practices, 401and pain

chronic, 109, 111, 370, 642, 675chronic persistent, 134persistent, 27

types of incisions, 1113 step analgesic ladder for cancer pain

(WHO), 147tizanidine, 383Tobias, J. D., 117Todd, K. H., 160“To Err is Human” study (Institute of

Medicine), 655Torgeson, W. S., 156






706 Index

Torrie, J. J., 425total hip arthroplasty (THA)

benefit of lumbar plexus block for, 268clonidine/local anesthetic for, 176EREM for, 328intramuscular morphine for, 197IV PCA/iontophoretic fentanyl for, 206rectal indomethacin for, 346

total knee arthroplasty (TKA)benefit of lumbar plexus block for, 267femoral/sciatic nerve block, 271, 455, 467intrathecal clonidine/morphine for, 176ketamine, low dose, 179multimodal analgesia, 459valdecoxib/morphine for, 353

TOTPAR (time-weighted resultantsummation value), 650. See alsoresearch in acute pain management

tramadol. See also Ultracet R©

for children, 494combined with acetaminophen, 198–199,

591–592description, 195inhibition of uptake of serotonin, 306for IV-PCA use, 206, 305–306postoperative use, 346for sickle cell disease, 555

tranquilizer abuse, 565transcutaneous electrical nerve stimulation

(TENS), 384–385, 392, 397–399for ambulatory surgery, 482–483historical background, 397mu receptor mediation of, 397and naloxone, 397research studies of, 398and serotonin, 397for sickle-cell disease, 554side effect reduction through, 399

transdermal therapeutic systems (TTS),323–325

alternatives to, 325–329extended release epidural morphine

(EREM), 327–329fentanyl iontophoretic transdermal

system, 326–327iontophoresis, 326–327lidocaine iontophoresis, 327

clonidine patches, 324diclofenac epolamine patch, 324–325fentanyl patches, 324

design modifications, 325IONSYSTM (fentanyl iontophoretic

transdermal system), 197, 206,326–327

lidocaine patches, 324mechanisms of action, 323scopolamine patch, 237, 410, 613

transient receptor potential V1 (TRPV1),672

Treiber, H., 230Tryon, W. W., 554tumor necrosis factor (TNF-alpha)

and allodynia, 25post-surgical increase, 28

Turner, J. A., 44Ty, T. C., 41

Ulrich, R. S., 50Ultracet R©, 198ultrasound guidance

axillary brachial plexus block, 258–259elbow blocks, 262femoral nerve block, 271–273infraclavicular brachial plexus blocks, 254interscalene nerve block, 250–251popliteal sciatic nerve block, 277–280psoas compartment block, 268–269wrist block, 266

Umrey, W. F., 249underreporting of/undertreatment for pain,

160, 165University of Kentucky, PCEA technique

evaluation, 235University of Wisconsin at Madison Practice

Change Program, 604urology surgery, 36urticaria, from opioid histamine release, 411Usichenko, T. I., 396USP MEDMARX program, 608, 614

valdecoxib, 54, 334. See also parecoxibanalgesic effects of, 61, 350–353with parecoxib, for laparoscopic

cholecystectomy, 353, 480removal from market, 346, 355, 480side effects of, 355

Vandermeulen, E., 246Vane, John, 55vanilloids, 672Varni-Thompson Pediatric Pain

Questionnaire, 552vascular system, pathophysiological pain

response, 25vasoconstrictors, as additive to local

anesthetics, 75vasodilators, properties of, 76verapamil (calcium channel blocker), 221,

224Vera-Portocarrero, L. P., 124Verbal Descriptor Scale (VDS), 151Verbal Rating Scale, 649Veterans Hospital Administration, 5th Vital

Sign strategy implementation, 148Villa, H., 476Virchow’s triad (hypercoagulability, venous

stasis, endothelial injury), 25virtual reality (management strategy), 48–49visceral nociceptive pain, 3Viscusi, E. R., 311Visual Analog Scale (VAS), 151, 153, 162,

649Von Dossow, V., 89

Wachta, M., 481Walch, J. M., 50Walco, G. A., 551Walder, B., 207, 305Wall, P. D., 4–5, 41, 109, 174, 394

Wallerian degeneration, 4Wang, H., 16Weinberg, R. J., 16White, P. F., 235–236, 295white patients, 34Williams, B. A., 270, 294Williams, S. R., 253willow tree (Salix alba), 53. See also

salicylatesWilson, J. E., 590“windup” transcription process, 6

onset/reversibility of, 15Winnie, Alon, 248, 251, 267–269Wong-Baker FACES Rating Scale, 154Woodhouse, A., 206, 210Woolf, C. J., 5, 9–10World Health Organization (WHO)

acetaminophen recommendations, 356approval of acupuncture, 393, 395on decision-making about opioids, 631endorsement of evidence-based medicine,

6303 step analgesic ladder for cancer pain,

147, 391would infiltration

ketamine enhancement of bupivacaine,91

by local anesthetic, 174–175with ketamine, 179with regional analgesia, 179–180

for postoperative analgesia in outpatients,296–298

wrist block, 262–266block techniques

blind, 264–265peripheral nerve stimulation, 265ultrasound guidance, 266

complications of, 266wrist anatomy, 264

Yale Medical School, 166Yale-New Haven Hospital

celecoxib dosing guidelines, 4804-step analgesic ladder, 147intrathecal morphine administration,

230with bupivacaine, 234

regional anesthesia for cesarean delivery,537

use of continuous epidural infusions/PCA,237

Yale Pain Management Service, 199epidural PCA orders/patient management

guidelines, 240–242management of Epi-PCA, 241treatment of respiratory depression (and

other adverse effects), 241–242Yaster, M., 557Youngstrom, M., 538Yuan, C. S., 408

Zayfert, C., 43Zeltzer, L., 554Zubieta, J. K., 14






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Index [assets.cambridge.org]assets.cambridge.org/97805218/74915/index/9780521874915... · 2009-05-19 · Index 681 patient-controlled epidural analgesia (PCEA) 3 step analgesic ladder