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Regional Anesthesia and Pain Management There are numerous regional blocks that may be performed to reduce nociception during and after surgery 80 mg tadapox free shipping erectile dysfunction viagra doesn't work. Three common neuroaxial blocks performed in children today are caudal tadapox 80mg without a prescription impotence with antihypertensives, epidural, and spinal blocks and these are described later. There has been a shift from neuroaxial to peripheral nerve blocks, both single-dose and continuous local anesthetic administration for perioperative pain management facilitated by the introduction of ultrasound guidance. Morbidity and mortality associated with regional anesthesia in children is exceedingly small and is not considered a substantive argument against its routine use in skilled hands. Caudal Blockade This block is useful for both lower abdominal and lower extremity surgeries in infants and children (<5 to 6 years) who are undergoing ambulatory surgery. It is usually performed under general anesthesia although in neonates, awake caudal and spinal blocks have been performed using local anesthetic infiltration and/or sedation. Single-shot caudal blocks with local anesthetic alone are commonly performed in ambulatory surgery. These blocks may last 4 to 6 hours, but if adjuvant medications are added, they may last even longer. After induction of anesthesia and once that airway is secured, the child is turned onto the lateral decubitus (the side is determined by the anesthesiologist; left-handed anesthesiologists generally prefer the right lateral decubitus position for the child), and the key anatomic sites on the sacrum are palpated: posterior superior iliac spines and the sacral hiatus subtended by the two sacral cornua (see also Chapter 42, Caudal Block section). The sacrococcygeal ligament traverses the space between the two cornua and the coccyx. The skin is then prepared with antiseptic solution and allowed to dry while local anesthetic is prepared. Once the sacrococcygeal ligament has been pierced, the cannula is laid almost flat against the skin (forming a 10-degree angle of the skin) and advanced 2 to 3 mm through the ligament. If any resistance is felt as the catheter is inserted, it is not within the caudal space and the entire cannula 3110 should be removed and the process repeated. If you are not certain the catheter is in the caudal canal, hold your thumb over the sacral hiatus and inject no more than 0. If resistance or a bulge is felt, desist from injecting fluid; subcutaneous fluid will obscure the anatomy and preclude a successful caudal block. If the catheter is properly positioned, then remove the needle and examine for blood or cerebrospinal fluid leaking out the catheter. Connect the syringe with local anesthetic and inject slowly 2 to 3 mL every 2 minutes, while observing the electrocardiogram. This concentration permits excellent analgesic with motor blockade that resolves within 1 hour of placement. Adjunctive medications have been used to prolong the duration of the caudal block for several hours at best. The catheter is inserted exactly as described above for caudal blocks and the catheter threaded to the spinal level necessary for perioperative analgesia. The catheter should be taped away from the anus or, alternately, tunneled under the skin to the side opposite the surgery. Catheters that are smaller than 21 ga may not thread to the desired dermatome level. Alternative strategies that may be used to achieve the desired level of block include the Tsui approach289 and inserting the catheter at an intervertebral space closer to the level of surgery. To reduce absorption of local anesthetic, epinephrine is routinely added to the 3111 bupivacaine. Fentanyl (1 to 2 μg/mL) is often added to the caudal/epidural solution, although there is no evidence that this improves the quality of the block in children provided the tip of the catheter is properly positioned, 0. In the case of levobupivacaine, a large study demonstrated no demonstrable benefit from the addition of fentanyl to epidural levobupivacaine in concentrations as small as 0. The most effective treatment for ventricular arrhythmias from local anesthetics is 1. Side effects of the block include nausea, vomiting, pruritus, urinary retention if opioids were included, and excessive motor blockade or twitching from local anesthetics. Local infection, fluid leakage, and bleeding at the catheter site are important to recognize and treat as indicated. These superficial infections do not migrate internally causing epidural abscesses; rather abscesses are due to a bacteremia. Epidural Block Epidural anesthesia is performed in the same manner as in adults except that a shorter 5-cm Tuohy 18G needle is more manageable. The distances from the skin to the dura in infants and children, for example, are much smaller as are the doses. Emergence and Recovery from Anesthesia As surgery concludes, recovery of neuromuscular function should be assured by monitoring the twitch response and antagonizing the blockade, and the child should be normothermic before contemplating removing the tracheal tube. Equipment including active suction, a face mask, and a source of oxygen should be immediately available to manage the airway and any complications that may ensue. The trachea may be extubated when the child is either fully awake or deeply anesthetized. Evidence suggests that the advantages and disadvantages of the two techniques are similar, notwithstanding confounding effects by comorbidities and concomitant drugs. For an awake extubation, the practitioner can follow one of two strategies: either the no-touch technique or direct stimulation. With the no touch technique, emergence from inhalational anesthesia follows three distinct phases: early, middle, and late. The early phase may last for several minutes depending on the anesthetic drugs present and the age of the child. During this phase, the child coughs intermittently, gags, struggles, and moves nonpurposefully. This phase passes relatively quickly as the child continues to emerge from anesthesia. During the second or quiescent phase, the child remains generally unresponsive, becoming apneic, agitated, or even breath-holding, straining, and/or desaturating. Desaturation should be treated immediately with continuous positive pressure airway pressure by dialing the adjustable pressure relief valve close until the SaO is more than 95%. As the child enters the third and2 final phase of emergence, respiration resumes at a regular rate, purposeful movement begins and the child flexes the hips. As these intensify, the child begins to cough and gag on the tracheal tube, and then grimaces and opens his/her eyes spontaneously. Removing the tracheal tube during either the early or middle phase markedly increases the risk of triggering an adverse airway event (e. It is only once the child is in this third phase of emergence that the practitioners should consider extubating the trachea. Leave the tube in situ for another minute (or two) until the child is definitely in the late or third phase of emergence. Complications do not occur from leaving a tube in for an extra minute, they only occur when the tube is removed prematurely. As the inhaled concentration decreases below these values, the child opens his/her eyes spontaneously and reaches for the tracheal tube, gags, and grimaces, all of which are consistent with a successful extubation. In contrast, with the direct stimulating technique, the anesthetic concentration decreases toward the same concentrations (sevoflurane <0. The child becomes highly aroused and gags on the tracheal98 tube for several seconds, but then falls back to a semiconscious state when the stimulation abates.

Labial inclination of implants and/or buccal implant prosthesis has been strongly correlated with an ade- placement contributes to a thin tissue biotype; this may quate soft tissue thickness around the implant order tadapox with a visa zinc causes erectile dysfunction, a thick peri- result in the grey shade of the implant structure showing 11 buy tadapox 80 mg online erectile dysfunction pills south africa,12 implant biotype. When a thin biotype is diagnosed, a through the tissue, recession, and exposure of the titanium subepithelial connective tissue graft can be used to prevent implant neck, for an inharmonious emergence profle of the potential long-term recession of the facial mucosa implant-supported restoration. Te level of clinical attachment on adjacent teeth to ated with soft tissue color mismatch to a level below clinical 23 support papillary height perception. Te thickness of the coronal soft tissue margin to ensure a proper emergence profle 3. Te thickness of labial soft tissue to simulate root emi- Limitations and Contraindications nence and prevent transillumination of underlying metallic structure General and specifc limitations apply to the use of this 4. Te position of the mucogingival junction and amount soft tissue augmentation technique around dental implants. Medical conditions associated with collagen disorders, such as erosive lichen planus, or pemphigoid may pose a risk to Connective Tissue Grafting During Implant the viability of autogenous connective tissue grafts placed on Surgery a recipient bed that exhibits a pathologic healing mechanism. A thorough, three-dimensional (3D) preoperative evaluation Tere is no published evidence to support the use of this of the edentulous site is critical to properly plan an implant technique in such cases. Two A key determinant in the success of this technique is diagnostic variables that should be taken into account preop- revascularization of the graft. Te preoperative assessment revealed a concave labial profle of the edentulous sites due to an inadequate amount of hard and soft tissues. Te preoperative prosthesis used ridge-lap pontics that rested on ridge concavi- ties at the edentulous sites. Autogenous block grafts were used for horizontal hard tissue ridge augmentation to establish the ideal three-dimensional placement of the implants. Two separate con- nective tissue grafting interventions were required to achieve an esthetically pleasing outcome. Note the contours of the coronal facial mucosa, the natural emergence profle of the restorations, and the illusion of a root prominence. Te patient was very satisfed with the pink gingival esthetics and sought tooth whitening for additional esthetic enhancement. Nicotine-associated vaso- procedure in a smoker, bearing in mind that proper patient constriction, in combination with lack of adherence of the selection is imperative to achieving the desired treatment fbroblasts24 and an alteration in immune response, 25,26 outcome. Preoperative interruption of the smoking habit, diminishes the chance for a successful outcome. Preoperative followed by a smoke-free period during the critical stages of assessment should attempt to identify such patients, and the initial revascularization, and adjunctive measures (e. Local have the patient frst participate in a smoking cessation factors that may also limit patient selection include lack of program and then return later for surgery. However, in clini- adequate tissue thickness at the palatal donor site and cal reality, this is not always an option. Te surgeon must restricted surgical access to intraoral donor sites, such as the make the fnal decision on whether to proceed with a delicate posterior aspect of the hard palate or tuberosity. Preoperative identifcation of potential soft and/ tissue augmentation alone will be adequate to develop the desired or hard tissue defciencies allows for construction of an implant treatment outcome or whether bone augmentation also is needed restoration that closely mimics the natural dentogingival complex to achieve ideal implant positioning and soft tissue esthetics. The treatment alternatives for bone augmenta- hard tissue should be evaluated radiographically. The 3D position- tion of ridge defects are discussed in a later chapter (see Chapter ing of the implant should allow the fxture to be surrounded by at 20, Site Preservation and Ridge Augmentation) (Figure 27-3, A). When planning treatment Continued Bilateral ridge concavities A2 A1 A4 Bone reconstruction alone is not sufficient in A3 yielding an ideal esthetic outcome Figure 27-3 A1, Indents in the soft tissue profle at the sites of the congenital missing maxillary lateral incisors. A4, Four-month postoperative photograph with fxation screws showing through the thin mucosal fap. Various modes of 1 : 100,000 epinephrine is administered as a regional block and conscious sedation can be used, such as oral sedation with a followed by local infltrations for hemostasis. For effciency, the benzodiazepine, inhalation of nitrous oxide, or intravenous seda- anesthetic is frst administered to the graft donor site, so that tion, depending on the patient’s level of anxiety and the surgeon’s hemostasis can be verifed, to enhance visualization of the graft preference. Patients should be instructed to rinse preoperatively during procurement; the recipient site then is anesthetized. The quality of the tissue harvested from the tuberosity harvest for obtaining connective tissue grafts are the: and superfcial palate is superior to that of the tissue obtained • Tuberosity harvest27 from the deep palatal site because the former are predominantly 28 composed of dense connective tissue with little adipose tissue. This broad piece of tuberosity can be longitudinally sec- tuberosity or the palate. The tuberosity generally provides enough tioned to increase the amount of donor tissue available for graft- tissue to cover a single implant site or a two-implant site; ing (Figure 27-3, B). B2, Histologic microphotograph of a full- thickness tissue graft harvested from the tuberosity of the same patient. On the distal aspect of the tuberosity, a single, crestal, beveled Tissue forceps and the suction tip should be used delicately during incision is made from the mucogingival junction to the distal-facial procurement of the graft to minimize trauma to the donor tissue line angle of the most distal tooth. The incision is located on the and to make sure the graft is not lost down the suction, respec- buccal aspect of the ridge crest, rather than midcrestal, and is tively. Use of an Orban knife enhances the access for prevent dehydration while the recipient bed is prepared. At this point, the palatal fap is raised until site fap is sutured closed at this time, preferably with 4-0 chromic the distal-palatal surface of the most distal tooth is exposed. The procured graft is kept in saline-soaked gauze squares incision will not involve a periodontal pocket of a palatal root; this until used. The palatal fap can be closed with either single inter- prevents postoperative recession. A single full-thickness horizon- rupted sutures or sling sutures around the maxillary teeth or as a tal incision is made at a right angle to the alveolar bone, within combination of the two types of sutures (Figure 27-3, D). This incision extends from the of the palate to minimize the risk of hemorrhage associated with mesial aspect of the palatal root of the maxillary frst molar as far traumatization of the major palatine artery during harvesting of anteriorly as needed, depending on the amount of donor tissue the graft. The rationale for using this via a partial-thickness incision; the periosteum is left intact. A technique is that sounding of the palate reveals a limited amount second anterior/posterior horizontal partial-thickness incision is of connective tissue beneath the palatal mucosa. In contrast to traced parallel to the frst incision at a position closer to the the tuberosity area, where connective tissue occupies the whole midline. The two connective tissue exists between the coronal epithelium and horizontal incisions are connected via anterior and posterior verti- apical adipose tissue (see Figure 27-3, B). Use of the deep palatal cal partial-thickness incisions on the mesial and distal aspects of harvest technique (as in Step 4B) is often contraindicated in the graft. Either a sharpened gingivectomy knife or a #15C blade patients with thin palatal mucosa since it may not yield an ade- is used to separate the graft from the underlying tissue, for an quate volume and thickness of connective tissue following the ideal thickness of 1. D3, An approximately 2-cm-long piece of connective tissue was harvested from the palatal donor site for transplantation into a site exhibiting a soft tissue defciency.

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In the lower leg and foot buy 80 mg tadapox amex erectile dysfunction over the counter medications, it gives off muscular order tadapox 80mg line zyrtec causes erectile dysfunction, articular (ankle), and cutaneous branches and terminates as the medial and lateral plantar nerves. Terminal Nerves of the Lumbar Plexus Genitofemoral Nerve (L1, L2) This nerve leaves the lumbar plexus at the lower border of the L3 vertebra. It pierces and then lies anterior to the psoas major muscle before descending subperitoneally and behind the ureter, where it divides into two branches (genital and femoral) at a variable distance above the inguinal ligament. The genital branch crosses the external iliac artery and traverses the inguinal canal. It supplies the cremaster muscle and skin over the scrotum and adjacent thigh (males) or the skin over anterior part of labium majus and mons pubis (females). The femoral branch descends lateral to the external iliac artery, passes under the inguinal ligament, enters the femoral sheath lateral to the femoral artery, and pierces the anterior layer of the femoral sheath and fascia lata. It innervates the skin immediately below the crease of the groin anterior to the upper part of the femoral triangle. Lateral Cutaneous Nerve of Thigh (aka, Lateral Femoral Cutaneous Nerve) (L2, L3) This nerve passes obliquely from the lateral border of the psoas major muscle over the iliacus to enter the thigh below or through the inguinal ligament, variably medial to the anterior superior iliac spine (Fig. On the right side of the body, the nerve passes posterolateral to the cecum, and on the left it traverses behind the lower part of the descending colon. The nerve lies on top of the sartorius muscle before dividing into anterior (supplies skin over the anterolateral aspect of the thigh) and posterior (supplies skin on the lateral aspect of thigh from the greater trochanter to the mid-thigh) branches. Occasionally, this nerve is a branch of the femoral nerve rather than its own nerve. Femoral Nerve (L2–L4) 2382 The femoral nerve is the largest nerve of the lumbar plexus, supplying muscles and skin on the anterior aspect of the thigh. It descends through the psoas major muscle and emerges low at its lateral border, coursing inferiorly between the iliacus and psoas major muscles to enter the thigh under the inguinal ligament (Fig. At the inguinal ligament (line running between anterior superior iliac spine and the medial pubic tubercle) and just distal to it (in the femoral triangle), the nerve lies slightly deeper (0. At the femoral (inguinal) crease (a few centimeters caudad to the inguinal ligament), the nerve lies underneath the fascia iliaca (iliopectineal fascia), deep to the fascia lata. Beyond the femoral triangle, the nerve branches into anterior (quite proximally) and posterior divisions. The anterior division gives muscular branches to the pectineus and sartorius muscles and cutaneous branches (intermediate and medial cutaneous nerves of thigh) to the skin on the anterior aspect of the thigh. The posterior division sends muscular branches to the quadriceps femoris muscle and gives rise to the saphenous nerve, its largest cutaneous branch. The saphenous nerve follows the femoral artery, lying lateral to it within the adductor (Hunter’s, subsartorial) canal and then crossing it anteriorly to lie medial to the artery. Distal to the canal, the saphenous nerve leaves the artery to lie superficial at the medial aspect of the knee; the nerve then continues inferiorly (subcutaneously) with the long (great) saphenous vein along the medial aspect of the leg down to the tibial aspect of the ankle. The saphenous branch supplies the skin on the medial aspect of the leg below the knee and on the medial aspect of the foot; it provides articular branches to the hip, knee, and ankle joints. Needle insertion sites (•) for blocking the lateral femoral cutaneous, femoral, and obturator nerves are shown. Obturator Nerve (L2–L4) The obturator nerve emerges from the medial border of the psoas major muscle at the pelvic brim to pass behind the common iliac vessels and lateral to the internal iliac vessels. It then courses inferiorly and anteriorly along the lateral wall of the pelvic cavity on the obturator internus muscle toward the obturator canal, through which it enters the upper part of the medial aspect of the thigh above and anterior to the obturator vessels. The nerve divides into its anterior and posterior branches near the obturator foramen (Fig. It supplies the adductor longus, gracilis, adductor brevis (usually), and pectineus (often) muscles. Cutaneous branches supply the skin on the medial aspect of the thigh and perhaps to the medial knee. The nerve’s posterior branch pierces the obturator externus muscle anteriorly and supplies it, then passes behind the adductor brevis muscle (sometimes supplies it) to descend on the anterior aspect of the adductor magnus muscle (medial to the anterior branch), which it supplies. It then traverses the adductor canal with the femoral artery and vein to enter the popliteal fossa, where it terminates as an articular branch to the back of the knee joint capsule 2384 (oblique popliteal ligament). Accessory Obturator Nerve (L3, L4) This nerve is present in about 30% of individuals. It descends along the medial border of the psoas major muscle, crosses the superior pubic ramus behind the pectineus muscle, supplies the muscle, and gives articular branches to the hip joint. Nerves at the Ankle By the time the femoral, tibial, and common peroneal nerves reach the ankle, there are five branches that cross this joint to provide innervation for the skin and muscles of the foot. Deep Peroneal Nerve (L5, S1) This nerve lies anterior to the tibia and interosseus membrane and lateral to the anterior tibial artery and vein at the ankle. It travels deep to and between the tendons of the extensor hallucis longus and extensor digitorum longus muscles. Beyond the extensor retinaculum, it branches into medial and lateral terminal branches; the medial branch passes over the dorsum of the foot and supplies the first web space through two terminal digital branches, and the lateral branch traverses laterally and terminates as the second, third, and fourth dorsal interosseus nerves. Tibial Nerve (aka, Posterior Tibial Nerve; S1–S3) On the posterior aspect of the knee joint, the tibial nerve joins the posterior tibial artery and then runs deep through to the lower third of the leg where it emerges at the medial border of the calcaneal tendon (Achilles tendon). Behind the medial malleolus it lies beneath several layers of fascia and is separated from the Achilles tendon only by the tendon of the flexor hallucis longus muscle. The nerve is posteromedial to the posterior tibial artery and vein, which are, in turn, posteromedial to the tendons of the flexor digitorum longus and tibialis posterior muscles. Just below the medial malleolus, the nerve divides into the lateral and medial plantar nerves. The nerve innervates the ankle joint through its articular branches and the skin over the medial malleolus, the inner aspect of the heel (including Achilles tendon), and the dorsum of the foot (through the medial and lateral plantar nerves) with its cutaneous branches. Superficial Peroneal Nerve The superficial peroneal nerve lies lateral to the deep peroneal nerve in the 2385 upper leg. In the anterolateral aspect of lower leg, it becomes superficial about 7 to 8 cm above the lateral malleolus and divides into medial and lateral dorsal cutaneous nerves to supply the dorsum of the foot. Sural Nerve This nerve arises from tibial (medial sural nerve) and common peroneal (lateral sural nerve) nerves. It emerges to the superficial compartment at a similar but posterior level to the superficial peroneal nerve, 7 to 8 cm above the lateral malleolus. Saphenous Nerve The saphenous nerve is the superficial terminus of the femoral nerve and supplies the skin over the medial lower leg (Fig. It leaves the femoral nerve proximally in the femoral triangle (Scarpa triangle), descends within the adductor canal, and courses beneath the sartorius muscle with the femoral artery (beginning lateral of the vessel at first and then crossing to the medial side superior to the artery just proximal of the lower end of the adductor magnus muscle). Further distally, the femoral artery departs away from the sartorius muscle, traveling deep to continue as the popliteal artery at the adductor hiatus. At this location, the saphenous nerve continues its course under the sartorius muscle, traveling adjacent to the saphenous branch of the descending genicular artery. It runs superficial at the medial surface of the lower leg and in front of the heel. Specific Techniques The remainder of this chapter is devoted to the procedural details of specific blocks, arranged by regions of the body. The nerve stimulator is set to deliver variable currents with a frequency of 2 Hz and pulse width of 0.

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A combination of pharmacologic treatment with physical discount 80mg tadapox with mastercard erectile dysfunction causes premature ejaculation, psychological purchase tadapox 80mg visa erectile dysfunction after age 50, or behavioral intervention is probably the most effective approach. Cancer Pain Significant pain is present in up to 25% of patients with cancer who are in active treatment and in up to 90% of patients with advanced cancer. Management of cancer pain should be multifaceted and include the following: (1) appropriate tumor-specific antineoplastic therapy, (2) pain medications, (3) interventional management, (4) behavioral and psychological management, and ultimately (5) hospice care. Opioids are the mainstay of treatment for cancer pain as approximately 75% to 95% of patients are responsive positively when appropriate guidelines are followed. Continuous intravenous opioid infusions can be performed during the later stages of the disease. Interventional treatments include neurolytic sympathetic nerve blocks and intrathecal opioids. Vertebroplasty or kyphoplasty may be required for vertebral compression syndromes. Neurolytic Blocks for Visceral Pain from Cancer Celiac Plexus Block The celiac plexus innervates all of the abdominal viscera except the left side of the colon and the pelvic viscera. The plexus contains two large ganglia that receive sympathetic fibers from the greater, lesser, and least splanchnic 4047 nerves. The splanchnic nerves are located retroperitoneally at the level of the T12 and L1 vertebrae, and the celiac plexus is anterior to the crura of the diaphragm and surrounds the abdominal aorta and the celiac and superior mesenteric arteries. Blockade of the celiac plexus can be achieved by the classic retrocrural approach, an anterocrural approach, or by neurolysis of the splanchnic nerves. In the retrocrural approach, the tip of the needle is advanced approximately 1 cm anterior to the anterior and upper border of L1. In the anterocrural or transaortic approach, the tip of the needle is advanced through the lower portion of L1 and the aorta on the left side until blood can no longer be aspirated through the needle. For splanchnic nerve block, the tip of the needle is placed at the anterior portion of the T12 vertebral body. Better results are usually seen with local anesthetics because of better spread (phenol is viscous and its vascular absorption may relieve pain). The dosages of the neurolytic agents are 30 to 40 mL for the retrocrural and anterocrural approach, and 10 to 15 mL on each side for splanchnic nerve blockade. Complications from the celiac plexus block include orthostatic hypotension, back pain, retroperitoneal hematoma, reactive pleurisy, hiccups, hematuria, transient diarrhea, abdominal aortic dissection, transient motor paralysis, and paraplegia. The paraplegia and transient motor paralysis may be due to spasm of the lumbar segmental arteries that perfuse the spinal cord, direct vascular or neurologic injury, or retrograde spread to the nerve roots or spinal cord. Note that the tip of the needle is in the upper third of L1 and about 1 cm beyond the border of the vertebral body for the retrocrural technique; the spread of the contrast medium is cephalad. In contrast, the tip of the needle is the lower third of L1 and about 3 cm beyond the border of the vertebral body for the anterocrural technique; the spread of the contrast medium is caudad and in front of the aorta. A meta-analysis of 21 retrospective studies in 1,145 patients concluded that adequate-to-excellent pain relief was achieved in 89% of the patients during the first 2 weeks following the block and partial-to-complete pain relief continued in 90% of the patients at the 3-month interval. The plexus is located in the retroperitoneum, bilaterally extending from the lower third of the fifth lumbar vertebra to the upper third of the first sacral vertebra. For blockade of the plexus, the patient is placed in the prone position and two 7-cm needles are inserted, under fluoroscopy, in medial and caudal directions until the tips lie anterior to the L5 to S1 intervertebral disc space. After injection of contrast medium, 6 to 8 mL of local anesthetic is used for a diagnostic block while phenol or alcohol is employed for neurolysis. Anterior ultrasound-guided superior hypogastric plexus blocks appear to be effective for pelvic pain. Case reports support the efficacy of neurolytic superior hypogastric plexus block both in reducing pelvic pain secondary to cancer and in decreasing opioid consumption. Visceral afferents innervating the perineum, distal rectum, anus, distal urethra, vulva, and distal third of vagina converge at the ganglion. Four to 8 mL of local anesthetic is used for diagnostic block and 8% to 10% phenol or 50% alcohol is used for neurolysis. Similar to superior hypogastric plexus blocks, there are no controlled studies on its efficacy, although case reports confirm its effectiveness in relieving perineal pain secondary to cancer. Pharmacologic Management of Pain Opioids Morphine is the standard for opioid therapy for cancer pain (see Chapter 20, Opioids). The metabolites of morphine include morphine-6-glucuronide, which causes additional analgesia, and morphine-3-glucuronide, which can cause adverse effects. Controlled-release preparations are available, reducing the need to take the drug frequently. Hydromorphone, a μ-receptor agonist, is three to five times more potent than morphine when given orally and five to seven times more potent when given parenterally. Pruritus, sedation, nausea, and vomiting occur less frequently compared with morphine. Its metabolite, hydromorphone-3- glucoronide, lacks analgesic property but possesses properties similar to that of morphine-3-glucuronide. Methadone has a 60% to 95% bioavailability, high potency, and a long duration of action. Its potency compared with morphine ranges from 1:1 to 1:2 on acute dosing but can be 1:4 with chronic dosing. It has a long and unpredictable half-life of 8 to 80 hours that makes it difficult to achieve steady-state plasma concentrations, increasing the risk of accumulation and the need for careful and individualized dosing. There has been an “epidemic” of deaths due to 4050 unintentional overdose from methadone111 because many physicians do not appreciate the consequences of the drug’s long and unpredictable half-life. Most reports are based on high-dose maintenance (>120 mg) for the treatment of addiction; however, such occurrences have also been reported with lower dosages. It has a high bioavailability (60%) and is associated with a low incidence of itching and hallucinations. The controlled-release preparation (OxyContin, Purdue Pharma) has good analgesic characteristics but became a popular drug for abuse prior to its reformulation to include abuse-deterrent technologies. Oxymorphone has greater affinity to the μ-receptor than morphine and has little or no affinity to the κ-opioid receptor. Due to extensive first-pass hepatic metabolism, the bioavailability of oxymorphone is only 10%. It should not be taken with alcohol because this increases its plasma concentration by as much as 300%. The efficacy of oxymorphone in chronic and cancer pain is similar to other opioids. Buprenorphine is a partial agonist at the μ-receptor, a κ-antagonist, and a weak δ-agonist. It has a rapid onset (30 minutes) when given orally and a long duration of action of 6 to 9 hours. Buprenorphine antagonizes the opioid effects of full agonists such as morphine or hydromorphone due to its partial opioid agonist pharmacodynamics. Approximately 9% of Caucasians do not have the enzyme and do not experience analgesia from codeine. Children under 12 years of age lack maturity of the enzyme and cannot convert the drug to morphine, experiencing the drug’s side effects with minimal analgesia.