pediatric palliative care consultant

PediatricPalliativeCareConsultant

GuidelinesforEffectiveManagementofSymptoms

Melissa O’Neill Hunt, PharmD Pediatric Clinical Pharmacist, HospiScript Services

Bridget McCrate Protus, PharmD, CGP, MLIS

Director of Drug Information, HospiScript Services

Janine Penfield Winters, MD Director, Pediatric Palliative Care

Assistant Clinical Professor of Family Medicine and Pediatrics Nationwide Children’s Hospital

Diane C. Parker, RN, MSN, NE‐BC, CHPN, CHPPN

Executive Director, Hands of Hope Pediatric Division of Hospice Care of South Carolina

DISCLAIMER: All clinical recommendations contained herein are intended to assist with determining the appropriate therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients attending physicians. Nothing in this document shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Use of product brand names are intended to assist the clinician in identifying products and does not connote endorsement or promotion of any kind. No financial support for the development of this book was provided by any product vendor or manufacturer.

© 2014, HospiScript, a Catamaran Company All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of HospiScript Services, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law. HospiScript, a Catamaran Company 4525 Executive Park Drive Montgomery, AL 36166 Tel: 866‐970‐7500 www.hospiscript.com ISBN‐13: 978‐0‐9889558‐3‐7 ISBN‐10: 0988955830

HospiScript, a Catamaran Company

Editors Melissa O’Neill Hunt, PharmD Pediatric Clinical Pharmacist HospiScript, a Catamaran Company Dublin, Ohio Bridget McCrate Protus, PharmD, CGP, MLIS Director of Drug Information HospiScript, a Catamaran Company Dublin, Ohio Janine Penfield Winters, MD Director, Pediatric Palliative Care Assistant Clinical Professor of Family Medicine and Pediatrics Nationwide Children’s Hospital Columbus, Ohio Diane C. Parker, RN, MSN, NE‐BC, CHPN, CHPPN Executive Director Hands of Hope® Pediatric Division of Hospice Care of South Carolina Spartanburg, South Carolina Associate Editors Marliese Gibson, PharmD Clinical Pharmacist HospiScript, a Catamaran Company Dublin, Ohio Jason Kimbrel, PharmD, BCPS Vice President of Clinical Services HospiScript, a Catamaran Company Dublin, Ohio Contributors Dianne Gray, BS President Hospice and Healthcare Communications Scottsdale, Arizona Lauren Sulcer Jenkins, PharmD Pediatric Consultant Huntsville, Alabama

Acknowledgements Thanks to Jason for envisioning a pediatric pharmacist position at HospiScript (and justifying full time status), for recognizing the need for a pediatric reference guide, and allowing me to make it happen. I appreciate everything you did to facilitate the development of this book.

Thanks to Bridget …there is just too much to thank you for! For accepting how long everything takes For meeting with me daily to help me repeatedly reword phrases For recognizing when “I just don’t like it” For declaring chapters done and advising me to move on For reminding me there is always the 2nd Edition For re‐formatting the general pain chapter For always figuring out the formatting issues that have me pulling my hair out For putting in all of the extra hours I couldn’t For everything you’ve taught me so far

I couldn’t have asked for a better colleague!

Thanks to Lauren for starting the process and notifying me of this amazing job opportunity. Thanks to everyone who reviewed chapters and provided feedback.

‐ MOH

We wish to thank all of our colleagues for their assistance in the creation of this resource. Without their generous support this work would not have been possible. Their compassionate commitment to improving end‐of‐life care for all individuals is an inspiration. – MOH, BMP

I wish to acknowledge Dr. Karen McCoy (Chief, Section of Pulmonary, Nationwide Children’s Hospital) whose mentorship has supported scholarly works. I also acknowledge and thank Dr. Garey Noritz, Dr. Karen McCoy and Dr. Brandon Strange for valued technical expertise. – JPW

I wish to thank Dr. Kevin McRedmond and all of the Hands of Hope® team for their passion to serve our patients and families and for always striving for excellence. They are the face of Hands of Hope, every day. Lastly, to our founders Todd Picou and David Niday, I am forever grateful for their visionary leadership and support. – DCP

Dedication

This work is dedicated to all parents, siblings, caregivers, healthcare professionals, and child advocates, and the children they love and serve.

In honor of my family: my husband Dan who supported my pursuit of a new career path; Savannah for always making me feel loved when I finally emerge from my office; Carolina whose birth delayed this publication by a few months and whose smile lights up a room; my parents for helping me get here with their love and encouragement; and of course, thanks to God who made it all happen and whose plan is always greater than mine. ‐MOH

To my husband, Seth, and my son, Zane for their love, encouragement, and support; in honor and memory of my mom, Carolyn McCrate, and my father‐in‐law, Herb Protus, for their encouragement, guidance, and inspiration. ‐BMP

To my husband John who supports me so that I can support others. Thanks to my parents and grandparents who nurtured me so I could reach my potential. I love you. ‐JPW

I dedicate this project to the memory of my mom “Maw Maw Peggy”. She encouraged me in so many ways through her loving and generous spirit. She was proud of our pediatric program and provided many blankets of love and volunteer hours. To my husband Tom, thank you for your amazing love and support for what we do and sharing our vision. ‐DCP

“Palliative care seeks to enhance quality of life and

the child’s ability to enjoy life in the face of an ultimately terminal condition.

The goal is to add life to the child’s years, not simply years to the child’s life…”

American Academy of Pediatrics

Committee on Bioethics and Committee on Hospital Care. Palliative care for children. Pediatrics 2000;106(2):351‐7.

PREFACE PPCC

Pediatric Palliative Care Consultant (PPCC) is intended to be a quick reference guide for palliative symptom management in pediatric patients. The authors and collaborators have systematically reviewed and collected the pertinent literature and resources related to pediatric palliative care and compiled the information into concise guidelines for effective management of symptoms. Each chapter provides relevant background information regarding the symptom, as well as non-pharmacological and pharmacological treatment options. The pharmacological options are then displayed in comprehensive drug tables, followed by step-by-step algorithms that walk practitioners through patient specific symptom management. The disease states seen in pediatric palliative care patients are often quite different than those seen in adult palliative care patients, therefore overviews of common pediatric life-limiting conditions are also included.

The majority of health care professionals providing care to pediatric patients with life-limiting conditions are not extensively trained to care for this population. In many situations, care for these children is provided by general pediatricians or adult palliative care teams. Knowledge of pediatric assessment and medication dosing is essential when dealing with infants and children. The aim of this guide is to equip all practitioners with the resources necessary to provide basic pediatric palliative medicine, regardless of their pediatric training, or lack thereof. This book can be used as a clinical resource, as well as an educational tool.

• For those experienced in treating pediatric patients, this book may be used as a resource for support of current practice and a quick reference guide.

• For those who only occasionally treat pediatric patients, this book may be used as a learning guide and a resource to ensure symptoms are appropriately treated.

• For educators, this book may be used as a training guide to address the basics of pediatric palliative care and assist learners in developing a comprehensive plan for symptom management.

This reference was designed to provide practical recommendations and improve symptom management in pediatric patients. It is the hope that this tool will aid all professionals who deal with pediatric patients with chronic, life-limiting conditions, whether they have pediatric-specific training or rarely see a pediatric patient.

PERMISSIONS PPCC

The following content was reprinted with permission:

Chapter Figure/Table Reference Permission obtained from Pediatric Palliative and Hospice Care

Table 1. Pediatric Diagnostic Categories for Hospice or Palliative Care

Widdas D, McNamara K, Edwards F. A Core Care Pathway for Children with Life-limiting and Life-threatening Conditions, 3rd Ed [Internet]. Bristol: Together for Short Lives; February 2013. Available from: www.togetherforshortlives.org.uk

Togetherforshortlives.org.uk LC03102014

Figure 1. Pediatric Palliative Care Model*

National Hospice and Palliative Care Organization (NHPCO). Standards of Practice for Pediatric Palliative Care and Hospice. Professional Development and Resources Series. NHPCO: Alexandria; c. 2010. [Cited September 5, 2013] Available from: http://www.nhpco.org/quality/nhpco’s-standards-pediatric-care

National Hospice and Palliative Care Organization

Key Pediatric Standards of Care

General Pediatric Considerations

Table 4. Developmental Alteration in Intestinal Drug Absorption

Kliegman RM, Stanton BF, St Geme JW, et al. Chapter 57, Principles of Drug Therapy. In: Nelson Textbook of Pediatrics, Nineteenth Edition. Philadelphia: Elsevier; c2011. p. 250.

Elsevier SN02212014

Medication Administration

Table 7. Age Guidelines for Use of Aerosol Delivery Device Types

Arzu A, Restrepo RD. AARC clinical practice guideline: aerosol delivery device selection for spontaneously breathing patients:2012. Resp Care 2012;57(4):613-626.

Copyright Clearance Center

Agitation

Figure 1. Pediatric Confusion Assessment Method for the ICU (pCAM-ICU)

Smith HA, Fuchs DC, Pandharipande PP, et al. Delirium: an emerging frontier in the management of critically ill children. Crit Care Clin 2009; 25:593–614.

W.B./Saunders via Copyright Clearance Center Confirmation: 11159750 License: 3331430269219

Table 7. Richmond Agitation Sedation Scale (RASS)

Sessler CN, Gosnell M, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care patients. Am J Respir Crit Care Med 2002;166:1338-1344.

American Thoracic Society DF02182014

Table 8. Pediatric Anesthesia Emergence Delirium Scale (PAED Scale)

Sikich N, Lerman J. Development and psychometric evaluation of the Pediatric Anesthesia Emergence Delirium Scale. Anesthesiology 2004;100(5):1138–1145.

Wolters Kluwer Health via Copyright Clearance Center 3343790050547

Constipation

Figure 1. Bristol Stool Chart

Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 1997;32(9):920-4.

Taylor & Francis via Copyright Clearance Center Confirmation: 11162837 License:3337790049075

Diarrhea Figure 1. Bristol Stool Chart

Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 1997;32(9):920-4.

Taylor & Francis via Copyright Clearance Center Confirmation: 11162837 License:3337790049075

Dyspnea Figure 1. Pediatric Dyspnea Scale

Khan FI, Reddy RC, Baptist AP. Pediatric Dyspnea Scale for use in hospitalized patient with asthma. J Allergy Clin Immunol 2009;123(3): 660-4.

W.B./Saunders via Copyright Clearance Center Confirmation: 11159071 License:3327170339298

Edema

Table 2. Quantifying Pitting Edema Scale

Acello B. Resident Assessment and Monitoring for Long Term Care: Essential Tools and Guidelines for Clinicians. Marblehead: HCPro, c2006. Edema, p. 179.

HCPro

PPCC PERMISSIONS

Chapter Figure/Table Reference Permission obtained from Mucositis Table 2. National

Cancer Institute Common Terminology Criteria for Mucositis

Lalla RV, Sonis ST, Peterson DE. Management of oral mucositis in patients who have cancer. Dent Clin N Am 2008;52:61-77.


Table 3. World Health Organization Scale for Mucositis

Nausea and Vomiting

Figure 2. BARF Nausea Scale8

Baxter AL, Watcha MF, Baxter WV, et al. Development and validation of a pictorial nausea rating scale for children. Pediatrics 2011;127:e1542-e1549.

American Academy of Pediatrics via Copyright Clearance Center Confirmation: 1116272 License: 333730513492

Pain

Table 6. CRIES Scale for Neonatal Pain

Krechel SW, Bildner J. CRIES: A new neonatal postoperative pain measurement score. Initial testing of validity and reliability. Paediatric Anaesthesia 1995;5:53-61.

Blackwell Publishing via Copyright Clearance Center Confirmation: 1116277 License: 3337831238557

Table 7. FLACC Behavior Scale for Pain in Young Children

Malviya S, Merkel SI, Shayevitz JR, et al. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatric Nursing 1997;23(3):293.

Jannetti Publications via Copyright Clearance Center License: 3336680928685

Figure 2. OUCHER Pain Scale

Beyer JE, Denyes MJ, Villarruel AM. The creation, validation, and continuing development of the Oucher: a measure of pain intensity in children. J Pediatr Nurs 1992;7(5):335-46. This figure was published in J Pediatr Nurs, Volume 7, Beyer JE, Denyes MJ, Villarruel AM, The creation, validation, and continuing development of the Oucher: a measure of pain intensity in children, 335-346, Copyright Elseiver.

Elsevier LPS02182014

Figure 3. Wong-Baker FACES® Pain Rating Scale

Hicks CL, von Baeye CL, Spafford PA, et al. The Faces pain scale- revised: toward a common metric in pediatric pain measurement. Pain 2001;93(2):173-83.

www.wongbakerfaces.org Confirmation: 598179732

Figure 4. Numeric and/or Color Analogue Pain Scale

McGrath PA, Seifert CE, Speechley KN, et al. A new analogue scale for assessing children’s pain: an initial validation study. Pain 1996;64(3):435-43.

www.iasp-pain.org

Figure 5. Adolescent Pediatric Pain Tool (APPT)

Savedra MC, Tesler MD, et al. Postoperative pain in children and adolescents: Assessing change over time with the Adolescent Pediatric Pain Tool (APPT). Nursing Research 1993;42(1):5-9.

Lippincott Williams & Wilkins via Copyright Clearance Center Confirmation:11159806 License: 3333250381448

Figure 6. WHO Analgesic Step Ladder Approach- Adapted for Children

World Health Organization (WHO). Guidelines for analgesic drug therapy. In: Cancer pain relief and palliative care in children. Geneva: WHO/IASP; c1998. p.24-8.

World Health Organization DC03132014

Pain Somatic Figure 1. Process of Nociception

Ferrante, VadeBoncouer. The four processes that make up nociception: transduction, transmission, modulation, and perception. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing and Allied Health, Seventh Edition. Philadelphia: Saunders; c2003.

Elsevier SN02212014

Figure 2. WHO Analgesic Step Ladder Approach- Adapted for Children



PERMISSIONS PPCC

Chapter Figure/Table Reference Permission obtained from Pain Visceral Figure 1. WHO

Analgesic Step Ladder Approach- Adapted for Children



Spasticity

Table 1. Ashworth Scale

Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987;67(2):206-207. Reprinted from Phys Ther. 1987;67:206-207, with permission of the American Physical Therapy Association. Copyright © 1987 American Physical Therpay Association

American Physical Therapy Association PTJ 23/14

Table 2. Tardieu Scale

Gracies JM, Burke K, Clegg NJ, et al. Reliability of the Tardieu Scale for assessing spasticity in children with cerebral palsy. Arch Phys Med Rehabil 2010;91:421-428.


Cystic Fibrosis Figure 1. CF Disease Trajectory

Dellon EP, Klick JC, Robinson WM. Chapter 41, Cystic Fibrosis. In: Wolfe J, Hinds PS, Sourkes BM, editors. Textbook of Interdisciplinary Pediatric Palliative Care. Philadelphia: Saunders; c2011. p.438-452.

Elseiver SN02212014

Appendix Lansky Play Performance Scale

Lansky SB, Lilst MA, Lansky LL, et al. The measurement of performance in childhood cancer patients. Cancer 1987;60:1651-1656.

John/Wiley & Sons, Inc. via Copyright Clearance Center Confirmation: 11162879 License:333740247200

CONTENTS PPCC

I. Introduction

Pediatric Palliative Care and Hospice Care Melissa O’Neill Hunt 1Prognostication & Disease Trajectory Janine Penfield Winters 5Ethical Considerations Melissa O’Neill Hunt 7Communicating with Pediatric Patients and their Families Dianne Gray 9Barriers to Pediatric Hospice Care Dianne Gray 13General Pediatric Considerations Melissa O’Neill Hunt, Lauren Sulcer Jenkins 15Medication Administration in Pediatric Patients Marliese Gibson 17Compounded Medications in Palliative Care Bridget McCrate Protus 30Polypharmacy and Drug Interactions in Palliative Care Bridget McCrate Protus 33Medication Therapy Management (MTMs) in Pediatrics Bridget McCrate Protus 34Medical Abbreviations Bridget McCrate Protus 35

II. Guidelines for Effective Management of Symptoms (PediGEMS™)

Agitation & Delirium Melissa O’Neill Hunt 37Anorexia & Cachexia Melissa O’Neill Hunt 48Anxiety Melissa O’Neill Hunt, Lauren Sulcer Jenkins 54Bowel Obstruction Melissa O’Neill Hunt 62Constipation Melissa O’Neill Hunt, Lauren Sulcer Jenkins 67Cough Melissa O’Neill Hunt 76Depression Melissa O’Neill Hunt, Lauren Sulcer Jenkins 85Diarrhea Melissa O’Neill Hunt, Lauren Sulcer Jenkins 96Dysphagia Melissa O’Neill Hunt 104Dyspnea Melissa O’Neill Hunt, Lauren Sulcer Jenkins 109Edema & Ascites Melissa O’Neill Hunt 117Fatigue & Somnolence Melissa O’Neill Hunt 123Fever Melissa O’Neill Hunt 129Gastroesophageal Reflux & Dyspepsia Melissa O’Neill Hunt 134Hiccups Melissa O’Neill Hunt 143Infections Melissa O’Neill Hunt 151Insomnia Melissa O’Neill Hunt 162Mucositis Melissa O’Neill Hunt 170Muscle Spasms Melissa O’Neill Hunt 176Nausea & Vomiting Melissa O’Neill Hunt, Lauren Sulcer Jenkins 181Pain Melissa O’Neill Hunt, Lauren Sulcer Jenkins 193 Somatic Pain Melissa O’Neill Hunt 207 Visceral Pain Melissa O’Neill Hunt 216 Bone Pain Melissa O’Neill Hunt 221 Neuropathic Pain Melissa O’Neill Hunt 226 Methadone Melissa O’Neill Hunt 234Pruritus Melissa O’Neill Hunt 240Secretions Melissa O’Neill Hunt, Lauren Sulcer Jenkins 249Seizures Melissa O’Neill Hunt, Lauren Sulcer Jenkins 255Spasticity Melissa O’Neill Hunt 273Xerostomia Melissa O’Neill Hunt 279

PPCC CONTENTS

III. Disease State Management

Anticipatory Guidance Janine Penfield Winters 285Life-Limiting Pediatric Diseases Bridget McCrate Protus 288Cystic Fibrosis (CF) Marliese Gibson 298Neurodegenerative & Neurodevelopmental Disorders Janine Penfield Winters

306

IV. Neonatal Management

Neonatal Hospice Considerations Melissa O’Neill Hunt 313

V. Appendices

Sample Pediatric Intake Form 323Play Performance Scale 324Sample Pediatric Comfort Care Kit Orders 325Immunization Guide 326Pediatric Growth Charts 332Drugs Affected by Cytochrome P450 Enzyme Metabolism 336Extrapyramidal Symptoms (EPS) from Medications 338Medications Associated with Anticholinergic Side Effects 339Drugs that Prolong the QT Interval or Induce Torsades de Pointes 340Confused Drug Names (Look-alike and Sound-alike) 341Do Not Crush or Chew List 344Glucocorticoid Equivalency Table 349Benzodiazepine Equivalency Table 351Insulin Comparison Chart 352Subcutaneous Administration Butterfly Procedure 353Cumulative Internet Resources 358 Index, pages i-xiv 361

Section II: PediGEMS Guidelines for Effective Management of Symptoms

• Agitation & Delirium • Anorexia & Cachexia • Anxiety • Bowel Obstruction • Constipation • Cough • Depression • Diarrhea • Dysphagia • Dyspnea • Edema & Ascites • Fatigue & Somnolence • Fever • Gastroesophageal Reflux & Dyspepsia • Hiccups • Infections • Insomnia • Mucositis • Muscle Spasms • Nausea & Vomiting • Pain • Pruritus • Secretions • Seizures • Spasticity • Xerostomia

AGITATION & DELIRIUM PediGEMS

Introduction and Background1-4

• According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), delirium is a disturbance of consciousness and cognition that develops over a short period, usually hours to days, and fluctuates over time. 5

• Serious physical illness can cause widespread cerebral dysfunction, leading to the development of delirium. • Delirium has been associated with rates of morbidity and mortality that surpass those of all other psychiatric

diagnoses. • Agitation is an unpleasant state of increased arousal. 6-7 • Terminal agitation, also known as terminal restlessness, is agitated delirium at the end of life. It is commonly

associated with impaired consciousness and non-purposeful movement.8

Prevalence1-3

• Delirium and agitation are very common in hospice patients, especially in the last few days of life. • Data is conflicted regarding the prevalence of perceptual disturbances and delusions among children

compared to adults. This may be accounted for by the variations in brain function across ages and/or developmental immaturity in children.

Causes3-4, 9-10

• Many different factors can contribute to the development of delirium or agitation in children (Table 1). • Given the advanced state of illness in this patient population, multiple causes of delirium may simultaneously

coexist, adversely affecting the metabolic environment of the whole brain. • Certain patients may be at higher risk of developing delirium (Table 2). Being aware of the potential risk

factors may help recognize the signs more quickly or even prevent them.

Table 1. Causes of Agitation & Delirium3-4,9

Cause Examples Biochemical Hypercalcemia, hyperosmolality, hypoglycemia, hyponatremia Cerebral disease Cancer, cerebral vascular accident, hypoxia, sepsis Discomfort Constipation, dyspnea, muscle spasm, pain, sleep deprivation, urinary retention Drugs Anticholinergics, benzodiazepines, corticosteroids, opioids, steroids, withdrawal Infection Urinary, neurological, respiratory, septicemia Organ failure Kidney, liver Psychosocial Anxiety, emotional or spiritual distress, fear, vision or hearing impairment

Table 2. Risk Factors for Delirium1 Predisposing Factors Precipitating Factors Environmental Factors • Age • Genetic predisposition • Neurological disease • Psychiatric illness • Visual impairment • Hearing impairment • Surgery

• Electrolyte disturbances • Hypoxia • Acidosis • Hypoalbuminemia • Fever • Hypotension • Sepsis • Infection • Polypharmacy • Oversedation • Medication withdrawal • Sleep deprivation

• Immobility • Light • Noise • Reduced social interactions • Pain • IV lines in place • Physical restraints

37

PediGEMS GUIDELINES FOR EFFECTIVE MANAGEMENT OF SYMPTOMS

Clinical Characteristics1-3,9-14

• Symptoms of delirium can vary greatly by patient, especially in pediatric patients (Table 3), and are often reversible.

• Pediatric patients may have subtle developmentally specific symptoms and signs of delirium. • In children, agitation may present as loud or angry speech, crying, increased muscle tension, diaphoresis,

tachycardia, or irritable mood.6 While the symptoms of agitation overlap with symptoms of anxiety, agitation typically includes more motor symptoms, rather than psychological.7

• Criteria for delirium include sudden onset and fluctuating symptoms throughout the day (Table 4). • At the end of life, delirium may have a more gradual onset and may be refractory to treatment. • Three clinical subtypes of delirium, hypoactive, hyperactive, and mixed, are recognized in both adult and

pediatric patients (Table 5). • The term hyperactive delirium refers to patients who present with symptoms of confusion, psychosis,

disorientation, agitation, hypervigilance, hyperalertness, fast or loud speech, combativeness, and behavioral problems.

• Patients with hypoactive or silent delirium present with somnolence, decreased activity, slow or decreased speech, psychomotor slowing, withdrawal, apathy, and confusion.

• Mixed delirium describes patients who fluctuate between hyperactive and hypoactive states. These critically ill patients present with an array of symptoms, in the context of possible pain, anxiety, and nausea, making it difficult to recognize delirium and identify the cause.

Table 3. Common Symptoms of Agitation & Delirium2,6,9,15

Category Agitation Symptoms Delirium Symptoms Cognitive disturbance Inability to concentrate or relax ↓ alertness, a en on, orienta on,

impaired memory, confusion, lethargy Daily course Alteration of sleep-wake cycle, terminal

restlessness Alteration of sleep-wake cycle, fluctuating nature, terminal restlessness

Language & thought disturbance Angry or loud speech Speech disturbance, delusions, vigilant/paranoid thinking

Mood changes Crying, irritability Anxious, depressed, irritable, labile or abnormal affect

Perceptual disturbance n/a Auditory or visual hallucinations, altered perception

Psychomotor alterations Frequent, non-purposeful movements, ↑ muscle tension

Agitation, apathy, psychomotor retardation

Table 4. Delirium Criteria1,5

Criteria Symptoms Disturbance of consciousness Decreased awareness of environment, reduced ability to focus, sustain or shift attention Change in cognition Memory deficit, disorientation, language disturbance, or development of a perceptual disturbance Temporal character Develops over a short period, usually hours to days, and fluctuates during the course of the day Etiology History, physical exam, laboratory findings of general medical condition related to the disturbance

38


Table 5. Delirium Subtypes1,14

Subtype Hyperactive Hypoactive Mixed Clinical features Psychomotor agitation

Increased verbal fluency & volume Restlessness Hyperarousal Hallucinations

Psychomotor retardation Diminished speech production & volume Apathy Withdrawal

Presence of hyperactive and hypoactive symptoms

Notes More easily identified Needs higher level of care Needs restraint for safety More distressing to family & patient

Often overlooked Often misdiagnosed as depression or oversedation More common in adults

Diagnosis confounded by mixed clinical picture

Possible etiologies Drug withdrawal Anti-cholinergic medications

Hepatic Metabolic encephalopathies Acute sedative or analgesic intoxication Hypoxia

Multiple etiologies

Pathophysiology Fast or normal EEG Increased cerebral metabolism Decreased GABA activity

Diffuse slowing on EEG Decreased cerebral metabolism Increased GABA activity

Multiple pathways

Treatment options Typical antipsychotic Atypical or typical antipsychotic Atypical antipsychotic

Assessment

• Diagnosis and assessment of delirium may be difficult in young children. Developmental age and maturity level should be considered when assessing children. 16

• Identify any potential reversible causes (Table 1) o Evaluate electrolytes if appropriate o Assess for signs of infection o Consider other causes of discomfort (e.g. pain, spasm, dyspnea, urinary retention, fecal impaction,

etc) • Evaluate for possible delirium subtype • Complete psychosocial & medication history • Family/caregiver observations and concerns • Although not validated in children, there are numerous tools available to help assess symptoms of delirium

(Table 6).3 These scales should be adjusted to the appropriate developmental level of the child to adequately assess symptoms in this population. The Delirium Rating Scale was shown applicable in children with scores comparable to adults.12

• The Pediatric Confusion Assessment Method for ICU (Figure 1) has been validated in critically ill children greater than five years of age.13 This tool is used in combination with the Richmond Agitation Sedation Scale (RASS) (Table 7)17. A similar scale was developed for emergence delirium after receiving sedation, The Pediatric Anesthesia Emergence Delirium Scale (Table 8).18 While not developed for patients in hospice or palliative care, these scales may be useful to assess delirium in the pediatric population.

Table 6. Delirium Assessment Tools3 (Not validated in children)Measure Tool Cognitive Disturbance Mini-Mental State Exam Delirium Symptoms Delirium symptom Interview

Confusion Assessment Method Delirium Symptom Severity Delirium Rating Scale

Memorial Delirium Assessment Scale

39


Figure 1. Pediatric Confusion Assessment Method for the ICU (pCAM-ICU)13

Table 7. Richmond Agitation Sedation Scale (RASS)17

Score Term Description +4 Combative Overtly combative, violent, immediate danger to staff+3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive+2 Agitated Frequent on-purposeful movement, fights ventilator+1 Restless Anxious, but movements not aggressive 0 Alert and calm -1 Drowsy Not fully alert, but has sustained awakening (eye-opening/eye contact to voice (>10

seconds) -2 Light sedation Briefly awakens with eye contact to voice (<10 seconds)-3 Moderate sedation Movement or eye opening to voice (but no eye contact)-4 Deep sedation No response to voice, but movement or eye opening to physical stimulation -5 Unarousable No response to voice or physical stimulation Table 8. Pediatric Anesthesia Emergence Delirium Scale (PAED Scale) 18

Score 0 1 2 3 4 Makes eye contact with caregiver Extremely Very much Quite a bit Just a little Not at all Actions are purposeful Extremely Very much Quite a bit Just a little Not at all Aware of his/her surroundings Extremely Very much Quite a bit Just a little Not at all Restless Not at all Just a little Quite a bit Very much Extremely Inconsolable Not at all Just a little Quite a bit Very much Extremely Score >10 compatible with delirium. Score 7-9 may indicate subsyndromal delirium requiring reevaluation.

40


Non-Pharmacological Treatment3,9

• Establish a safe, soothing environment o Familiar staff, family, objects, bedding, toys, photographs, smells, and music o Minimal noise o Adequate lighting

• Avoid vitals, medications, or stimulation over-night • Provide appropriate day/night cycles of light and stimulation • Minimize risk of injury (especially for agitated patients) • Educate caregivers about delirium, its causes, and the plan of treatment • Soft restraints, if needed, using the least restrictive method for the shortest period of time

Pharmacotherapy3,7,9,13

• The first step for treatment of delirium or agitation is to identify and treat potential causes. If the underlying cause or causes of delirium can be corrected, delirium usually resolves in a matter of hours to days.

• For children with delirium, typical antipsychotics are the mainstays of treatment. Haloperidol (Haldol) is the drug of choice in children >3 years of age.

• Benzodiazepines can be effective in combination with haloperidol and can decrease the risk of extrapyramidal symptoms (EPS) seen with haloperidol. However, when used alone, benzodiazepines may worsen delirium. Benzodiazepines can also cause paradoxical agitation and delirium at higher doses.

• Atypical antipsychotics should be considered in patients with hypoactive or mixed delirium.1 These agents should be used cautiously due to the risk of increased cardiometabolic adverse effects, such as age-inappropriate weight gain, obesity, hypertension, and lipid and glucose abnormalities.19

• Onset of action is delayed with antipsychotics compared to benzodiazepines. • Patients should be monitored for the risk of QT prolongation when using antipsychotics. • Severe, refractory delirium at the end of life may require sedation. • For children with acute agitation, benzodiazepines are the first-line treatment. But, patients should be

thoroughly evaluated for signs/symptoms of delirium since benzodiazepines can worsen delirium. • PHENobarbital or antihistamines can be used as second-line agents in pediatric patients with agitation.

PHENobarbital has been shown effective, especially in those patients with cerebral irritation.

Clinical Pearls • Start at the lower end of the dosing range of a given pharmacological agent, but recognize that standard or

higher doses may be required. • Assess treatment response and side effects frequently. • Avoid abrupt discontinuation of antipsychotics, benzodiazepines, and barbiturates. • Clinical situations requiring antipsychotic medication doses in excess of those recommended for approved

indications are unusual. • Aggressively treat sleep deprivation. • Consider palliative or respite sedation if symptoms are not controlled with optimal doses of antipsychotics. • Thoroughly evaluate for possible causes of delirium, such as urinary retention or fecal impaction, especially at

end of life.

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Table 9. Pharmacological Management of Agitation & Delirium20

Medication & Age Guide*

Typical Starting Dose** Routes Pediatric Formulation Considerations

Typical Antipsychotics21

chlorproMAZINE (Thorazine)23

≥6 months

6 mon-12 yoa: 0.5-1 mg/kg q6h Max: <5 years: 40 mg/day Max: 5-12 years: 75 mg/day PR: 1 mg/kg q6-8h prn Adult: PO: 30-200 mg/day IM/IV: 25 mg q6h Max: 400 mg

PO SL PR IM IV

Tablets: 10, 25, 50, 100, 200 mg Injection: 25 mg/mL • Tablets contain benzoic acid • IV: dilute with NS to max concentration: 1 mg/mL. NTE

0.5 mg/minute. Hypotension risk with IV. • Do not administer SQ (tissue damage)

• 6 months-12 yoa: PO used more than IM/IV • EPS may occur in pediatric patients • May lower seizure threshold; Do not administer with carbamazepine suspension • Caution: cardiovascular, renal, hepatic, chronic respiratory, or seizure disorders

haloperidol (Haldol)22

≥3 yoa IV: >18 yoa

3-12 yoa: Agitation: PO: 0.01-0.03 mg/kg/day Psychosis: PO: 0.015-0.075 mg/kg q8-12h Max: 0.15 mg/kg/day • >6 mg/day no ↑’d efficacy >12 yoa: Agitation PO: 1-15 mg/dose Psychosis: PO: 0.5 mg-5 mg bid IM (lactate): 2-5 mg q4-8h prn Usual Max: 30 mg/day

PO SQ IM PR SL

Solution: 2 mg/mL Tablets: 0.5, 1, 2, 5, 10, 20 mg Injection (lactate): 5 mg/mL • Avoid contact with oral solution and skin, may cause

contact dermatitis • Dilute oral solution in water or acidic beverage • IV formulation not approved in children

• Deaconate form not recommended for delirium • Avoid IV push due to risk of QT prolongation • EPS common in children, but rare in low doses • Caution: seizures, cardiovascular, renal, hepatic, or respiratory disease

Atypical Antipsychotics18,24

ARIPiprazole (Abilify)29-31

≥6 yoa IV: >18 yoa

6-17 yoa: PO: 2 mg/day Max: 15 mg/day Adult: PO: 10-15 mg/day IM: 9.75 mg Max: 30 mg/day • >10 mg/day no ↑’d efficacy • No pediatric delirium dosing

PO IM

Solution: 1 mg/mL Tablets: 2, 5, 10, 15, 20, 30 mg Tablets, ODT: 10, 15 mg Injection: 7.5 mg/mL • Oral solution contains propylene glycol • ODT tablets contain phenylalanine • Injection not approved in children • Not available generically

• Studied for agitation in autism patients32 • May increase risk of suicidal thinking/behavior in children and young adults • Caution: seizures • May cause neuroleptic malignant syndrome • SE (↑ in children): EPS, fatigue, somnolence, weight gain

OLANZapine (ZyPREXA)33-35

≥13 yoa ER IM: >18 yoa

4-6 yoa: PO: 1.25 mg qhs, IM: 5 mg 6-12 yoa: PO: 2.5 mg qhs, IM: 10 mg >12 yoa: PO: 5 mg qhs, IM: 10 mg Max: PO: 20 mg/day, IM: 30 mg/day • No PO delirium dosing

PO IM

Tablets: 2.5, 5, 7.5, 10, 15, 20 mg Tablets, ODT: 5, 10, 15, 20 mg Injection: 10 mg • Short-acting injection contains lactose • ER IM injection not approved in children; associated with

post injection delirium • Warnings: neuroleptic malignant syndrome, hyperglycemia • SE (↑ in children): weight gain, sedation, ↑LDL cholesterol, total cholesterol, triglycerides, prolac n, & liver

transaminase levels continued

42




Atypical Antipsychotics18,24 continued QUEtiapine (SEROquel)36

>10 yoa

> 10 yoa: 25 mg bid Adult: 25-50 mg bid Max: 800 mg/day • No pediatric delirium dosing

PO Tablets: 25, 50, 100, 150, 200, 300, 400 mg

• Delirium considered off label use • Can increase suicidal thoughts or actions in children • Most sedating of atypical antipsychotics • SE: hypertension, somnolence, headache, EPS, hyperglycemia, xerostomia, weight gain, constipation,

cholesterol alterations risperiDONE (RisperDAL)14,25-

28

≥5 yoa

4 mon- 5 yoa: 0.1-0.2 mg qhs >5 yoa: 0.2-0.5 mg qhs Max: <20 kg: 1 mg/day; 20-45 kg: 2.5 mg/day; >45 kg: 3 mg/day Adult: 0.25-1 mg bid

PO Solution: 1 mg/mL Tablets: 0.25, 0.5, 1, 2, 3, 4 mg Tablets, ODT: 0.25, 0.5, 1, 2, 3, 4 mg • Solution contains benzoic acid • ODT tablets contain phenylalanine

• Drug of choice • Extensive metabolism in liver by CYP2D6 • Warnings: EPS (at higher doses), lowers seizure threshold, neuroleptic malignant syndrome, hepatotoxicity in

pediatric patients24,27 • Caution: seizures, renal or hepatic impairment • SE (↑ in children): weight gain, sedation, leukocytopenia, fever, constipation, increased salivation, abdominal

pain, dry mouth Benzodiazepines- for Agitation clonazePAM (KlonoPIN)

0.01 mg/kg q8-12h Max: 0.2 mg/kg/day Adult: 0.25 mg bid Max: 4 mg/day • No specific agitation dosing

PO SL/buccal PR

Suspension: 0.1 mg/mL Tablets, ODT: 0.125, 0.25, 0.5, 1, 2 mg Tablets: 0.5, 1, 2 mg • Tabs may be crushed for SL or PR • ODT tabs expensive • Injection not available in U.S.

• Not FDA approved for agitation in children • Caution: respiratory, hepatic, or renal dysfunction • SE: drooling, sedation, cognitive effects, increased risk of suicidal behavior or ideation • Avoid abrupt discontinuation

diazepam (Valium) >6 months

PO: 0.12-0.8 mg/kg/day divided IM, IV: 0.04-0.3 mg/kg q2-4h prn Max: 0.6 mg/kg in 8 hours Adult: PO: 2-10 mg bid-qid IM, IV: 2-10 mg q3-4h prn • Dosing for anxiety, sedation,

muscle relaxation

PO SL/buccal PR IM (poor) IV

Solution: 5 mg/5 mL, 5 mg/mL Tablets: 2, 5, 10 mg Injection: 5 mg/mL Rectal gel (Diastat): 2.5, 10, 20 mg • Tabs may be crushed for SL or given PR • Well absorbed PR (slower) and SL • Rectal gel typically used for seizures • IV formulation may be given PR • Dilute injection & administer at a rate NTE 2 mg/min.

Rapid IV push may cause apnea. • Injection contains benzyl alcohol.

• Pediatric population more sensitive to SE • Avoid abrupt discontinuation • Long-acting; active metabolites can accumulate • Reports of pain & thrombophlebitis via IV • Significant drug interactions

continued

43




Benzodiazepines- for Agitation continued LORazepam (Ativan)

0.05 mg/kg q4-8h Max: 2 mg Adult: 1-10 mg/day in 2-3 divided doses • Dosing for anxiety, sedation

PO SL PR IM SQ IV

Solution: 2 mg/mL Tablets: 0.5, 1, 2 mg Injection: 2, 4 mg/mL • IV and oral solutions contain benzyl alcohol,

polyethylene, and propylene glycol • Tablets can be crushed • IV: dilute with equal volume; IVP over 2-5 min • IV form may be given rectally

• Drug of choice • Children are more susceptible to the therapeutic effects • Short-acting; no active metabolites • Less risk of hypotension than midazolam6

midazolam (Versed) >6 months

PO/PR: 0.2-0.5 mg/kg Intranasal: 0.2 mg/kg IV: 0.05 mg/kg; IM: 0.1-0.15 mg/kg Max: 10 mg; IM: 6 mg Cont IV: 0.06-0.12 mg/kg/hr • Dosing for sedation • Dose based on ideal body

weight in obese

PO SL/Buccal Intranasal IV SQ IM

Syrup: 2 mg/mL Injection: 1, 5 mg/mL • Injection may be given buccally • Oromucosal as effective as IV or PR diazepam • Divide IN between nares • Do not administer by rapid IV in neonates

• Short-acting; rarely used for agitation • May be useful as SQ continuous infusion for terminal restlessness37 • Higher risk of respiratory depression6 • Infants <6 months at higher risk for airway obstruction and hypoventilation

Barbiturates- for Terminal Sedation PHENobarbital38 PO: 2 mg/kg q8h

IV/IM/SQ: 3-5 mg/kg qhs Adult: 30-120 mg/day • Dosing for sedation

PO PR IV IM SQ

Elixir: 20 mg/5 mL Tablets: 15, 16.2, 30, 32.4, 60, 100 mg Injection: 65, 130 mg/mL • Well absorbed rectally; same dose as oral • Dilute injection with equal volume of compatible fluid

and administer at a rate NTE 1 mg/kg/min. Risk of extravasation.

• An alcohol free suspension can be made from PHENobarbital tablets (10 mg/mL)

• Used for terminal sedation; not routinely used for delirium or agitation • Significant drug interactions • Can cause hyperactivity in younger children • SE: Cognitive dysfunction, sedation, rash, ↓ bone density, respiratory depression • Signs of toxicity: drowsiness, nystagmus, ataxia • Avoid abrupt discontinuation • May aggravate absence seizures in high doses • More sedating than benzodiazepines

Antihistamine hydrOXYzine (Atarax, Vistaril) >2 yoa

PO/IM: 0.5 mg/kg q6h Max: <6 yoa: 50 mg/day; >6 yoa: 100 mg/day Adult, PO/IM: 50-100 mg q6h • Dosing for anxiety

PO IM

Solution : 10 mg/5 mL (Atarax), 25 mg/5 mL (Vistaril) Tablets: 10, 25, 50 mg Capsules: 25, 50, 100 mg Injection: 25, 50 mg/mL • IM painful; IV & SQ not recommended • Injection contains benzyl alcohol

• Atarax (hydrOXYzine HCL) & Vistaril (hydrOXYzine pamoate) are different salt forms of same active drug • SE: anticholinergic (may worsen delirium), sedation, dizziness, dry mouth • High risk of thrombosis and extravasation with IV

*Use cautiously in patients outside of FDA & manufacturer recommended age parameters. **Do not exceed usual maximum adult starting doses. Not intended for use in neonatal population.

44


45


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36. Devlin JW, Roberts RJ, Fong JJ, et al. Efficacy and Safety of Quetiapine in Critically Ill Patients With Delirium: A Prospective, Multicenter, Randomized, Double-Blind, Placebo-Controlled Pilot Study. Crit Care Med 2010;38(2):419-27.

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47

INDEX PPCC

i

abbreviation, 35‐36

abdomen, 5, 19, 24, 43, 62, 67‐

68, 70‐71, 74, 76, 98, 100, 103,

134, 138, 147, 153, 181, 183‐

184, 192, 216, 274, 294‐295,

299‐300, 304, 307, 317, 354

absorption, 15‐17, 21‐24, 26‐

27, 31, 96, 98, 100, 111, 113,

136‐139, 172, 175, 201, 242,

257, 264, 267, 271, 275, 295,

298‐299, 310, 315, 319, 321,

352‐353, 355

abstinence, 86, 238, 323

acetaminophen, 24, 33, 130‐

131, 133, 160, 172, 176, 199,

202, 208‐209, 216, 222, 252,

316, 325, 335, 347

acetazolamide, 120, 259

acetylcholine, 181, 185, 194

acetylcysteine, 252

acidosis, 18, 37, 109, 120, 153,

261, 267, 292, 314

acinetobacter, 153

actinomyces, 155, 159

acupressure, 77, 87, 185, 199

acupuncture, 77, 87, 144, 163,

185, 199, 280

acyclovir, 160, 172, 240

addiction, 57

adenocarcinoma, 134

adenoidectomy, 78, 84, 204,

206, 208, 213, 290

adenovirus, 96, 152

adherence, 9, 11, 13, 33‐34,

86, 200, 257

adjuvants, 125, 128, 172, 180,

199‐200, 208, 217, 225, 232

adolescent, 33, 46‐47, 61, 74,

83, 92‐95, 128, 133, 163, 168‐

169, 255, 270, 288, 291, 293,

296, 299

adrenal, 50‐51, 53‐54, 97, 106,

113‐114, 125‐126, 184, 190,

218, 223, 243‐244, 316, 319‐

320, 349

adult, 1‐2, 9, 11, 13, 15‐20, 23,

37‐39, 42‐44, 46‐51, 54‐55, 57‐

59, 64, 70‐72, 75, 78, 80‐81,

85‐87, 89‐90, 95, 100‐101, 103,

106, 112‐114, 117, 119‐120,

125‐126, 128, 131, 134, 136,

138‐139, 144‐148, 155‐161,

165‐166, 170, 172‐173, 177‐

178, 186‐190, 193, 196, 199‐

200, 202‐203, 208‐211, 213‐

214, 216‐218, 222‐223, 226‐

230, 232‐238, 240‐245, 252,

255, 257, 262‐263, 265‐268,

270‐272, 275, 281, 288, 291‐

293, 296, 299, 301‐302, 304,

314‐315, 320, 325, 349, 354‐

355

aerosol, 24‐25, 29, 302

aerosolized, 22, 24, 29, 252

agenesis, 294, 323

aggression, 47, 59, 61, 261,

266, 318

agitation, 31, 33, 37‐47, 59, 85,

88, 136‐137, 143, 146‐147,

180, 197, 203, 270, 277, 320‐

321, 323, 325, 352

agrophobia, 55

airway, 24‐25, 44, 58, 76‐77,

109‐110, 144, 249, 256, 286,

295‐296, 299‐301, 305, 309‐

310

akathisia, 55, 58, 337

albumin, 117, 314

albuterol, 19, 113, 162, 302,

339

alcohol, 18, 43‐44, 50, 57‐59,

64, 72, 78, 100, 104, 106, 112‐

114, 119, 125, 130, 134, 137‐

138, 143, 146‐147, 165‐166,

177, 186‐190, 202, 217‐218,

223, 226, 243‐245, 255, 258,

262‐263, 265, 267, 275, 280‐

281, 291, 314, 316‐319, 352‐

353, 355

aldactone, 120

aldosterone, 118

alfluzosin, 339, 347

algorithms, 46‐47, 53, 61, 74,

83, 92, 103, 116, 122, 133,

141, 150, 161, 168, 175, 180,

192, 205, 213, 225, 232, 247,

254, 270

alimentary, 53, 128, 170‐171,

175, 247

alkaline, 70, 303

allergies, 19, 76‐77, 83‐84, 97,

116, 119‐120, 154, 161, 173,

183‐184, 186, 200, 240‐242,

250, 309, 323

allodynia, 204, 232

allopurinol, 129

alprazolam, 24, 57, 240, 335,

340

alveolar, 111, 286, 300, 308

amantadine, 339‐340

ambrisentan, 345

ambulatory, 49, 51, 100, 128,

185, 323, 341

aminobutyric, 194, 207, 273

aminocaproic, 297

aminoglycosides, 76, 154‐155,

314

amiodarone, 336, 339‐340

amitriptyline, 59, 90, 228, 232,

279, 335, 337‐339

amlodipine, 117, 240, 335, 340

amnesia, 51, 262

amoxicillin, 153‐154, 158, 173,

345

amphotericin, 76, 129, 160

ampicillin, 155, 158

anaerobic, 153, 155, 300

analgesia, 27, 39, 112, 125,

128, 143, 169, 172‐173, 175,

200‐203, 206, 208, 210, 213‐

214, 217, 220‐222, 225, 230,

232‐239, 241‐242, 247, 262,

279, 296, 318, 356

anaphylaxis, 54

anencephaly, 288, 306‐307,

323

anesthesia, 33, 39‐40, 46, 56,

78, 122, 131, 144, 146, 150,

172, 175, 177, 205, 214, 228,

242, 290, 335

angiotensin, 76, 279, 335

PPCC INDEX

ii

anorexia, 48‐50, 52‐53, 67, 74,

76, 87‐88, 90, 105, 143, 185,

192, 200, 221, 323

anoxia, 273, 306

antacids, 70, 135‐139, 157,

303, 340

anthracyclines, 170

antiarrhythmics, 88, 236, 338

antibacterial, 161

antibiotics, 20, 27, 76, 96‐97,

99, 101, 103, 119, 129‐130,

143, 151‐155, 157‐159, 161,

170, 172‐173, 181, 241, 286,

290, 292, 296, 301‐303, 335

anticholinergic, 27, 37, 44, 63‐

64, 67, 79‐81, 90, 104, 106,

109, 165, 185‐189, 217‐218,

243, 250, 254, 279, 309, 338

anticoagulants, 109, 131, 155‐

156, 221

anticonvulsants, 23, 62, 67,

117, 129, 145, 264‐268, 272,

279, 321

antidepressants, 56, 59, 62, 67,

85, 87‐90, 92, 94, 129, 162,

164‐165, 177‐178, 185, 204,

227‐228, 232, 236, 242, 244,

274, 279, 296, 335, 337‐338

antiemetics, 23, 27, 51, 54‐55,

185‐188, 192, 236, 337‐338

antiepileptics, 29, 227, 229,

249, 256, 260, 264, 270‐272,

289, 292‐296, 309‐310, 338

antifibrinolytics, 297

antiflatulant, 139, 146

antifungals, 106, 139, 153,

160, 172‐173, 240‐242

antihistamines, 41, 44, 51, 59,

78‐80, 83, 162, 164‐165, 172,

185‐186, 188‐189, 241, 243,

279, 335, 338

antihypertensives, 97, 279

antimicrobials, 18, 33, 130,

151, 153, 161, 175, 279, 281

antimuscarinic, 72, 254, 317

antineoplastic, 51, 192

antipsychotics, 33, 39, 41‐43,

46, 55, 58, 88, 144, 236, 296,

335, 337‐338

antipyretics, 23, 125, 129‐131,

133

antispasmodics, 63, 177, 180,

275, 277, 338

antitussives, 80, 83, 148

antivirals, 106, 160‐161, 172,

335

anuria, 71, 119‐120, 317

anxiety, 31, 33, 37‐38, 40, 43‐

44, 48, 51, 54‐61, 85‐88, 92,

94‐95, 104, 109‐112, 143, 162‐

165, 177, 181, 183‐186, 189‐

190, 193, 203, 205, 221, 240‐

241, 244, 255‐256, 262, 274,

279, 286, 300, 323, 325

apathy, 38‐39, 86, 93, 124

apnea, 43, 57, 84, 125, 134,

162, 206, 213, 256, 290, 294,

307‐309, 313, 323

appendicitis, 97, 183‐184

appetite, 48‐49, 51, 53, 78, 85‐

86, 88, 90, 98, 106, 126, 181,

195, 221, 243, 301, 318

aprepitant, 335‐336

aspartame, 18, 64, 90, 100,

126, 138, 147, 155‐156, 158,

189, 210, 218, 230, 317

aspartate, 207, 227, 234, 237

aspergillosis, 160, 299, 301

asphyxia, 255, 306, 313

aspiration, 21, 69, 75‐78, 104‐

106, 129, 134, 144, 151, 172,

250, 256, 286‐287, 293, 308‐

309, 323

aspirin, 130‐131, 173, 202,

204, 209, 222, 303, 343‐344

asthenia, 88, 151

asthma, 19, 29, 54, 76, 78, 83,

109‐110, 116, 131, 135, 173,

209, 222, 303, 323, 349

ataxia, 44, 80, 226, 245, 261,

265, 267, 289, 293, 295, 308,

319

atomizer, 26‐27, 262

atonic, 258‐259

atopic, 240

atresia, 134, 295

atrophy, 66, 220, 296, 307,

323, 357

atropine, 64, 99, 217, 254, 279,

316, 338

autism, 42, 47, 294

autonomic, 129, 181, 183, 185,

258, 288, 337

azithromycin, 154, 157, 303,

339

baclofen, 144, 150, 177, 180,

274‐275, 277‐278, 338

bacteria, 76, 84, 97‐99, 103,

129, 151, 155‐157, 171, 184‐

185, 240, 290, 295‐296, 301,

313

barbiturates, 41, 44, 85, 143,

203, 265, 336

barriers, 2, 13‐14, 16, 64, 99,

136, 152, 177, 189, 196, 217,

250, 274‐275, 277, 314‐315,

317

batten, 2, 288, 307

behavioral, 38, 46, 54‐57, 67‐

68, 86‐89, 92‐93, 95, 145, 163‐

164, 168, 193, 196, 199, 205,

207, 255, 261, 266, 289, 291,

295, 318

benzodiazepines, 33, 37, 41,

43‐44, 56‐58, 62, 67, 85, 109,

111‐113, 125, 129, 143, 146,

164‐165, 168, 177, 185‐186,

203‐204, 262, 264, 274‐275,

335

benzonatate, 80, 148, 346

bereavement, 3, 13, 86, 285,

357

beverages, 42, 58, 71, 100,

124, 134, 143, 186

bicarbonate, 118, 136, 138,

147, 171, 344

bilirubin, 70, 153, 314, 317

bioavailability, 31, 201, 289,

315

INDEX PPCC

iii

bioequivalent, 145, 156, 229,

268, 303

bioethics, 3, 12, 14, 287, 312,

357

biofeedback, 56, 68, 199

bipolar, 86, 88, 296

bisacodyl, 24, 69‐70, 343‐344

bisphosphonates, 222, 293

bites, 105, 148, 240, 256

bladder, 256, 258, 300, 310,

323

bleeding, 23, 50, 71, 93, 100,

106, 113‐114, 120, 125‐126,

131, 171, 173, 183, 190, 200,

209, 218, 222‐223, 243‐244,

250, 286, 297, 303, 316, 319‐

320, 323

bleomycin, 129, 170

blindness, 162, 164, 291, 294‐

296

bloating, 19, 22, 67, 71, 101,

134, 183, 280

bolus, 21‐22, 120, 122, 173,

201, 264, 317, 353, 355

bosentan, 347

botulinum, 78, 274, 278

bowel, 21, 23, 48, 50, 62‐64,

66‐69, 72, 74‐75, 86, 97‐98,

128, 134, 136‐137, 139, 146,

181, 183‐184, 186‐188, 201,

203, 216, 218, 220, 256, 295,

299, 309, 318, 323, 349

bradycardia, 137, 147, 236,

262, 316, 320

brain, 2, 16, 37, 54, 64, 85,

117, 122, 129, 162, 177, 181,

189, 194, 207, 217, 225‐226,

235, 240, 250, 255, 258, 265,

270, 273‐275, 277, 288‐295,

306‐308, 314‐315, 317

brainstem, 143, 194, 309

bran, 68, 71, 74

breasts, 67, 78, 96, 241, 303,

323, 354

breathing, 12, 15, 24‐26, 29,

55, 104, 109‐111, 116, 144,

162, 197, 238, 249‐250, 255‐

256, 279‐280, 286, 288, 290,

293‐294, 300‐301, 308‐309,

337

buccal, 22, 43‐44, 57‐58, 146,

177, 261‐264, 270, 275, 318,

320

budesonide, 347, 349

bulimia, 90, 183

bumetanide, 119, 122

buprenorphine, 201‐203

bupropion, 90, 94‐95, 240,

335‐337, 340, 343, 347

burning, 19, 152, 170, 177,

196, 226, 228, 240, 242, 279,

288, 353

buspirone, 59, 61, 158, 335,

340

butyrophenones, 184, 186

cachexia, 48‐50, 52‐53, 74,

105, 109, 185, 192

caffeine, 54, 99, 113, 134, 162‐

163, 280, 316, 335

calcitonin, 222, 225

calcium, 85, 100, 117‐118, 136‐

137, 156, 172‐173, 275, 289,

294, 335, 337

camphor, 100, 242, 247

cancer, 2, 12, 37, 46, 48, 51,

53‐54, 61‐62, 66, 75‐76, 86,

94‐95, 116, 123, 125, 128, 133,

151, 161, 171, 175‐176, 185,

199, 204, 206, 208, 213‐216,

220‐221, 225‐226, 232‐233,

237‐238, 247, 249, 254, 283,

288, 323‐324

candida, 104, 106, 151‐153,

160‐161, 170‐172, 240‐241,

279‐280

canker, 104, 280

capsaicin, 177, 228, 242

carafate, 139, 173

carbamazepine, 42, 145, 229,

259‐261, 265, 270‐271, 289,

336‐338, 340, 343‐344

carbapenems, 154

carbidopa, 279, 294

carbohydrate, 290‐292

carcinoid, 98, 240

carcinoma, 54, 85, 129, 283

cardiac, 76‐77, 88, 95, 109,

117, 128, 137, 213‐214, 235,

275, 289‐290, 292, 296‐297,

307, 315, 323, 339, 349

cardiovascular, 42, 54, 58‐59,

87, 95, 126, 128‐129, 144, 225,

281, 288, 300

caregivers, 7‐8, 10, 12, 17, 19,

22‐23, 27, 34, 39‐41, 48, 77,

85, 110, 118, 130, 162‐164,

176, 196‐197, 200, 235, 249,

280, 285‐286, 293, 352

carisoprodol, 178, 277, 335,

338

carvedilol, 117, 335, 340

cefazolin, 155, 340

cefdinir, 154, 156

ceftriaxone, 153‐154, 156, 314,

340

cefuroxime, 154, 156, 344

celecoxib, 221, 225, 335‐336

celiac, 67, 97‐98, 184, 217, 297

cellulitis, 152‐153

cephalosporins, 129, 153‐157,

161, 173

cerebral, 2, 37, 39, 41, 104,

117, 120, 143, 178, 180, 184‐

186, 189‐190, 249, 254‐255,

273‐274, 277‐278, 290‐291,

306‐308, 311, 323

cetirizine, 79, 340

chaplain, 87, 111

chemoreceptors, 184‐187

chemotherapy, 17, 48, 62, 67,

72, 85, 97, 104‐106, 134, 170‐

173, 175, 181, 184‐188, 192,

226, 341

chipps, 1, 83, 357

chlamydia, 77, 152, 157

chloramphenicol, 153, 336

chlorothiazide, 120, 279

chlorpheniramine, 79, 243,

335‐336, 338, 344

PPCC INDEX

iv

chlorpromazine, 24, 31, 42, 46,

56, 58, 144, 184, 186‐187, 256,

335‐340, 354

choking, 77, 90, 100, 104, 134,

250, 280

cholecystitis, 183‐184, 296,

299, 323

cholestasis, 240‐241, 244‐245,

247‐248, 299

cholesterol, 42‐43, 293, 335

cholestyramine, 100, 241, 244,

247

cholinergic, 39, 54, 249‐250,

280‐281

chromosomal, 2, 288, 296‐298,

306‐307, 336

chylothorax, 66, 220

ciprofloxacin, 154, 157, 336,

339

circadian, 129, 164, 349

cirrhosis, 117‐118, 248, 279,

299

citalopram, 88‐89, 93‐94, 335‐

337, 339

clarithromycin, 154, 236, 335‐

336, 339

cleft, 151, 307

clobazam, 259, 263, 271

clomipramine, 335‐336, 338‐

339

clonazepam, 24, 43, 57, 177,

261, 263, 275, 340

clonidine, 178, 180, 208, 277,

279, 340, 345

clostridium, 96, 151‐152, 155,

158

clotrimazole, 153, 172‐173,

242

clotting, 49, 109, 221, 297

clozapine, 335, 338‐339

coagulopathies, 355

codeine, 78, 83‐84, 200, 202‐

204, 206, 208, 210, 213, 216,

240, 279, 335

cognition, 9, 17, 24, 37‐39, 43‐

44, 54‐57, 68, 87, 89, 93, 95,

124, 177, 193, 199, 205, 245,

261, 263, 265‐267, 272, 275,

288‐290, 292, 294‐297, 306,

319, 321, 337

colic, 62‐63, 216‐218

colon, 66, 69, 216, 220, 349

combativeness, 38, 40, 262

compounds, 20, 23, 30‐32,

172, 217, 307, 317

consciousness, 37‐38, 151,

256, 258, 352

constipation, 33, 37, 43, 48‐49,

53‐55, 62, 64, 67‐75, 79, 88,

98, 100, 103, 111, 136‐137,

177, 181, 183‐189, 192, 203,

216‐217, 228, 235, 241, 244,

250, 261, 280, 300, 308‐310,

323, 338

contraindications, 50, 64, 69,

71‐72, 84, 89‐90, 100, 137,

139, 145‐146, 158‐159, 187‐

189, 206, 213, 229, 268, 318

conversations, 9‐12, 264, 357

convulsant, 130, 255‐256, 258,

265‐267, 270‐271, 319

coping, 9‐11, 13, 87, 110, 196

corticosteroids, 24‐26, 37, 49‐

50, 63, 66, 78, 85, 106, 109,

113‐114, 125‐126, 134, 143,

152‐153, 162, 164, 177, 185‐

186, 190, 217, 222‐223, 225,

241‐244, 265, 292, 349

cough, 19, 33, 76‐84, 104‐105,

109, 134‐136, 144, 150, 152,

250, 252, 266, 286, 300‐301,

308‐310, 318, 323

counseling, 54, 56, 111, 203,

341

crackles, 300, 309

cramping, 19, 22, 49, 69‐71,

98, 100, 118, 136‐137, 152,

176, 216‐218, 289

creatinine, 15‐16, 170, 314

crying, 24, 38, 195, 197, 205,

256, 258, 290, 313

culture, 7, 20, 98, 173, 301

cyclobenzaprine, 178, 279,

335, 338, 343

cyclophosphamide, 170, 335,

344

cyclosporine, 335, 340

cyproheptadine, 51, 53, 243,

338

cytotoxic, 22, 129, 170, 172

dairy, 70, 137, 281, 303

deficiency, 19, 30, 54, 69, 78,

97, 99, 145, 204, 208, 258,

288‐290, 294‐296, 299, 307

deformities, 162, 290‐291,

293, 306, 308‐310

degenerative, 109, 226, 255,

292‐293, 296, 306, 308, 310

dehydration, 67, 71, 96, 98‐

100, 109, 118‐119, 130, 134,

159‐160, 170, 176, 181, 183,

186, 204, 249, 279, 295, 299,

355‐356

delirium, 33, 37‐47, 54‐55, 63,

85, 151, 162, 164, 203‐204,

250, 255, 323, 338, 352

dental, 279, 281, 289, 297, 309

dependency, 69, 126, 237,

255, 295

depressants, 18, 26, 39, 44, 48,

51, 55‐56, 58‐59, 61, 71, 78‐80,

85‐95, 99‐100, 104, 112, 124,

128, 143, 153, 162‐165, 173,

183, 186‐189, 193, 203‐204,

208, 211, 221, 227, 235‐236,

244, 262, 279, 300, 316, 319,

323

dermatitis, 18‐19, 42, 186, 240,

250

desipramine, 59, 90, 232, 335,

339‐340

deterioration, 291, 294‐295,

308

developmental, 2, 4, 8‐9, 15‐

17, 28, 33‐34, 37‐39, 46‐47, 58,

61, 67, 74, 85‐86, 89, 104, 119,

122, 153, 168, 175, 192, 194‐

196, 205, 235, 270, 285, 288‐

297, 299, 306‐307, 311, 313‐

314

INDEX PPCC

v

dexamethasone, 18, 24, 50, 53,

106, 113, 117, 119, 125, 185‐

186, 190, 223, 225, 243, 261,

265, 316, 335‐336, 354

dexmedetomidine, 339, 354,

356

dexmethylphenidate, 162,

339‐340

dextroamphetamine, 126, 128,

339

dextromethorphan, 78‐81, 83,

335, 345

diabetes, 18, 97‐98, 184‐185,

227, 232, 240, 279, 292, 299,

302, 305, 323, 351

diaphoresis, 38, 55, 216, 323

diaphragm, 143‐144, 150, 181,

309

diarrhea, 19, 22‐23, 62, 67, 70‐

71, 74‐75, 78, 88, 96‐100, 102‐

103, 136, 151‐153, 155, 158,

170, 173, 181, 183, 185, 188,

192, 280‐281, 286, 289, 295,

323

diazepam, 23‐24, 43‐44, 57‐58,

112, 177, 180, 261‐264, 270‐

271, 275, 278, 316, 318, 335,

354

diclofenac, 335, 343

dicyclomine, 189, 217, 338

diet, 18, 48‐49, 68‐69, 71, 97‐

99, 105, 108, 118, 124, 134‐

135, 171, 250, 289, 293, 299,

303

digestive, 74, 192, 279, 297,

299, 308‐309

diphenhydramine, 31, 50, 72,

79, 83, 139, 159‐160, 165, 168,

172, 185‐188, 243, 279, 336,

338‐340, 354

disabilities, 2, 5, 47, 74, 86,

168, 194, 273, 288‐290, 293‐

294, 296‐297, 306‐308, 311

discontinuation, 33, 36, 41, 43‐

44, 57, 59, 63, 77, 88‐89, 92‐

93, 99‐101, 113, 125, 164‐166,

168, 203, 210, 227, 230, 237‐

238, 244‐245, 257, 274, 285,

301‐302, 319, 337

disease, 1‐3, 5‐6, 10, 12, 17‐18,

23, 33, 37, 42, 48, 51, 53‐55,

57‐58, 66‐67, 69, 76‐77, 84, 95,

97‐98, 101, 104, 109‐111, 117‐

118, 120, 128‐129, 134, 141‐

143, 154‐157, 161‐162, 164,

173, 176, 178, 180, 183‐187,

196, 200, 206, 213, 216‐217,

221, 226, 240, 245, 247‐248,

255, 270, 273, 277, 279, 281,

285‐286, 288‐305, 307‐311,

313, 323, 349, 354, 357

disopyramide, 338‐340

distention, 5, 62‐63, 100, 134,

143‐144, 146, 153, 183, 216,

300, 354

distraction, 56, 105, 124, 185,

196‐197, 199, 241

distress, 12‐13, 23‐24, 37, 39,

48, 85, 104, 109‐110, 113, 123,

189, 196‐197, 249, 274, 285,

287, 294, 312, 313‐314, 323,

337

disulfiram, 18, 336

diuretics, 113, 117‐120, 122,

162, 267, 279, 294, 297, 317,

321

divalproex, 145, 229, 268, 344

dizziness, 18, 44, 51, 71, 79‐80,

88, 90, 100, 118‐120, 136‐138,

146‐147, 177‐178, 229, 242,

261, 317, 320

dobutamine, 339, 341

documentation, 10, 13, 34‐35,

118‐119, 176, 242, 249, 255,

266, 318

docusate, 24, 63, 69‐70, 75,

344

dopamine, 72, 90, 181, 184,

194, 294, 337, 339, 341

doxepin, 59, 244, 338‐339

doxycycline, 153‐154, 346

drainage, 26, 117‐118, 151‐

152, 250, 300

drooling, 43, 57, 104, 177, 249,

254, 263, 275, 309

drowsiness, 44, 78‐81, 88, 90,

99, 120, 148, 163, 177, 218,

243, 245, 252, 261‐262, 265,

267, 275, 319, 338

duloxetine, 89, 94, 335, 337,

341, 344

dying, 12, 46, 48, 61, 69, 111,

130, 151, 154, 249, 286

dyskinesia, 50, 64, 72, 76, 139,

146, 187‐188, 318, 337

dyspepsia, 88, 106, 134‐138,

140, 142, 162, 183‐184, 300,

323

dysphagia, 48, 104‐106, 108,

143, 170, 249‐250, 280, 293,

300, 307, 310, 352

dyspnea, 19, 33, 37, 39, 54‐55,

77‐78, 88, 109‐113, 115‐116,

118‐119, 128, 143, 162, 165,

235, 249, 286, 295, 300, 310,

313, 323, 325

dystonia, 83, 180, 277, 293,

296, 337

dystrophy, 2, 67, 226, 292, 323

ears, 64, 76, 84, 151‐152, 171,

189, 218, 289, 294, 297

edema, 54, 63, 109, 117‐122,

136‐138, 147, 225, 229, 249,

295, 323, 354

electrolytes, 37, 39, 54, 69, 74,

118‐119, 135, 176, 181, 186,

236, 240, 279, 294, 298, 313,

317, 355

embolism, 54, 109, 323

encephalopathies, 39, 54, 143,

145, 157, 183‐184, 226, 229,

268, 306, 308, 313, 323

endocrine, 54, 85, 97, 194,

292, 299‐300, 349

enema, 23, 69‐71, 317

enterobacter, 153, 156‐157,

159

enterocolitis, 100, 103, 105,

135‐136, 141, 159, 184, 295,

313, 321

PPCC INDEX

vi

environmental, 37, 56, 105,

162, 199, 250, 307

enzymes, 76, 78, 88, 203‐204,

208, 210, 217, 234, 236, 241,

257, 260, 262, 266, 279, 281,

288‐290, 292‐296, 299, 303,

307, 315, 335‐336

epidural, 201, 208, 247

epigastric, 134, 172, 183

epileptic, 54, 129, 227, 255‐

259, 264, 266‐268, 270‐272,

274, 288, 291, 306, 308‐309,

321, 335, 337, 357

eps, 41‐43, 50, 58, 64, 72, 79‐

81, 139, 144, 146, 186‐189,

318, 337

equianalgesic, 202, 214, 233,

236‐237

erythema, 67, 129, 152, 170‐

171, 226, 279‐280

escitalopram, 58, 88‐89, 94,

336‐337, 339

esomeprazole, 138, 141‐142,

346‐347

esophagitis, 104, 106, 134,

141‐142, 170, 183‐184, 216,

286, 299, 309

ethics, 8

ethnicity, 11, 196, 205

everolimus, 170, 343, 347

excipients, 18‐19, 21, 28, 30

excretion, 70, 122, 315, 317

existential, 55‐56, 193

expectorant, 76‐78, 109, 249‐

250

extemporaneous, 64, 120, 144,

177, 189‐190, 245, 268, 272,

275

extrapyramidal, 41, 50, 72,

186, 318, 337

extravasation, 44, 80, 112,

120, 178, 187, 189, 245, 265,

267, 319

famotidine, 137, 141, 146, 339

fatigue, 3, 42, 53, 55, 76, 86‐

90, 104, 116, 118, 123‐125,

127‐128, 143, 164, 178, 221,

258, 261, 266, 279, 289, 295‐

296, 300, 318

fecal, 39, 41, 67, 69‐70, 74, 97‐

98, 100, 183, 234

feeding, 5‐6, 21‐22, 28, 49, 67,

96, 104‐105, 108, 134‐136,

138, 141, 145, 151, 157, 161,

184, 201, 217, 229, 249, 257,

262, 264‐265, 267‐268, 270‐

271, 289, 291, 293‐294, 296‐

297, 303, 307, 309‐310, 315,

319, 321, 323, 343

felbamate, 259‐261, 336, 339

fentanyl, 28‐29, 111, 113, 116,

200, 202, 210, 213‐214, 238,

317, 321, 335, 343‐344, 354,

356

fever, 33, 37, 43, 64, 76, 98,

101, 124‐125, 129‐131, 133,

143, 151‐154, 161‐162, 209‐

210, 252, 255, 258, 288, 316,

323, 325, 337‐338

fibrosis, 2, 53, 67, 76, 78, 97,

109, 111, 116‐117, 134, 162,

252, 298, 300, 302, 304‐305,

323

fistulae, 66, 98, 183‐184, 220

flatulence, 19, 67, 71, 101,

138, 147

flavors, 20, 28, 31, 155, 158‐

161, 250, 281

fluconazole, 153, 160, 336, 339

fluids, 15‐16, 22‐23, 44, 50, 67‐

71, 77, 98‐100, 105‐106, 109,

114, 117‐118, 125‐126, 130,

137, 151‐152, 159, 163, 172,

190, 217, 223, 243‐245, 249‐

250, 265, 274, 277, 290, 292,

294‐295, 297, 309, 313, 316,

319‐320, 355

fluoxetine, 58, 61, 88‐89, 93‐

95, 232, 335‐336, 339‐341, 346

flush, 19, 21‐22, 28, 64, 99,

316, 338, 343, 353

fluvoxamine, 61, 88, 95, 335‐

337, 341

focal, 183, 255‐256, 258‐259,

271, 288, 299

forebrain, 237, 288, 307

forehead, 27, 195, 289

fosphenytoin, 261, 264, 267,

319, 339

fracture, 76, 109, 221, 226,

293, 300, 308‐310

frost, 205, 213, 220, 225

fruit, 68, 70, 97, 99, 134, 138,

147, 336

fungal, 30, 106, 155, 171, 223,

240‐242

furosemide, 109, 112‐113, 116,

119‐120, 122, 279, 317, 321,

339, 354

gabapentin, 117, 144‐145, 150,

227, 229, 259, 261, 266, 289,

345

gag, 78, 104, 134, 144, 250,

280, 308, 310

galactase, 19, 71, 288‐289, 323

gallbladder, 156, 183, 299

gasping, 18, 144, 197, 314

gastric, 15‐17, 21‐22, 48‐49,

134‐136, 139, 141‐144, 146,

170, 181, 183, 185, 187‐188,

200, 286, 292, 308‐310, 315

gastroenteritis, 74, 96, 103,

135, 141, 183‐184, 192

gastroesophageal, 21, 76, 106,

108, 134, 136‐138, 140‐142,

184, 186, 255, 297, 299‐300,

323

gastrointestinal, 17, 23, 48, 53‐

54, 62, 66, 69, 74‐75, 80, 97,

99, 101, 103, 108, 129, 135‐

136, 139, 141, 150, 155, 170,

175, 181, 185, 192, 216, 221,

226, 254, 256, 283, 288‐289,

299, 304, 306, 310, 320, 323

gastroparesis, 21, 98, 183‐185

gastroschisis, 295

gastrostomy, 21‐22, 63, 142,

291, 297

gene, 288‐291, 294‐295, 298,

307

INDEX PPCC

vii

genetics, 3, 37, 84, 97, 206,

213, 291‐294, 296‐297, 306‐

307, 309‐310, 312, 335‐336,

357

genitourinary, 299, 309

gentamicin, 154‐155

gestation, 15‐17, 196, 294,

314, 323

gingival, 152, 173, 261, 267,

309, 319

glomerular, 16, 314‐315

glucose, 41, 64, 101, 218, 256,

300, 302

glucuronidation, 112, 173, 203,

206, 211, 214, 314, 319

glycoprotein, 277, 279

glycopyrrolate, 18, 64, 106,

185‐186, 189, 217, 250, 254,

279, 317, 354

glycosaminoglycan, 290, 292,

295

grief, 3, 85, 357

guaifenesin, 78‐80, 83, 252,

340, 345

guanfacine, 279, 340, 345

gut, 2, 49, 66‐67, 74, 97, 185,

220, 295

haemophilus, 152, 154, 157,

301

hallucinations, 18, 38‐39, 64,

165, 178, 203‐204, 228‐229,

235, 250, 292, 316, 338

haloperidol, 24, 31, 33, 41‐42,

46, 56, 58, 125, 184, 186, 192,

204, 325, 335‐337, 339, 354

headaches, 18, 43, 71, 78, 86,

88, 90, 99, 129, 136‐137, 146,

152, 171, 183, 187, 252, 258,

261‐262, 300, 323

hemorrhage, 18, 129, 255,

273, 313

hepatic, 17, 23, 33, 39, 42‐43,

48, 51, 57‐59, 79‐80, 88‐90,

99‐100, 117, 119‐120, 131,

138, 144‐145, 147, 155, 157‐

159, 162‐163, 172‐173, 187,

200, 209, 217, 222, 228, 234,

241, 244, 255, 261, 263, 265‐

266, 268, 272, 275, 303‐304,

310, 314‐316

hepatitis, 117, 138, 184, 279,

314

hepatotoxic, 43, 47, 131, 145,

178, 209, 229, 264, 268, 272,

275, 316

hernia, 134, 184, 290

herpes, 104, 172, 306

hiccups, 31, 143‐150, 323

histamine, 136, 181, 185, 207,

210, 240‐241, 295, 317

honey, 77‐78, 83‐84, 105

hospice, 1‐5, 8, 11, 13‐14, 17,

23, 31, 33‐34, 37, 39, 69, 76,

83, 106, 129, 150‐151, 153,

161‐162, 164, 176, 204, 221‐

222, 225, 238‐240, 249, 255‐

256, 270, 301, 304, 310‐311,

314, 320‐321, 325, 356‐357

hospitalization, 5, 13, 33, 46,

54‐55, 59, 61, 75, 86, 90, 116,

151, 162, 214, 233, 238, 256,

286, 355

humidifier, 77, 111, 152, 279‐

280, 286

hydralazine, 129, 340

hydranencephaly, 290, 306‐

307, 323

hydration, 16, 77, 99‐100, 103,

119, 124, 134, 159, 161, 163,

171‐172, 250, 280, 295‐296,

355‐356

hydrocephalus, 143, 184, 273,

290‐291, 306

hydrochlorothiazide, 120, 279,

339

hydrocodone, 79, 81, 200, 202,

209, 340

hydrocortisone, 160, 227, 241‐

242, 335, 349

hydromorphone, 24, 112, 116,

200, 202‐204, 206, 210, 340,

344, 354

hydroxyurea, 170, 344‐345

hydroxyzine, 44, 59, 186, 188‐

189, 243, 336, 338, 340, 354

hygiene, 64, 124, 163, 189,

250, 281, 310

hyoscyamine, 18, 64, 185, 189,

217‐218, 317, 325, 338, 345‐

346

hyperactivity, 19, 38‐39, 44,

62, 78, 94, 168, 185, 245, 261,

265, 273, 289, 319

hyperalgesia, 204, 216, 235‐

236

hyperbilirubinemia, 153, 159,

313

hypercalcemia, 37, 67, 137,

181, 183, 279

hyperglycemia, 42‐43, 49‐50,

106, 113‐114, 125‐126, 183,

190, 218, 223, 243‐244, 279,

316, 319‐320, 323

hypernatremia, 71, 120, 255

hyperphosphatemia, 69, 71,

294

hyperplasia, 97, 184, 261, 267,

319

hypersensitivity, 64, 120, 176,

195, 317

hypertension, 41, 43, 50, 88‐

90, 106, 109, 113‐114, 117,

125‐126, 190, 218, 223, 243‐

244, 294, 296, 299, 316, 319‐

320, 323

hypnosis, 68, 87, 111, 144,

185, 199, 241

hypnotics, 59, 90, 123, 125,

165, 203

hypoalbuminemia, 37, 117

hypocalcemia, 143, 236, 255,

294, 339

hypodermoclysis, 354‐356

hypoglycemia, 37, 255, 291,

313, 323

hypogonadism, 289, 299

hypokalemia, 62, 67, 118, 120,

176, 236

hypomagnesemia, 176, 236,

255

PPCC INDEX

viii

hyponatremia, 37, 69, 71, 88,

120, 143, 145, 183, 229, 261,

265, 267, 297, 299

hypotension, 18, 37, 42, 44,

71, 88, 118‐119, 165, 178, 183,

208, 262, 267, 317‐319, 323

hypotonia, 291, 293‐294, 307‐

310

hypoxia, 37, 39, 54, 111, 255,

306, 308, 313, 323

ibuprofen, 117, 130‐131, 133,

173, 202, 209, 221‐222, 279,

303, 335, 345

ileus, 5, 23, 62, 100, 183‐184,

299

immune, 48, 129, 135, 151,

154, 162, 286, 296, 299, 314,

323, 326‐330, 335

immunocompromised, 2, 23,

53, 97, 128‐129, 152, 172, 185,

265, 323

incontinence, 67, 76, 279, 291,

300

indomethacin, 117, 297, 335‐

336

infancy, 4, 8‐9, 15‐16, 18‐20,

23‐24, 28‐29, 44, 46, 56, 58,

64, 66‐71, 74‐78, 97‐98, 103‐

104, 108, 110, 112, 119, 122,

130, 133‐136, 138‐139, 141‐

142, 147, 151, 154, 160‐161,

163, 166, 168, 173, 184, 189,

192, 194‐197, 201, 203, 205‐

207, 211, 213‐215, 217, 220,

232‐233, 237, 242, 255, 258‐

259, 266‐268, 272, 288‐297,

299, 301, 306‐307, 312, 313‐

315, 317, 320‐321, 323, 325,

355‐357

infections, 2, 24, 37, 39, 54‐55,

76, 83, 85, 97‐101, 103, 109,

129‐130, 135, 141, 143, 151‐

155, 157, 159, 161, 170‐173,

181, 183‐185, 226, 240‐242,

249‐250, 255‐256, 261, 274,

286, 289‐290, 292, 295‐296,

298‐299, 301, 305‐309, 313,

323, 353‐355

inflammation, 62‐63, 78, 98,

109, 117, 176, 217, 221, 240‐

241, 265, 296, 298, 353‐354

influenza, 152, 154‐159, 161,

301

inhalation, 24‐25, 36, 242, 302‐

303, 305, 315

insomnia, 33, 49‐50, 59, 76,

88‐90, 94, 106, 113‐114, 123‐

126, 136‐137, 143, 146‐147,

162‐166, 168‐169, 190, 203,

218, 221, 223, 243‐244, 249,

265, 316, 319‐320, 323

insulin, 64, 218, 299, 302, 336,

349, 351

interdisciplinary, 2‐3, 8, 34, 46,

48‐49, 53, 55, 61, 66, 74, 83,

92, 103, 108, 111, 116, 128,

141, 150, 168, 175, 192, 205,

213, 220, 225, 247, 270, 283,

304, 320

intestinal, 15, 62‐63, 66, 70,

74, 96‐98, 103, 135, 141‐142,

184, 216, 220, 289, 291‐292,

295, 299, 315, 352

intracranial, 120, 122, 181,

186, 190, 200, 255, 265, 267,

299

intractable, 75, 143‐144, 150,

192, 205, 270‐271, 287‐288

intramuscular, 36, 47, 154,

201, 215, 271, 274, 315, 356

intranasal, 29, 44, 58, 161,

169, 210, 214, 232, 263‐264,

270‐271, 317, 321

intrathecal, 36, 177, 180, 274‐

275, 277‐278

intravascular, 117‐118

intravenous, 35‐36, 154, 201,

206, 213‐215, 233, 238, 241,

247, 271‐272, 289, 314, 321,

355

intussusception, 62, 97, 184,

299

ischemia, 54, 117, 255, 295,

306, 313, 323

itching, 152, 201, 203, 240‐

242, 247‐248, 353

jaundice, 183, 289, 296, 299

jaw, 197, 249, 256

jejunum, 21, 185, 217, 264

kernicterus, 156, 183‐184, 314

ketamine, 175, 228, 232, 340,

354

ketoconazole, 336, 339

ketorolac, 117, 209, 222, 279,

340

kidneys, 37, 119, 153, 248,

268, 288‐289, 291‐292, 294‐

295, 307, 314, 323, 335

klebsiella, 151‐152, 155‐157,

159

lacosamide, 261, 266, 271

lactose, 19, 42, 98, 289

lactulose, 69, 71, 74, 289

ladder, 200, 206, 208, 213, 217

lamotrigine, 162, 257, 259‐

261, 266, 340

lansoprazole, 136, 138, 142,

147, 172, 336, 346

laxatives, 18, 23, 33, 63, 68‐71,

75, 97‐98, 241

lesions, 35, 86, 104, 152, 162,

170, 184‐185, 194, 221‐222,

241‐242, 265, 280, 288

lethargy, 38, 48, 124, 173

leukemia, 54, 129, 221, 240,

297

levetiracetam, 259, 261, 264,

266, 271‐272, 318, 321

levofloxacin, 157, 302, 305,

339

lidocaine, 31, 78, 106, 144,

156, 172‐173, 201, 227, 232,

242, 335, 354

lipids, 27, 41, 48, 160, 288‐289,

293‐294, 307, 315

lipophilic, 277, 314‐315

lissencephaly, 291, 306, 323

lithium, 337, 339, 345

INDEX PPCC

ix

liver, 23, 37, 42‐43, 66, 78,

101, 130, 142, 145, 156, 159,

183, 200, 203‐204, 206, 208,

216, 229, 234, 240, 245, 247‐

248, 261, 268, 289‐293, 295‐

296, 299, 304, 315, 335

loratadine, 80, 83, 279, 344

lorazepam, 18, 24, 31, 44, 46,

57, 113, 164‐165, 185‐186,

190, 204, 257, 261‐262, 271,

314, 318, 325, 340, 354

lovastatin, 335‐336, 343

lozenge, 36, 77, 80, 280, 343‐

344

lubricant, 20, 24, 69, 75, 279‐

280, 292

lungs, 24‐25, 55, 76, 109‐111,

134, 143, 153, 164, 185, 216,

249, 286, 289‐290, 293, 295‐

296, 300‐301, 304‐305, 308,

323, 335, 349, 354

lymph, 117, 240, 293

lymphoma, 54, 62, 85, 129,

240

macrolide, 154, 157, 186, 335

magnesium, 35, 69, 71, 85, 97,

118, 136‐137, 172, 303

malabsorption, 19, 97, 170,

289, 295, 299

malaise, 129, 137, 151, 183,

221

malformation, 151, 288, 290‐

291, 294, 296‐297, 306‐309,

311, 313

malignancy, 42‐43, 48, 53, 62,

66, 76, 85, 109, 117, 128, 131,

133, 151, 162, 176, 183, 214,

220‐221, 225, 233, 238, 240,

242, 337

malnutrition, 63, 151, 185

mannitol, 117, 120, 302

meals, 36, 49‐51, 68, 72, 99,

104‐105, 134‐139, 147, 158,

163, 171, 183, 185, 187‐188,

244, 280‐281, 303, 351

meclizine, 189, 279, 338

meconium, 70, 184, 299, 317

megestrol, 49, 51, 53, 117, 240

melatonin, 164, 166, 168‐169

meningitis, 30, 143, 157, 159,

183‐184, 306

menstrual, 145, 229, 258, 268,

297

meperidine, 158, 200, 202‐

203, 206, 279, 338

mesalamine, 343, 345‐346

metastases, 48, 85, 109, 111,

118, 185, 221‐222, 225, 255,

265

methadone, 24, 111, 200, 202,

210, 214, 227‐228, 230, 232‐

239, 279, 318, 335‐336, 339‐

340, 354

methicillin, 152, 156, 159, 301

methylphenidate, 87, 89‐90,

95, 126, 128, 162, 339‐340,

344

metoclopramide, 24, 31, 49‐

50, 55, 63‐64, 72, 97, 108, 135,

139, 141‐142, 144, 146, 184‐

188, 318, 325, 335‐337, 354

metolazone, 120, 122, 340

metoprolol, 117, 335, 340

metronidazole, 18, 99, 101,

153‐155, 159, 340

microcephaly, 291, 297

midazolam, 24, 26, 44, 47, 58,

146, 150, 169, 261‐264, 270‐

271, 318, 335, 354, 356

migraine, 26, 59, 88, 90, 145,

165, 183‐184, 255, 267‐268,

323

milestones, 291, 296

mimic, 55, 58, 85, 196, 255‐

256

mineral, 50, 69‐70, 75, 106,

122, 243, 295

mineralocorticoid, 113, 119,

125, 190, 218, 223

mirtazapine, 49, 95, 279, 339

mitochondrial, 226, 291‐292,

307, 311, 357

morphine, 18, 24, 35, 75, 78,

100, 112‐113, 172‐173, 175,

200, 202‐204, 206, 208, 210‐

211, 214‐215, 232‐233, 236‐

238, 240, 247, 319, 325, 340,

343‐345, 354

mortality, 18, 37, 77, 295‐296,

298, 306, 311, 320

mosaic, 296‐297, 306

motility, 15, 28, 49, 62‐63, 69,

72, 98‐100, 134‐135, 157, 185,

315

mouthwash, 31, 172, 281

mucopolysaccharides, 104,

281, 290, 292, 295, 357

mucositis, 26‐27, 48, 71, 76,

78, 98‐99, 104, 106, 118, 139,

144, 151‐152, 160, 170‐175,

183, 185, 201, 206, 228, 241,

249‐250, 280, 286, 299‐300,

309, 315

muscarinic, 249‐250, 254, 283

muscular, 2, 67, 292, 296, 307,

309, 323, 357

musculoskeletal, 54, 76, 88,

104, 178, 216, 221, 297, 300,

306

mutation, 288‐294, 298, 302,

304

mycin, 72, 186, 188, 303, 344

mycoplasma, 152, 154, 157

myoclonus, 176, 203‐204, 235,

258‐259, 261‐263, 266‐267,

270, 295, 313

myopathies, 50, 106, 113‐114,

125‐126, 162, 190, 218, 223,

243‐244, 316, 319‐320

myths, 111, 204, 235

nalbuphine, 202‐203, 244, 247

naloxone, 75, 83, 202‐204,

241, 244, 247, 340, 354

naproxen, 117, 131, 133, 209,

221‐222, 279, 335, 346‐347

nasal, 26‐27, 76‐78, 104, 144,

152, 295, 299‐300, 309

nasogastric, 63, 106, 271, 297,

321

nausea, 18, 22, 31, 33, 38, 48,

53, 55, 62‐63, 67, 70‐72, 74,

PPCC INDEX

x

78, 80, 88, 98‐100, 118, 122,

134, 136, 141, 148, 150‐153,

162, 165, 168, 181‐192, 200‐

201, 203, 216, 235, 252, 262,

281, 289, 323, 325, 352

nebulization, 19, 24‐25, 29, 36,

77‐78, 109, 111‐113, 116, 148,

252, 302‐303, 305

necrosis, 57, 69, 100, 105, 135‐

136, 141, 171, 173, 184, 263,

295, 313, 316, 321, 353

neonatal, 2, 15‐16, 21, 44, 46,

51, 53, 58‐59, 61, 64, 66, 72,

75, 79‐81, 83‐84, 90, 92, 97,

101, 103, 106, 108, 112, 114,

116, 120, 122, 126, 128, 131,

133‐134, 136‐139, 141‐142,

146‐148, 150‐153, 160‐161,

166, 168, 173, 175, 177‐178,

180, 182, 184, 190, 192, 196‐

197, 201, 203, 205‐206, 211,

213‐214, 218, 220, 223, 225,

230, 232, 238, 242, 245, 247,

252, 254‐255, 257, 262‐263,

268, 270‐272, 275, 278, 281,

283, 291, 293‐295, 299, 304‐

305, 313‐321, 323

nephrolithiasis, 261, 267, 272,

299

nephrotoxicity, 159‐160

neuralgia, 226‐227, 232, 240

neuroblastoma, 129, 216, 227

neurodegenerative, 67, 104,

162, 226, 249, 296, 306‐310,

312

neurodevelopmental, 164,

168, 294, 306‐308, 310‐312

neuroleptics, 31, 42‐43, 104,

337

neuromuscular, 69, 104, 109,

162, 164, 176, 194, 274, 352

neuronal, 194, 256, 288, 291

neuropathies, 87‐88, 164‐165,

176, 194, 196, 200‐201, 210,

221, 226‐230, 232, 234‐235,

238, 240, 242, 244, 266‐267,

288‐289, 291, 295, 299, 309

neurotoxicity, 112, 173, 176,

203‐204, 211, 234‐236, 261,

319

neurotransmitters, 181, 184‐

185, 194, 235, 241, 274

neutropenic, 68‐69, 130, 170,

201

newborns, 70, 141, 153, 289,

291, 304, 317

nhpco, 3‐4, 14, 320, 357

nicotine, 163, 279, 344

nightmares, 86, 165, 195

nmda, 207, 210, 227‐228, 230,

234‐235, 237, 318

nociception, 194, 199, 207‐

208, 213, 216, 221, 226, 228

nocturnal, 83‐84, 176

norepinephrine, 89, 207, 227,

234‐235, 337

nortriptyline, 59, 90, 94, 228,

335, 338‐339

nosebleeds, 297

npo, 36, 70, 264, 323

NSAIDs, 67, 97, 117, 130‐131,

134, 160, 162, 176, 181, 209,

221‐222, 228, 241‐242, 279,

335

numbness, 55, 148, 240, 242

nutrition, 17, 20‐22, 28, 49‐50,

63, 74, 98‐99, 103, 106, 108,

124, 130, 141, 152, 155, 162‐

163, 171, 175, 199, 250, 280,

289, 295‐300, 304, 309, 313‐

314

nystagmus, 44, 80, 229, 245,

265, 267, 308, 319

nystatin, 153‐154, 160, 172‐

173, 241‐242, 319

obesity, 41, 44, 58, 134, 162,

263, 323

obstruction, 23, 44, 48, 50, 54,

58, 62‐64, 66, 69‐70, 72, 76,

84, 97‐98, 109‐110, 117, 125,

136‐137, 139, 146, 181, 183‐

188, 201, 216, 218, 220, 298‐

300, 307, 309, 318, 352

occlusion, 26‐27, 62, 242, 295‐

296

octreotide, 63‐64, 66, 101,

218, 220, 354, 356

odor, 20, 49, 68, 154, 250, 252

olanzapine, 42, 47, 279, 335,

337, 339‐340

omeprazole, 136, 138, 142,

144, 147, 335‐336, 346‐347

ondansetron, 184, 186‐187,

192, 241, 247‐248, 335, 337,

339

ophthalmic, 27, 64, 281, 316

opioids, 29, 31, 33, 37, 48, 63,

68‐70, 85, 98, 109, 111‐112,

116, 123, 125, 128‐129, 172,

176‐177, 181, 184‐185, 199‐

210, 213‐214, 216‐217, 221‐

222, 227‐228, 230, 232‐238,

240‐241, 244, 247, 274, 279,

296, 300, 309, 317, 338, 343,

356

oromucosal, 44, 58, 263, 318

oropharyngeal, 172, 206, 250

orthostasis, 59, 90, 228, 323

osmotic, 22, 68‐69, 71, 78, 98,

117, 120, 160

osteogenesis, 2, 293, 323

osteoporosis, 136, 225, 299,

308‐309

otitis, 97, 134, 151‐154, 156,

158, 161, 184

ototoxicity, 118‐119, 159, 317

overdose, 18, 22, 28, 35‐36,

130, 181, 201, 204, 235, 252,

323, 343

overfeeding, 97, 134, 309

oversedation, 37, 39, 123

oxcarbazepine, 259‐261, 267,

336, 338, 340

oxybutynin, 279, 338

oxycodone, 24, 112, 200, 202,

209, 211, 240, 335, 340

oxygen, 55, 111‐112, 116, 164,

197, 279, 286, 300

pacemaker, 292, 323

pacifier, 19‐20, 199, 314

INDEX PPCC

xi

pain, 1, 3, 5, 7, 13, 19, 26, 28‐

29, 33, 36, 37‐39, 43, 46‐48,

53‐56, 59, 61‐63, 66‐67, 70‐71,

74, 76‐77, 83, 85‐88, 90, 92,

98, 103‐105, 109‐111, 116,

118, 122‐123, 125, 128, 133‐

134, 138, 141, 147, 150‐152,

161‐162, 164‐165, 168, 170‐

173, 175‐176, 178, 180‐181,

183, 186, 192‐210, 212‐218,

220‐223, 225‐230, 232‐240,

242, 244, 247, 254, 256, 266‐

267, 270, 274, 283, 285, 288,

292‐293, 295‐296, 300‐301,

310, 313, 317, 321, 323, 325,

353‐355, 357

palatability, 19‐20, 31, 69

palliative, 1‐4, 6, 8‐14, 17, 29‐

34, 39, 41, 46‐47, 53, 61, 66,

74, 76, 83, 85, 87, 92, 103, 105,

108‐109, 116, 122, 128, 133,

141, 144, 146, 150, 153, 161,

168, 175‐176, 180‐181, 186,

192, 194, 204‐206, 210, 213‐

214, 220, 222, 225, 232‐233,

237‐240, 247, 254, 270, 272,

277, 280, 283, 304, 311‐312,

313‐314, 320‐321, 323, 356‐

357

palpitations, 51, 55, 250

palsy, 2, 104, 180, 249, 254,

273, 277‐278, 293, 306, 308,

311, 323

pancrealipase, 346‐347

pancreas, 21, 54, 85, 98, 117,

145, 156, 183‐185, 216‐217,

229, 261, 268, 295, 298‐299,

303, 309, 344, 346

pancytopenia, 137, 147, 320

panic, 18, 55, 197

pantoprazole, 138, 142, 147,

335, 346

paradoxical, 41, 64, 78‐79, 113,

162, 164‐165, 188‐190, 217‐

218, 243, 262, 302, 317

paralysis, 64, 176, 189, 217,

274, 290‐291, 293, 317, 337

parenteral, 16, 22, 28, 49, 63,

117, 186, 232, 236‐238, 261,

264, 295‐296, 301‐302

paresthesia, 256, 261, 295

paroxetine, 88, 95, 279, 335‐

336, 338‐340

penicillins, 129, 153‐154, 240

peptic, 141, 183‐184, 186

perfusion, 111, 300, 310, 315

perinatal, 122, 320‐321, 357

peritoneal, 66, 117, 183, 216,

220

perphenazine, 335‐336

personality, 288, 352

pertussis, 76‐78, 154, 157, 184

pet, 56, 76, 87, 111, 199

pharmacists, 17, 20‐21, 23, 25‐

31, 33‐34, 74, 83, 92, 214, 233,

238, 270, 335, 338‐339, 343,

351

pharmacodynamics, 122, 141‐

142, 206, 213, 233‐234, 237

pharmacokinetics, 16‐17, 21,

23‐24, 26‐27, 47, 78, 83, 94‐95,

122, 141‐142, 162, 168, 175,

202‐204, 206, 208, 213‐214,

225, 233‐234, 237‐239, 262,

264, 267, 272, 314‐315, 319,

321

pharyngeal, 17, 76, 104, 134,

144, 151‐153, 184‐185, 309‐

310

phenobarbital, 41, 44, 90, 241,

245, 247, 257, 259‐261, 264‐

265, 271, 319, 335‐336, 341,

354

phenothiazines, 67, 184‐187,

192, 337

phenylketonuria, 18, 158

phenytoin, 22, 90, 136, 240,

259‐261, 264, 267, 270‐272,

289, 314, 319, 321, 335‐336

photosensitivity, 19, 79‐81,

113, 119‐120, 131, 138, 147,

243, 275, 317

phrenic, 143‐144, 148

physiotherapy, 77, 300

piroxicam, 335, 340, 344

pneumonia, 75‐76, 97, 104,

109, 134‐136, 141, 152, 154,

157, 161, 184, 249‐250, 286,

293, 299, 308, 323

polycystic, 145, 229, 268, 294

polymorphisms, 335‐336

polypharmacy, 33, 37, 144

popsicles, 20, 250, 280

positioning, 26‐27, 77, 105,

135, 141, 176, 199, 274, 308‐

309

postoperative, 205‐206, 214‐

215, 226, 232, 238

potassium, 118, 120, 158, 207,

299, 344‐345, 347

pregabalin, 117, 229, 259, 261,

270

pregnancy, 183‐184, 288, 291,

313, 357

premature, 2, 16, 18, 23, 75,

119, 122, 130, 272, 306, 313‐

315, 317, 323

probiotics, 101, 103

procainamide, 338‐339

prochlorperazine, 24, 184, 186,

338, 354

prognosis, 2, 5‐7, 11‐12, 48,

57, 117‐118, 130, 143, 288,

290‐292, 295, 304, 306‐308,

310‐311

prokinetic, 50, 63‐64, 72, 135,

139, 141, 146, 186‐188, 335,

337

prolapse, 289, 299

promethazine, 24, 79‐81, 165,

169, 184‐187, 189, 192, 335,

337‐339, 354

prophylaxis, 141, 159, 161,

172, 263, 290

prostaglandins, 112, 207, 216,

241

pseudoephedrine, 339, 343‐

345

pseudomembranous, 97, 155‐

156, 159, 170

PPCC INDEX

xii

pseudomonas, 153, 155, 157,

299, 301‐302, 305

psychiatry, 46‐47, 61, 92‐95,

128, 168‐169

psychogenic, 76‐77, 97, 184

psychopharmacology, 46‐47,

61, 92‐95

pulmonary, 2, 53‐54, 76‐77,

84, 109, 112, 117, 120, 249,

275, 281, 286, 290, 293‐294,

296, 298‐299, 301, 304‐305,

310, 323

pyogenes, 157‐159

quetiapine, 43, 47, 335, 339‐

340

quinidine, 335‐336, 338‐339,

341

quinine, 335, 339, 341

radiation, 48, 76, 97‐98, 104‐

106, 129, 170‐171, 173, 181,

222, 279, 281

radiotherapy, 104, 184‐185,

221, 283

ranitidine, 137, 141, 172, 320,

336, 354

rash, 44, 78, 145, 152, 229,

241, 245, 252, 261, 265‐268,

286, 319, 323

rectal, 23‐24, 28‐29, 31, 43‐44,

57, 63, 68‐71, 113, 129‐130,

144‐145, 165, 177, 183, 190,

201, 215, 232, 245, 261‐267,

270, 275, 299, 315‐319, 349

reflux, 5, 16, 21, 76, 104, 106,

108, 134‐138, 140‐144, 146‐

147, 181, 183‐184, 186, 255,

297, 299‐300, 308‐309, 313,

323

refractory, 38, 41, 63, 89, 112,

144, 146, 186, 214, 226, 233,

238, 242, 256, 264, 268, 271‐

272, 288, 321

regurgitation, 104, 134, 183

rehydration, 99, 101, 103, 185,

355

relationships, 3, 9‐10, 12, 30,

83, 87, 196, 201, 214, 233, 264

relaxation, 43, 56, 68, 87, 111,

134, 144, 163, 185, 199, 241,

258

renal, 2, 33, 42‐43, 57‐59, 79‐

80, 88‐90, 99‐100, 112, 117‐

120, 122, 129, 131, 136‐138,

143‐146, 155‐157, 159‐160,

162‐163, 172‐173, 177‐178,

181, 185, 200, 204, 206, 209,

211, 217, 221‐222, 228‐229,

234‐235, 241, 248, 255, 263,

266‐268, 275, 279, 288, 294,

296, 299, 303, 309‐310, 314‐

316, 318‐319, 323

respiratory, 2, 15, 18, 37, 42‐

44, 57‐58, 71, 76, 78‐80, 83,

98‐100, 104, 109‐112, 116,

141, 144, 151‐153, 161‐162,

173, 183, 186‐189, 197, 203‐

204, 208, 211, 235, 249, 261‐

262, 289‐290, 292‐296, 298‐

301, 306‐309, 313‐314, 319,

323

restlessness, 37‐40, 44, 46, 55,

110, 153, 162, 195, 197, 250,

337‐338

rifampin, 158‐159, 241, 248,

336

rigidity, 195, 273, 291, 337

risperidone, 43, 46‐47, 335,

337, 339, 341

sadness, 85‐86, 193

saline, 23, 26, 69, 77‐78, 109,

112‐113, 116‐117, 120, 122,

148, 152, 241, 252, 302, 353‐

355

saliva, 105, 152, 170, 201, 249‐

250, 279‐281

salmonella, 96, 157‐158

sandostatin, 63‐64, 101, 218

sarcoma, 62, 129, 221, 227

scopolamine, 64, 189, 217‐218,

279, 354

screening, 92, 163, 168, 289,

291, 295, 299, 357

secretions, 15, 26, 63, 76, 78,

96, 98, 109, 111, 113, 117‐118,

134, 249‐250, 252‐254, 279‐

280, 298‐300, 308‐310, 313,

315‐316, 323, 325, 356

sedation, 18, 33, 39‐44, 46, 50‐

51, 57‐59, 64, 72, 79‐81, 88,

90, 111, 123, 125, 139, 144,

146, 164‐165, 169, 177‐178,

186‐189, 192, 203, 208, 228‐

229, 235, 243‐245, 256, 261‐

263, 265, 275, 318‐319, 356

seizure, 18, 23, 26‐27, 29, 42‐

44, 46‐47, 51, 54, 57‐58, 76,

80, 88, 90, 126, 135‐137, 139,

144‐146, 157, 165‐166, 176‐

178, 180, 186‐189, 203‐204,

210, 229‐230, 255‐259, 261‐

272, 274‐275, 277, 288‐296,

307, 310, 313‐314, 316, 318,

321, 323

sennosides, 70, 75

sepsis, 37, 184, 295‐296, 313

serotonin, 56, 58, 88‐89, 93,

129, 162, 181, 184, 186, 194,

207, 216, 227, 234‐235, 240‐

241, 243, 279, 337

sertraline, 58, 88‐89, 94, 336‐

337, 339‐340

shaking, 18, 271, 321, 338

shivering, 129‐130, 197

shortness, 55, 104, 109, 301

sialorrhea, 249‐250, 254

sickle, 247, 295, 323

simethicone, 139, 146, 320

skeletal, 144, 178, 194, 222,

275, 289‐290, 292

sleeping, 76, 125, 130, 143,

195‐196, 201, 295, 324

sodium, 50‐51, 64, 70‐72, 78‐

80, 100, 106, 114, 117‐118,

125, 136‐139, 145‐147, 155‐

156, 171, 187‐189, 218, 223,

229, 234, 243‐244, 266, 268,

280, 298‐299, 316‐318, 320

softeners, 63, 68‐70

somatic, 86, 194, 199, 207‐

210, 212‐214, 216‐217, 221,

227, 230

INDEX PPCC

xiii

somatosensory, 207, 216

somatostatin, 63‐64, 66, 220

somnolence, 38, 42‐43, 49, 51,

88‐89, 123‐125, 127, 136, 145,

229, 256, 261, 266‐268

sorbitol, 19, 22, 24, 58, 69, 71,

75, 97, 119, 145, 229, 265, 280

spacer, 24‐25

spasms, 37, 39, 104, 106, 129,

176‐178, 180‐181, 200, 258‐

259, 267‐268, 273, 291, 307,

323

spastic, 46, 64, 176‐177, 180,

185, 189, 197, 217, 262, 270,

273‐275, 277‐278, 293, 296,

307, 309‐310, 317, 321, 323,

337

spectrum, 33, 155‐160, 264,

292

sphincter, 23, 97, 134

spinal, 2, 67, 143, 178, 194,

207, 217, 221‐222, 226, 232,

237, 273‐274, 290, 296, 307‐

308, 323, 357

spironolactone, 118, 120, 122,

321

spleen, 240, 289, 293, 295

SSRIs, 56, 58, 88‐89, 93, 95,

129, 158, 162, 227, 240, 279

staphylococcus, 152, 155‐157,

299, 301

starvation, 97, 99

steatorrhea, 98, 217, 300

stepladder, 199, 208, 216‐217

steroids, 37, 76, 117, 130‐131,

134, 162, 199, 208‐209, 216,

222, 241, 279, 335, 349

stiffness, 195, 256, 274, 290

strength, 105, 159, 228, 274,

293, 300, 325, 341

streptococcus, 151‐152, 154‐

158

stretching, 176, 216‐218, 221,

274

stridor, 110, 134‐135

subcutaneous, 27, 36, 47, 201,

206, 214‐215, 232, 237, 351‐

356

sublingual, 17‐18, 22, 31, 36,

63, 165, 201, 261‐262, 264,

279, 281

sucking, 195, 199, 290, 309,

314

suctioning, 21, 26, 29, 63, 105,

250, 286

suicidality, 42‐43, 49, 57, 59,

85‐89, 92, 165, 210, 227, 229‐

230, 244

sulfamethoxazole, 153‐154,

159, 314, 336

sulfonamides, 19, 76, 120, 129,

143, 153

suppositories, 23, 28, 31, 36,

69‐70, 80, 112, 131, 172‐173,

187, 189, 209‐211, 316‐317,

319, 325

swaddling, 26, 56, 199, 314

swallowing, 16‐18, 20, 28, 31,

49, 63, 72, 76, 104‐106, 108,

135, 152, 171, 173, 188, 201,

249‐250, 257, 264, 279‐281,

290, 292‐294, 303, 308‐310,

323, 338, 343

sweating, 88, 110, 129, 151,

181, 203, 281, 288, 298‐299,

338

syncope, 76, 88, 165, 183, 189,

255, 323

syncytial, 152, 301

syndromes, 42‐43, 48, 50, 53‐

55, 64, 76, 88‐89, 93, 97‐98,

100, 106, 113‐114, 117, 125‐

126, 130, 145, 151, 153, 159,

162, 164, 168, 183‐184, 189‐

190, 200, 204, 216‐218, 223,

226, 229, 238, 240, 243‐244,

256, 258, 261, 265‐266, 268,

270‐271, 279, 283, 289‐290,

294‐297, 299, 301, 306‐309,

313‐314, 316‐317, 319‐320,

323, 337, 339

taper, 33, 88, 92, 123, 125,

177, 203‐204, 237‐238, 257,

264, 274

tardive, 50, 64, 72, 139, 146,

187‐188, 318, 337

taste, 17, 19‐20, 48, 63, 70,

105, 137, 159, 185, 201, 266‐

267, 279, 286, 318

TCAs, 59, 67, 88, 90, 129, 158,

162, 164, 227‐228, 244, 279

teenagers, 20, 23, 56, 87, 270,

296

telithromycin, 335, 339, 345

temperature, 20, 27, 111, 120,

129‐130, 137, 143, 147, 151,

158, 163, 194, 291, 300, 302‐

303, 308‐309, 320, 338

tendon, 153, 157, 274, 292

teratogenic, 22, 145, 229, 265

thiazides, 118, 120, 122, 321

thickener, 21, 105, 135‐136,

141

thrombocytopenia, 23, 138,

145, 147, 153, 200, 229, 268,

297

thrush, 151‐154, 184, 281, 313

thyroid, 54, 85, 104, 240‐241

tiagabine, 259‐261, 341

tingling, 226, 240, 242

titrating, 68, 88, 100, 111, 144‐

145, 165, 177, 199, 201‐202,

208, 217, 228‐229, 235‐236,

244, 257, 265‐267, 272, 274‐

275, 304, 318, 321, 338

tobacco, 143, 151, 280, 336

tobramycin, 154‐155, 303

toddlers, 15, 74‐75, 163, 192,

195, 247

tongue, 17, 20, 100, 144, 152,

171, 280, 309, 320, 337

tonic, 255‐256, 258‐259, 262,

266‐267, 280

tonsillectomy, 78, 84, 175,

204, 206, 208, 213, 290

topical, 16, 18, 27‐28, 31, 36,

56, 106, 153‐154, 172‐173,

175, 177, 227‐228, 241‐242

PPCC INDEX

xiv

topiramate, 259‐261, 267, 272,

309, 336, 347

torsade de pointes, 235‐236,

238, 339

toxicities, 16‐18, 27, 31, 44, 58,

83, 88‐89, 135, 175, 178, 203,

235, 242, 245, 247, 261, 265,

319

toxins, 97‐98, 143, 184‐185,

274, 278

tracheomalacia, 76‐77, 109,

308

trajectories, 2, 5‐6, 285, 298,

310

transdermal, 27, 29, 31, 64,

189, 201‐202, 210, 213, 218,

232, 295, 315, 317

transition, 1, 57, 237, 286, 301,

312

transplant, 54, 134, 142, 153,

170, 172‐173, 175, 206, 279,

289‐290, 293, 295, 301, 305

trazodone, 88, 90, 94, 125,

164‐165, 335, 339, 341, 346

tremor, 55, 88, 90, 145, 197,

203, 229, 261, 268, 289, 323,

337

trigger, 111, 177, 184‐187, 258

trimethoprim, 153‐154, 159,

336, 339

trisomy, 296‐297, 307‐308,

323, 357

tubes, 21‐22, 25, 28, 35, 40,

49, 53, 76, 106, 108, 135‐136,

138, 144‐145, 147, 151, 157,

159, 201, 229, 235, 249‐250,

257, 262, 264‐268, 270‐271,

288, 291, 294, 307, 309‐310,

318‐319, 321, 323, 343, 352‐

353, 355

tumors, 48, 53‐54, 62, 67, 76,

85, 98, 104‐105, 109, 117, 129,

131, 133, 143, 216, 221‐222,

225‐226, 240, 255, 261, 265,

270, 273, 279, 354

turgor, 98, 118‐119, 183

ulceration, 171, 209, 222, 280

ulcers, 134, 171, 200, 296

umbilical, 290, 295, 354

unpredictable, 31, 176, 267,

315, 319

unresponsive, 131, 153, 186‐

187, 324

uremia, 54, 97, 183‐184, 240‐

242, 244, 247‐248, 255

urinary, 15, 37, 39, 41, 70, 76,

88, 97‐99, 104, 117‐119, 151‐

153, 159, 162, 177, 183, 203,

228, 234, 250, 280, 288, 295,

299, 309, 315, 323, 338

urticaria, 240‐242, 252

vaccination, 154, 161

vagal, 144, 148, 185

valproic, 145, 229, 259‐261,

264, 268, 272, 338

vancomycin, 101, 129, 153,

158‐159

venlafaxine, 89, 94‐95, 227,

279, 335, 339

ventilation, 111, 143, 286, 290,

292, 294

ventilator, 40, 286, 296

ventricular, 88, 117, 235, 323

vertigo, 54, 131, 183, 275, 323

vestibular, 183‐186, 188‐189

visceral, 194, 199‐200, 208,

213, 216‐218, 220

viscous, 22, 106, 172‐173, 279,

298‐299

vitamins, 54, 69, 124, 139, 242,

280, 289, 295, 299, 304

vocalization, 104, 197, 256,

258, 286

voiding, 300, 309‐310

volvulus, 62, 184, 295, 309

vomiting, 5, 18‐19, 31, 33, 48‐

49, 53, 62‐63, 67, 70‐72, 74,

76‐77, 88, 98‐99, 103‐104, 118,

122, 134‐135, 141, 144, 150‐

152, 168, 177, 181‐187, 189‐

192, 201, 203, 216, 252, 262,

266, 280‐281, 289, 300, 318,

323, 325, 352

wakening, 38, 124, 130, 162‐

165, 197

walking, 221, 238, 293‐295,

308

warfarin, 88, 90, 136, 335

watery, 96, 98, 152, 249, 279

weakness, 48, 104, 109, 118,

124, 137, 273‐274, 292, 294‐

296, 309, 352

weaning, 237‐238

weight, 15‐16, 18, 27, 41‐44,

48‐49, 53, 58, 64, 77, 85‐86,

88‐89, 98, 104‐105, 118, 122,

125, 134‐135, 141, 143, 145,

153, 155, 170, 183, 186, 189,

218, 221, 229, 257, 261, 263‐

264, 266‐268, 274, 286, 300‐

301, 309, 313‐315, 317‐318,

320‐321, 323, 325, 355

wheezing, 19, 77, 134, 300

withdraw, 7, 11, 30, 37‐39, 49‐

50, 54‐55, 57‐58, 67, 86‐89, 97,

99, 106, 113‐114, 125, 145,

165, 177, 180‐181, 190, 203,

210, 218, 223, 227, 230, 236‐

238, 243‐244, 255, 257, 262,

274‐275, 277‐278, 314, 316,

319‐320, 323, 356

xerostomia, 33, 43, 63, 71, 88,

104, 138, 147, 171, 229, 279‐

281, 283, 323

ziprasidone, 47, 335, 337, 339

zolpidem, 125, 165, 168, 335

zonisamide, 259‐261, 268

pediatric palliative care consultant

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