Botulismus toksini Tip A 15 yýldan daha uzun süredir çeþitli primer baþ aðrýsý tiplerinin tedavisi ve profilaksisi amacý ile kullanýlmaktadýr. Bu ajanýn baþ aðrýsý tedavisindeki etki mekanizmasý pek çok çalýþmada incelenmiþtir. Asetil kolin salýnýmý üzerindeki bilinen etkisine ek olarak bir veya daha fazla sayýda aðrý ile ilgili transmitterin salýnýmýný bloke ederek antinosiseptif etki gösterdiði düþünülmektedir. Botulinum toksininin primer baþ aðrýlarýndaki klinik kullanýmýný inceleyen körlü olmayan ilk çalýþmalar, pozitif sonuçlar vermiþtir, ancak son zamanlarda yapýlan metodoloji açýsýndan yeterli çalýþmalar kanýta dayalý bir yaklaþýmla incelendiðinde bu ajanýn yaygýn klinik kullanýma girmesini desteklememektedir. Bu derlemede botulinum toksininin kullanýmý; etki mekanizmasý, enjeksiyon teknikleri ve konu hakkýndaki kanýta dayalý veriler öncelikli olarak incelenmiþtir.

Botulinum toxin type A has been used clinically for the prophylaxis and treatment of various types of primary headache disorders for over 15 years. Several studies have been performed to demonstrate its mechanism of its effect. There is adequate data to support the idea that; beside its well-known effect on acetylcholine release an additional antinociceptive effect related to a possible block in one or more pain transmitters exist. Earlier open-labeled studies investigating the clinical outcome of botulinum toxin in primary headache disorders have come out with positive results on the topic however recent evidence based evaluation of data do not seem to support the widespread clinical use of this agent. In this manuscript use of botulinum toxin is reviewed with special emphasize on its mechanism of effect, injection techniques and recent evidence-based data.

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Aðrý, hastalar tarafýndan kanserin en korkulan sonuçlarýndan birisidir. Çeþitli eðitim programlarýna, giriþim stratejilerine ve multidisipliner aðrý topluluklarýna raðmen, kanser hastalarýnýn yaklaþýk olarak %60’ý aðrý çekmektedir. Kanser aðrýsý, hastanýn yaþamýnýn her yönünü etkilemekte ve sonuçta yaþam kalitesi üzerinde büyük bir etkisi bulunmaktadýr. Yeterli aðrý yönetiminde saðlýk bakým profesyonelleri, saðlýk bakým sistemi ve hastalarý kapsayan bariyerler mevcuttur. Aðrý yönetimindeki bariyerlerin en önemli nedenleri bilgi eksikliði, opioidler hakkýnda olumsuz tutumlar, yetersiz tanýlama ve organizasyonla ilgili konularý içermektedir.
Bu makalenin amacý; kanser aðrý yönetiminde etkili olan bariyerler hakkýnda bilgi vermektir.

Pain is one of the most feared consequences of cancer experienced by patients. Despite numerious education programs, intervention strategies and multidiciplinary pain societies that approximately 60% of patients with cancer are experiencing pain. Cancer-related pain may affect patient’s life in every way, and therefore it has a great influence on the overall quality of life. Barriers to adequate pain management exist, including those related to health-care professionals, the health-care system, and the patients. The most reasons for the barriers to pain management include knowledge deficits, misconceptions about opioids and their side effects, inadequate assessment, and organizational issues.
The purpose of this articles, provides information to regarding barriers to effective cancer pain management.

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Tüm gebeliklerin % 1.5-2’sinde anestezi ve cerrahi gereksinimi olmaktadýr. Maternal anatomi ve fizyoloji de meydana gelen deðiþiklikler, hem anne hem de fetüs için risk oluþturabilmektedir. Gebelik döneminde cerrahi bir giriþim gereksiniminde, anestezik yaklaþým her iki hastayý birden kapsamalýdýr. Gastrik adenokarsinom gebelik döneminde nadir görülen ve kötü prognozla seyreden bir tablodur. Bu vaka takdiminde gastrik adenokarsinom tanýsý alan 26 haftalýk gebe hastada anestezik yaklaþým sunulmaktadýr. Hastamýzda fetüsün yaþayabilirliðinin saðlanacaðý döneme kadar gebeliðin devamýný saðlamak ve bu süre içinde annenin yaþam kalitesini en yüksek düzeyde tutmak amacýyla distal subtotal gastrektomi planlandý. Hem anne hem fetus için anestezi riskini en aza indirmek, fizyolojik stresi azaltmak ve ayný zamanda cerrahi sýrasýnda ortaya çýkan nöroendokrin cevabý azaltmak amaçlanarak, genel anestezi ile birlikte torakal epidural anestezi uygulandý. Hasta 30. gebelik haftasýnda elektif sezaryen operasyonu için tekrar çaðrýlarak, postoperatif 10. günde taburcu edildi.

Anesthesia and surgery are required in up to 1.5% to 2% of all pregnancies. Alterations in maternal anatomy and physiology create potential risks for both mother and fetus. The anesthetic considerations for any surgery during pregnancy must take both patients into account. Gastric adenocarcinoma presenting during pregnancy is a rare conditions and has a poor prognosis. This report describes anaesthetic management the case of a woman who was diagnosed with gastric adenocarcinoma at 26 weeks’ gestation. Distal subtotal gastrectomy was planned in an attempt to maximize the mother’s life expectancy while maintaining the pregnancy until the fetus reached viable gestation. A combination of general anesthesia and thoracic epidural anesthesia was used. The goal was to reduce physiological stress and minimize anesthesia risk for both mother and fetus and also diminish the neuroendocrine response during surgery. The patient was discharged from hospital 10 days after surgery and was then readmitted at 30 weeks’ gestation for an elective cesarean section.

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AIM: In this study, we aimed to determine the effects of combined spinal-epidural block onto low back pain incidence after vaginal delivery.
MATERIAL-METHODS: 198 patients included to the study. Patients were separated into two groups regarding labor analgesia request. Combined spinal-epidural analgesia was performed in sitting position for the first group (Group CSE, n=104). In the second group no analgesic technique was applied as requested by the patients (non-epidural group, n= 94). The patients were asked for low back pain and other symptoms related to it after the first day, third day, one month and sixth month after delivery.
RESULTS: We determined 60 new onset low back pain after delivery in all (32 in CSE and 28 in non-epidural group). We didn’t establish any significant differences during long-time follow-ups between the groups.
CONCLUSION: We concluded that, combined spinal-epidural analgesia could be performed safely without increasing the backache incidence after delivery.

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Deksketoprofen trometamol nonsteroid antiiinflamatuar bir ajan olan ketoprofenin aktif enantiomeridir. Bu çalýþmada postoperatif analjezide dexketoprofenin etkinliðini deðerlendirmeyi amaçladýk. Abdominal histerektomi planlanan ASA I-II grubu 50 olgu çalýþmaya alýndý ve randomize olarak 2 gruba ayrýldý. Operasyondan 1 saat önce ve operasyondan sonra 8. ve 16. saatlerde grup I’e oral plasebo, grup II’ye 25 mg deksketoprofen verildi. Bütün olgulara standart genel anestezi uygulandý. Cerrahinin sonunda olgulara IV Hasta kontrollü analjezi (HKA) cihazý ile tramadol uygulandý. Aðrý ve sedasyon skorlarý 3,6,12 ve 24.saatlerde deðerlendirildi. Çalýþma sonunda tramadol tüketimi, yan etkiler ve hasta memnuniyeti kaydedildi. Aðrý skorlarý ve tramadol tüketimi deksketoprofen grubunda daha düþük bulundu (p<0.05). Sedasyon skorlarý, yan etkiler ve hasta memnuniyeti gruplar arasýnda benzer bulundu (p>0.05). Sonuç olarak, abdominal histerektomi operasyonlarýnda preoperatif ve postoperatif uygulanan deksketoprofen, opioid ihtiyacýný azaltmakta ve analjezik etki saðlamaktadýr.

Dexketoprofen trometamol is a water-soluble salt of the dextrorotatory enantiomer of nonsteroidal anti-inflamatory drug ketoprofen. The aim of the study was to investigate the effect of dexketoprofen on postoperative pain. This study was performed on 50 (ASA I-II) patients planned for abdominal hysterectomy. Fifty patients were randomized into two equal groups. Patients received oral placebo (group I) and 25 mg dexketoprofen (group II) 1h before surgery and 8 -16 h after surgery. All patients received a standard anesthetic protocol. At the end of surgery, all patients received tramadol IV via a PCA (Patient Controlled Analgesia) -device. Pain scores and sedation scores were assessed at 3,6,12 and 24 h after surgery. Tramadol consumption, adverse effects, and patient satisfaction were noted during 24 h after the surgery. The pain scores were significantly lower in the dexketoprofen group compared with the placebo group (p<0.05). The cumulative tramadol consumption was lower in the dexketoprofen group than placebo group (p<0.05). No significant difference was observed in sedation scores, adverse effects and patient satisfaction between the groups (p>0.05). We conclude that the preoperative and postoperative administration of dexketoprofen provided a significant analgesic benefit and decreased the opioid requirements in patients undergoing abdominal hysterectomy.

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Çalýþmada, NMDA reseptör antagonisti olan ketaminin intravenöz yolla insizyon öncesi ve sonrasý uygulamalarýnýn preemptif etkisinin araþtýrýlmasý amaçlandý.
Total abdominal histerektomi uygulanacak 60 hasta, etik komite izni ile çalýþmaya dahil edilerek, rastgele üç gruba ayrýldý. Standart anestezi uygulanan bütün hastalara insizyon öncesi ve insizyon sonrasý olmak üzere, sýrasýyla kontrol grubu olan Grup S’de serum fizyolojik (SF), Grup Kpre’de ketamin 0.4 mg/kg ve SF, Grup Kpost’da SF ve ketamin 0.4 mg/kg uygulandý. Postoperatif analjezileri i.v. morfin PCA ile saðlanan hastalarýn aðrýlarý 1., 2., 3., 4., 8., 12. ve 24. saatlerde Vizüel Analog Skala (VAS), Sözel Aðrý Skalasý (VRS) ile deðerlendirildi. Ýlk analjezik zamanlarý, tüketilen morfin miktarlarý ve yan etkiler kaydedildi. Postoperatif VAS, VRS, toplam morfin, ilk PCA zamaný deðerlendirildiðinde istatistiksel olarak fark bulunmadý (p>0.05). SF uygulanan Grup S’de sedasyon skorlarý daha düþük olup, ketamin kullanýlan gruplarla karþýlaþtýrýldýðýnda anlamlý fark bulundu (p<0.05). Sonuçta abdominal histerektomi operasyonlarýnda preemptif intravenöz ketaminin analjezik etkinliðinin olmadýðý, doz ve uygulama zamaný yönünden farklý operasyon türlerine göre daha ileri çalýþmalarýn yapýlmasý gerektiði kanýsýna varýldý.

The aim of this study was to determine if preemptive use of the NMDA receptor antogonist ketamine decreases postoperative pain in patients undergoing abdominal hystrectomy.
A total of 60 patients admitted for total abdominal hysterectomy were included in this study after the approval of the ethic committee, and the patients were randomly classified into three groups. After standart general anaesthesia, before or after incision patients received bolus saline or ketamine. Group S received only saline while Group Kpre received ketamine 0.4 mg/kg before incision and saline after incision, and Group Kpost received saline before incision and 0.4 mg/kg ketamine after incision. Postoperatif analgesia was maintained with i.v. PCA morphine. Pain scores were assessed with Vizüal Analog Scale (VAS), Verbal Rating Scale (VRS) at 1., 2, 3., 4., 8., 12. ve 24. hours postoperatively. First analgesic requirement time, morphine consumption and side effects were recorded.
There were no significant differences between groups with respect to VAS / VRS scores, the time for first analgesic dose, and morphine consumption (p>0.05). Patients in Group S had significantly lower sedation scores than either of the ketamine treated groups (p<0.05). In conclusion, a single dose of ketamin had no preemptive analgesic effect in patients undergoing abdominal hysterectomy, but further investigation is needed for different operation types and dose regimens

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