Günümüzde kronik aðrý, toplumlarda bireylerin psikososyal durum ve iþlevselliklerinin ciddi ölçülerde bozulmasý açýsýndan evrensel bir problemdir. Klinik gözlemler, baþta majör depresyon olmak üzere çeþitli psikiyatrik bozukluklarýn ve psikososyal deðiþkenlerin de kronik aðrý sürecinin biçimlenmesinde kayda deðer etkilerinin olduðunu göstermektedir. Kronik aðrý yaþantýsýna eþlik eden psikiyatrik durum ve psikososyal faktörlerin varlýðý kronik aðrý tedavisine yönelik klasik tedavi yaklaþýmlarýnýn da deðiþmesini gerekli kýlmýþ ve multidisipliner aðrý kliniklerinin sayýsý dünya çapýnda giderek artmaya baþlamýþtýr. Kronik aðrý yaþantýsýnýn çok boyutlu bir yaklaþýmla ele alýndýðý bu kliniklerde temel amaç yalnýzca kronik aðrýnýn geliþiminde ve sürmesinde rol oynayan çoklu etyolojilerin belirlenmesi deðil, ayný zamanda, daha spesifik olarak, diyagnostik ya da tedavi hedefli giriþimsel müdahaleleri gerektiren kronik aðrý durumlarýnda, aðrýyý yaþantýlayan bireyin psikolojik açýdan müdahaleye uygunluðunun da deðerlendirilebilmesidir. Çünkü aðrýnýn altýnda yatan organik patolojiler benzer olsa da, aðrýyý azaltmaya yönelik giriþimsel müdahalelerin etkinliði farklý kiþilerde farklý düzeylerde olabilmektedir. Literatürde, kronik aðrýya yönelik cerrahi giriþimlerin olumsuz sonuçlarýný yordayan en önemli deðiþkenlerin baþýnda depresyon, anksiyete ve somatizasyon düzeylerinin geldiði bildirilmektedir. Bu üçlüyü, aðrýnýn þiddeti veya bedendeki aðrýlý bölge sayýsý gibi aðrý þikayeti ile ilgili deðiþkenler izlemektedir. Özellikle son on yýlda yoðunluðu artan bu çalýþmalar ýþýðýnda, bu küçük çaplý derlemede, kronik aðrý sendromlarýna yönelik giriþimsel müdahalelerin etkinliðini belirleyen biyopsikososyal faktörlerin çoklu rolü tartýþýlacak ve bu deðiþkenlerin müdahale öncesi deðerlendirilmesine iliþkin yöntemlerle ilgili meseleler üzerinde durulacaktýr.

Chronic pain is considered a universal problem in terms of serious impairment in the biopsychosocial functioning of individuals. The psychiatric and psychosocial factors accompanying chronic pain necessitated alterations in classical therapeutic approaches towards chronic pain and resulted in a substantial increase in the number of multidisciplinary pain clinics worldwide. In these pain clinics, the primary goal is not only to predetermine the multiple etiologies playing a role in the acquisition and maintenance of chronic pain, but also to specify whether the individual in pain is psychologically suitable for a surgical intervention for either diagnostic or treatment purposes. This specific question stems from the fact that even though the underlying organic pathologies are similar, the effectiveness of invasive interventions for determining the cause of or attenuating pain may vary between individuals. The most important predictors of adverse outcomes of invasive interventions for chronic pain stated in the literature are primarily depression, anxiety and somatization followed by features of pain such as severity or number of painful body sites. In line with the vast body of research, especially over the previous decade, this small scale review aims to emphasize the interactional roles of biopsychosocial factors on the effectiveness of surgical interventions and to discuss the issues regarding the assessment of these predictors.

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Amaç: Deksketoprofen trometamol nonsteroid antiienflamatuvar bir ajan olan ketoprofenin aktif enantiomeridir. Bu çalýþmada postoperatif analjezide intravenöz (iv) deksketoprofenin etkinliðini deðerlendirmeyi amaçladýk.
Gereç ve Yöntem: Abdominal histerektomi planlanan ASA I-II grubu 50 olgu çalýþmaya alýndý ve randomize olarak iki gruba ayrýldý. Operasyondan 1 saat önce ve operasyondan sonra 8. ve 16. saatlerde Grup I’e serum fizyolojik, Grup II’ye 50 mg deksketoprofen iv verildi. Bütün olgulara standart genel anestezi uygulandý. Cerrahinin sonunda olgulara iv hasta kontrollü analjezi cihazý ile morfin uygulandý. Aðrý skorlarý 2., 6., 12. ve 24. saatlerde deðerlendirildi. Çalýþma sonunda morfin tüketimi ve yan etkiler kaydedildi.
Bulgular: Aðrý skorlarý ve morfin tüketimi deksketoprofen grubunda daha düþük bulundu (p<0.05). Yan etkiler gruplar arasýnda benzer bulundu (p>0.05).
Sonuç: Sonuç olarak, abdominal histerektomi operasyonlarýnda iv deksketoprofen güvenilir ve etkin bir analjezi saðlamakta, morfin tüketimini azaltmaktadýr.

Objectives: Dexketoprofen trometamol is a water-soluble salt of the dextrorotatory enantiomer of the nonsteroidal anti-inflammatory drug ketoprofen. The aim of this study was to investigate the effect of intravenous dexketoprofen on postoperative pain.
Methods: This study was performed on 50 (ASA I-II) patients scheduled for abdominal hysterectomy. Fifty patients were randomized into two equal groups. Patients received saline solution (Group I) or 50 mg intravenous dexketoprofen (Group II) 1 hour (h) before surgery and 8-16 h after surgery. All patients received a standard anesthetic protocol. At the end of surgery, all patients received intravenous (IV) morphine via a PCA (patient- controlled analgesia) device. Pain scores were assessed at 2, 6, 12 and 24 h after surgery. Morphine consumption and adverse effects were noted during the first 24 h after the surgery. The pain scores were significantly lower in the dexketoprofen group compared with the control group (p<0.05).
Results: The cumulative morphine consumption was also lower in the dexketoprofen group than the control group (p<0.05). No significant difference was observed in adverse effects between the groups (p>0.05).
Conclusion: We conclude that the administration of IV dexketoprofen provided a significant analgesic benefit and decreased the morphine requirements in patients undergoing abdominal hysterectomy.

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Amaç: Aðrý polikliniðinde kanser aðrýsý nedeniyle takip edilen hastalarda kaçak aðrý sýklýðý ve oral transmukozal fentanil sitratýn (OTFC) kaçak aðrý üzerindeki etkinliðini araþtýrýldý.
Gereç ve Yöntem: Bir aydan uzun süredir güçlü opioid analjezik kullanan ve kronik aðrýlarý kontrol altýnda olan 124 hasta incelemeye alýndý. Bu hastalarda kaçak aðrý sýklýðý saptandý. Ýncelemeye alýnan hastalar içerisinden kaçak aðrý tarifleyen ve çalýþmaya dahil edilme ölçütlerine uyan 52 hasta çalýþmaya dahil edildi. Çalýþmaya dahil edilen hastalar ilk 3 gün titrasyon dönemine alýnarak uygun OTFC dozu saptandý. OTFC’nin kaçak aðrý üzerine etkinliði Aðrý Rahatlama Skoru (ARS) ile deðerlendirildi. Titrasyon dönemine 200 µg OTFC ile baþlandý ve 800 µg üst doz olarak belirlendi. Titrasyon döneminden sonra hastalar 10 gün daha izlendi. Kaçak aðrý takip formu kullanýlarak OTFC’nin etkinliði (ARS ile), etki etme süresi, yan etkileri, OTFC kullanýmý öncesi ve sonrasý Vizüel Analog Skala (VAS) deðerleri kaydedildi.
Bulgular: Ýncelemeye alýnan hastalarýn %63.7’sinde kaçak aðrý ataðý görüldü. Titrasyon döneminde uygun OTFC dozu 10 hasta için 200 µg, 21 hasta için 400 µg, 17 hasta için 800 µg bulundu ve 4 hastada kaçak aðrý ataklarýnýn kontrolünde OTFC baþarýsýz oldu. Uygun doz OTFC kaçak aðrý ataklarýnýn %81.1’inde etkili bulundu. OTFC kullanýmý öncesi ve sonrasý VAS deðerleri arasýnda anlamlý fark saptandý (p<0.001). OTFC’ýn ortalama etki süresi 17.7±8.28 dakika bulundu. Hiçbir hastada ciddi bir yan etki ile karþýlaþýlmadý.
Sonuç: Kanser hastalarýnda kaçak aðrý ataklarýnýn tedavisinde OTFC etkin ve güvenilirdir.

Objectives: We aimed to search the frequency of breakthrough pain (BP) and the efficiency of oral transmucosal fentanyl citrate (OTFC) for the treatment of BP in cancer patients.
Methods: One hundred twenty-four patients who had used strong opioid analgesics for more than one month were included in the study. The frequency of BP in those patients was determined. Fifty-two of the patients who described BP and complied with the inclusion criteria for the study were included in our study. Appropriate dose of OTFC to take those patients to titration phase for 3 days was determined. Titration phase was started with 200 µg OTFC, and 800 µg was established as the maximum dose. The patients were monitored for a further 10 days after the titration phase. Using the Breakthrough Pain Questionnaire, the efficiency of OTFC (with Pain Relief Score), duration of effect, side effects, and visual analogue scale (VAS) values before and after OTFC were recorded.
Results: The frequency of BP was found as 63.7% in our study. The appropriate OTFC dose in the titration phase was found as 200 µg for 10 patients, 400 µg for 21 patients, and 800 µg for 17 patients; in 4 patients, OTFC failed to control their BP attacks. An appropriate dose of OTFC was found effective in 81.1% of BP attacks. A significant difference was determined in VAS scores before and after OTFC use (p<0.001). The average duration effect of OTFC was determined as 17.7 ± 8.28 minutes. No serious side effect was reported in any patient.
Conclusion: OTFC is effective and reliable in the treatment of BP attacks in cancer patients.

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Amaç: Çalýþmamýzda deksmedetomidin infüzyonunun operasyon boyunca tüketilen opioid ve operasyondan sonra hastanýn ihtiyaç duyduðu analjezik miktarý ve aðrý skorlarý üzerine
etkisini araþtýrmayý amaçladýk.
Gereç ve Yöntem: ASA I-II, 18-50 yaþ arasýnda ve mastoidektomi operasyonu geçirecek olan 40 hasta çalýþmaya alýndý. Hastalar randomize iki gruba, grup deksmedetomidin (grup D, n=20) ve grup plasebo (grup P, n=20) olarak ayrýldý. Grup D olgularýna operasyonda deksmedetomidin 0.5 mcg/kg/saat hýzla, grup P olgularýna %0.9’luk NaCl ayný hýz ve volümde verildi. Postoperatif dönemde hastalara tramadol ile hazýrlanmýþ hasta kontrollü analjezi (HKA) cihazlarý takýlarak 24 saat takip edildi. Takiplerde Ramsay Sedasyon Skalasý, Vizüel Analog Skala (VAS), non-invazif sistolik kan basýncý (SKB), diyastolik kan basýncý (DKB) ve ortalama kan basýnçlarý (OKB), endtidal sevofluran, ekstübasyon zamanlarý, toplam remifentanil miktarlarý, HKA’dan toplam talep ve tramadol tüketimi kaydedildi.
Bulgular: Gruplar arasýnda demografik veriler ve ekstübasyon süreleri açýsýndan fark saptanmadý. Kontrol grubunun total remifentanil tüketimi ve ek analjezik ihtiyacý, HKA toplam talep, HKA toplam tramadol tüketim miktarý ve VAS ortalamalarý daha fazlaydý. Çalýþma grubunun HKA ilk talep zamaný daha uzundu.
Sonuç: Çalýþma sonuçlarýmýz, cerrahi sýrasýnda deksmedetomidinin sürekli infüzyonunun,
ekstübasyon zamanýný etkilemeksizin postoperatif hasta konforunu tramadol tüketimini azaltarak saðlayabildiðini göstermiþtir.

Objectives: We aimed to investigate the effect of dexmedetomidine infusion on the amount of opioid that is consumed during the operation, the amount of analgesic that the patient requires after the operation and on pain scores.
Methods: Forty patients who were ASA I-II, between 18-50 years old, and who were scheduled for mastoidectomy operation were included in the study. Patients were randomized into two groups as group Dexmedetomidine (Group D) and group Placebo (Group P). Dexmedetomidine was administered at the rate of 0.5 mcg/kg/hour to the cases in Group D during operation and 9% NaCl was administered at the same rate and volume to the cases in Group P. Patients were connected to a Patient-Controlled Analgesia (PCA) device prepared with tramadol. Patients were followed for 24 hours. Ramsay Sedation Scale, visual analog scale (VAS), non-invasive systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), end-tidal sevoflurane, extubation times, total remifentanil consumption, total demand of PCA, and total tramadol consumption from PCA were recorded.
Results: No difference was determined between groups in demographic level and extubation times. Total remifentanil consumption, additional analgesic requirement, total demand of PCA, total amount of PCA consumption, and mean VAS were higher in the control group. First demand time of PCA was longer in the study group.
Conclusion: Results of our study demonstrated that continuous infusion of dexmedetomidine during the operation could provide postoperative patient comfort without affecting the extubation time while concomitantly decreasing the consumption of tramadol.

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Amaç: Laparaskopik kolesistektomi semptomatik safra kesesi taþýnýn ilk tedavi seçeneðidir. Bu çalýþmada, laparaskopik kolesistektomi sonrasýnda aðrý tedavisinde intravenöz (iv) parasetamol ile intramuskuler (im) diklofenak Na+’un etkinliðini karþýlaþtýrmayý amaçladýk.
Gereç ve Yöntem: Hastanemiz etik komite onayý ve yazýlý hasta onayý alýnarak laparoskpik kolesistektomi uygulanacak ASA I-II grubu 40 hasta çalýþmaya kabul edildi. Genel anestezi tekniði standardize edildi. Operasyon bitiminden 15 dakika önce hastalara 1 g iv parasetamol, (Grup I, n=20) veya ÝM diklofenak Na+ (Grup II, n=20) uygulandý. Aðrý deðerlendirmesi sayýsal deðerlendirme ölçeði (NRS) ile derlenme ünitesine geliþte (NRS 1), yarým saat sonra (NRS 2) ve bir saat sonra (NRS 3) deðerlendirilip kaydedildi. NRS deðeri 5 ve üzeri olan hastalara iv 10 mg pethidin HCl uygulandý. Üç ölçüm zamanýnda NRS ile birlikte total pethidin HCl kullanýmý, bulantý ve kusma kaydedildi.
Bulgular: Deðerlendirmeler tedavi protokolünden habersiz bir anestezist tarafýndan yapýldý. NRS 3 deðeri Grup I’ de Grup II’ ye göre anlamlý yüksek bulundu (p<0.05). Ýki grubun total opioid kullanýmý ve yan etki görülme oraný benzer bulundu.
Sonuç: Postoperatif aðrý tedavisinde opioidlere ek olarak iv parasetamol kullanýmýný önerebiliriz, tek baþýna kullanýmý için ise yüksek doz çalýþmalarýna ihtiyaç olduðu görüþündeyiz.

Objectives: Laparoscopic cholecystectomy is the first treatment choice for symptomatic gallstone disease. We compared the efficacy of intravenous (i.v.) paracetamol and intramuscular (i.m.) diclofenac Na+ after laparoscopic cholecystectomy.
Methods: Following approval from the Local Ethics Committee and receipt of written informed consent, 40 ASA physical status I-II patients who underwent laparoscopic cholecystectomy were enrolled into the study. General anesthesia was standardized. The patients received 1 g i.v. paracetamol (Group I, n: 20) or 75 mg diclofenac Na+ i.m. (Group II, n: 20) 15 minutes (min) before the end of the operation. Pain was assessed by numeric rating scale (NRS) after arrival in the postanesthesia care unit (PACU) (NRS 1) and at the 30th minute (NRS 2) and 1st hour (NRS 3) of the PACU stay. 10 mg i.v. pethidine HCL was administered to the patient with NRS >5. The following measures were recorded: intensity of pain by NRS at arrival and after 30 and 60 min, total consumption of pethidine HCL, and nausea and vomiting.
Results: All assessments were performed by an anesthesiologist blinded to the study protocol. NRS 3 scores were significantly higher in Group I than Group II (p<0.05). Opioid consumption was not different between the groups. Two patients in each group had postoperative nausea and vomiting; no other adverse effects were noted.
Conclusion: We recommend the use of i.v. paracetamol as an opioid adjuvant. Regarding its use as a unique drug for postoperative pain therapy, further comparative studies with higher doses of paracetamol are needed.

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Amaç: Bu çalýþmada, midazolam ve deksmedetomidin epidural anestezi altýnda sedatif, kardiyovasküler ve solunum parametreleri üzerine olan etkileri deðerlendirildi.
Gereç ve Yöntem: Çalýþma etik kurul ve hasta onamlarý alýnmýþ elektif histerektomi operasyonu uygulanacak randomize ve tek kör çalýþma planýnda toplam 50 olguda gerçekleþtirildi. Olgular midazolam (Grup M) ve deksmedetomidin (Grup D) olmak üzere ikiye ayrýldý. Perifix No: 18 epidural kateter, L3-4 aralýðýndan epidural aralýða yerleþtirildi. Lidokain 60 mg/3 ml test dozu sonrasý (izobarik bupivakain %0.5) segment baþýna 1 ml olacak þekilde verildi. Blok T10’a ulaþtýktan sonra, ameliyat baþlangýcýna kadar 10 dk içinde Grup M’ye 0.015 mg kg-1 bolus midazolam ve 0.1-0.2 mg kg -1 saat-1) dozda sürekli infüzyona baþlandý. Grup D’ye ise, 1 µg/kg deksmedetomidin bolus 10 dk içinde verildi, (0.4-0.7 µg kg-1 saat-1) dozda sürekli infüzyona baþlandý. Hastalarýn sistolik kan basýnç, diyastolik kan basýnç, ortalama kan basýncý (OAB), kalp atým hýzý (KAH), SpO2, Ramsay sedasyon skoku, Bispektral indeks ve solunum sayýsý deðerleri kaydedildi. Sedatif infüzyonuna her iki grupta da cilt dikiþleri kapanmaya baþlanýncaya kadar devam edildi. Yan etkiler kaydedildi.
Bulgular: D grubunda OAB deðerleri, M grubundan istatistiksel olarak anlamlý derecede yüksek, D grubunun KAH deðerleri M grubuna göre düþük bulundu (p<0.05).
Sonuç: Epidural anestezi uygulamalarýnda her iki ilacýn da hemodinamiyi bozmadan, solunum depresyonu yapmaksýzýn hastalarýn uyandýrýlabilir ve koopere durumda olduklarý bir sedasyon saðlayabildiði sonucuna varýldý. Ancak midazolamýn daha az maliyet nedeni ile ilk tercih olduðunu düþünmekteyiz.

Objectives: We aimed to assess the sedative effects of midazolam and dexmedetomidine and their effects on hemodynamics and the cardiovascular system under epidural anesthesia.
Methods: This study included 50 patients. Approval of the ethics committee and written consent from patients were obtained. The patients were separated into two groups to receive dexmedetomidine (D group) or midazolam (M group). Perifix no. 18 was placed in the epidural space from the L3-4 interspace. After lidocaine 60 mg/3 ml was applied, isobaric bupivacaine 0.5% was given as 1 ml per segment. After block reached the T10 level, midazolam was given to the M group as a bolus of 0.015 mg kg-1 in 10 minutes until beginning the operation, followed by continuous infusion as 0.1-0.2 mg kg-1h-1 dosage. Dexmedetomidine 1 mcq kg-1 was given to the D group as a bolus dosage in 10 minutes until beginning the operation, followed by continuous infusion as 0.4-0.7 mcq kg-1 h-1 dosage. Systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), heart rate (HR), SpO2, Ramsay Sedation Score (RSS), bispectral index (BIS), and respiratory rate (RR) were recorded. Sedative infusion was stopped when skin suture was closed. Adverse effects were also recorded.
Results: In group D, MAP was significantly higher and HR was significantly lower than in group M (p<0.05).
Conclusion: We concluded that both drugs provided good sedation with no respiratory depression, stable hemodynamics and alertness with good cooperation. However, we consider midazolam as the first option due to its cost benefit.

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Vertigo, sersemlik veya görme bulanýklýðý; idyopatik saplanma aðrýsý, supraorbital nevralji veya trigeminal sinir oftalmik dal nevraljisi gibi, trigeminal sinir innervasyon alanlarýnda ortaya çýkan aðrýlý durumlarda bildirilmiþtir. Sýk olmamakla beraber, oksipital nevraljide aðrý baþýn ön kýsýmlarýna doðru yayýlabilir. Bu yazýda, oksipital nevraljiform paroksizmleri ipsilateral göze kadar yayýlan ve eþ zamanlý olarak görme bozukluðu geliþen bir hasta sunuldu; yayýlmanýn ve görme bozukluðunun mekanizmasý tartýþýldý.

Vertigo, dizziness and visual blurring have been reported in painful conditions in trigeminal innervation zones such as in idiopathic stabbing headache, supraorbital neuralgia or trigeminal nerve ophthalmic branch neuralgia. Although not common, pain in occipital neuralgia can spread through the anterior parts of the head. In this article, we present a case whose occipital neuralgiform paroxysms spread to the ipsilateral eye with simultaneous visual obscuration; the mechanisms of propagation and visual obscuration are discussed.

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Ultrasonun (US) periferik sinir bloklarýnda kullanýlmasý ile birlikte sinir stimülasyonun uygun olmadýðý olgularda da baþarýlý sinir bloklarý gerçekleþtirilebilir. Bu olgu sunumunda elektrik yanýðý sonrasýnda ön kolu el bileði seviyesinden ampute edilmiþ, güdük bölgesinde debridman greftleme planlanan ve nörostimülasyona kas cevabýnýn mümkün olmadýðý 37 yaþýnda, ASA I, erkek hasta sunuldu. US eþliðinde toplam 20 ml lokal anestezik karýþýmý (10 ml %0.5 levobupivakain ve 5 mcg/ml adrenalin içeren 10 ml %2 lidokain) ile lateral sagital infraklaviküler blok uygulandý. Uygulamadan 20 dakika sonra cerrahiye hazýr hale gelen hastanýn operasyonu baþarý ile gerçekleþtirildi.

When ultrasound (US) is used in peripheric nerve blocks, successful nerve blocks can be performed even if nerve stimulation is not possible. In this case report, we present a 37-year-old male patient, ASA physical status I, undergoing debridement and grafting for incomplete arm whose upper extremity (forearm) was amputated due to electric shock; motor response to nerve stimulation was not possible. With the help of US, lateral sagittal infraclavicular block was performed with 20 ml local anesthetic mixture (10 ml of 0.5% levobupivacaine and 10 ml 2% lidocaine with 5 mcg/ml epinephrine). After 20 minutes, the patient was ready for surgery and the operation was performed successfully.

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