Özet
Giriþ: Bu çalýþmanýn amacý; farklý klinik parametreler üzerinde sadece total intravenöz anestezi ve total intravenöz anestezi ile kombine epidural analjezinin etkilerini araþtýrmaktýr.
Metod: Bu prospektif, çift kör, randomize çalýþmaya major abdominal cerrahi geçirecek yüksek riskli 60 hasta dahil edildi. Anestezi indüksiyonu; IV remifentanil 0.5 mg/kg ve 40 ile 50 arasýnda bispectral index elde edilecek halde titre edilmiþ propofol ile yapýldý. Entübasyon sonrasý; Grup E için 0.1% bupivkain and 2 µg/ml fentanil infüzyon hýzý 0. 15 ml/kg/h olacak þekilde epidural kataterden baþlandý. Grup C’ ye ise ayný hýzda serum salin infüzyonu baþlandý.
Sonuçlar: Intraoperatif ortalama arter basýnçlarý Grup E de Grup C’ye oranla düþük bulundu (p<0.05). Ekstübasyon süresi, göz açma ve sözel cevap süresi Grup E de Grup C’ye oranla düþük bulundu (p<0.05). Total anestezik ilaç tüketimi Grup C de Grup E’ye gore daha yüksek bulundu (p<0.05).
Tartýþma: Düþük doz remifentanil ve propfol kullanýmýnýn klinik parametreler üzerine olumlu etkilerine dayanarak; bispektral indeks klavuzluðunda kombine epidural analjezi ve total intravenöz anestezinin tek baþýna total intravenöz anesteziye oranla daha üstün olduðunu öne sürmekteyiz.

Background and Objectives: The aim of this study is to investigate the effects of combined epidural analgesia with total intravenous anaesthesia and only total intravenous anaesthesia on the different clinical parameters.
Methods: Sixty high risk patients undergoing a major abdominal surgical procedure were included in this prospective, double blind, randomized study. Induction of anaesthesia was performed with IV remifentanil 0.5µg/kg and propofol titrated to achieve bispectral index score between 40 and 50. After intubation; in Group E, 0.1% bupivacaine and 2 µg/mL fentanyl were administered by an infusion rate at 0. 15 ml/kg/h via the epidural catheter and Group C received epidural normal saline as same infusion rate.
Results: In group E, intraoperative MAP values were significantly lower than those in group C (p<0.05). Time of extubation, time of eye opening with audible warning and time of verbal response was significantly lower in group E than those in group C. Total anaesthetic drug consumption was significantly higher in group C than those in group E (p <0.05).
Conclusions: Based on lower requirements for propofol and remifentanil as well as the favourable effects on clinical parameters; we conclude that bispectral index score guided combined epidural with total intravenous anaesthesia is superior to solely total intravenous anaesthesia in this type of surgery.

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Amaç: Bu araþtýrma, Sistemik Lupus Eritematozus’lu hastalarda oluþan aðrý ve yorgunluðun günlük yaþam aktivitelerine etkisini belirlemek amacýyla planlanmýþtýr.
Gereç ve Yöntem: Araþtýrmanýn evrenini; 30 Eylül 2009 -15 Mayýs 2010 tarihleri arasýnda bir üniversite hastanesi ve iki ilçe hastanesi dahiliye polikliniklerine baþvuran Sistemik Lupus Eritematozus hastalarý oluþturmuþtur. Araþtýrmanýn verileri, araþtýrmacý tarafýndan Yorgunluk Þiddeti Ölçeði, Katz’in Günlük Yaþam Aktiviteleri Ýndeksi, Lawton ve Brody’nin Enstrümental Günlük Yaþam Aktiviteleri Ýndeksi, McGill Aðrý Ölçeði ile toplanmýþtýr.
Bulgular: Araþtýrmada Yorgunluk Þiddeti Ölçeði puan ortalamasý 6,0 (yorgun); Günlük Yaþam Aktiviteleri Ýndeksi puan ortalamasý 18,0 (baðýmsýz); Enstrümental Günlük Yaþam Aktiviteleri Ýndeksi puan ortalamasý 24,0 (baðýmsýz); McGill Aðrý Ölçeði’ne göre sorulan andaki aðrý puan ortalamasý 1,56 (rahatsýz edici) olarak saptanmýþtýr. Yorgunluk Þiddeti Ölçeði ile Günlük Yaþam Aktiviteleri Ýndeks puanlarý arasýnda düþük düzeyde negatif bir iliþki olduðu bulunmuþtur. Yorgunluk Þiddeti Ölçek puaný arttýkça Günlük Yaþam Aktiviteleri Ýndeks puaný azalmaktadýr (p<0,05, r=-0,298). Yorgunluk ile Enstrümental Günlük Yaþam Aktiviteleri Ýndeks puanlarý arasýnda düþük düzeyde negatif yönde bir iliþki bulunmuþtur. Yorgunluk Þiddeti Ölçek puaný arttýkça Enstrümental Günlük Yaþam Aktiviteleri Ýndeks puaný azalmaktadýr (p<0,05,r=-0,354). Yorgunluk Þiddeti Ölçeði ile Aðrý Ölçeði puanlarý arasýnda orta düzeyde pozitif yönde anlamlý bir iliþki olduðu bulunmuþtur. Yorgunluk Þiddeti Ölçek puaný arttýkça aðrý þiddeti puaný da artmaktadýr (p<0,05,r=0,478).
Sonuç: Bu araþtýrma aðrý ve yorgunluðun Sistemik Lupus Eritematozus’lu hastalarýn günlük yaþam aktivitelerine etki ettiðini göstermiþtir. Bu araþtýrmanýn daha büyük örneklemlerde tekrarlanmasý önerilir.

Objective: The aim of this study was to determine the effects of pain and fatigue on daily life activities of Systemic Lupus Erythematosus patients.
Methods: The study sample included 74 Systemic Lupus Erythematosus patients who presented to outpatient departments of a university hospital and two local hospitals between 30.9.2009 and 15.5.2010. Data was collected using the Fatigue Severity Scale, Katz’s Activity's Daily Living Index, Lawton and Brody’s Instrumental Activities of Daily Living, and the McGill Pain Questionnaire.
Results: The mean scores were 6.0 (fatigue) on the Fatigue Severity Scale, 18.0 (independent) on the Daily Life Activities Index, 24.0 (independent) on the Instrumental Daily Life Activities Index, and 1.56 (discomforting) on the McGill Pain Scale for pain felt at the moment of questioning. A low-level negative relationship was observed between the scores on the Fatigue Severity Scale and the Daily Life Activities Index (p<0.05, r = -0.298), and between Fatigue and Instrumental Daily Life Activities scores (p<0.05, r = -0.354). A medium-level positive relationship was observed between the scores on the Fatigue Severity Scale and the McGill Pain Scale (p<0.05, r = 0.478).
Conclusion: This study determined that pain and fatigue affected the daily lives of Systemic Lupus Erythematosus patients. The study should be repeated on a larger sample.

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Amaç: Miyofasiyal aðrý sendromu(MFAS), çizgili kas içinde tetik noktalar ile karakterize bir kompleks aðrý sendromudur. Çalýþmamýzda, fizik tedavide kullanýlan temel cihazlardan biri olan ultrasonun (US) tetik nokta tedavisindeki etkinliðini araþtýrmak amaçlandý.

Materyal ve Metod: Trapez kasý üst liflerinde saptanan tetik noktalara baðlý MFAS tanýsý konulan 59 hasta (49 kadýn, 10 erkek) randomize olarak tedavi (n=30) ve kontrol grubu (n= 29) olarak iki gruba ayrýldý. Tedavi grubuna 15 gün boyunca, günde bir kez 6 dakika süreyle 1.5 Watt/cm2 dozunda, 1 MHz devamlý konvansiyonel US tedavisi, kontrol grubuna ise ayný sürede plasebo US tedavisi uygulandý. Tedavi öncesi, tedavi sonrasý ve tedaviden üç ay sonra vizüel analog skala ile olgularýn istirahat ve aktivite sýrasýndaki aðrý düzeyi, sýfýr-beþ skalasý ile tetik nokta hassasiyeti, algometre ile tetik nokta üzerindeki basýnç aðrý eþiði ve Beck depresyon ölçeði ile depresyon düzeyleri, tedavi grubunu bilmeyen bir klinisyen tarafýndan deðerlendirildi.

Bulgular: Olgularýn yaþ ortalamasý tedavi grubunda 37.43±9.07, kontrol grubunda 35.83± 5.68 idi. Tedavi öncesi deðerlerle karþýlaþtýrýldýðýnda, tedaviden sonra ve üç ay sonraki kontrollerde her iki grupta da aðrý yakýnmalarý, tetik nokta hassasiyeti ve depresyon düzeyinde anlamlý bir azalma (p < 0,01), basýnç aðrý eþiðinde anlamlý artýþ (p<0,01) saptanmakla birlikte, gruplarýn birbiriyle karþýlaþtýrýlmasýnda aðrý, tetik nokta hassasiyeti ve depresyon düzeyindeki azalma ile basýnç aðrý eþiðindeki artýþýn tedavi grubunda kontrol grubuna göre anlamlý derecede daha yüksek olduðu görüldü (p<0,001).

Sonuç: Sonuçlarýmýz, ultrason tedavisinin miyofasiyal aðrý sendromlu olgularýn tedavisinde etkili olduðunu göstermektedir.

Objectives: Myofascial pain syndrome (MPS) is a complex pain syndrome characterized with trigger points (TP) in skeletal muscles. We aimed to assess the efficacy of ultrasound (US) therapy, which is one of the main devices used in physical rehabilitation, for the treatment of TP in MPS.
Materials and Methods: 59 patients (49 females, 10 males) with active TP on the upper trapezius fibers were randomized into the treatment (n=30) and the control groups (n= 29). The treatment group received conventional US therapy for 6 minutes, on 1,5 Watt/cm2 dose with 1 MHz frequency for 15 days whereas a placebo US therapy was administered to the control group. Prior to the treatment, immediately and 3 months later pain severity during rest and physical activity was assessed with visual analog scale (VAS), TP tenderness was measured with 0-5 scale, pressure pain threshold (PPT) was analyzed with algometer and the depression level was evaluated with Beck’s depression questionnaire (BDP) by a clinician blinded to the groups.
Results: The mean age of the patients were 37.43±9.07 and 35.83± 5.68 years, in the treatment and control groups, respectively. Compared to the pre-treatment values VAS, 0-5 scale and BDP scores decreased (p < 0.01) along with an increase in PPT (p < 0.01) in both groups at the follow-up visits. 0-5 scales and BDP scores were significantly lower and PPT was significantly higher in the treatment group, compared to the control group (p<0.001).Our results revealed that US treatment is effective on MPS.

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Amaç: Kronik böbrek yetmezliðinin tedavisinde, hemodiyaliz yaþamsal öneme sahip bir tedavidir. Aðrý ise, kronik böbrek hastalýðýnýn her evresinde sýk görülen ve klinik tablonun bir parçasý olan yakýnmadýr. Çalýþmamýzda, hemodiyaliz tedavisi uygulanan hastalarda aðrýyý ve aðrý nedenlerini araþtýrmayý ve aðrý tedavisi ile ilgili uygulamalarýn yeterliliðini saptamayý amaçladýk.
Gereç ve Yöntem: Hemodiyaliz tedavisi uygulanan 18-60 yaþ tüm hastalar çalýþmaya dahil edildiler. Aðrý deðerlendirmesi, Algoloji Aðrý Deðerlendirme Formu ile yapýldý. LANSS kullanýlarak nöropatik aðrý semptom ve bulgularý deðerlendirildi.
Bulgular: 70 hemodiyaliz hastasýnýn 53 tanesinde (%75.7) aðrý yakýnmasýnýn olduðu tespit edildi. Aðrý, baþaðrýsý (31 hasta, %58.5), alt ekstremite aðrýsý (21 hasta, %39.6) ve kramp þeklinde kasýlmalara baðlý aðrýlar (28 hasta, %52.8 ) olarak kaydedildi. Hastalarýn 81.4’ünün günlük iþlerini yapabildiðini, aðrýnýn günlük yaþam aktivitesini belirgin olarak deðiþtirmediðini belirledik. Çalýþmada LANSS ≥ 12 puan olan 37 hasta (%71.8) vardý. Çalýþmaya dahil ettiðimiz hastalar “Aðrý için tedavi uygulandý mý?” sorusuna, %58.5 (31 hasta) HAYIR, %41.%’i (22 hasta) ise EVET cevabý vermiþtir. Bununla birlikte hastalarýn %54.7 ‘sinin (29 hasta) aðrý için ilaç KULLANDIÐI, %45.3’nün (24 hasta) ise aðrý yakýnmasý için ilaç KULLANMADIÐI belirlenmiþtir.
Sonuç: Böbrek yetmezliði gibi kronik hastalýðý olan hasta gruplarýnda, aðrýnýn sorgulanmasý, deðerlendirilmesi ve aðrý tedavisinin de kronik böbrek yetmezliði tedavisi ile birlikte yapýlarak hastalarýn aðrýsýz yaþamalarýnýn saðlanmasý gerektiði görüþündeyiz.

Objective: Hemodialysis is a vital therapy in treatment of chronical renal failure. Pain is a complaint seen at every stage of chronical renal failure and is a part of clinical status. We aimed to investigate pain and its causes and the sufficiency of pain treatment in use.
Methods: Patients aged 18 – 60 undergoing hemodialysis were included in this study. Pain evolution was obtained by form of Algology. Neuropathic pain symptoms and signs were evaluated by using LANNS.
Results: 53 patients undergoing hemodialysis (75.7%) complained of pain. The types of pain were recorded to be headache (31 patients, 58.5%), lower extremity pain (21 patients, 39.6%) and pain due to cramps (28 patients, 52.8%). We saw that 81.4% of our patients were capable of doing on their own and that the pain did not affect daily activities of our patients. There were 37 patients (71.8%) who had LANSS score ≥ 12. Patients included in this study answered the question “Did you get any treatment for this pain?” as NO in 58.5% (31 patients) and as YES in 41% (21 patients). Nevertheless, 29 patients (54.7%) stated that they used drugs because of the pain and 24 patients (45.3%) stated that they haven’t used any drugs for pain management.
Conclusion: The patients with chronical diseases like chronical renal failure, we believe that pain should be interrogated and assessed and along with the treatment of chronical renal failure, patients should be treated for pain and a pain-free life must be provided to these group of patients.

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Amaç: Bu çalýþmada doku defekti nedeniyle, kýsmi kalýnlýkta deri grefti (KKDG) uygulanan hastalarda donör alaný aðrý þiddeti incelendi.
Gereç ve Yöntem: Bu tanýmlayýcý çalýþma Ýstanbul’da bir kamu hastanesinin, Plastik ve Rekonstrüktif Cerrahi Kliniðinde gerçekleþtirildi. Örneklem seçimi yapýlmadý, 2013 yýlýnda KKDG yapýlmýþ olgularýn tümü (31) ile çalýþýldý. Veri toplama aracý olarak, Hasta Bilgi Formu ve Görsel Aðrý Deðerlendirme Ölçeði (VAS) kullanýldý. Verilerin analizinde, yüzdelik, ortalama, Kruskal-Wallis, Mann-Whitney U kullanýldý. Bulgular: Hastalarýn %38.71 kadýn, %61.29 u erkekti. Greftleme uygulamasýnýn en çok alt ekstremite bölgesinde yapýldýðý, %61'inin bireysel fonksiyonlarýný baðýmsýz gerçekleþtirebildiði, ayrýca; yarý baðýmlý olan hastalarýn aðrý þiddetinin, baðýmsýz olan hastalardan daha fazla olduðu saptandý. Donör alaný geniþledikçe aðrý þiddetinin arttýðý gözlendi. Hastalarýn %64,52’sinde greft donör alaný 10 cm² den daha geniþti, Alt ekstremitede KKDG ile onarým yapýlan hastalarýn postoperatif aðrý þiddetinin, üst ekstremite alanýnda onarým yapýlan hastalardan daha yüksek olduðu gözlendi.
Sonuç: KKDG ile onarým yapýlan hastalarýn donör alaný aðrý þiddetinin ameliyat sonrasý birinci gün en yüksek, altýncý gün en düþük olduðu gözlendi. Sonuç olarak donör alaný aðrý deðerlendirilmesinin özellikle ameliyat sonrasý birinci günde hemþireler tarafýndan mutlaka yapýlmasý gerektiði sonucuna varýldý.

Objective: Ýn this study we examined the donor site pain intensity of the patients who were reconstructed by split thickness skin graft (STSG) due to tissue defect.
Methods: This descriptive study was performed in a Plastic and Reconstructive Surgery Clinic of a State Hospital in Istanbul. Sampling selection wasn’t made, all (31) cases were studied with STSG in 2013. As data collection forms, we used Patient Information Form and Visual Analog Scale (VAS). In the analysis of the data percentage, Kruskal-Wallis and Mann-Whitney-U tests were used.
Results: 38.71% of the patients were female and 61.29% were male. It was determined that grafting application was mostly made in the lower extremity and 61% of the patients were able to perform individual functions independently. It was observed that pain intensity increased as the donor area expanded. It was also determined that semi-dependent patients’ pain intensity was higher than independent patients’. In 64.52% of the patients graft donor area was wider than 10cm². The postoperative pain intensity of the patients who were reconstructed by STSG in the lower extremity was higher than patients who were reconstructed by STSG in the upper extremity area.
Conclusion: It was observed that the donor area pain intensity of patients was the most severe on the first day after surgery and the least severe on the sixth day after surgery. In conclusion, the pain evaluation of the donor area has to be assessed by the nurse on the first day after surgery.

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The application of ultrasound-guided transversus abdominis plane (TAP) block in paediatric population is gaining popularity among anaesthetists. We present a case series of ultrasound-guided TAP block in ten neonate and infants undergoing colostomy and reversal of stoma. Classical TAP as described by Hebbard was carried out and a maximum dosage of 1ml/kg of 0.25% levobupivacaine was injected. Pain score was assessed using Neonatal Infant Pain Scale for 24 hours. In all patients, the block was successful with minimal hemodynamic changes intraoperatively and no additional systemic analgesia was needed intraoperative and immediate postoperatively. Ultrasound-guided TAP block has an important role in providing safe and effective analgesia for colostomy creation and reversal of stoma surgeries in paediatric population.

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Fallot tetralojisi en sýk görülen siyanotik konjenital kalp hastalýðýdýr. Bu hastalarda doðum sonrasý meydana gelen ani hemodinamik deðiþiklikler ciddi, yaþamý tehdit eden multiorgan komplikasyonlarýna yol açar. Bu yüzden anestezi seçimi zordur. 33 haftalýk düzeltilmemiþ fallot tetralojili gebe sezeryan operasyonuna alýndý. Sorunsuz bir þekilde epidural anestezi uygulandý. Hastanýn vital bulgularý ve genel durumu stabil seyretti ve postoperatif yoðun bakýmda 4 gün takipten sonra kadýn doðum servisine devredildi. Fallot tetralojili gebe hastada epidural anestezi uygulamasýnda bölünmüþ ve artan dozlarda levobupivakain uygulamasýnýn güvenli olduðu kanýsýndayýz. Bununla birlikte, bizim bu verilerimiz klinik uygulama miktarýnýn artýrýlmasý ile daha da güçleneceði kanýsýndayýz.

Tetralogy of Fallot is the most common cyanotic congenital cardiac disease. The hemodynamic changes which are present immediately after abdominal delivery may be resulted with serious, life-threatening multiorgan complications. Therefore the choice of anesthesia is very difficult. We describe the case of pregnant, 33 weeks gestation, with uncorrected tetralogy of Fallot who underwent caesarian section. The epidural anesthesia was performed uneventfully. After having stabile vital signs and a good general condition patient was followed up at the intensive care unit for 4 days. She was transferred to the obstetric service. We think that application of epidural anaesthesia with fragmented and increasing doses of slow levobupivacain in pregnant women with tetralogy of Fallot is safe. Nonetheless, this data of ours will grow stronger with the increase of the clinical application amount.
Keys words: Caesarean section, tetrology of Fallot, epidural anaesthesia

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Giriþ: aðrýlý oftalmopleji periorbital veya hemikranyal baþa aðrýsý ile beraber ipsilateral okular motor sinir parezileri ile karakterizedir ve birçok deðiþik etiyoloji sonucu oluþabilir. Tolosa Hunt Sendromu (THS) aðrýlý oftalmopatiye neden olabilen, kavernöz sinus, superior orbital fissur ve orbat apeksinin nonspesifik inflamasyonu sonucu oluþan nadir bir hastalýktýr.
Olgu sunumu: Burada sol göz aðrýsý ve diplopi ile baþvuran 45 yaþýnda kadýn hasta sunulmuþtur. Muayenesinde periorbital ödem ve sol palpebral semiptoz, sol parsiyel 3. kranyal sinir felci, 4., 6. felci ve 5. sinir oftalmik ve maksiller divizyon alanýnda hiposetezi saptandý. Kan analizi, postkontrast kranyal ve orbital magnetik resonans görüntülemesi ve BOS incelemesinde patoloji saptanmadý. Klinik tanýsý 'THS' kriterlerini dolduruyordu. Steroid tedavisi sonrasý semptom ve bulgularý tamamen düzeldi.
Tratýþma: Aðrýlý oftalmopleji THS gibi inflamatuar durumlar ile birlikte olabilir ve bu durumda steroid tedavisine tam aynýtlýdýr. fakat mutlaka iyi bir ayýrýcý taný yapýlmalýdýr. THS tanýsý nadiren kullanýlmasý gereken bir tanýdýr.

Introduction: Painful ophthalmoplegia consists of periorbital or hemicranial pain with ipsilateral ocular motor nerve palsies. There are many etiologies of painful ophthalmoplegia. Tolosa-Hunt syndrome (THS) is an uncommon disease caused by non-specific inflammation of the cavernous sinus, superior orbital fissure and the apex of the orbit. Case presentation: A 45-year-old female reported episodes of reversible left eye pain and diplopia. Examination showed periorbital oedema and left palpebral semiptosis, paresis of the partial left third nerve palsy with normal pupillary reactions, fourth and sixth left cranial nerves, and hypoesthesia over the first and second division of the left trigeminal nerve. Blood analysis, postcontrast cranial and orbital magnetic resonance (MR) imaging, cranial MR angiography and CSF analysis demonstrated no abnormalities. The clinical diagnosis satisfies the criteria for " Tolosa-Hunt syndrome ". After steroid therapy her symptoms and clinical signs dramatically reverses. Conclusion: Painful ophthalmoplegia with inflammatory conditions such as Tolosa Hunt syndrome is highly responsive to corticosteroids but should be diagnoses of exclusion. The THS diagnosis should be used rarely and with great caution.

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Gözden Kaçan Bir Antite: Notaljia Parestetika

An Overlooked Clinical Entity: Notalgia Paresthetica

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