Nöropatik aðrý tedavisi yeni tedavilere raðmen hala zordur ve tüm sorunlar ve altta yatan mekanizmalarý için iþe yarayan tek bir tedavi bulunmamaktadýr. Etkin nöropatik aðrý tedavileri için giderek artan kanýtlar göz önüne alýnacak olursa, klinisyenin aðrýyý rahatlatmada hangi ilaçlarýn en etkili olduðunu ve ilaçlarla iliþkili en az sayýdaki advers etkileri bilmesi önem kazanmaktadýr ve nöropatik aðrý durumlarýnýn tedavi edilmesi için
kanýta dayalý bir algoritmaya ihtiyaç duyulmaktadýr. Ýdealde, böyle bir algoritmada non-opioid ve opioid ilaç seçimleri için gereken kanýtlar bir ilacýn hem etkinlik
hem de yan etkiler açýsýndan diðerleriyle doðrudan bir þekilde karþýlaþtýrýlmasýna dayalý olmalýdýr. Bugün için mevcut olan bu tür doðrudan karþýlaþtýrmalar az sayýdadýr.

Treatment of neuropathic pain is difficult despite new treatments and there is no single treatment that Works for all conditions and their underlying mechanisms. Given the increasing evidence for effective treatments of neuropathic pain, it is important for the clinician to know which drugs are most effective neuropathic pain relieving pain and associated with the fewest adverse effects and there is a need for an evidence-based
algorithm to treat neuropathic pain conditions. Ideally, the evidence for the non-opioids and opioids choices in such an algorithm would be based on direct comparisons of one drug with another, for both efficacy and side effects. There are very few such direct comparisons available.

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Günübirlik yapýlan artroskopik diz operasyonlarýnda aðrý taburcu olmayý ve erken rehabilitasyonu önleyen önemli bir engeldir. Bu çalýþmada diz artroskopisi operasyonlarýndan sonra intraartiküler uygulanan lornoksikam, bupivakain ve serum fizyolojiðin postoperatif aðrý üzerine olan etkileri karþýlaþtýrýlmýþtýr. Etik komitenin izni ve hastalarýn onamlarý alýndýktan sonra yaþlarý 18-65 arasýnda deðiþen ve ASA deðeri I-II olan, artroskopik menisektomi uygulanacak 90 hasta bu randomize, tek kör, prospektif çalýþmaya alýndý. Hastalar üçe ayrýldý (her grupta 30 hasta): Grup L’de (GL) hastalara 8 mg lornoksikam; Grup B’de (GB) hastalara 50 mg bupivakain ve Grup S’de (GS) hastalara serum fizyolojik 20 mL intraartiküler olarak uygulandý. Postoperatif analjezide ilk 4 saat boyunca intravenöz tramadol hidroklorit 50 mg uygulanýrken çalýþmanýn kalaný boyunca parasetamol 500 mg ve kodein 7.5 mg preparatý uygulandý. Sayýsal aðrý skalasý (SAS) kullanýlarak 4, 12, 24 ve 48. saatlerdeki istirahat, aktif ve pasif hareketler sýrasýndaki aðrý düzeyleri, ilk 4 saatteki tramadol tüketimi, 48 saat sonundaki toplam analjezik tüketimi (tablet olarak) kaydedildi. Tramadol gereksinimi olan hastalar açýsýndan GS ile GL ve GS ile GB arasýnda anlamlý farklar olduðu (p<0.05 ve p<0.05) görüldü. GL’deki hastalarýn 48 saatteki analjezik tüketimi GB’den ve GS’den azdý (p<0.001 ve p<0.05). GL’deki hastalarýn tüm ölçüm zamanlarýnda SAS deðerleri diðer gruplardan daha düþük bulundu; ama bu sadece belli zamanlarda istatistiksel açýdan anlamlý idi. Diz artroskopilerinde postoperatif analjezi amacý ile lornoksikamýn intraartiküler uygulanmasýnýn bupivakain ve serum fizyolojikten daha iyi bir analjezi saðladýðý sonucuna varýlmýþtýr.

Postoperative pain is an important factor for discharge and rehabilitation in daycase arthroscopic knee surgery. This study compared the efficacy of intraarticular application of lornoxicam, bupivacaine and placebo on postoperative pain after arthroscopic knee surgery. With the approval of the local ethics committee and informed consent of the patients, 90 patients (ASA score I-II), aged between 18-65 years undergoing arthroscopic meniscectomy were included in this randomized, blinded, prospective study and were divided into three groups (30 patients each): 8 mg lornoxicam were applied to Group L (GL), 50 mg bupivacaine to Group B (GB) and normal saline to Group S (GS) in 20 mL volume intraarticularly. Postoperative analgesia was maintained by intravenous tramadol-HCl 50 mg/h at the first 4 h and then paracetamol 500 mg plus codeine 7.5 mg preparation as needed. The numeric rating scale (NRS) values were evaluated at rest and at active-passive motion at 4, 12, 24 and 48 h, total analgesic consumption were recorded. There were statistically significant differences between GS and GL and GS and GB in term of tramadol consumption (p<0.05 and p<0.05). The analgesic consumption of GL patients at the end of 48 h were lower than GB and GS (p<0.001 and p<0.05). The NRS values of GL were always lower than the other groups with statistical significance at certain times. We concluded that intraarticular lornoxicam provided better pain control than bupivacaine and saline in arthroscopic knee surgery.

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Bu çalýþmada preoperatif lornoksikamýn PO, ÝM ve ÝV uygulamasýnýn postoperatif aðrýyý önlemedeki etkisini araþtýrdýk.
ASA I-II grubuna giren, 18-65 yaþ arasý 40 olgu randomize dört gruba ayrýldý. 8 mg lornoksikam operasyondan 1 saat önce oral, ÝM, veya ÝV (Grup PO, Grup ÝM, Grup ÝV) verildi. Kontrol grubuna (Grup K) analjezi yapýlmadý. Postoperatif ilk analjezik gereksinimi zamaný, tüketilen ilaç miktarlarý, VAS ve VRS aðrý skorlarý kaydedildi. VAS ≥ 3 olduðu zaman lornoksikam infüzyonu HKA cihazý ile verildi.
Grup K’da, diðer gruplara göre postoperatif aðrý baþlama süresinin daha kýsa; postoperatif 2. saatte VAS ve VRS skorlarý daha yüksek ve total lornoksikam tüketiminin ise daha fazla olduðu saptandý. Grup PO, ÝM ve ÝV arasýnda aðrý baþlama süresi ve total lornoksikam tüketimi açýsýndan anlamlý fark bulunmadý.
Preoperatif 8 mg lornoksikam kullanmý postoperatif aðrý baþlama süresini uzatmakta ve analjezik ihtiyacýný azaltmaktadýr. PO, IM, ÝV uygulamalar arasýnda analjezik etki açýsýndan fark saptanmamýþtýr.

In this study we evaluated the postoperative analgesic efficacy of lornoxicam PO, IM and IV administration preoperatively. Fourty patients, aged between 18-65 years, ASA I-II class, were randomized to four groups. Lornoxicam 8 mg was administired PO, IM, IV (Group PO, Group IM, Group IV) 1 hour before the operation. Analgesia was not performed in control group (Group C). First analgesic requirement time, analgesic consumption and the VAS and VRS pain scores were recorded postoperatively. When VAS 3 patient controlled analgesia with lornoxicam was begun. We found that first analgesic requirement time was shorter, postoperative 2nd hour VAS and VRS scores and drug consumptions were higher in Grup C cases according to the other groups. There was no significant difference in first analgesic requirement time and analgesic consumption. Preoperative administration of 8 mg lornoxicam delayed the first analgesic requirement time and decreased total analgesic requirement. There was no difference on analgesic effect between PO, IM, and IV administrations.

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Sezaryen operasyonlarý sonrasý uygulanacak analjezi teknikleri, annelerin bebeklerinin bakýmýna izin verecek erken mobilizasyon ile birlikte etkin analjezi saðlamalýdýr. Bu çalýþmada, hasta kontrollü epidural analjezide (HKEA) kullanýlan yalnýz %0.2 ropivakain ve %0.2 ropivakain+0.75 µg mL-1sufentanilin karþýlaþtýrýlmasý amaçlandý.
50 kadýn olgu (ASA I) çalýþmaya dahil edildi. Tüm hastalara kombine spinal-epidural anestezi uygulandý. Duyu bloðu 2 dermatom gerileyince analjezik solüsyonlarýn infüzyonuna baþlandý. Hastalar randomize olarak 2 gruba ayrýldý (n=25). Grup-I’de %0.2 ropivakain ve 0.75 µg mL-1sufentanil, Grup II’ de yalnýz %0.2 ropivakain kullanýldý (yükleme 1.25 mL, kilit süresi 30 dakika, 2.5 mL saat-1 infüzyon ile). Ameliyat sonrasý 24 saat süresince aðrý (vizuel analog skala), motor blok (bromaj skalasý) ve sedasyon (four-point skala) deðerlendirildi. Hemodinamik ve solunumsal parametreler, yan etkiler, total ilaç tüketimi ve ek analjezik gereksinimi kaydedildi. Ýstatiksel analizde student-t, chi-square ve Mann Whitney U testleri kullanýldý.
Demografik veriler, sedasyon skalalarý, hemodinamik ve solunumsal parametrelerde gruplar arasýnda fark saptanmamýþtýr. Motor blok ve aðrý skorlarý 2 ve 4. saatte Grup-II’de anlamlý þekilde yüksek bulunmuþtur. Total ilaç tüketiminin Grup-I’de 65.24±4.20 mL, Grup II’de 81.1±6.44 mL olduðu gözlenmiþtir (P<0.05). Grup-I’de 4 hasta, Grup-II’de 21 hasta ek analjezik kullanmýþtýr. Kaþýntý Grup-I’de daha fazla gözlenmiþtir.
Sezaryen sonrasý HKEA’de %0.2 ropivakaine 0.75 µg mL-1 sufentanil eklenmesi ropivakaine göre, özellikle erken postoperatif dönemde daha etkin analjezi ve daha az motor blok saðlamýþtýr.

Analgesic techniques after c-section must be effective producing early mobilisation to enable mothers to care effort their babies. In this study, the comparison of ropivacaine 0.2% alone, with ropivacaine 0.2%+sufentanil 0.75 µg mL-1 for patient controlled epidural analgesia (PCEA) was aimed.
Fifty women (ASA-I) were enrolled in the study. All patients had combined spinal-epidural anaesthesia. Infusion of analgesic solutions was started when sensory level decreased by two dermatome levels. The patients randomly assigned, into two groups (n=25). In Group-I, ropivacaine 0.2% and sufentanil 0.75 µg mL-1, in Group-II, ropivacaine 0.2% alone were applied (bolus 1.25 mL, lockout 30 min, with 2.5 mL h-1 background infusion). Pain, motor blockage and sedation were evaluated during 24 hours after Caesarean, using the scales of visual analogue, bromage, and four-point, respectively. Haemodynamic and respiratory parameters, side effects, total drug consumption and additional analgesic need, were recorded. Statistical analysis included student-t, chi-square, and Mann Whitney U tests.
There was no difference in demographic data, sedation scores, haemodynamic and respiratory parameters, between the groups. Motor block and pain scores were significantly higher in Group-II than in Group-I at 2 and 4. h. Total drug consumption was 65.24±4.20 mL for Group-I and 81.1±6.44 mL for Group-II, (P<0.05). Four patients in Group-I and 21 patients in Group-II received additional analgesic. Pruritus was observed more frequently in Group-I.
The addition of sufentanil 0.75 µg mL-1 to ropivacaine 0.2% for PCEA after Caesarean led to more effective analgesia and less motor weakness when compared to ropivacaine 0.2% alone, especially during early postoperative period.

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Bu çalýþmada, anesteziyoloji aðrý bölümüne kabul edilen kanser hastalarýnýn aðrý tedavisinde uygulanan Dünya Saðlýk Örgütünün analjezik basamak tedavisi ve diðer tedavi yöntemlerinin sonuçlarýný deðerlendirdik. Hasta özellikleri, hastalarýn kanser patolojilerine göre daðýlýmý, analjezik basamak tedavisine göre ilk ve son daðýlýmlarý, diðer invaziv ve noninvaziv tedavi yöntemleri, tedaviye baðlý yan etkiler ve diðer veriler incelenmiþtir. 475 hastanýn 416’sý (% 87.5) WHO analjezik basmak tedavisi ile, 57 hasta ise (% 12) invaziv giriþimlerle tedavi edildi. 1. basamakta 49 (% 11.77), II. basamakta 307 (% 73.79), III. basamakta ise 60 (% 14.42) hasta baþarý ile tedavi edilmiþtir. 416 hastanýn 181’i (% 43.50) antikonvülsan veya nöroleptik, 341 (%81.97) hasta ise antideprasan kullanmýþtýr. 31 (%7.5) hastada, analjezik basamak tedavisinin etkinliðini artýrmak için non invaziv veya invaziv tedavi yöntemleri basamak tedavisine eklendi. Tüm çalýþma sürecinde hastalarýn % 17’si yan etki bildirdi. Hastalarýn ortalama takip süreleri 42 ± 109.7 gün, ortalama görüþme sayýlarý 5.6±7.6 kez, en uzun takip süresi 1380 gün, ayný hasta ile en çok görüþme sayýsý ise 68 oldu.
Sonuç olarak, Dünya saðlýk örgüyü analjezik basamak tedavisine sadýk kalýnarak, uygun hasta için uygun analjezik ve adjuvanlarýn uygun oral dozlarýnýn verilmesi ile hastalarýn büyük çoðunluðu baþarý ile tedavi edilebileceði kanýsýndayýz.

In this study we evaluated the results of pain treatment practices according to the World Health Organization analgesic ladder treatment. and other treatment modalities in cancer patients who were admitted to an anesthesiology-based pain service. Patient characteristics, distribution of the patients according to the primary pathologic sites, initial and last distribution of the patients according to analgesic ladder treatment, other invasive or non-invasive treatment modalities, side effects, and other data related with the patients were examined. 416 of 475 (87.5%) patients were treated using the WHO analgesic ladder treatment, 57 patients (12 %) were treated by invasive techniques. The number of successfully treated patients in step I, II and III were 49 (11.77%), 307 (73.79%) and 60 (14.42) respectively. 181 of 416 (43.50%) patients used anticonvulsants or neuroleptics, 341 of 416 (81.97%) patients used antidepressants. In 31 of 416 patients (7.5%), non-invasive or invasive treatment modalities had become necessary to augment the WHO analgesic ladder treatment. Over the entire treatment period, side effects were reported in 17.05% of the patients. The follow-up time for the patients was 42 ± 109.7 days, the mean interview number was 5.6±7.6, the longest follow-up time was 1380 days, and the maximum number of the interviews made by the same patient was 68. In conclusion, we think that, using the World Health Organization analgesic ladder treatment and administering appropriate analgesics and adjuvants in appropriate oral doses determined for appropriate subjects could successfully treat a great number of these patients.

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Horner sendromu cerrahi, ilaçlar (çoðunlukla yüksek konsantrasyonda lokal anestezikler) bölgesel basý (hematom veya tümör) ya da peroperatif uygunsuz hasta pozisyonu sonucu ayný taraftaki servikal sempatik zincirin (stellat gangliyon) felci sonucu oluþur. Horner Sendromu brakiyal pleksusunun interskalen bloðuyla % 100 oranýnda görülür ve ayný zamanda diðer supraklavikular blok tiplerinde de görülebilir.
Horner sendromu önemli klinik sonuçlarý olmamasý nedeniyle istenmeyen bir yan etki olarak tanýmlanabilir. Bu nedenle anesteziyolojistler bu sendromdan haberdar olmalý ve görüldüðü takdirde hastaya güven verilerek yakýndan takip edilmelidir. Biz bu yazýmýzda yeni tanýmlanan bir teknik olan lateral sagittal infraklavikular blok (LSÝB) sonrasý geliþen Horner sendromu vakasýný sunduk.
Anahtar kelimeler: Horner sendromu, brakiyal pleksus bloðu, lateral sagittal infraklavikular blok.

Horner’s syndrome results from paralysis of the ipsilateral sympathetic cervical chain (stellate ganglion) caused by surgery, drugs (mainly high concentrations of local anesthetics), local compression (hematoma or tumor), or inadequate perioperative positioning of the patient. It occurs in 100 % of the patients with an interscalene block of the brachial plexus and can also occur in patients with other types of supraclavicular blocks.
Horner's syndrome may be described as an unpleasant side effect because it has no clinical consequences in itself. For this reason anesthesiologists should be aware of this syndrome and if it occurs patients should be reassured and monitored closely. In this case report, we presented a case of Horner’s Syndrome following lateral sagittal infraclavicular block (LSIB), a newly described technique.
Keywords: Horner’s syndrome, brachial plexus block, lateral sagittal infraclavicular block.

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Miyastenya gravis nöromüsküler kavþakta asetilkolin reseptörlerine karþý antikor oluþumuyla karakterize otoimmün bir hastalýktýr. Çeþitli anestezik ajanlarla etkileþiminden dolayý anestezistler için özel bir ilgi alaný oluþturur. Literatürde miyastenya gravisli çocuk hastalarda eriþkin miyastenik hastalardan farklý olarak, anestezik yaklaþýmla ilgili çok az bilgiye rastlanmýþtýr ve mevcut bilgilerin çoðunluðu timektomi için yapýlan uygulamalarla ilgilidir. Buna ek olarak kaudal anestezi pediyatrik hastalarda oldukça yaygýn kullanýlan bir teknik olmakla beraber miyastenik hastalarda kullanýmýna iliþkin bir bilgiye rastlanmamýþtýr.
Biz bu olgu sunumunda 2 yaþ, 12 kg aðýrlýðýnda miyastenya gravisli erkek hastada kaudal anestezi uygulamasýný sunduk. Orþiyopeksi ameliyatý planlanan hastada konjenital miyastenya gravis nedeniyle jeneralize güçsüzlük, solunum sýkýntýsý ve göz kapaklarýnda düþüklük mevcuttu. Operasyon odasýnda rutin monitorizasyonu takiben hasta 1mg midazolam ve 10 mg ketamin ile sedatize edilerek, 1 mL.kg-1 % 0.25 bupivakain ile kaudal blok yapýldý. Lokal anestezik enjeksiyonunu takiben 17 dakika sonra operasyon baþladý ve 45 dakika sürdü. Hastada intraoperative ek analjezik ihtiyacý olmadý ve postoperatif takip sorunsuz geçti.
Miyastenya gravisli hastalarda respiratuar ve istemli kas aktivitesinin korunmasýna özel bir önem gösterilmelidir. Kaudal anestezi miyastenya gravisli hastalarda kas gevþetici ve endotrakeal entübasyon olmadan havayolunun kontrolüne izin verir.
Sonuç olarak, biz kaudal anestezinin miyastenik pediyatrik hastalarda uygun ve güvenli bir teknik olduðunu ve bu hastalarda genel anesteziye alternatif olarak uygulanabileceðini düþünüyoruz.

Myasthenia gravis is an autoimmune disease with antibodies directed against the acetylcholine receptor at the neuromuscular junction. Anesthetists have a special interest in myasthenia gravis because of its interaction with various anesthetic agents. Unlike adult myasthenic patients; very little report has been written about the anesthetic management in children, other than in relation to thymectomy. Although the use of caudal anesthesia in pediatric patients is common, have not seen any report concerning its use in a myasthenic child.
In this case report, we represented a 2 year-old boy was performed caudal anesthesia for orchiopexy operation. He had presented difficulty in breathing, generalized weakness and droopy eyes due to congenital myasthenia gravis. In the operating room, following the routine monitoring, the patient was sedated with intravenous 1mg midazolam and 10 mg ketamine. Then caudal block was performed. 17 minutes later from the local anesthetic injection; operation was started and lasted 45 minutes. The patient did not require intraoperative supplemental analgesia and postoperative course was uneventful.
Specific attention should be paid to voluntary and respiratory muscle strength in myasthenia gravis patients. Caudal anesthesia allowed airway control of myasthenia gravis patients without endotracheal intubations and muscle relaxant.
In conclusion, we think that caudal anesthetic technique may be considered as a safe and suitable for the myasthenic child and it may represent a valid alternative to general anesthesia for these patients.

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