Günümüzde ileri evre kanser hastalarýnýn palyatif bakýmý için çok yönlü yaklaþýmlara ihtiyaç vardýr. Bu hastalar için temel hedef aðrý ve diðer semptomlarýn giderilmesi, psikososyal ve spiritüel gereksinimlerinin karþýlanmasý ve yaþam kalitelerinin yükseltilmesidir. Bunun yanýnda bakým verici aile üyelerin fiziksel ve psikososyal gereksinimlerinin karþýlanmasý talepleri karþýmýzda durmaktadýr. Amacý hasta ve ailesine bütüncül bir yaklaþýmla etkili ve kaliteli bakým sunma olan, bakým koordinasyonu ve multidisipliner ekip iþ birliðine dayalý yaklaþýmlardan biri vaka yönetimidir. Vaka yönetiminde multidisipliner ekip tarafýndan hazýrlanan bakým protokolleri kullanýlmaktadýr. Bakým protokolü belirlenen hasta bakým sonuçlarýna ulaþmak için ilgili disiplinler tarafýndan yapýlmasý gereken aktiviteleri belli bir zaman çizelgesi üzerinde gösteren, multidisipliner bir klinik yönetim aracýdýr. Palyatif bakým protokolünde hasta ve ailesi için ulaþýlacak hedefler, taný, tedavi ve bakým uygulamalarý, ekip üyelerinin sorumluluklarý bulunmaktadýr. Bir çok rehber ve uzman bir ekip ile geliþtirilen bu bakým protokolünün palyatif bakým aktivitelerine katký saðlayacaðý ve bu hastalarla çalýþan ekip üyelerine yol gösterici olacaðý düþünülmektedir.

Today, multifaceted approach is needed for the palliative care of advanced stage cancer patients. The main objective for these patients, elimination of pain and other symptoms, psychosocial and spiritual needs are met and to increase the quality of life. We are also faced with the challenge of meeting the physical and psychosocial needs of family members. The purpose of a holistic approach to patient and family who provide effective and quality care, care coordination and case management of a multidisciplinary team approach is based on cooperation. Care protocols specified patient care activities to be carried by the related disciplines to achieve results on a timeline that shows a certain, a multidisciplinary clinical management tool. A lot of care guidelines and protocols developed by a team of experts to contribute to the palliative care activities, and this is thought to be a guiding team members, working with patients.

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Amaç: Bu çalýþma, huzurevinde yaþayan yaþlýlarýn aðrý yönetim durumunun belirlenmesi amacýyla yapýlmýþtýr.
Gereç ve Yöntem: Tanýmlayýcý olarak yapýlan bu çalýþma Þubat-Temmuz 2012 tarihleri arasýnda Ýzmir’de iki huzurevinde yapýlmýþtýr. Çalýþmaya toplam 82 yaþlý birey katýlmýþtýr. Çalýþmada veriler Yaþlý Tanýtým Formu, Mini-Mental Skala, McGill Aðrý Skalasý (MAS), Aðrý Yönetim Envanteri ile toplanmýþtýr.
Bulgular: Çalýþmada yaþlý bireylerin en yüksek oranlarda %64.6 diz ve %58.5 baþ aðrýsý yaþadýklarý belirlenmiþtir. Çalýþmaya katýlan yaþlýlarýn aðrý yönetiminde en yüksek oranda %96.3’ü aðrý kesici kullandýklarý ve kullandýklarý yöntemler arasýnda en yüksek oranda dinlenme ve dikkati baþka yöne çekme (X=5.76±0.87) ve reçete edilen aðrý kesiciyi almayý (X=5.69±0.87) yararlý bulduklarý saptanmýþtýr.
Sonuç: Yaþlý bireylerde aðrýnýn farmakolojik ve nonfarmakolojik yöntemlerle kullanýlarak yönetilmesi önemlidir. Bu nedenle yaþlý bireylerin aðrý yönetiminde en çok kullandýðý yöntemlerin belirlenmesi ve bakým planýna entegre edilmesi önerilmektedir.

Objectives: The aim of this study was to determine pain management status of the elderly in nursing homes.
Methods: The descriptive study sample included 82 elderly who presented to two nursing homes in Ýzmir between February-July 2012. In this study, Elderly Identification Form, Mini-Mental Scale, McGill Pain Scale (MAS) and Pain Management Inventory were used as the data collection tool.
Results: It was determined that the highest rates of complaints the elderly individuals had were knee pain (64.6%) and headache (58.5%) in this study. Of the elderly people participating in the study, 96.3% took pain relievers for pain management and according to their statements, of the pain management methods they used, resting and directing attention to something else (X = 5.76 ± 0.87) and taking prescribed pain relievers (X = 5.69 ± 0.87) were very beneficial.
Conclusion: In elderly individuals, it is important to use pharmacological and non-pharmacological methods for pain management. Therefore, it is recommended to determine the most frequently used methods for pain management by the elderly and to integrate them into the care plan.

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Amaç: Bu çalýþmada intravenöz rejyonal anestezide (IVRA) prilokain ve buna eklenen deksketoprofen ve deksametazonun anestezik ve analjezik etkinliklerinin karþýlaþtýrýlmasý amaçlanmýþtýr.
Gereç ve Yöntem: El ve el bileði cerrahisi geçirecek 18-60 yaþ, ASA I-II 45 olgu rastgele 3 gruba ayrýldý. Grup P’ye 3 mg/kg % 0.5 prilokain, Grup PDK’ya 3 mg/kg % 0.5 prilokain ile 50 mg deksketoprofen, Grup PDM’ye 3 mg/kg % 0.5 prilokain ile 8 mg deksametazon total 40 ml verildi. Duyusal ve motor blok baþlama ve dönüþ zamanlarý, hemodinamik veriler, analjezi süresi, turnike süresi, intraoperatif fentanil alan hasta sayýsý, ilk analjezik zamaný, vizüel analog skala (VAS), 24 saat analjezik tüketimi ve hasta memnuniyet skorlarý kaydedildi.
Bulgular: Duyusal blok baþlama zamaný Grup P’de uzun bulunurken,motor blok baþlama zamaný daha uzun ve motor blok dönme zamaný daha kýsa bulundu (p<0.05). Duyusal blok dönme zamanlarý açýsýndan 3 grup arasýnda anlamlý fark bulunmadý Ýntraoperatif turnike aðrýsý baþlama zamaný Grup PDM ve Grup PDK’da daha uzun bulunurken (p<0.05), intraoperatif fentanil ihtiyacý olan hasta sayýsý Grup P’de daha fazlaydý (p<0.05). Ýlk analjezi verilme zamaný Grup PDK’da her iki gruptan uzun (p<0.05) bulunurken, total analjezik tüketimi Grup P’de diðer iki gruptan daha fazla (p<0.05), Grup PDM’de de Grup PDK’dan fazla bulundu (p<0.05). Grup P’de intraoperatif VAS deðerleri daha yüksek (p<0.05) bulunurken, hasta memnuniyet skorlarý daha düþük bulundu (p<0.05)
Sonuç: IVRA’de prilokaine eklenen deksketoprofen ve deksametazonun hem analjezik hem de anestezik kaliteyi artýrdýðý ancak deksketoprofenin postoperatif ilk 24 saatte daha iyi analjezi saðladýðý gösterilmiþtir.

Objective: The aim of this study was to compare the anesthetic and analgesic effects of prilocaine alone, prilocaine added dexketoprofen and dexamethasone during intravenous regional anesthesia (IVRA).
Methods: Forty five patients undergoing forearm or hand surgery were randomly assigned to one of three groups to receive (Group P) 3 mg/kg 0.5% prilocaine; (Group PDK) 3 mg/kg 0.5% prilocaine plus 50 mg dexketoprofen; (Group PDM) 3 mg/kg 0.5% prilocaine plus 8 mg dexamethasone in total 40 ml volume for IVRA. The onset and duration of sensory and motor blocks, hemodynamic datas, duration of analgesia and tourniquet, time to first analgesic requirement, visual analog scale (VAS), total analgesic consumption in 24 hours and patient satisfaction score were assessed and recorded.
Results: Time to onset of sensory block was found to be longer in Group P (p<0.05), though no significance was found according to sensory block recovery times amoung groups. Time to onset of motor block was found to be longer and recovery time of motor block was found to be shorter in Group P (p<0.05). Time to first analgesic requirement was found to be longer in Group PDK,and was found to be high in Group PDM than Group PDK(p<0.05). The VAS scores was found to be high and patient satisfaction scale was found to be low in Group P (p<0.05).
Conclusion: The addition of dexketoprofen and dexamethasone to prilocaine during IVRA improves the quality of both anesthesia and analgesia moreover dexketoprofen provides beter postoperative analgesia during the first 24 hour after surgery.

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Preemptif analjezi postoperatif aðrýnýn kontrol altýna alýnmasýnda ve cerrahinin oluþturduðu stres yanýtýn engellenmesinde önemli bir faktördür. Amacýmýz gabapentin ve nimesulid’in postoperatif analjezik tüketimine, vizüel analog skala (VAS) üzerine etkisini ve oluþabilecek yan etkilerini plasebo grubu ile karþýlaþtýrmaktýr.
ASA I-II risk grubunda bulunan 18–70 yaþ aralýðýnda, fonksiyonel sinüs cerrahisi (FESC) geçirecek olan 90 hasta çalýþmaya dahil edildi. Hastalar rastgele üç gruba ayrýldý. Operasyondan bir saat önce hastalara oral yolla Grup 1’de plasebo kapsül, Grup 2'de gabapentin 1200 mg, Grup 3'de nimesulid 100 mg verildi. Bütün hastalarda peroperatif hemodinamik parametreler ölçüldü. Postoperatif ilk 24 saat içerisindeki bulantý kusma, hipotansiyon, hipertansiyon, bradikardi, taþikardi gibi yan etkiler, operasyon bitiminden itibaren ilk diklofenak ihtiyacýnýn olduðu süre ve VAS kaydedildi.
Postoperatif 24 saat boyunca yapýlan takiplerin hepsinde ilk diklofenak ihtiyaç süresi, operasyon bitiminden itibaren; Grup 2>Grup 3>Grup 1olarak gerçekleþti. Total diklofenak tüketimi Grup 2’ de; Grup 1 ve Grup 3’ e göre istatistiksel olarak anlamlý bir þekilde düþük bulundu. Postoperatif VAS deðeri Grup 2'de Grup 1 ve 3'e göre daha düþük bulundu.
Sonuç olarak, FESC sonrasý postoperatif analjezi amacýyla gabapentinin veya nimesulidin preemptif olarak güvenli bir þekilde kullanýlabileceðini düþünüyoruz.

Preemptive analgesia is an important factor in controlling the postoperative pain and avoiding the stress response caused by the surgery. We aim to compare impact of Gabapentin and Nimesulide on postoperative analgesic consumption on the visual analog scale (VAS) as well as any potential side effects, to those of the placebo group.
Ninety patients aged 18–70 under ASA I-II risk, who were to undergo Functional Endoscopic Sinus Surgery (FESS), were included in the study. Patients were randomized into three groups. One hour before the surgery, oral placebo capsules were administered to Group I patients, Gabapentin 1200 mg to Group II patients and Nimesulide 100 mg to Group III patients. Perioperative hemodynamic parameters were measured for all patients. During the first 24 hours of the postoperative period, side effects such as nausea, vomiting, hypotension, hypertension, bradycardia, tachycardia were noted, and the time from end of the surgery to the first diclofenac need was recorded in addition to VAS scores.
In all of the follow-ups for 24 hours of the postoperative period, time from end of the surgery until the first diclofenac requirement; Group 2 > Group 3 > Group 1. Total diclofenac consumption of group 2 was found to be significantly lower than Group 1 and Group 3 on a statistical basis. Postoperative VAS score in Group 2 was lower than Group 1 and Group 3.

To conclude, we believe that Gabapentin or Nimesulide may be safely used preemptively for the purposes of postoperative analgesia after FESS procedures.

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Amaç: Bu çalýþmanýn amacý; lomber mikrodiskektomi uygulanan olgularda preemptif intravenöz tek doz uygulanan deksketoprofenin postoperatif analjezik etkisini araþtýrmaktýr.
Gereç ve Yöntemler: Bu çalýþmaya laminektomi operasyonu olacak ASA I-II toplam 50 olgu alýndý. Olgular iki gruba ayrýldý. Operasyon baþlamadan 10 dakika önce, verilen ilacýn içeriðini bilmeyen anestezi hekimi tarafýndan, Grup A’daki olgulara 50 mg (2 ml) deksketoprofen, Grup K’daki olgulara ise 2 ml serum fizyolojik intravenöz olarak verildi. Bütün olgulara standart genel anestezi uygulandý. Postoperatif analjezi için tüm hastalara tramadol ile hasta kontrollü analjezi uygulandý. Hastalarýn postoperatif 1, 4, 8, 16 ve 24.saatlerdeki VAS deðerleri, sedasyon skorlarý ve hasta memnuniyetleri ile toplam tramadol tüketimi deðerlendirildi.
Bulgular: Deksketoprofen uygulananlarda postoperatif ilk 8 saatte kaydedilen VAS deðerleri ile toplam tramadol miktarý kontrol grubuna göre daha düþüktü, hasta memnuniyeti ise daha iyi idi. Sedasyon skorlarý ve yan etkiler gruplararasýnda benzerdi.
Sonuç: Preemptif intravenöz tek doz uygulanan deksketoprofenin, lomber mikrodiskektomi uygulanan olgularda özellikle ilk 8 saatte postoperatif analjezik etki saðlayýp, toplam tramadol tüketimini azalttýðý sonucuna varýldý.

Objective: The objective of this study was to evaluate the postoperative analgesic effect of a preemptive, single-dose intravenous dexketoprofen administration in patients undergoing lumbar microdiscectomy.
Material and Methods: A total of 50 ASA I-II patients candidate to laminectomy were included in this study. They were divided in two groups. Patients in Group A were given 50 mg (2 mL) dexketoprofen and those in Group K 2 mL normal saline intravenously by a blinded anesthesia physician, 10 minutes before the start of intervention. All cases underwent general anesthesia. All patients received postoperative patient-controlled analgesia with tramadol. The VAS scores 1, 4, 8, 16 and 24 hours following the operation, sedation and patient satisfaction scores and tramadol consumption were evaluated.
Results: VAS scores recorded during the first 8 postoperative hours and total tramadol amounts were lower, and the patient satisfaction scores higher, in patients given dexketoprofen than control group. Sedation scores and side effects were similar in both groups.
Conclusion: Single-dose preemptive intravenous dexketoprofen provides effective analgesia especially in the first 8 postoperative hours, reducing tramadol use.

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Tolosa-Hunt sendromu (THS) aðrýlý oftalmopleji ile prezente olan, steroide yanýtlý, kavernöz sinüs/superior orbital fissür'ün inflamasyonunun neden olduðu bir hastalýktýr. Diyabetik hastalarda kraniyal nöropati nadir görülmekle birlikte yaþlý ve düzenli kan þekeri takibi yapýlmayan hastalarda sýk görülür.
56 yaþýnda kadýn hasta periorbital aðrý ile eþ zamanlý baþlayan sað VI., sol III., IV., VI., VII. kraniyal sinirler ve trigeminal sinirin maksiller dalý tutulumu ile baþvurdu. THS ve diyabetik kraniyal nöropati birlikteliði sýk görülmemekle birlikte eþzamanlý baþlayan multipl kraniyal sinir felci ve aðrýlý oftalmoplejisi olan hastalarda tanýda düþünülmelidir. Diyabetik hastamýzý ilginç birliktelik ve THS’na fasiyal sinir felcinin de eþlik etmesi nedeniyle tipik kraniyal magnetik rezonans (MR) görüntüleri ile sunmayý uygun bulduk.

Tolosa-Hunt syndrome(THS) is described as painful ophtalmoplegia caused by nonspesific inflammation of cavernous sinus or superior orbital fissure, which is response to steroid theraphy. Cranial neuropathies in diabetic patients are extremely rare and occur in older patients with poorly controlled diabetes.
56 year old diabetic female patient who developed simultaneous right VI., left III., IV., VI., VII. and maxiller branch of trigeminal nerve palsies with acute periorbital pain applied to our outpatient clinic. Although the coexistence of THS and diabetic cranial neuropathy is an uncommon condition, this should be considered as a possible diagnosis on patients who are admitted with painful ophtalmoplegia and simultaneous multipl cranial neuropathies. We approved to present our diabetic patient with cranial magnetic imaging because of this interesting unity and fasial nerve palsy accompanying to THS.

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Giriþ: Hiperaljezi normalde aðrýlý olan uyarana karþý verilen cevabýn artmasýdýr. Opioid hiperaljezisi, genellikle morfinin çok yüksek dozlarda kullanýlmasý sonucu görülmektedir.
Olgu: 40 yaþýnda, 45 kilogram aðýrlýðýnda erkek hastaya 2.5 yýl önce evre IV Kolon Ca tanýsý konulmuþ. Hasta son 1 yýl süresinde artan aðrýlarý için kontrolsüz ve geliþigüzel NSAII, opioid analjezikler ve steroid preperatlarý kullanmýþtý. Aðrý kontrolü için beþ kez baþvurdu. Son kontrolde, epidural analjeziðe cevap vermeyen þiddetli abdominal, kasýk, rektal aðrýlarý (VAS 8) olan hasta uykusuz, huzursuz ve panik halindeydi. Opioid toleransý düþünülerek hastaya intratekal 1 mg morfin uygulandý. Ýþlem sonrasý bir saat içinde giderek artan aðrýlarý (VAS 8-9) olmasý nedeniyle opioid hiperaljezisi (OIH) düþünülerek hastaya i.v. deksketoprofen, diazem verildi. Þikayetlerinde gerileme olmadý. Sonra i.v. bolus deksmedetomidin (1µg/kg) takiben deksmedetomidin infüzyonu (0.2 µg/kg/h) baþlandý. Þikayetleri gerileyen hastaya 3 gün sonra diagnostik intratekal klonidin(30 µg) uygulandý, 30 dakika sonra aðrýlarý (VAS 1-2) rahatlayan hastaya intratekal port yerleþtirildi. 90 µg/gün klonidin ile hem kanser aðrýsý hem de OIH kontrol altýna alýndý. Hasta çok rahatladý, aðrýsý ölünceye kadar dayanabilir düzeydeydi.

Tartýþma-Sonuç: Ýntratekal klonidin uygulanmasý OIH tedavisinde etkili bir yöntem olabilir.

Introduction: Hyperalgesia is normally an increase in the response to a painful stimulant. Opioid-induced hyperalgesia (OIH) is a situation frequently encountered in algology clinics. Its treatment is complicated and problematic and often requires alternative methods.
Case: A 45-kilogram, 40-year-old male patient had been diagnosed with stage IV colon cancer 2.5 years ago. He had used non-steroid antiinflammatory drugs (NSAIDs), opioid analgesics and steroid preparations casually for his increased pain without any monitoring for one year. He was admitted five times for pain control. In the last visit, he complained of severe abdominal, pubic and rectal pain (visual analogue scale [VAS] 8), which was unresponsive to epidural analgesic, and later presented to the algology clinic; he was sleep-deprived, restless and in a panic state. Intrathecal morphine (1 mg) was applied considering his opioid tolerance. Because of increased pain (VAS 8-9) one hour after surgery for abscess in the liver and peritonea, the patient was given intravenous dexketoprofen trometamol and diazem considering his OIH. Then, bolus dexmedetomidine (1 µg/kg) followed by dexmedetomidine infusion (0.2 µg/kg/h) was started. Three days later, diagnostic intrathecal clonidine (30 µg) was applied, and the patient’s complaints regressed. With the patient reporting relaxed pain (VAS 1-2) after 30 minutes, an intrathecal port was placed. Both cancer pain and OIH were controlled with clonidine 90 µg/day. He was more relaxed, and his pain was tolerable until his death.
Discussion-Conclusion: Intrathecal clonidine administration may be an effective method for the treatment of OIH.

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Giriþ: Stellate ganglion bloðu çok sýk kullanýlan sempatik blok yöntemlerinden biridir. Deneyimli kiþiler tarafýndan yapýlmasýna raðmen komplikasyonlar geliþebilmektedir.
Olgu: Araç içi trafik kazasý sonrasý sað kolda güçsüzlük, aðrý þikayeti ile ortopedi kliniðine baþvuran hastaya sað brakial pleksus hasarý teþhisi koyulmuþtur. Bayan, 44 yaþýndaki hastanýn medikal tedaviye yanýtý yoktu ve sað kolunda dirsek ekleminin distalinde, radial ve median sinir trasesine uyan alanda duyu kaybý mevcuttu. Hastanýn EMG sinde C6-T1 kök avülzyonu, MR’ýnda sað alt brakiyel pleksus düzeyinde kök avülzyonu saptandý. Hasta CPRS (Kompleks rejyonel aðrý sendromu) 1. evre olarak deðerlendirildi. Medikal tedavisi yeniden düzenlendi ve stellat ganglion blokajý yapýldý. Enjeksiyondan 4-5 dakika sonra solunum arresti geliþtiði gözlendi. 2 saat boyunca mekanik ventilatöre baðlandý ve 24 saat sonra hastanýn vital fonksiyonlarýnýn normal olmasý üzerine taburcu edildi. 1 yýl sonra hasta ayný bölgede þiddetli aðrý þikayeti ile yeniden aðrý polikliniðine baþvurdu. Stellat ganglion RF yapýlmasý planlandý. C kollu skopi altýnda RF kanüllerinin birincisi yerleþtirildi. Ýkinci kanül yerleþtirilirken BOS geldiði görüldü ve kanül çekildi. Baþka bölgeden üçüncü kanül yerleþtirildi ve iki kanülden konvansiyonel RF iþlemi uygulandý. Anatomik yapý defekti olabileceði düþünülerek, servikal MR myelografi planlandý. Servikal MR myelografi bulgusunda, C5-T1 brakial pleksus düzeyinde travmatik psödomeningosel görüldü. Bu sebeple stellat ganglion blokajý sýrasýnda intraspinal blok yapýldýðý anlaþýldý.
Sonuç: Travma sonrasý tedavi nedeniyle yapýlan stellat ganglion blokajýnýn ultrason veya floroskopi ile yapýlmasý gerektiðini düþünmekteyiz.

Aim: Stellate ganglion block (SGB) is one of the most often used sympathetic blockade procedure. Despite performed by experienced physicians some complications may occur.
Case: The right brachial plexus injury was diagnosed in the patient who admitted to orthopedia clinic, with weakness in the right arm, and pain after motor vehicle accident. There was no response to medical treatment of fortyfour-years-old female patient and there was loosing of sensation from dis the right elbow joint to fingers on the radial and median nerve tracing. In the electromyelography; C5-T1 root avulsion, and MRI; Patient was evaluated as CPRS I (Complex regional pain syndrome) phase 1. In spite of medical treatment, SGB was performed. Respiratory arrest occurred 4-5 minutes after injection. Patient was breated with mechanical ventilator during 2 hours, and discharged 24 hours later with normal vital functions. One year later, the patient admitted the algology polyclinic with strong pain in the same area. Stellate ganglion Radyofreguency (RF) was planned. The first RF cannula was placed under fluoroscopy. Cerebrospinal fluid was seen in the second canula, and canula was withdrawn. Third cannula was placed in another region, and conventional RF was performed through two canuls. For anatomical structure defect, we planned cervical MR myelography. In the cervical MR myelography, traumatic pseudomeningocele was observed at the level of C6-T1 on the brachial plexus. Intraspinal block was thought to develop during blockade of stellate ganglion due to this.

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