MEDICAL ETHICS EDUCATION IN TURKEY; STATE OF PLAY and CHALLENGES

ABSTRACTMedical ethics can be traced back to Hippocratic oat in antiquity. Last decade witnessed improvements in science and technology which attracted attention to the ethical impacts of the innovations in medicine. The need to combine medical innovations with a preservation of human values and to cultivate ethical competencies required by professionalism conceived medical ethics education in various levels in medical schools. Despite the diversities regarding teaching hours, methodology and content of the courses, medical ethics became a fundamental part of medical education around the world. In Turkey medical ethics education is given both in undergraduate and postgraduate levels. The high increase in the number of medical schools and shortfall of instructors who have medical ethics as their primary academic focus creates a big challenge in medical ethics education in both levels. Currently there are 89 medical schools in Turkey and only six medical schools are giving postgraduate medical ethics education. In 2010 only 33 of all medical schools could establish a separate department dedicated to medical ethics. There are no medical ethics courses embedded in residency programs. The quality and standardization of undergraduate medical ethics education has started but there are no initiatives to do so in postgraduate level. 

Hyperbaric levobupivacaine in anal surgery : spinal perianal and spinal saddle blocks

An ideal anesthetic technique for anal surgery on an outpatient basis should permit early mobilization without pain or residual complications of anesthesia. The aim of this study was to analyze the reliability and efficacy of spinal perianal and spinal saddle block by using two different doses of levobupivacaine for perianal surgery and their effects on voiding, first analgesic requirement and hospital discharge times. A prospective, randomized, double-blinded study was conducted on 78 ASA I-II patients scheduled for elective perianal surgery. Patients were randomized into two groups, the spinal perianal group and the spinal saddle group. Hyperbaric levobupivacaine 1.5 mg (perianal) or 6 mg (saddle) was administered intrathecally through the L4-5 intervertebral space by a 25-gauge Whitacre spinal needle with the patient in the sitting position. Sensory block was evaluated using a surgical toothless clamp until satisfactory block reached the S4 sensory level and motor block was evaluated using a modified Bromage scale. Patient and surgeon satisfaction were recorded for each patient. Ambulation, voiding and hospital discharge times were assessed. There was no statistical difference between the two groups demographically. Perianal low dose levobupivacaine use resulted in no motor block (Bromage=0, p=0.006) and a sensory block limited to the S4 level. The low and conventional doses of levobupivacaine provided sufficient anesthesia during the surgical procedures. The sensory block regression time in the perianal block group was shorter than the saddle group (p=0.048). Time to first analgesic requirement was significantly longer in the saddle block group (p < 0.05). The times of first ambulation, the first voiding and hospital discharge in patients with the perianal block were significantly shorter than patients in the saddle block (p < 0.05, p < 0.01, p < 0.05, respectively). The results of the study showed that the use of 1.5 mg hyperbaric levobupivacaine provides sufficient and satisfactory anesthesia in ambulatory perianal surgery

The ımportance of extravascular lung water measurement in major surgeries

Majör cerrahilerde postoperatif pulmoner komplikasyonlar %1-23 arasında değişmekte ve ciddi mortaliteye neden olabilmektedir. Perioperatif ekstravasküler akciğer sıvısı (EVLW) ölçümü, komplikasyonların önlenmesinde olduğu kadar ventilatörden ayırma, sıvı yönetimi ve farmako lojik müdahalelere yanıtın gözlenmesinde de yararlıdır. EVLW akciğerlerde pulmoner damarlar dışında bulunan interstisyel, intrasellüler, alveoler ve lenfatik sıvıyı kapsar. Sağlıklı kişilerde normal değerleri 3-7 ml/kg’dir ve 10 ml/kg üzerindeki değerlerin pulmoner ödeme işaret etmek tedir. EVLW ölçümünde altın standart gravimetrik yöntem olmakla birlikte, bu yöntemin post mortem uygulanabilmesi nedeniyle ultrasonografi ve transpulmoner termodilüsyon gibi yön temler geliştirilmiştir. EVLW ölçümü renal replasman tedavisi, ekstrakorporeal membran oksije nizasyonu (ECMO), plevral effüzyonlar ve yüksek PEEP kullanımı gibi durumlardan etkilenebil mektedir. Gelecekte majör cerrahilerde EVLW ölçümünün postoperatif hemodinamik takip ve tedaviye etkilerini araştıracak yeni çalışmalara gereksinim vardır

Bilateral sympathicotomy for hyperhidrosis without using single-lung ventilation

Background/aim: The goal of this retrospective study was to evaluate the outcomes and complications of bilateral videothoracoscopic sympathicotomy without using single-lung ventilation in the treatment of primary hyperhidrosis and facial blushing. Materials and methods: We retrospectively reviewed 154 consecutive patients (70 females and 84 males) who underwent bilateral sympathicotomy for palmar, axillary, and facial/scalp hyperhidrosis or facial blushing from February 2005 to June 2013. The patients were intubated with single-lumen endotracheal tube, and then sympathicotomies were performed via videothoracoscopy during controlled apnea periods. Results: Sympathicotomies were performed at costal levels 2, 3, and 4. No perioperative mortality or conversion to open surgery was recorded. Mean operation time was 31.2 ± 2.4 min and mean hospital stay was 1.1 ± 0.6 days. One patient experienced a unilateral pneumothorax that required treatment. There were no abnormal hemodynamic parameters measured during the perioperative apnea periods. The long term follow-up period was 21.4 ± 5 months. Twenty-nine cases (18.8%) were complicated by compensatory sweating. No recurrence was observed during the follow-up period. Conclusion: Video-assisted thoracoscopic sympathicotomy without lung isolation provides effective cure of primary hyperhidrosis and facial blushing. This procedure can shorten the operative time without any aberrant hemodynamic shifts

Comparación de la Morfina Administrada por Vía Intravenosa y Vía Epidural con/sin Bupivacaína o Ropivacaína en el Tratamiento del Dolor Pos toracotomía con la Técnica de Analgesia Controlada por el Paciente

ResumenJustificativa y objetivos: El objetivo de este estudio aleatorio, doble ciego y prospectivo fue determinar la eficacia y los efectos colaterales de la administración por vía intravenosa o epidural de morfina, bupivacaína o ropivacaína en el tratamiento del dolor pos toracotomía.Métodos: Sesenta pacientes sometidos a procedimientos de toracotomía electiva fueron aleatoriamente ubicados en cuatro grupos con el uso de la técnica de sobres lacrados. Los grupos MIV, ME, MEB y MER recibieron morfina controlada por el paciente por vía intravenosa, epidural, morfina-bupivacaína y morfina-ropivacaína, respectivamente. La frecuencia cardíaca, presión arterial y la saturación de oxígeno perioperatorias y el dolor postoperatorio en reposo y durante la tos, los efectos colaterales y la necesidad de analgésicos de rescate fueron registrados a los 30 y 60 minutos y las 2, 4, 6, 12, 24, 36, 48 y 72 horas.Resultados: La necesidad de sodio diclofenaco durante el estudio fue menor en el grupo ME. El área bajo la curva de tiempo en la VAS fue menor en el grupo ME en comparación con el Grupo MIV, pero similar al Grupo MEB y MER. Las puntuaciones de dolor en reposo fueron mayores en los tiempos 12, 24, 36 y 48 horas en el Grupo MIV en comparación con el grupo ME. Las puntuaciones de dolor en reposo fueron mayores a los 30 y 60 minutos en los Grupos ME y MIV en comparación con el Grupo MEB. Las puntuaciones de dolor durante la tos a los 30 minutos fueron mayores en el grupo ME en comparación con el Grupo MEB. No hubo diferencia entre los Grupos MIV y MER. Conclusiones: La morfina administrada por vía epidural fue más eficaz que por la vía intravenosa. La eficacia fue mayor en el grupo EM en el período postoperatorio tardío y en el Grupo MEB en el período postoperatorio inicial. Concluimos entonces que la morfina administrada por vía epidural fue la más eficaz y nuestra preferida

Uzamış postoperatif ağrının tedavisinde ultrason yardımıyla TAP blok - alternatif bir yaklaşım

Transversus abdominis plane (TAP) block is a relatively new regional anesthesia technique in which T7-12 intercostal nerves, ilioinguinal and iliohypogastric nerves, and cutaneous branches of L1-3 nerves are blocked between the internal oblique and transversus abdominis muscles. This technique is mostly used for the treatment of acute postoperative pain following abdominal surgery. In this case report, we evaluate the usage of TAP block in prolonged pain following upper abdominal surgery

Effects of alfentanil or fentanyl added to propofol for sedation in colonoscopy on cognitive functions: Randomized controlled trial

Background/Aims: To assess the effect of propofol supplemented with alfentanil or fentanyl on cognitive functions for sedation during elective colonoscopy. Materials and Methods: Patients (n=150, 18-65 years old, American Society of Anesthesiologists risk group I-III) scheduled undergo elective colonoscopy were included. They were randomized into three groups using the closed envelope methodpropofol-alfentanil (Group A), propofol-fentanyl (Group F), and propofol only (Group P).Group A patients were given an alfentanil (10 mcg/kg)-supplemented propofol bolus infusion and 5 mcg/ kg alfentanil when necessary. Group F patients were given fentanyl (1 mcg/kg)-supplemented propofol and 0.5 mcg/kg fentanyl when necessary. Group P patients were given 1 mg/kg propofol and 0.5 mg/kg propofol when necessary. Vital signs, depth of sedation, recovery parameters, and patient and endoscopist satisfaction were recorded. Trieger dot test (TDT) and Digit Symbol Substitution Test (DSST) were performed post procedure. Results: Demographic data were similar among all patients in the groups. Bispectral index values were lower in Group P (p<0.001). DSST scores were higher in Group A (p=0.004). TDT scores and Facial Pain Scale scores were higher in Group P (p<0.005). Apnea incidence (p=0.009) and Observer’s Assessment of Alertness/Sedation Scale scores (p=0.002) were also higher in Group P. Patient satisfaction and endoscopist satisfaction were similar among all patients. Conclusions: Compared with propofol-alfentanil and propofol-fentanyl, propofol alone is associated with an increased incidence of apnea, drug consumption, and reported pain. Propofol-alfentanil has a less negative effect on cognitive functions than propofol alone or propofol-fentanyl

The efficacy of submucosal tramadol in the postoperative treatment of pain following septoplasty operations

Tramadol is a centrally acting opioid which is effective for moderate-severe pain and is being used for various acute and chronic pain scenarios. The primary endpoint of this controlled, randomized double blind study was to evaluate the effect of submucosal tramadol on VAS scores after septoplasty operations and secondary endpoint was to investigate the effects on total opioid and additional analgesic consumption and patient satisfaction. 60 patients scheduled for septoplasty under general anaesthesia were enrolled. In Group T, at the end of surgery following hemostasis, 2 mg/kg tramadol was applied as submucosal infiltration to both surgical sites, 2 ml (total 4 ml), by the surgeon. In Group P, at the end of surgery following hemostasis, 2 ml isotonic solution (total 4 ml) was applied as submucosal infiltration to both surgical sites by the surgeon. Total opioid consumption, VAS scores, patient satisfaction was evaluated at the end of 24 h VAS values were higher in Group P on the first and second postoperative hours. Patient controlled analgesia demand and delivery values were higher in Group P on the postoperative 1, 2, 4, 6, 12 and 24th hours. Patient satisfaction was higher and opioid consumption was lower in Group T compared to Group P. There was no difference in additional analgesic consumption between two groups.The results show that patients receiving tramadol had lower VAS scores compared with the placebo groups postoperatively

The effect of magnesium added to levobupivacaine for femoral nerve block on postoperative analgesia in patients undergoing ACL reconstruction

Purpose The aim of this prospective randomised doubleblind study is to investigate the effect of magnesium added to local anaesthetics on postoperative VAS scores, total opioid consumption, time to first mobilisation, patient satisfaction and rescue analgesic requirements in arthroscopic ACL reconstruction surgery. Methods A total of 107 American Society of Anaesthesiologists physical status grade I and II patients between 18 and 65 years of age who were scheduled to undergo elective anterior crucial ligament (ACL) reconstruction with hamstring autografts were enrolled in the study. The patients were randomly allocated to Groups L (n = 51) and LM (n = 56) using the closed-envelope method. Group LM was administered 19 ml of 0.25 % levobupivacaine and 1 ml of 15 % magnesium sulphate, while Group L was administered 20 ml of 0.25 % levobupivacaine for femoral blockade. General anaesthesia was administered using laryngeal airway masks following neural blockade in both groups. The patients were evaluated for heart rate and mean arterial pressure, oxygen saturation, visual analogue score (VAS), verbal rating scale (VRS), rescue analgesic requirements, total opioid consumption, side effects and time to first mobilisation at the 1st, 2nd, 4th, 6th, 12th and 24th hours postoperatively. Results There was no statistically significant difference in terms of demographic data, mean arterial pressure, heart rate or oxygen saturation between groups. The area under the curve VAS and VRS scores were lower at 4, 6, 12 and 24 h in Group LM (p = 0.001, p = 0.016, respectively). The rescue analgesic requirement and the total opioid consumption were significantly lower in Group LM (p = 0.015, p = 0.019, respectively). The time to first mobilisation and the Likert score (completely comfortable; quite comfortable; slight discomfort; painful; very painful) were higher, and the block onset time was lower in Group LM (p = 0.014 and p = 0.012, respectively). There was no difference in terms of side effects. Conclusions The addition of magnesium to levobupivacaine prolongs the sensory and motor block duration without increasing side effects, enhances the quality of postoperative analgesia and increases patient satisfaction; however, the addition of magnesium delays the time to first mobilisation and decreases rescue analgesic requirements