Pain Management

Postoperative pain is caused by neuronal damage that occurs during the surgical procedure and the stimulation of the nociceptors. In postoperative period, total knee arthroplasty (TKA) is painful, and pain management is quite difficult. The main purpose of postoperative pain relief is to reduce the pain of the patient, to contribute to the healing process, to shorten the length of hospital stay, and to reduce hospital costs. Techniques such as intravenous analgesia, epidural analgesia, and peripheral nerve blocks are used to prevent postoperative pain. In addition, oral and parenteral analgesics, patient-controlled analgesia (PCA), nerve blocks, and periarticular injection methods are used as multimodal analgesia methods. Pain scales such as visual analogue scale (VAS), verbal descriptive scale (VDS), and numerical rating scale (NRS) are used as the standard methods in the evaluation of pain of patients. Systemic opioids, nonsteroidal anti-inflammatory drugs, and local anesthetics are used for postoperative analgesia. Preemptive analgesia, defined as analgesia initiated prior to surgical incision, and multimodal analgesia have been shown to reduce opioid consumption associated with high complication rates. Postoperative pain management should be planned considering the clinical characteristics of the patient, experience of the anesthetist, and clinical facilities. Early postoperative analgesia reduces systemic complication rates and improves early rehabilitation, patient satisfaction, and quality of life

Cost Benefit Analysis Of The Structures Designed For Alternative Seismic Hazard Levels

In this study, multiple performance objectives under the various earthquake hazard levels are investigated. In case of well defined earthquake hazard, as an alternative of classical earthquake resistant design principles, it is possible to design structures at different performances depending on structure's initial cost and economic life. In this study, costs of the structure with different performance levels are discussed.Current study is carried out on the reinforced concrete structures that are designed and analyzed for various seismic hazard levels. The aim is to determine, if the risk is released, whether the economic losses can be acceptable or not. In the study, cost of reinforced concrete ductile frames and dual systems that are designed for various seismic performances, are also compared for the economical aspects.To that end, in the first step 3, 5 and 8 storey frames and dual systems of several structures at Life Safety and Immediate Occupancy performance levels was designed for the earthquake hazards of 2% and 10% probability of exceedance in 50 years. The study reveals that if both direct and indirect effects of earthquake such as retrofitting costs, cost of temporary moving, temporary accommodation costs, cost of demolition and reconstructing the building, cost of damage to household goods and business disruption, social disturbance, are be taken into consideration, initial design performance level can be accepted as Immediate Occupancy performance level rather than Life Safety performance which is proposed current earthquake codes. The cost due to injuries and cost due to loss of lives are not included

Evaluation of Emergency Interhospital Patient Transfers from Province of Mardin to Out-of-Province Hospitals in a Year

Abstract Objective: This study aimed to assess patients who were transferred from emergency services throughout the province of Mardin to out-of-province hospitals by ambulance in a year. Material and Methods: In this study, all patients transferred from emergency services in the province of Mardin to out-of-province hospitals via ambulances by the Patient Referral Assessment Committee, founded under the Provincial Directorate of Health, between the dates of December 31, 2010 and December 31, 2011 were evaluated retrospectively. No exclusion criteria were used. Patients were grouped and analyzed according to their demographic characteristics, transport properties, and reasons for referral. Results: The total number of the patients included in the study was 1518 (55.8% males, 41±27 mean age). Of all, 621 patients (40.9%) were transferred from the center of Mardin province, and the other patients were transferred from 8 district hospitals and two private hospitals. It was found that the patients were transferred to 37 hospitals in 8 provinces, and a total of 562 patients (37%) were transferred to private hospitals. Cardiology (23.3%), pediatrics (11.5%), and obstetrics and gynecology (8.8%) departments were the first three clinics that patients were transferred to frequently, respectively. In total, 274 patients (18.1%) were transferred inappropriately. There was a statistically significant difference between patients' transfer hospitals (state hospital/private hospital) and the age of the patients (younger than 18 years/18 years or older) (p<0.001). In addition, the rate of adult patients' transfers to tertiary healthcare centers was significantly higher (p<0.001). Conclusion: In Mardin, cardiology, pediatrics and obstetrics and gynecology patients are the most common group of emergency patients transferred by 112 ambulances to out-of-province hospitals. Approximately 40% of the patients were transferred to private hospitals. Inappropriate patient transfers seem to be a major problem in this study, as in other studies conducted in Turkey. (JAEM 2014; 13: 62-6

Epidemiology of surgery associated acute kidney injury (EPIS-AKI): a prospective international observational multi-center clinical study

Purpose: The incidence, patient features, risk factors and outcomes of surgery-associated postoperative acute kidney injury (PO-AKI) across different countries and health care systems is unclear. Methods: We conducted an international prospective, observational, multi-center study in 30 countries in patients undergoing major surgery (> 2-h duration and postoperative intensive care unit (ICU) or high dependency unit admission). The primary endpoint was the occurrence of PO-AKI within 72 h of surgery defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary endpoints included PO-AKI severity and duration, use of renal replacement therapy (RRT), mortality, and ICU and hospital length of stay. Results: We studied 10,568 patients and 1945 (18.4%) developed PO-AKI (1236 (63.5%) KDIGO stage 1500 (25.7%) KDIGO stage 2209 (10.7%) KDIGO stage 3). In 33.8% PO-AKI was persistent, and 170/1945 (8.7%) of patients with PO-AKI received RRT in the ICU. Patients with PO-AKI had greater ICU (6.3% vs. 0.7%) and hospital (8.6% vs. 1.4%) mortality, and longer ICU (median 2 (Q1-Q3, 1-3) days vs. 3 (Q1-Q3, 1-6) days) and hospital length of stay (median 14 (Q1-Q3, 9-24) days vs. 10 (Q1-Q3, 7-17) days). Risk factors for PO-AKI included older age, comorbidities (hypertension, diabetes, chronic kidney disease), type, duration and urgency of surgery as well as intraoperative vasopressors, and aminoglycosides administration. Conclusion: In a comprehensive multinational study, approximately one in five patients develop PO-AKI after major surgery. Increasing severity of PO-AKI is associated with a progressive increase in adverse outcomes. Our findings indicate that PO-AKI represents a significant burden for health care worldwide

Alt ekstremite cerrahisinde kombine spinal epidural blok uygulanan hastalarda, preoperatif gabapentinin postoperatif ağrı üzerine etkisinin değerlendirilmesi

TEZ8216Tez (Uzmanlık) -- Çukurova Üniversitesi, Adana, 2010.Kaynakça (s. 69-79) var.ix, 80 s. : res., tablo ; 29 cm.Amaç: Alt ekstremite cerrahisinde, Kombine Spinal Epidural Anestezi (CSEA) sık olarak uygulanmaktadır. Nöropatik ağrı ve kronik ağrıdaki etkinliği kanıtlanmış olan gabapentinin son zamanlarda preoperatif uygulamalarının postoperatif ağrıyı azalttığı bildirilmektedir. Bu çalışmamızda alt ekstremite cerrahisinde, kombine spinal epidural anestezi uygulanan hastalarda, preoperatif gabapentinin postoperatif ağrı ve yan etkiler üzerine etkileri araştırıldı. Gereç ve Yöntem: Etik Kurul onayı ve olguların yazılı onayı alındıktan, sonra çalışmamıza alt ekstremite cerrahisi uygulanan 18-65 yaş arası, ASA I-III grubu olgular alındı. Olgular rastgele iki gruba ayrıldı. Grup 1'e (n=30) (Grup P); Spinal aralıktan % 0,5 levobupivakain (10-15 mg) ve fentanil (25 ug) uygulandı. Postoperatif dönemde spinal blok kalktıktan sonra epidural aralıktan morfin (3mg) uygulandı. Grup 2; (n=30) (Grup G); Grup I'e ilave olarak preoperatif 1-2 saat önce 600 mg gabapentin uygulandı. Postoperatif dönemde hemodinamik veriler (SAB, DAB, KAH), ağrı skoru (VAS), sedasyon skoru, kaşıntı skoru, antihistaminik gereksinimi, ek doz analjezik gereksinimi ve diğer yan etkiler (bulantı, hipotansiyon, solunum depresyonu, EKG değişikliği, bradikardi) değerlendirildi. Bulgular: Grupların demografik özellikleri, hemodinamik parametreleri, operasyon süreleri, sedasyon skorları birbirine benzerdi. Postoperatif ağrı skorlarının (VAS) 30. dakika, 60. dakika, 18 ve 24. saatlerde grup G'de daha düşük olduğu saptandı (p<0,05). Postoperatif dönemde Grup P'de 18. saatte 10 hastada, 24. saatte 8 hastada kaşıntı saptandı. Grup G'de ise hiçbir hastada kaşıntı saptanmadı. (p<0,001, p<0,005). Grupların, bulantı skorları ve diğer yan etkiler arasında istatistiksel olarak anlamlı bir fark yoktu. Sonuç: Alt ekstremite cerrahisinde CSEA uygulanan hastalarda, preoperatif gabapentinin postoperatif ağrı düzeyini ve opioidlere bağlı olarak gelişen kaşıntıyı istatiksel olarak azalttığı, bulantıyı ise etkilemediği sonucuna varıldı.Purpose: Combined Spinal Epidural Anesthesia (CSEA) is frequently implemented in the surgery of lower extremity. It has been reported that preoperative implementations of Gabapentin the activity of which was approved on neurophaeutic and chronicle pains reduce the postoperative pains. In this study, the effects of the preoperative implementations of gabapentin on postoperative pain and adverse effects were investigated on the patients who had combined spinal epidural anesthesia during the surgery of lower extremity. Material and Method: After the consent of the Ethics Committee and the written consent of the cases were taken, cases from ASA I-III aged between 18 and 65 who had surgery of lower extremity were taken into our study. The cases were classified into tow groups randomly. 0.5% levobupivakain (10-15 mg) and fentanile (25 ug) were given to the group 1 (n=30) (Group P) from the spinal space. In the postoperative period, morphine (3 mg) was given from the epidural space after the spinal block was removed. 600 mg of gabapentin was given to Group 2 1-2 hours before in the preoperative period in addition to the Group 1. In the postoperative period, hemodynamic data (SAB, DAB, KAH), pain score (VAS), sedation score, pruritus score, the need of antihistaminic, the need of extra analgesic and the other adverse effects (sicchasia, hypotension, respiration depression, the change of EKG, bradycardia) were assessed. Results: The demographic features, hemodynamic parameters, the operation periods and sedation scores of the groups were similar. It was found that the postoperative pain scores (VAS) were lower in group G in the 30th, 60th minutes and at 18th and 24th hours (p<0.05). In the postoperative period, sichassia was observed in 10 patients at 18th hour and in 8 patients at 24th hour in Group P whereas sichassia was not observed in any patients in Group G (p<0.001, p<0.005). There was not a statistically meaningful difference between the groups in terms of sichassia scores and the other adverse effects. Conclusion: It was deduced that the preoperative gabapentin statistically reduced the postoperative pain level and pruritus developed due to opioids but did not affect the sicchasia on the patients who had combined spinal epidural anesthesia in the surgery of lower extremity

Serotonin Syndrome Due to Overdose Intake of SSRI

Serotonin syndrome is a drug side effect resulting from serotonergic hyperactivity. The severity of its symptoms can be mild and overlooked and sometimes it may cause life-threatening serious consequences. This syndrome is caused by the administration of one or more drugs having serotonergic activity. This case is a 25-year-old female patient who attempted suicide by ingesting an overdose of her prescription medications: 60 units of 100-mg Faver (Fluvoxamine), 20 units of 50-mg Setral (Setraline), and 10 units of 20-mg Paxil (Paroxetine)

Evaluation of the Practice of Antibiotic Prophylaxis in a State Hospital

In terms of antibiotic prophylaxis in surgical patients, incorrect application in hospitals is still one of the most frequently made errors in the medical practice. Surgical site infections, with a rate of 15%-18%, are seen as the second most prevalent of all nosocomial infections.The aim of our study was to investigate the use of antibiotics implemented in surgical prophylaxis. The study was conducted on 180 patients on whom elective surgery was performed in Mardin State Hospital between the dates of September 1 and December 31, 2013. Drug distribution was made according to age, gender, risk factors for surgical site infection; ASA (American Society of Anesthesiologists) score, the name of the prophylactic antibiotics used, clinics distribution, and wound classification. Our study determined that in 71.7% of the cases, prophylaxis was given in incorrect doses; that it was continued for too long a period in 56.2%; and that an inappropriate antibiotic had been selected in 51.7%. It has become more important for the infection control committee to not only create a guide, but also to periodically update training in coordination with anesthesiologists and surgical specialists and take necessary measures. The contribution of the clinical pharmacy practice to the solution of this problem must be discussed. [Med-Science 2015; 4(3.000): 2441-9

Clinical Study Comparison of the Effects of Intrathecal Fentanyl and Intrathecal Morphine on Pain in Elective Total Knee Replacement Surgery

Objective. Total knee replacement is one of the most painful orthopedic surgical procedures. In this study, our goal was to compare the intraoperative and postoperative hemodynamic effects, the side effects, the effect on the duration of pain start, the 24-hour VAS, and the amount of additional analgesia used, of the fentanyl and morphine we added to the local anesthetic in the spinal anesthesia we administered in cases of elective knee replacement. Materials and Methods. After obtaining the approval of the Erciyes University Medical Faculty Clinical Drug Trials Ethics Committee, as well as the verbal and written consent of the patients, we included 50 patients in our prospective, randomized study. Results. In our study, the morphine group (Group M) had lower pain scores in the 2nd, 6th, 12th, and 24th hours compared to the fentanyl group (Group F). When additional analgesic requirements were compared, it was found that in the 2nd, 6th, and 24th hours fewer Group M patients needed more analgesics than did Group F patients. Conclusion. The fentanyl group also had lower first analgesic requirement times than did the morphine group. In terms of nausea and vomiting, there was no statistically significant difference between the two groups

Comparison of the Effects of Intrathecal Fentanyl and Intrathecal Morphine on Pain in Elective Total Knee Replacement Surgery

Objective. Total knee replacement is one of the most painful orthopedic surgical procedures. In this study, our goal was to compare the intraoperative and postoperative hemodynamic effects, the side effects, the effect on the duration of pain start, the 24-hour VAS, and the amount of additional analgesia used, of the fentanyl and morphine we added to the local anesthetic in the spinal anesthesia we administered in cases of elective knee replacement. Materials and Methods. After obtaining the approval of the Erciyes University Medical Faculty Clinical Drug Trials Ethics Committee, as well as the verbal and written consent of the patients, we included 50 patients in our prospective, randomized study. Results. In our study, the morphine group (Group M) had lower pain scores in the 2nd, 6th, 12th, and 24th hours compared to the fentanyl group (Group F). When additional analgesic requirements were compared, it was found that in the 2nd, 6th, and 24th hours fewer Group M patients needed more analgesics than did Group F patients. Conclusion. The fentanyl group also had lower first analgesic requirement times than did the morphine group. In terms of nausea and vomiting, there was no statistically significant difference between the two groups