{"id":521,"date":"2023-08-21T10:34:59","date_gmt":"2023-08-21T07:34:59","guid":{"rendered":"https:\/\/tatd.org.tr\/geriatri\/?p=521"},"modified":"2023-08-21T10:35:01","modified_gmt":"2023-08-21T07:35:01","slug":"yasli-hastalarda-akut-agri-yonetimi","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/geriatri\/genel\/yasli-hastalarda-akut-agri-yonetimi\/","title":{"rendered":"Ya\u015fl\u0131 Hastalarda Akut A\u011fr\u0131 Y\u00f6netimi"},"content":{"rendered":"\n

\u201cEn hafif a\u011fr\u0131 ba\u015fkas\u0131n\u0131n a\u011fr\u0131s\u0131d\u0131r\u201d<\/em><\/strong> <\/strong>Anonim                    <\/p>\n\n\n\n

\u0130nsanlar\u0131n ya\u015famlar\u0131 \u00fczerinde \u00e7ok b\u00fcy\u00fck bir etkiye sahip olan a\u011fr\u0131 rahats\u0131zl\u0131k verici duysal ve duygusal deneyim olarak tan\u0131mlanmaktad\u0131r (1). Akut a\u011fr\u0131, k\u0131sa s\u00fcrelidir (<30 g\u00fcn) ve nedeni her zaman belli de\u011fildir. Uzun kemik k\u0131r\u0131klar\u0131, apandisit, yan\u0131klar ve i\u015flemsel a\u011fr\u0131 gibi genellikle tek bir tedavi edilebilir olay\u0131n bir par\u00e7as\u0131d\u0131r ve genellikle ta\u015fikardi, hipertansiyon, terleme gibi otonom sinir sistemi tepkileriyle ili\u015fkilidir (2). Teknolojideki ve t\u0131p alan\u0131ndaki geli\u015fmeler \u0131\u015f\u0131\u011f\u0131nda insan \u00f6mr\u00fc uzamakta ve sonu\u00e7ta a\u011fr\u0131 ile ilgili \u015fikayetlerle ba\u015fvuran ya\u015fl\u0131 yeti\u015fkinlerin say\u0131s\u0131 da artmaktad\u0131r.<\/p>\n\n\n\n

Geriatrik hastalarda a\u011fr\u0131, s\u0131k g\u00f6r\u00fclen ancak genellikle altta yatan sa\u011fl\u0131k sorunlar\u0131 nedeniyle karma\u015f\u0131k bir durumdur. Ya\u015fl\u0131 yeti\u015fkinler en s\u0131k d\u00fc\u015fmelerle ilgili kas-iskelet sistemi yaralanmalar\u0131, postoperatif a\u011fr\u0131, enfeksiyonlara ba\u011fl\u0131 a\u011fr\u0131 ve n\u00f6ropatik a\u011fr\u0131 olmak \u00fczere piyelonefrit, nefrolithiazis, kardiyak, vask\u00fcler, abdominal ve genito\u00fcriner patolojilerden kaynaklanan a\u011fr\u0131 ile de ba\u015fvurabilirler (3) Ya\u015flanman\u0131n da etkisi ile \u00e7e\u015fitli sa\u011fl\u0131k sorunlar\u0131na yatk\u0131n hale gelen geriatrik yeti\u015fkinlerin a\u011fr\u0131 y\u00f6netimi ihtiya\u00e7lar\u0131 artar.<\/p>\n\n\n\n

Amerikan Acil Hekimleri Koleji (ACEP), acil serviste hastalar\u0131n akut a\u011fr\u0131 y\u00f6netimini iyile\u015ftirmeyi ama\u00e7lamakta ve h\u0131zl\u0131, g\u00fcvenli ve etkili a\u011fr\u0131 y\u00f6netiminin gereklili\u011fini kabul etmektedir (2). Acil servisler i\u00e7in yayg\u0131n olan ba\u015fvuru nedeni olan a\u011fr\u0131n\u0131n etkili bir \u015fekilde tedavisi \u00f6nemlidir; tedavi edilmemi\u015f akut a\u011fr\u0131, hastanede kal\u0131\u015f s\u00fcrelerini artt\u0131rmakta, kronik a\u011fr\u0131ya d\u00f6nmesine ve fonksiyonel durumlar\u0131n\u0131n k\u00f6t\u00fcle\u015fmesine ve sonu\u00e7ta deliryuma yol a\u00e7abilmektedir (4,5). Ya\u015fl\u0131 hastalarda yetersiz a\u011fr\u0131 tedavisinin \u00f6n\u00fcndeki engeller<\/strong> hasta veya sa\u011fl\u0131k \u00e7al\u0131\u015fanlar\u0131na ba\u011fl\u0131 nedenler olabilir (Tablo 1) <\/strong>(6,7).<\/p>\n\n\n\n

Hasta kaynakl\u0131<\/strong><\/td>Sa\u011fl\u0131k \u00e7al\u0131\u015fanlar\u0131 kaynakl\u0131<\/strong><\/td><\/tr>
Yetersiz ifade, a\u011fr\u0131ya katlanma (stoisizm)<\/strong><\/td>Hastan\u0131n ag\u0306r\u0131s\u0131na inanmamak<\/strong><\/td><\/tr>
A\u011fr\u0131 nedenli hastaneye yat\u0131\u015f ile ilgili endi\u015feler<\/td>A\u011fr\u0131 de\u011ferlendirme ara\u00e7lar\u0131n\u0131n kullan\u0131lmamas\u0131<\/td><\/tr>
Polifarmasi\u2014tedavilerin yan etkileri<\/td>\u00c7e\u015fitli mitler (ba\u011f\u0131ml\u0131l\u0131k yapar, etkinlik eksikli\u011fine yol a\u00e7ar)<\/td><\/tr>
Tedaviyi zorla\u015ft\u0131ran problemlerin \u00e7e\u015fitlili\u011fi<\/td>Bu konuda e\u011fitim eksikli\u011fi<\/td><\/tr><\/tbody><\/table><\/div>
Tablo 1. <\/strong>Ya\u015fl\u0131 hastalarda yetersiz a\u011fr\u0131 tedavisi verilmesinin \u00f6n\u00fcndeki engeller.<\/figcaption><\/figure>\n\n\n\n

Ya\u015fl\u0131 hastalarda a\u011fr\u0131n\u0131n do\u011fru bir \u015fekilde de\u011ferlendirilmesi, etkili tedavi stratejilerinin belirlenmesi i\u00e7in kritik \u00f6neme sahiptir. Akut a\u011fr\u0131n\u0131n optimal y\u00f6netimi; tespit, de\u011ferlendirme, a\u00e7\u0131klama, g\u00fcvence <\/strong>ve tedavi s\u00fcrecini<\/strong> gerektirmektedir.<\/p>\n\n\n\n

Geriatrik a\u011fr\u0131 y\u00f6netiminde ilk bak\u0131\u015f a\u00e7\u0131s<\/em><\/strong>\u0131 fark\u0131ndal\u0131k<\/strong> <\/em>geli\u015ftirmektir. Optimal akut a\u011fr\u0131 y\u00f6netimi, m\u00fcmk\u00fcn olduk\u00e7a hastaya \u00f6zg\u00fc<\/em> olmal\u0131 ve a\u011fr\u0131 sendromuna y\u00f6nelik bir yakla\u015f\u0131m\u0131 i\u00e7eren \u00e7ok y\u00f6nl\u00fc bir yakla\u015f\u0131m\u0131 i\u00e7ermelidir. Farmakolojik veya non farmakolojik olabilir (2). Geriatrik a\u011fr\u0131 y\u00f6netiminde ikinci bak\u0131\u015f a\u011fr\u0131n\u0131n de\u011ferlendirilmesi-\u00f6l\u00e7eklendirmesidir.<\/em><\/strong> Geriatrik hastalarda a\u011fr\u0131n\u0131n y\u00f6netimi, genellikle altta yatan t\u0131bbi durumlar\u0131n anla\u015f\u0131lmas\u0131n\u0131 i\u00e7erir ve tedavinin etkinli\u011fini deg\u0306erlendirmek i\u00e7in de her zaman gerektirmektedir. Fizik muayene, dikkatli bir hasta \u00f6yk\u00fcs\u00fcn\u00fcn al\u0131nmas\u0131, hastan\u0131n de\u011ferlendirilmesi ve a\u011fr\u0131 skalalar\u0131n\u0131n kullan\u0131m\u0131 gibi y\u00f6ntemler, a\u011fr\u0131n\u0131n \u015fiddeti ve karakteristi\u011fi hakk\u0131nda bilgi sa\u011flayabilir. A\u011fr\u0131n\u0131n de\u011ferlendirilmesi ve tedavi ihtiyac\u0131n\u0131 yaln\u0131zca hastan\u0131n bildirdi\u011fi a\u011fr\u0131 skorlar\u0131na dayand\u0131rmak yerine, hastan\u0131n durumunu genel ve i\u015flevsel de\u011ferlendirmeyi i\u00e7eren bir yakla\u015f\u0131ma dayand\u0131rmak \u00f6nerilmektedir (2). Ya\u015fl\u0131 eri\u015fkinlerde a\u011fr\u0131y\u0131 de\u011ferlendirirken, kognitif bozuklu\u011fun (\u00f6r; demans) a\u011fr\u0131y\u0131 kendi kendine bildirme yetene\u011fini s\u0131n\u0131rlayabilece\u011fi bilinmelidir. Bu durum klinisyenin a\u011fr\u0131n\u0131n olmad\u0131\u011f\u0131n\u0131 alg\u0131lamas\u0131na ve a\u011fr\u0131n\u0131n yetersiz tedavisine neden olabilmektedir (8). Fonksiyonel manyetik rezonans g\u00f6r\u00fcnt\u00fcleme (fMRI) de\u011ferlendirmesini kullanan ara\u015ft\u0131rmalar, bili\u015fsel olarak engelli hastalarda zararl\u0131 uyaranlara artan ilgiyi g\u00f6stermi\u015flerdir ve fMRI\u2019\u0131n yaln\u0131zca ifade edilen a\u011fr\u0131 d\u00fczeyinin de\u011fil, a\u011fr\u0131 patolojisini (\u00f6r; akut k\u0131r\u0131k) de g\u00f6sterdi\u011fini vurgulam\u0131\u015flard\u0131r (9).<\/p>\n\n\n\n

Ya\u015fl\u0131 yeti\u015fkinlerde bir\u00e7ok a\u011fr\u0131 de\u011ferlendirme y\u00f6ntemi tan\u0131mlanm\u0131\u015f ve ara\u015ft\u0131r\u0131lm\u0131\u015ft\u0131r. Bili\u015fsel olarak sa\u011flam olan hastalar<\/em><\/strong> i\u00e7in G\u00f6rsel Analog \u00d6l\u00e7ek (VAS-Visual Analogue Scale)<\/em>; Say\u0131sal Derecelendirme \u00d6l\u00e7e\u011fi (NRS-Numeric Rating Scale); <\/em>S\u00f6zel Derecelendirme \u00d6l\u00e7e\u011fi (VRS-Verbal Rating Scale)<\/em>; S\u00f6zel Tan\u0131mlay\u0131c\u0131 \u00d6l\u00e7ek (VDS-Verbal Descriptor Scale)<\/em>; A\u011fr\u0131 Termometresi (PT-Pain Thermometer)<\/em>; Y\u00fcz A\u011fr\u0131 \u00d6l\u00e7e\u011fi (FPS-Faces Pain Scale) <\/em>gibi\u00e7e\u015fitli ag\u0306r\u0131 deg\u0306erlendirme \u00f6l\u00e7ekleri bulunmaktad\u0131r (2). En kolay, en yayg\u0131n olarak uygulanan ve hastalar taraf\u0131ndan da tercih edilen Say\u0131sal Derecelendirme \u00d6l\u00e7e\u011fi [Numeric Rating Scale (NRS)<\/em>] ile S\u00f6zel Tan\u0131mlay\u0131c\u0131 \u00d6l\u00e7ek [Verbal Descriptor Scale (VDS)] \u015eekil 1’de verilmi\u015ftir.<\/p>\n\n\n\n

NRS: <\/strong>1 2 3 4 5 6 7 8 9 10 (0, a\u011fr\u0131 yok; 10, deneyimledi\u011fi en \u015fiddetli a\u011fr\u0131<\/td><\/tr>
VDS: <\/strong>a\u011fr\u0131 yok, hafif a\u011fr\u0131, orta derecede a\u011fr\u0131, ciddi a\u011fr\u0131, a\u015f\u0131r\u0131 a\u011fr\u0131, hayal edilebilecek en \u015fiddetli a\u011fr\u0131<\/td><\/tr><\/tbody><\/table><\/div>
\u015eekil 1.<\/strong> Say\u0131sal Derecelendirme \u00d6l\u00e7e\u011fi ve S\u00f6zel Tan\u0131mlay\u0131c\u0131 \u00d6l\u00e7ek.<\/figcaption><\/figure>\n\n\n\n

Bili\u015fsel bozuklu\u011fu olan ya\u015fl\u0131 yeti\u015fkinlerde<\/em><\/strong> a\u011fr\u0131n\u0131n de\u011ferlendirmesi genellikle hasta \u00f6z bildirimleri, a\u011fr\u0131n\u0131n potansiyel nedenlerini ara\u015ft\u0131rma, hastan\u0131n y\u00fcz ifadeleri ve davran\u0131\u015flar\u0131n\u0131 g\u00f6zlemleme ve analjezik tedavi denemesi gibi \u00e7oklu kaynaklardan gelen bilgileri birle\u015ftirir. Bu ara\u00e7lar aras\u0131nda Abbey A\u011fr\u0131 \u00d6l\u00e7e\u011fi (Abbey), Bunama Protokol\u00fcyle Rahats\u0131zl\u0131k De\u011ferlendirmesi, S\u00f6zel Olmayan A\u011fr\u0131 G\u00f6stergeleri Kontrol Listesi, S\u00f6zel Olmayan \u0130leti\u015fim Yetene\u011fi S\u0131n\u0131rl\u0131 Hastalar\u0131n A\u011fr\u0131 De\u011ferlendirme Arac\u0131, S\u0131n\u0131rl\u0131 \u0130leti\u015fim Yetene\u011fine Sahip Ya\u015fl\u0131lar i\u00e7in A\u011fr\u0131 De\u011ferlendirme Kontrol Listesi (PACSLAC ve PACSLAC-D-G\u00f6zden Ge\u00e7irilmi\u015f), Geli\u015fmi\u015f Bunama A\u011fr\u0131 De\u011ferlendirmesi, Kritik Bak\u0131m A\u011fr\u0131 G\u00f6zlem Arac\u0131 (CPOT), ve ALGOPLUS (\u015eekil 2) yer al\u0131r (4).Muhtemelen en uygun g\u00f6zlem \u00f6l\u00e7e\u011fi, akut a\u011fr\u0131y\u0131 tespit etmek i\u00e7in Fransa\u2019da Doloplus collectif <\/em>taraf\u0131ndan geli\u015ftirilen 5-maddelik ALGOPLUS \u00f6l\u00e7e\u011fidir. <\/strong>Skor 2\u2019 den b\u00fcy\u00fckse ag\u0306r\u0131dan \u015f\u00fcphelenilmelidir. Bu \u00f6l\u00e7eklerin birbirine \u00fcst\u00fcnl\u00fckleri tespit edilememi\u015ftir ve acil servis i\u00e7in \u00f6zel bir \u00f6l\u00e7ek belirtilmemi\u015ftir.<\/p>\n\n\n\n

\"\"<\/figure>\n\n\n\n

\u015eekil 2.<\/span><\/b> A\u011fr\u0131 tespitinde kullan\u0131lan ALGOPLUS <\/b>\u00f6l\u00e7eg\u0306i.<\/span><\/p>\n\n\n\n

Bili\u015fsel olarak bozuk hastalar\u0131n hepsinde a\u011fr\u0131n\u0131n de\u011ferlendirilmesine ve varsa tedavi edilmesine \u00e7aba g\u00f6sterilmesinin \u00f6l\u00e7ek se\u00e7iminden daha de\u011ferli oldu\u011fu vurgulanm\u0131\u015f ve Amerikan Geriatri Derne\u011fi taraf\u0131ndan, ileti\u015fim kuramayan, demansl\u0131 ya\u015fl\u0131 hastalarda de\u011ferlendirilmesi gereken alt\u0131 <\/em>a\u011fr\u0131 davran\u0131\u015f\u0131n\u0131n tan\u0131mlanmas\u0131 yap\u0131lm\u0131\u015ft\u0131r (Tablo 2) (6).<\/p>\n\n\n\n

Y\u00fcz ifadeleri:<\/strong> Hafif ka\u015flar\u0131n\u0131 \u00e7atma, \u00fczg\u00fcn, korkmu\u015f y\u00fcz, ek\u015fiyen y\u00fcz, buru\u015fuk al\u0131n, kapal\u0131 veya gergin g\u00f6zler, herhangi bir \u00e7arp\u0131k ifade, h\u0131zla g\u00f6z k\u0131rpma<\/td><\/tr>
 S\u00f6zler, vokalizasyon:<\/strong> \u0130\u00e7 \u00e7ekme, inleme, homurdanma, s\u00f6ylenme, ba\u011f\u0131rma, seslendirme, g\u00fcr\u00fclt\u00fcl\u00fc nefes alma, yard\u0131m isteme<\/td><\/tr>
 V\u00fccut hareketleri:<\/strong> Sert, gergin v\u00fccut duru\u015fu, korunma, k\u0131p\u0131rdatma, artan soluma, sallanma, hareket s\u0131n\u0131rlamas\u0131, y\u00fcr\u00fcy\u00fc\u015f veya hareket de\u011fi\u015fiklikleri<\/td><\/tr>
 Ki\u015fisel etkile\u015fimlerdeki de\u011fi\u015fiklikler:<\/strong> Sald\u0131rgan, sava\u015f\u00e7\u0131, bak\u0131ma kar\u015f\u0131 diren\u00e7, sosyal etkile\u015fimlerde azalma, sosyal uyumsuzluk, y\u0131k\u0131c\u0131, geri \u00e7ekilmi\u015f, s\u00f6zle taciz<\/td><\/tr>
 Etkinlik d\u00fczenlerinde veya rutinlerinde de\u011fi\u015fiklikler:<\/strong> Yeme\u011fi reddetme, i\u015ftah de\u011fi\u015fikli\u011fi, dinlenme veya uyku s\u00fcrelerinde art\u0131\u015f, dinlenme d\u00fczeninde de\u011fi\u015fiklik, genel rutinlerin aniden durmas\u0131, artan gezinme<\/td><\/tr>
 Zihinsel durum de\u011fi\u015fiklikleri:<\/strong> a\u011flama veya g\u00f6zya\u015f\u0131, artan kar\u0131\u015f\u0131kl\u0131k, sinirlilik veya s\u0131k\u0131nt\u0131<\/td><\/tr><\/tbody><\/table><\/div>
Tablo 2. <\/strong>Demansl\u0131 ya\u015fl\u0131 hastalarda a\u011fr\u0131 davran\u0131\u015flar\u0131 tan\u0131mlamas\u0131.<\/strong><\/figcaption><\/figure>\n\n\n\n

\u00dc\u00e7\u00fcnc\u00fc bak\u0131\u015f a\u00e7\u0131m\u0131z hastan\u0131n tedavisinin erken ba\u015flanmas\u0131 ve<\/strong> bireyselle\u015ftirilmi\u015f bak\u0131m\u0131<\/em><\/strong>n hasta merkezli bir yakla\u015f\u0131m\u0131 i\u00e7ermesidir. <\/strong>Geriatrik hastalarda akut a\u011fr\u0131 y\u00f6netimi, multidisipliner yakla\u015f\u0131m gerektiren karma\u015f\u0131k bir s\u00fcre\u00e7tir ve hastan\u0131n bireysel sa\u011fl\u0131k durumu, ya\u015fam tarz\u0131 ve tercihleri dikkate al\u0131narak hasta merkezli<\/em> bireyselle\u015ftirilmelidir. A\u011fr\u0131 \u015fiddetinin yan\u0131 s\u0131ra, a\u011fr\u0131 t\u00fcr\u00fcn\u00fcn de belirlenmesi tedavi i\u00e7in \u00f6nemlidir. \u00c7\u00fcnk\u00fc Nosiseptif a\u011fr\u0131larda kulland\u0131\u011f\u0131m\u0131z analjezik ajanlar, n\u00f6ropatik a\u011fr\u0131lar i\u00e7in kulland\u0131klar\u0131m\u0131zdan s\u0131kl\u0131kla farkl\u0131d\u0131r. Nosiseptif a\u011fr\u0131 mekanik, kimyasal veya termal olarak uyar\u0131lmas\u0131 sonucunda olu\u015fur. Somatik ve visseral a\u011fr\u0131 alt gruplar\u0131ndan olu\u015fur. Hem opioid hem de non-opioidlerle tedavi edilebilirler. Nonsteroid antiinflamatuvar ila\u00e7lar (NSA\u0130D) ve adjuvan ila\u00e7lar (antidepresanlar, antikonv\u00fclzanlar) bu grup tedaviler i\u00e7in kullan\u0131labilirler.<\/p>\n\n\n\n

N\u00f6ropatik a\u011fr\u0131 somatosensoryal sistemin hasarlanmas\u0131 veya hastal\u0131klar\u0131 ile geli\u015fen yan\u0131c\u0131, kar\u0131ncalanma ve elektrik \u00e7arpmas\u0131 tarz\u0131nda olabilir ve hastalar uyu\u015fukluk, duyarl\u0131k, allodini, s\u0131ca\u011fa hassasiyet ve duyu kayb\u0131 tarif edebilir. N\u00f6ropatik a\u011fr\u0131 klasik olmayan analjeziklere iyi yan\u0131t verir (2). Akut a\u011fr\u0131n\u0131n optimal y\u00f6netiminde tedavinin verilmesi ve de\u011ferlendirme yinelenen bir s\u00fcreci kapsamal\u0131d\u0131r (10).<\/p>\n\n\n\n

Medikasyon<\/strong><\/p>\n\n\n\n

1. Sistemik tedavi<\/strong><\/p>\n\n\n\n

Geriatrik hastalarda kas k\u00fctlesi ve total vuc\u00fct suyu azalm\u0131\u015f ve g\u00f6receli olarak ya\u011f dokusu da artm\u0131\u015f olaca\u011f\u0131ndan, hidrofilik ila\u00e7lar\u0131n serum konsantrasyonlar\u0131 artacakt\u0131r. Bu nedenle analjezikler \u00f6nerilen dozlarda kullan\u0131ld\u0131\u011f\u0131nda ya\u015fl\u0131 hastalarda eri\u015fkinlerde g\u00f6re beklenenden daha fazla etkiye ve yan etkiye neden olabilmektedir. Bu s\u00fcrece ileri ya\u015flardaki organ disfonksiyonlar\u0131 da katk\u0131da bulunmaktad\u0131r. Bir\u00e7ok akut a\u011fr\u0131l\u0131 durumun farmakolojik tedavisi ideal olarak bir opioid olmayan ajanla ba\u015flamal\u0131d\u0131r.<\/p>\n\n\n\n

Non-steroid anti-inflamatuvar ila\u00e7lar (NSAID’ler)<\/strong>: Hafif \u015fiddetteki a\u011fr\u0131lar, s\u0131kl\u0131kla re\u00e7etesiz a\u011fr\u0131 kesiciler ve basit y\u00f6ntemler (istirahat vb) ile tedavi edilmektedir. B\u00f6brek, kalp yetmezli\u011fi ve gastrointestinal kanama e\u011filimi olanlarda dikkatli kullan\u0131lmal\u0131d\u0131r (3). Orta \u015fiddetteki a\u011fr\u0131larda re\u00e7eteli a\u011fr\u0131 kesiciler (oral opioid gibi), \u015fiddetli a\u011fr\u0131larda ise iv opioidler kullan\u0131labilir (\u015eekil 3) (3).<\/p>\n\n\n\n

\"\"<\/figure>\n\n\n\n

\u015eekil 3.<\/strong> Ya\u015fl\u0131 hastalarda a\u011fr\u0131 palyasyonu algoritmas\u0131.<\/p>\n\n\n\n

Parasetamol:<\/strong> Oral, rektal ve parenteral (iv) olarak hafif-orta dereceli a\u011fr\u0131lar i\u00e7in iyi bir ba\u015flang\u0131\u00e7 analjezi\u011fidir. IV parasetamol a\u011f\u0131z yoluyla al\u0131nanlara benzer etkilere sahiptir ve pahal\u0131 bir ila\u00e7t\u0131r.<\/p>\n\n\n\n

Sub-dissosiyatif doz ketamin (SDK):<\/strong> Travmatik ve travmatik olmayan a\u011fr\u0131larda tek ba\u015f\u0131na veya \u00e7oklu y\u00f6ntemin bir par\u00e7as\u0131 olarak kullan\u0131labilir. Ancak hafif, ge\u00e7ici yan etkilere neden olabilece\u011fini hastalara a\u00e7\u0131klanmal\u0131d\u0131r.<\/p>\n\n\n\n

\u0130ntraven\u00f6z Lidokain:<\/strong> Bilinen yap\u0131sal kalp hastal\u0131\u011f\u0131 veya ritim bozuklu\u011fu olmayan hastalarda belirli akut a\u011fr\u0131l\u0131 durumlar i\u00e7in faydal\u0131 olabilir (\u00f6r; renal kolik, akut radik\u00fcler bel a\u011fr\u0131s\u0131, herpes\/post-herpetik n\u00f6ralji).<\/p>\n\n\n\n

Opioid analjezikler:<\/strong> Acil serviste akut \u015fiddetli a\u011fr\u0131lar ve non-opioidlere yan\u0131t vermeyen a\u011fr\u0131lar\u0131 y\u00f6netmekte yayg\u0131n olarak kullan\u0131l\u0131r. Hasta tedavi \u00f6ncesinde \u00f6ncesinde iyice de\u011ferlendirilmeli; sedasyon, solunum depresyonu, tolerans ve hiperaljezi riski gibi ciddi advers etkiler konusunda bilgilendirilmelidir. Opioidler yan\u0131ta g\u00f6re artan dozlarda titrasyon yap\u0131larak uygulanmal\u0131d\u0131r. Genellikle uzat\u0131lm\u0131\u015f sal\u0131ml\u0131 (OxyContin, Opana ER, fentanil yamas\u0131 gibi) veya uzun etkili opioidlerle (metadon gibi) tedavi ba\u015flat\u0131lmamal\u0131d\u0131r (2).<\/p>\n\n\n\n

Morfin <\/strong>(0.05-0.1 mg\/kg IV veya 4-6 mg sabit doz PO)<\/strong> birinci basamak opioid analjezi olarak d\u00fc\u015f\u00fcn\u00fclebilir. Alternatif olarak, hidromorfon <\/strong>(gerekti\u011finde erken tekrarlanan doz ile 0.5 mg IV)<\/strong> <\/strong>kullan\u0131labilir. Morfin ve hidromorfon gibi renal klirense ba\u011fl\u0131 aktif metabolitleri olan opioidler oldu\u011fundan dikkatli kullan\u0131lmal\u0131, gerekirse renal klirense daha az ba\u011f\u0131ml\u0131 olan ve bu ila\u00e7lar\u0131n dozunu d\u00fc\u015f\u00fcren fentanil <\/strong>(0.5-1.0 mcg\/kg IV)<\/strong> <\/strong>d\u00fc\u015f\u00fcn\u00fclebilir (3).<\/strong> <\/strong><\/strong><\/p>\n\n\n\n

Trisiklik antidepresanlar, duloksetin, gabapentin ve pregabalin<\/strong> genellikle birinci basamak hekiminin veya algoloji uzman\u0131n\u0131n ilgi alan\u0131 olarak n\u00f6ropatik a\u011fr\u0131larda etkin olarak kullan\u0131labilirler. Opioidler bu ila\u00e7lar\u0131n etkilerini artt\u0131rabilir, solunum depresyonunu k\u00f6t\u00fcle\u015ftirebilir ve sedatif etkilere sahip olabilirler. Terap\u00f6tik etkiyi optimize etmek i\u00e7in daha uzun s\u00fcreli kullan\u0131m gerektirdi\u011finden, acil serviste yararl\u0131 olduklar\u0131 d\u00fc\u015f\u00fcn\u00fclmemektedir (3).<\/p>\n\n\n\n

2. Topikal Tedavi<\/strong><\/p>\n\n\n\n

N\u00f6ropatiler, yumu\u015fak doku gerilmeleri ve burkulmalar\u0131, kont\u00fczyonlar, yan\u0131klar, deri veya bacak \u00fclserleri, akut herpetik zoster, bel a\u011fr\u0131s\u0131, osteoartrit alevlenmeleri ve kansere ba\u011fl\u0131 a\u011fr\u0131lar\u0131n t\u00fcm\u00fc topikal analjeziklerden fayda g\u00f6rebilecek a\u011fr\u0131l\u0131 durumlard\u0131r. Topikal analjezik \u00f6rnekleri aras\u0131nda; diklofenak, ketoprofen, ibuprofen, %4-5 lidokain band\u0131, EMLA kremi <\/strong>ve<\/strong> kapsaisin kremi<\/strong> bulunur (3).<\/strong><\/p>\n\n\n\n

3. Giri\u015fimsel yakla\u015f\u0131m<\/strong><\/p>\n\n\n\n

Sinir blokajlar\u0131 ve sedoanaljezi <\/strong>(Ketamin-<\/strong>0.1-0.3 mg\/kg IV<\/strong>) kullan\u0131labilir.Belirli akut a\u011fr\u0131l\u0131 durumlarda tek ba\u015f\u0131na veya di\u011fer tedavileri g\u00fc\u00e7lendirme ama\u00e7l\u0131 kullan\u0131labilir. Sistemik yan etkileri de daha az oldu\u011fundan etkin ve g\u00fcvenli bir tedavi y\u00f6ntemidir.<\/p>\n\n\n\n

4. \u0130lgilenme-konu\u015fma ve g\u00fcven vermede psikososyal yakla\u015f\u0131mlar kullan\u0131labilir.<\/strong><\/p>\n\n\n\n

Empatik hasta-merkezli ileti\u015fim, acil bak\u0131m sa\u011flay\u0131c\u0131lar\u0131 i\u00e7in temel bir yetenektir. Empati ve g\u00fcvenle karakterize edilen hasta-hekim etkile\u015fimleri, optimal sonu\u00e7lara daha olas\u0131 bir \u015fekilde yol a\u00e7ar.<\/strong><\/p>\n\n\n\n

5.<\/strong> Non-Farmakolojik Tedaviler<\/strong><\/p>\n\n\n\n

Analjeziklerin potansiyel advers etkileri nedeni ile hasta-merkezli ileti\u015fim teknikleri, fiziksel m\u00fcdahaleler, buz\/s\u0131cak, atel, sabitleyici bandaj, ortez ve TENS (Transcutaneous Electrical Nerve Stimulation), topikal so\u011futucu spreyler, aktivite ve egzersiz \u00f6nerileri ve gev\u015feme teknikleri de dahil olmak \u00fczere farmakolojik olmayan tedaviler kullan\u0131labilir. Zihin-beden terapileri, baz\u0131 a\u011fr\u0131 t\u00fcrlerinin y\u00f6netiminde tek ba\u015f\u0131na veya di\u011fer modalitelerle kombinasyon halinde kullan\u0131labilir ancak acil servis hastalar\u0131 i\u00e7in etkinlikleri hakk\u0131nda kan\u0131t yoktur (2).<\/p>\n\n\n\n

6. Hastane yat\u0131\u015f karar\u0131<\/strong><\/p>\n\n\n\n

A\u011fr\u0131 palyasyonu sa\u011flanamayan ve \u015fiddetli a\u011fr\u0131s\u0131 olan hastalar yat\u0131\u015f gerektirebilir. Taburculuk \u00f6ncesi hastan\u0131n evde ya\u015fama durumu ve tekrarlayan yaralanma riskleri de\u011ferlendirilmelidir. Ayr\u0131ca hastalara aktif kalmalar\u0131 ve normal aktivitelerine d\u00f6n\u00fc\u015flerini geciktirebilecek yatak istirahatinden ka\u00e7\u0131nmalar\u0131 \u00f6nerilmelidir (3).<\/p>\n\n\n\n

7. Medikasyonda istenmeyen durumlar<\/strong><\/p>\n\n\n\n

Ya\u015fl\u0131 yeti\u015fkinlerde olumsuz ila\u00e7 etki risklerinin artm\u0131\u015f olmas\u0131 nedeniyle analjezik dozlar\u0131n\u0131 ayarlarken “d\u00fc\u015f\u00fck dozla ba\u015fla ve yava\u015f\u00e7a art\u0131r”<\/strong> ilkesi \u00f6nerilir (11). Tolerans, fiziksel ba\u011f\u0131ml\u0131l\u0131k, ba\u011f\u0131ml\u0131l\u0131k meydana gelebilir. Opioid ind\u00fckl\u00fc hiperaljezi<\/strong> nosisepsiyonel duyarl\u0131la\u015fma ile g\u00f6r\u00fclebilir, paradoksal bir durum ortaya \u00e7\u0131kabilir ve tolerans ile kar\u0131\u015fabilir (2). <\/strong><\/p>\n\n\n\n

Acil Servisteki Ya\u015fl\u0131 Hastalarda Ka\u00e7\u0131n\u0131lmas\u0131 Gereken \u0130la\u00e7lar olas\u0131 advers etkileri nedeni ile \u201cBeer’in Potansiyel Olarak Uygunsuz \u0130la\u00e7 Kullan\u0131m\u0131 Kriterleri\u201dnde listelenmi\u015ftir (12). Siklobenzaprin, metaksalon, metokarbamol, karisoprodol ve orfenadrin gibi iskelet kas\u0131 gev\u015feticiler<\/em><\/strong>, artan ba\u015f d\u00f6nmesi, halsizlik ve d\u00fc\u015fme riskleri nedeniyle, Tramadol<\/em><\/strong> b\u00f6brek klirensine ba\u011fl\u0131d\u0131r ve n\u00f6bet, hiponatremi, hipoglisemi ve serotonin sendromu geli\u015ftirmesi ve Trisiklik antidepresanlar, gabapentin ve pregabalin de opioid etkilerini g\u00fc\u00e7lendirmesi, solunum depresyonunu k\u00f6t\u00fcle\u015ftirmesi, yat\u0131\u015ft\u0131r\u0131c\u0131 etkilere sahip olmas\u0131 nedeni ile bu kriterler i\u00e7inde listelenmi\u015ftir (12).<\/p>\n\n\n\n

8. Kalite g\u00f6stergeleri<\/strong><\/p>\n\n\n\n

Society for Academic Emergency Medicine ve American College of Emergency Physicians taraf\u0131ndan \u201cSavunmas\u0131z Ya\u015fl\u0131lar\u0131n Bak\u0131m\u0131n\u0131 De\u011ferlendirme kalite g\u00f6stergesi\u201d kriterleri hasta bak\u0131m kalitesi standartlar\u0131n\u0131n \u00f6l\u00e7\u00fclmesi amac\u0131 ile olu\u015fturulmu\u015ftur (Tablo 3) (2,7).<\/p>\n\n\n\n

Akut a\u011fr\u0131 varl\u0131\u011f\u0131 i\u00e7in resmi de\u011ferlendirme, acil servise var\u0131\u015ftan sonraki 1 saat i\u00e7inde<\/strong> belgelenmelidir.<\/td><\/tr>
Bir hasta 6 saatten uzun<\/strong> s\u00fcre acil serviste kal\u0131rsa, ikinci bir a\u011fr\u0131 de\u011ferlendirmesi<\/strong> belgelenmelidir.<\/td><\/tr>
Bir hasta a\u011fr\u0131 tedavisi al\u0131yorsa, acil servisten taburculuktan \u00f6nce bir a\u011fr\u0131 yeniden<\/strong> de\u011ferlendirmesi belgelenmelidir.<\/td><\/tr>
Bir hasta orta d\u00fczeyden \u015fiddetliye<\/strong> kadar a\u011fr\u0131 ya\u015f\u0131yorsa, a\u011fr\u0131 tedavisi ba\u015flat\u0131lmal\u0131d\u0131r<\/strong> (veya neden ba\u015flat\u0131lmad\u0131\u011f\u0131 belgelenmelidir).<\/td><\/tr>
Meperidin (Demerol<\/strong>), ya\u015fl\u0131 yeti\u015fkinlerde a\u011fr\u0131y\u0131 tedavi etmek i\u00e7in kullan\u0131lmamal\u0131d\u0131r.<\/td><\/tr>
Bir hasta acil servisten taburcu edildi\u011finde opioid analjezikler<\/strong> re\u00e7ete edilirse, ayn\u0131 zamanda ba\u011f\u0131rsak d\u00fczenlemesi de sa\u011flanmal\u0131d\u0131r.<\/td><\/tr><\/tbody><\/table><\/div>
 
Tablo 3. <\/strong>Savunmas\u0131z Ya\u015fl\u0131lar\u0131n Bak\u0131m\u0131n\u0131 De\u011ferlendirme kalite g\u00f6stergesi.<\/figcaption><\/figure>\n\n\n\n

Uygun a\u011fr\u0131 y\u00f6netimi, ya\u015fl\u0131 hastalar\u0131n ya\u015fam kalitesini art\u0131rabilir ve sa\u011fl\u0131k sonu\u00e7lar\u0131n\u0131 olumlu y\u00f6nde etkileyebilir. Akut a\u011fr\u0131 acil serviste ya\u015fl\u0131 hasta y\u00f6netiminde her durumda akl\u0131m\u0131z\u0131n bir k\u00f6\u015fesinde bulundurulmal\u0131d\u0131r.<\/p>\n\n\n\n

Kaynaklar<\/strong><\/p>\n\n\n\n

1. Merkey HB, Bogduk N. Classification of chronic pain. International Association for the Study of Pain Press, Seattle (1994)<\/p>\n\n\n\n

2. The American College of Emergency Physicians. Pol\u0131cy Statement. Optimizing the Treatment of Acute Pain in the Emergency Department Ann Emerg Med . 2017 Sep;70(3):446-448. doi: 10.1016\/j.annemergmed.2017.06.043<\/p>\n\n\n\n

3. Pain in Older Adults. Section. https:\/\/www.emra.org\/books\/pain-management\/geriatric-painCh. 19-22.) Ula\u015f\u0131m 10.08.2023<\/p>\n\n\n\n

4. Ula Hwang, Timothy F. Platts-Mills. Acute Pain Management in Older Adults in the Emergency Department Clin Geriatr Med 29 (2013) 151\u2013164 http:\/\/dx.doi.org\/10.1016\/j.cger.2012.10.006<\/a><\/p>\n\n\n\n

 5.Desbiens NA, Mueller-Rizner N, Connors AF Jr, Hamel MB, Wenger NS. Pain in the oldest-old during hospitalization and up to one year later. HELP investigators. Hospitalized elderly longitudinal project. J Am Geriatr Soc. 1997;45:1167\/1172<\/p>\n\n\n\n

6. Sophie Pautex, \u00c7eviri: Dr. Ay\u015fe Ba\u015faran. Acil Servise Ba\u015fvuran Ya\u015fl\u0131larda A\u011fr\u0131 Y\u00f6netimi. Geriatrik Acil T\u0131p. Edt: Christian Nickel, Abdelouahab Bellou, Simon Conroy. \u00c7ev Edt: Arzu Denizba\u015f\u0131, \u00d6zg\u00fcr Karc\u0131o\u011flu, Cem Oktay, \u00d6zlem K\u00f6ksal, Tanzer Korkmaz, Sinan Karacabey,Erkman Sanr\u0131,Murat \u00c7etin, Kongre Kitabevi, 2020, Antalya, ISBN: 978-3-319-19317-5<\/p>\n\n\n\n

7. (Terrell KT, Hustey FM, Hwang U, et al. Quality indicators for geriatric emergency care. Acad Emerg Med 2009;16:441\u201350<\/p>\n\n\n\n

8. Feldt, K.S., M.B. Ryden, and S. Miles, Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip-fracture. J Am Geriatr Soc, 1998. 46(9): p. 1079-85<\/p>\n\n\n\n

9. Cole<\/a> JJ, Farrell<\/a> MJ, Duff<\/a> EP, J Bruce Barber<\/a> JB et al. Pain sensitivity and fMRI pain-related brain activity in Alzheimer’s disease. Brain, 2006. 129(Pt 11): p. 2957-65<\/p>\n\n\n\n

10. Wells N, Pasero C, McCaffery M. Improving the quality of care through pain assessment and management. patient safety and quality: an evidence-based handbook for nurses. Rockville (MD), Agency for Healthcare Research and Quality; 2008<\/p>\n\n\n\n

11. Fine PG. Treatment guidelines for the pharmacological management of pain in older persons. Pain Med 2012;13(Suppl 2):s57\u201366<\/p>\n\n\n\n

12. By the American Geriatrics Society Beers Criteria Update Expert, P., American Geriatrics Society 2019 Updated AGS Beers Criteria(R) for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc, 2019. 67(4): p. 674-694.<\/p>\n\n\n\n

<\/span><\/p><\/p>\n","protected":false},"excerpt":{"rendered":"

\u201cEn hafif a\u011fr\u0131 ba\u015fkas\u0131n\u0131n a\u011fr\u0131s\u0131d\u0131r\u201d Anonim                     \u0130nsanlar\u0131n ya\u015famlar\u0131 \u00fczerinde \u00e7ok b\u00fcy\u00fck bir etkiye sahip olan a\u011fr\u0131 rahats\u0131zl\u0131k verici duysal ve duygusal deneyim…<\/p>\n","protected":false},"author":1185,"featured_media":524,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[1,10014],"tags":[10020,10018,10022],"class_list":["post-521","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-genel","category-akademik-blog-yazisi","tag-acil-tip","tag-geriatri","tag-karin-agrisi"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/521","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/users\/1185"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/comments?post=521"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/521\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media\/524"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media?parent=521"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/categories?post=521"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/tags?post=521"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}