{"id":2142,"date":"2017-02-20T00:00:00","date_gmt":"2017-02-19T21:00:00","guid":{"rendered":"https:\/\/tatd.org.tr\/tatdus\/2020\/02\/27\/acil-servise-cilt-ve-yumusak-doku-enfeksiyonu-ile-basvuran-hastalarda-mevcut-standart-bakima-kiyasla-abse-tanisi-konmasinda-odaklanmis-ultrasonografinin-basarisi-ne-kadar-sistematik-derleme\/"},"modified":"2022-03-02T16:29:37","modified_gmt":"2022-03-02T13:29:37","slug":"acil-servise-cilt-ve-yumusak-doku-enfeksiyonu-ile-basvuran-hastalarda-mevcut-standart-bakima-kiyasla-abse-tanisi-konmasinda-odaklanmis-ultrasonografinin-basarisi-ne-kadar-sistematik-derleme","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/tatdus\/2017\/02\/20\/acil-servise-cilt-ve-yumusak-doku-enfeksiyonu-ile-basvuran-hastalarda-mevcut-standart-bakima-kiyasla-abse-tanisi-konmasinda-odaklanmis-ultrasonografinin-basarisi-ne-kadar-sistematik-derleme\/","title":{"rendered":"Acil Servise Cilt ve Yumu\u015fak Doku Enfeksiyonu ile Ba\u015fvuran Hastalarda Mevcut Standart Bak\u0131ma K\u0131yasla Abse Tan\u0131s\u0131 Konmas\u0131nda Odaklanm\u0131\u015f Ultrasonografi\u2019nin Ba\u015far\u0131s\u0131 Ne Kadar? Sistematik Derleme ve Meta-Analiz"},"content":{"rendered":"\r\n\r\n\r\n<p>Cilt ve yumu\u015fak doku enfeksiyonlar\u0131 (YDE), acil servislerde s\u0131k kar\u015f\u0131la\u015f\u0131lan bir durumdur. Acil hekimlerinin tedavi y\u00f6netimi a\u00e7\u0131s\u0131ndan en s\u0131k birbirinden ay\u0131rmas\u0131 gereken iki antite apse ve sel\u00fclittir. \u00c7o\u011funlukla inspeksiyon ve palpasyonla apse tan\u0131s\u0131 konabilirken, bazen sel\u00fclit ve apselerin klinik olarak de\u011fi\u015fen derecelerde birliktelik g\u00f6stermesi ile tan\u0131 koymak zorla\u015fabilir. Bu durum, fizik muayenenin bazen yan\u0131lt\u0131c\u0131 olabildi\u011fi \u00f6zellikle pediatrik pop\u00fclasyonda \u00e7ok daha karma\u015f\u0131k hale gelebilmektedir. Sel\u00fclit sistemik antibiyotik uygulamas\u0131 ile; apse ise, \u2018apse e\u015fittir drenaj art\u0131 antibiyotik\u2019 mottosu ile tedavi edildi\u011finden gereksiz giri\u015fimsel i\u015flemlerin ve dolay\u0131s\u0131yla da malpraktis davalar\u0131n\u0131n azalt\u0131lmas\u0131 a\u00e7\u0131s\u0131ndan bu ikisinin ayr\u0131m\u0131n\u0131 yapmak \u00f6nemlidir. <a href=\"http:\/\/dx.doi.org\/10.1136\/bmjopen-2016-013688\" target=\"_blank\" rel=\"noreferrer noopener\">10.1136\/bmjopen-2016-013688<\/a><\/p>\r\n\r\n\r\n\r\n<p><strong>\u00c7al\u0131\u015fman\u0131n;<\/strong><\/p>\r\n\r\n\r\n\r\n<ul class=\"wp-block-list\">\r\n<li>primer amac\u0131, cilt ve YDE bulgular\u0131yla acil servise ba\u015fvuran hastalarda apse tan\u0131s\u0131n\u0131n konmas\u0131nda odaklanm\u0131\u015f ultrasonografinin (USG) isabet oran\u0131n\u0131n belirlenmesi iken,<\/li>\r\n<li>sekonder ama\u00e7 olarak bu oran\u0131n pediatrik alt grupta ne kadar oldu\u011funun incelenmesi olarak belirlenmi\u015f.<\/li>\r\n<\/ul>\r\n\r\n\r\n\r\n<p>Bu ama\u00e7la acil kliniklerinde yap\u0131lan, eri\u015fkin ve pediatrik acil servis hastalar\u0131n\u0131n incelendi\u011fi prospektif \u00e7al\u0131\u015fmalar sistematik olarak de\u011ferlendirilmi\u015f. Biraz detayland\u0131r\u0131rsak; yazarlar, PubMed, EMBASE, MEDLINE ve Cochrane sistematik derleme veri tabanlar\u0131ndan, 1946-2015 y\u0131llar\u0131 aras\u0131nda yap\u0131lan, tan\u0131mlanm\u0131\u015f bir odaklanm\u0131\u015f USG protokol\u00fcn\u00fcn uyguland\u0131\u011f\u0131, cilt ve YDE (apse veya sel\u00fclit) incelendi\u011fi, prospektif kohort ve vaka kontrol \u00e7al\u0131\u015fmalar\u0131n\u0131 sistematik olarak derlemi\u015fler. \u0130ndeks test olarak acil servise YDE bulgular\u0131yla ba\u015fvuran hastalarda apse tan\u0131s\u0131n\u0131n konmas\u0131nda odaklanm\u0131\u015f USG\u2019nin kullan\u0131m\u0131 ara\u015ft\u0131r\u0131lm\u0131\u015f. Bu \u00e7al\u0131\u015fmalar\u0131 derlemeye dahil ederken kombine referans standard\u0131 olarak: (1) p\u00fcr\u00fclan ak\u0131nt\u0131l\u0131, insizyon ve drenaj yap\u0131lan vakalar, (2) radyolog taraf\u0131ndan apse veya sel\u00fclit olarak yorumlanan BT g\u00f6r\u00fcnt\u00fclerinin yer ald\u0131\u011f\u0131 veya (3) klinik takip ile tan\u0131n\u0131n kondu\u011fu \u00e7al\u0131\u015fmalar dikkate al\u0131nm\u0131\u015f. Ultrasonografinin kullan\u0131m \u015fekli ile ilgili herhangi bir k\u0131s\u0131tlama yap\u0131lmam\u0131\u015f. Olgu sunumlar\u0131, retrospektif \u00e7al\u0131\u015fmalar ve farkl\u0131 tipteki vaka-kontrol \u00e7al\u0131\u015fmalar\u0131 derleme d\u0131\u015f\u0131 b\u0131rak\u0131lm\u0131\u015f.<\/p>\r\n\r\n\r\n\r\n<p>Derleme, Cochrane Handbook ve PRISMA k\u0131lavuzlar\u0131na g\u00f6re yap\u0131lm\u0131\u015f. QUADAS-2 kriterlerine g\u00f6re metodolojik kalitesi olan t\u00fcm ili\u015fkili, potansiyel at\u0131flar iki ba\u011f\u0131ms\u0131z derleyici taraf\u0131ndan tespit edilmi\u015f ve derlemeye dahil edilmi\u015f. Pediatrik vakalar\u0131n yer ald\u0131\u011f\u0131 \u00e7al\u0131\u015fmalardan da bir alt grup olu\u015fturulmu\u015f. Bu alt grupta, cilt ve YDE y\u00f6netiminin pediatrik pop\u00fclasyon \u00fczerindeki etkileri ve farkl\u0131l\u0131klar\u0131 post hoc olarak ara\u015ft\u0131r\u0131lm\u0131\u015f.<\/p>\r\n\r\n\r\n\r\n<p>Burada QUDAS kriterlerinden de bahsedersek; bu kriterler, primer tan\u0131sal isabet \u00e7al\u0131\u015fmalar\u0131n\u0131n sistematik derlemelerinde kullan\u0131lan, testin uygulanabilirli\u011finin ve \u00f6n yarg\u0131 (bias) riskinin de\u011ferlendirildi\u011fi bir test niteli\u011finde. \u0130ki bin \u00fc\u00e7 y\u0131l\u0131nda York ve Amsterdam \u00fcniversitelerinin i\u015f birli\u011fi ile olu\u015fturulduktan sonra, ilk olarak Cochrane Collaboration taraf\u0131ndan sistematik derlemelerde kullan\u0131lmaya ba\u015flanan QUADAS kriterleri daha sonra NICE ve AHQR taraf\u0131ndan da \u00f6nerilmi\u015f. 2010 y\u0131l\u0131nda ise g\u00fcncellenerek QUADAS-2 kriterleri olu\u015fturulmu\u015f.<\/p>\r\n\r\n\r\n\r\n<p><strong>QUADAS-2<\/strong>, d\u00f6rt ana maddeden olu\u015fmakta;<\/p>\r\n\r\n\r\n\r\n<ol class=\"wp-block-list\">\r\n<li><em>Hasta se\u00e7imi,<\/em>\u00a0vaka-kontrol \u015feklinde dizayn edilen, ard\u0131\u015f\u0131k olmayan dahil edilmelerin oldu\u011fu veya uygun olmayan d\u0131\u015flama kriterlerinin yer ald\u0131\u011f\u0131 \u00e7al\u0131\u015fmalarda bias riski y\u00fcksek olacakt\u0131r,<\/li>\r\n<li><em>\u0130ndeks test,\u00a0<\/em>insizyon ve drenaj\u0131n sonu\u00e7lar\u0131 ultrasonografi ile birle\u015ftirilmedi\u011finde bias riski y\u00fcksek olacakt\u0131r,<\/li>\r\n<li><em>Referans standartlar\u0131,\u00a0<\/em>referans standartlar\u0131 hedef durumu yanl\u0131\u015f s\u0131n\u0131fland\u0131r\u0131yor veya odaklanm\u0131\u015f ultrasonografi bilgisi ile yorumlan\u0131yorsa bias riski y\u00fcksek olacakt\u0131r\u00a0ve<\/li>\r\n<li><em>Ak\u0131\u015f ve zamanlama,\u00a0<\/em>e\u011fer t\u00fcm hastalar ayn\u0131 odaklanm\u0131\u015f USG protokol\u00fcne tabi tutulmam\u0131\u015fsa (indeks test), ayn\u0131 referans standartlar\u0131 ile de\u011ferlendirilmemi\u015fse veya hastalar\u0131n bir k\u0131sm\u0131 \u00e7al\u0131\u015fmaya dahil edilmi\u015fse bias riski y\u00fcksek olacakt\u0131r.<\/li>\r\n<\/ol>\r\n\r\n\r\n\r\n<p>Toplanan 3028 makaleden, QUADAS-2 kriterlerine iyi ila m\u00fckemmel d\u00fczeyde uyum g\u00f6steren 8 adet makale derlemede yer alm\u0131\u015f. \u00dc\u00e7\u00fc eri\u015fkin\u00a0(1)\u00a0(2)\u00a0(3), be\u015fi\u00a0(4)\u00a0(5)\u00a0(6) (7)\u00a0(8) pediatrik pop\u00fclasyonu konu alan bu \u00e7al\u0131\u015fmalarda toplamda 747 hasta incelenmi\u015f. Bir \u00e7al\u0131\u015fman\u0131n\u00a0(4) \u00a0haricinde t\u00fcm \u00e7al\u0131\u015fmalar ABD\u2019deki acil servislerde yap\u0131lm\u0131\u015f. Veri toplama i\u015fini yapan iki ba\u011f\u0131ms\u0131z derleyici aras\u0131nda ise 0.80 gibi \u2018\u00f6nemli derecede uyu\u015fma\u2019 durumunu g\u00f6steren bir Cohen\u2019in kappa (\u03ba) de\u011feri elde edilmi\u015f.<\/p>\r\n\r\n\r\n\r\n<p>\u0130ncelenen \u00e7al\u0131\u015fmalar i\u00e7erisinde, duyarl\u0131l\u0131k de\u011feri %65-%100, \u00f6zg\u00fcll\u00fck de\u011feri ise %30-%100 aras\u0131nda iken, kombine test karakteristikleri olarak, acil servislere cilt ve YDE bulgular\u0131 ile ba\u015fvuran hastalarda apse tan\u0131s\u0131n\u0131n konmas\u0131nda odaklanm\u0131\u015f USG\u2019nin\u00a0<strong>duyarl\u0131l\u0131\u011f\u0131 %96,2<\/strong>\u00a0(%95 CI %91,1-%98,4),\u00a0<strong>\u00f6zg\u00fcll\u00fc\u011f\u00fc %82,9<\/strong>\u00a0(%95 CI %60,4-%93,9),\u00a0<strong>pozitif LR 5.63<\/strong>\u00a0(%95 CI 2.2-14.6) ve\u00a0<strong>negatif LR 0.05<\/strong>\u00a0(%95 CI 0.01-0.11) olarak belirlenmi\u015f.<\/p>\r\n\r\n\r\n\r\n<p><strong>Pediatrik alt grupta<\/strong>\u00a0kombine test karakteristikleri; duyarl\u0131l\u0131k %93,9 (%95 CI %84,8-%97,7), \u00f6zg\u00fcll\u00fck %82,9 (%95 CI %34,2-%97,9), pozitif LR 5.5 (%95 CI 0.9-33.9) ve negatif LR 0,07 (%95 CI 0,03-0,15) olarak bulunmu\u015f. Bu hasta grubunda, tedavi y\u00f6netimi a\u00e7\u0131s\u0131ndan %14 ila %27 oran\u0131nda de\u011fi\u015fiklik olmu\u015f. Fizik muayene sonucu drenaj planlamas\u0131 yap\u0131lan hastalar\u0131n %12 ila %20\u2019sinde odaklanm\u0131\u015f USG ile inceleme sonras\u0131 drenajdan vazge\u00e7ilmi\u015f. Tersine, fizik muayene ile drenaj ihtiyac\u0131 olmad\u0131\u011f\u0131 d\u00fc\u015f\u00fcn\u00fclen hastalar\u0131n %13 ila %18\u2019inde odaklanm\u0131\u015f USG sonras\u0131 drenaj yap\u0131lm\u0131\u015f.<\/p>\r\n\r\n\r\n\r\n<p>Bahsi ge\u00e7en oranlar eri\u015fkin ya\u015f grubunda daha y\u00fcksek olarak saptanm\u0131\u015f. Drenaj planlan\u0131p odaklanm\u0131\u015f USG sonras\u0131 gerek g\u00f6r\u00fclmeyen hasta oran\u0131 %12-%36 olurken, planlanmam\u0131\u015f drenaj yap\u0131lan hastalar\u0131n oran\u0131 %23-%40 aras\u0131 olarak tespit edilmi\u015f.<\/p>\r\n\r\n\r\n\r\n<p>Odaklanm\u0131\u015f USG sonras\u0131 t\u00fcm hastalardaki\u00a0<strong>tedavi y\u00f6netim de\u011fi\u015fikli\u011fi oran\u0131<\/strong>\u00a0<strong>%17-%56<\/strong>\u00a0oran\u0131nda olmu\u015f ki bu da neredeyse hastalar\u0131n yar\u0131s\u0131 anlam\u0131na geliyor. Yazarlar bu durumun fizik muayenenin apseyi tespit etmede ne duyarl\u0131 ne de \u00f6zg\u00fcl oldu\u011fu anlam\u0131na geldi\u011fini \u00f6ne s\u00fcr\u00fcyorlar. Buna ek olarak da odaklanm\u0131\u015f USG\u2019 nin hem eri\u015fkin hem de pediatrik pop\u00fclasyonda apse tan\u0131s\u0131n\u0131 koymada fizik muayeneden daha \u00fcst\u00fcn oldu\u011funu g\u00f6sterdiklerini belirtiyorlar.<\/p>\r\n\r\n\r\n\r\n<p><em>\u00c7al\u0131\u015fman\u0131n g\u00fc\u00e7l\u00fc y\u00f6nleri ele al\u0131nd\u0131\u011f\u0131nda<\/em>, sistematik derleme metodolojisine sad\u0131k kal\u0131nmas\u0131, standardize edilmi\u015f ve do\u011frulanm\u0131\u015f veri toplama y\u00f6ntemlerinin kullan\u0131lmas\u0131yla bias riskinin azalt\u0131lmaya, de\u011ferlendiriciler aras\u0131 g\u00fcvenirlili\u011fin (inter-rater reliability) art\u0131r\u0131lmaya \u00e7al\u0131\u015f\u0131lmas\u0131 \u00f6ne \u00e7\u0131kmakta. Bununla birlikte, fizik muayene, kan tetkikleri ve i\u011fne aspirasyonu gibi giri\u015fimsel i\u015flemleri \u00e7o\u011funlukla tolere edemeyen pediatrik pop\u00fclasyonun da bu derlemede alt grup olarak de\u011ferlendirilmesi \u00e7al\u0131\u015fman\u0131n olumlu y\u00f6nlerinden. Fakat, bu kadar s\u0131k\u0131 sistematik derleme metodunun izlenmesi de veri toplanmas\u0131 a\u015famas\u0131nda \u00e7al\u0131\u015fmaya dahil edilen 3028 makaleden sadece sekizinin derlemeye al\u0131nmas\u0131yla nispeten daha k\u00fc\u00e7\u00fck bir \u00f6rneklem b\u00fcy\u00fckl\u00fc\u011f\u00fcn\u00fc de\u011ferlendirmi\u015f oluyor. Bu durum da bias oran\u0131 ile ilgili sorular\u0131 akla getiriyor. Ek olarak, derleme i\u00e7indeki sadece bir \u00e7al\u0131\u015fmada\u00a0(4) duyarl\u0131l\u0131k ve \u00f6zg\u00fcll\u00fck ile ilgili veriler payla\u015f\u0131l\u0131yor. Yazarlar taraf\u0131ndan da derlemede belirtildi\u011fi \u00fczere baz\u0131 hastalarda YDE ilk \u00f6nce sel\u00fclit \u015feklinde ba\u015flay\u0131p apse geli\u015febilmekte. Bu y\u00fczden derlemeye dahil edilen \u00e7al\u0131\u015fmalardaki hastalar\u0131n acil servislere enfeksiyonun hangi d\u00f6neminde ba\u015fvurduklar\u0131 da sonu\u00e7lar\u0131n do\u011frulu\u011fu a\u00e7\u0131s\u0131ndan hayati \u00f6nem ta\u015f\u0131yor.<\/p>\r\n\r\n\r\n\r\n<h2 class=\"wp-block-heading\">Kaynak\u00e7a<\/h2>\r\n\r\n\r\n\r\n<p>1.\u00a0<em>ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue infections.\u00a0<\/em><strong>Squire BT, Fox JC, Anderson C<\/strong>. Acad Emerg Med, 2005, Cilt 12, s. 601-6.<\/p>\r\n\r\n\r\n\r\n<p>2.\u00a0<em>The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department.\u00a0<\/em><strong>Tayal VS, Hasan N, Norton JH et al.<\/strong>\u00a0Acad Emerg Med, 2006, Cilt 13, s. 384-8.<\/p>\r\n\r\n\r\n\r\n<p>3.\u00a0<em>Bedside ultrasound performed by novices for the detection of abscess in ED patients with soft tissue infections.\u00a0<\/em><strong>Berger T, Garrido F, Green J et al.<\/strong>\u00a0Am J Emerg Med, 2012, Cilt 30, s. 1569-1573.<\/p>\r\n\r\n\r\n\r\n<p>4.\u00a0<em>Ultrasonography in the evaluation of neck abscesses in children.\u00a0<\/em><strong>Quraishi MS, O&#8217;Halpin DR, Blavney AW.<\/strong>\u00a0Clin Otolaryngol, 1997, Cilt 22, s. 30-3.<\/p>\r\n\r\n\r\n\r\n<p>5.\u00a0<em>Effect of bedside ultrasound on management of paediatric soft tissue infection.\u00a0<\/em><strong>Sivitz AB, Lam SHF, Ramirez-Schrempp D et al.<\/strong>\u00a0J Emerg Med, 2010, Cilt 39, s. 637-643.<\/p>\r\n\r\n\r\n\r\n<p>6.\u00a0<em>The effect of bedside ultrasound on diagnosis and management of soft tissue infections in a paediatric ED.\u00a0<\/em><strong>Iverson K, Haritos D, Thomas R et al.<\/strong>\u00a0Am J Emerg Med, 2012, Cilt 30, s. 1347-1351.<\/p>\r\n\r\n\r\n\r\n<p>7.\u00a0<em>Emergency ultrasound-assisted examination of skin and soft tissue infections in the paediatric emergency department.\u00a0<\/em><strong>Marin JR, Dean AJ, Bilker WB et al.<\/strong>\u00a0Acad Emerg Med, 2013, Cilt 20, s. 545-553.<\/p>\r\n\r\n\r\n\r\n<p>8.\u00a0<em>Point-of-care ultrasonography for the diagnosis of paediatric soft tissue infeciton.\u00a0<\/em><strong>Adams CM, Neuman MI, Levy JA.<\/strong>\u00a0J Pediatr, 2016, Cilt 169, s. 122-7.<\/p>\r\n","protected":false},"excerpt":{"rendered":"<p>Cilt ve yumu\u015fak doku enfeksiyonlar\u0131 (YDE), acil servislerde s\u0131k kar\u015f\u0131la\u015f\u0131lan bir durumdur. Acil hekimlerinin tedavi y\u00f6netimi a\u00e7\u0131s\u0131ndan en s\u0131k birbirinden ay\u0131rmas\u0131 gereken&hellip;<\/p>\n","protected":false},"author":1529,"featured_media":2138,"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":[19,12],"tags":[95,110],"class_list":["post-2142","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-literatur-ozetleri-surekli-yayinlar","category-surekli-yayinlar","tag-selulit","tag-yumusak-doku-usg"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/posts\/2142","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/users\/1529"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/comments?post=2142"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/posts\/2142\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/media\/2138"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/media?parent=2142"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/categories?post=2142"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/tags?post=2142"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}