{"id":2179,"date":"2017-08-11T00:00:00","date_gmt":"2017-08-10T21:00:00","guid":{"rendered":"https:\/\/tatd.org.tr\/tatdus\/2020\/02\/27\/politravmali-hastalarda-okult-hemorajik-sokun-erken-taninmasinda-splenik-doppler-resistive-index-faydali-mi\/"},"modified":"2022-03-02T16:53:45","modified_gmt":"2022-03-02T13:53:45","slug":"politravmali-hastalarda-okult-hemorajik-sokun-erken-taninmasinda-splenik-doppler-resistive-index-faydali-mi","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/tatdus\/2017\/08\/11\/politravmali-hastalarda-okult-hemorajik-sokun-erken-taninmasinda-splenik-doppler-resistive-index-faydali-mi\/","title":{"rendered":"Politravmal\u0131 Hastalarda Ok\u00fclt Hemorajik \u015eokun Erken Tan\u0131nmas\u0131nda Splenik Doppler Res\u0131st\u0131ve Index Faydal\u0131 M\u0131?"},"content":{"rendered":"\r\n\r\n\r\n

Giri\u015f<\/strong><\/h3>\r\n\r\n\r\n\r\n

Hemorajik \u015fok, politravmal\u0131 hastalarda en s\u0131k \u00f6l\u00fcm sebebi oldu\u011fundan erken tan\u0131nmas\u0131 bu hastalar\u0131n res\u00fcsitasyonunu y\u00f6nlendirmede anahtar rol oynamakta. Kaybedilen kan hacminin tahmin edilmesinde Injury Severity Score (ISS), inferior vena kava (IVC) \u00e7ap ve kollapsibilite indeksi, laktat ve bazdefisiti, vital bulgular, hemoglobin\/hematokrit oran\u0131 gibi bir \u00e7ok parametre kullan\u0131lmakta ancak bu parametrelerin hi\u00e7 biri hemodinamik olarak stabil olan hasta grubunda erken hemorajik \u015fokun saptanmas\u0131nda yeterli sensitiviteye sahip de\u011fil\u00a0(1).<\/p>\r\n\r\n\r\n\r\n

Yazarlar \u00e7al\u0131\u015fman\u0131n temelini daha \u00f6nceden yap\u0131lan hayvan deneylerine dayand\u0131rm\u0131\u015flar\u00a0(2)\u00a0(3)\u00a0(4). Bu \u00e7al\u0131\u015fmalarda deneysel olarak hemorajik \u015foka sokulan hayvanlarda dalak boyutlar\u0131nda azalma izlenmi\u015f. Ayr\u0131ca yay\u0131nlanan bir olgu sunumunda(5), travma sonras\u0131 dalak boyutlar\u0131ndaki k\u00fc\u00e7\u00fclmenin muhtemelen artm\u0131\u015f adrenerjik stim\u00fclasyonun sebep oldu\u011fu splenik vazokonstr\u00fcksiyon olabilece\u011fi belirtilmi\u015f.<\/p>\r\n\r\n\r\n\r\n

Bununla birlikte yazarlar, dalak boyutlar\u0131 \u00f6l\u00e7\u00fcm\u00fcn\u00fcn splenik dola\u015f\u0131m\u0131n indirekt bir g\u00f6stergesi olabilece\u011fini, Doppler resistive indexin (RI) daha direkt ve daha az de\u011fi\u015fken bir parametre oldu\u011fundan daha sa\u011fl\u0131kl\u0131 fikir verebilece\u011fini \u00f6ne s\u00fcrm\u00fc\u015fler. Bu ama\u00e7la splenik Doppler RI\u2019 in hemorajinin erken d\u00f6nemde tespitinde kullan\u0131labilecek noninvaziv bir metod olup olamayaca\u011f\u0131n\u0131 ara\u015ft\u0131rmay\u0131 planlam\u0131\u015flar.<\/p>\r\n

\u00a010.1097\/SHK.0b013e31826d1eaf<\/a><\/p>\r\n\r\n\r\n\r\n

Method<\/strong><\/h3>\r\n\r\n\r\n\r\n

Bu prospektif \u00e7al\u0131\u015fma birinci seviye bir travma merkezi olan Cenova\u2019daki San Martino Hastanesi Acil Servisi\u2019ne 30 Nisan 2010 ile\u00a028 \u015eubat 2011 aras\u0131nda politravma ile ba\u015fvuran hasta pop\u00fclasyonunda ger\u00e7ekle\u015ftirilmi\u015f.<\/p>\r\n\r\n\r\n\r\n

D\u0131\u015flama kriterleri olarak;<\/p>\r\n\r\n\r\n\r\n

    \r\n
  • ISS\u226416 olan hastalar<\/li>\r\n
  • 18 ya\u015f alt\u0131 ve 65 ya\u015f \u00fcst\u00fc hastalar<\/li>\r\n
  • Hb\u226410 g\/dL<\/li>\r\n
  • SKB<90 mmHg<\/li>\r\n
  • Penetrantravmalar<\/li>\r\n
  • Vazoaktif ila\u00e7 deste\u011fi alt\u0131ndaki hastalar<\/li>\r\n
  • Kronik karaci\u011fer hastal\u0131\u011f\u0131 \u00f6yk\u00fcs\u00fc<\/li>\r\n
  • Diyabet<\/li>\r\n
  • FAST ile bat\u0131n i\u00e7i serbest s\u0131v\u0131 saptanan hastalar<\/li>\r\n
  • Splenik damarlar\u0131n ultrason ile g\u00f6r\u00fcnt\u00fclenemedi\u011fi hastalar<\/li>\r\n
  • BT\u2019desplenik yaralanma saptanan hastalar<\/li>\r\n
  • Ekspirasyon sonu \u00f6l\u00e7\u00fclen IVC \u00f6n-arka \u00e7ap\u0131n\u0131n <9 mm olan hastalar<\/li>\r\n<\/ul>\r\n\r\n\r\n\r\n

    Toplam 159 hastadan d\u0131\u015flama kriterlerinin d\u0131\u015f\u0131nda kalan 49 hasta \u00e7al\u0131\u015fmaya dahil edilmi\u015f. Daha sonra bu hastalar 24.saatte hemorajik \u015fok geli\u015fen (n=22) ve geli\u015fmeyen(n=27) olarak iki ayr\u0131 gruba ayr\u0131lm\u0131\u015f. Yazarlar hemorajik \u015foku; d\u00fc\u015f\u00fck idrar \u00e7\u0131k\u0131\u015f\u0131n\u0131n (<30 ml\/s) e\u015flik etti\u011fi hipotansiyon (SKB<90 mmHg), kan laktat de\u011ferinin 2 mmol\/L\u2019den fazla olmas\u0131, 2 \u00fcnite ve fazla eritrosit s\u00fcspansiyonu transf\u00fczyonu gerektiren veya anjiyografik ya da cerrahi giri\u015fim ile hemostaz sa\u011flanmas\u0131 zorunlulu\u011fu olan klinik tablo olarak tan\u0131mlam\u0131\u015flar.<\/p>\r\n\r\n\r\n\r\n

    \u00c7al\u0131\u015fmaya dahil edilen t\u00fcm hastalar ATLS \u00f6nerileri do\u011frultusunda muayene edilmi\u015f. Arter ve ven\u00f6z kan \u00f6rneklemeleri ve crossmatch g\u00f6nderilmi\u015f. FAST inceleme yap\u0131lm\u0131\u015f. FAST negatif hastalarda tomografi \u00f6ncesinde splenik Doppler RI \u00f6l\u00e7\u00fcml\u00fc yap\u0131lm\u0131\u015f. FAST pozitif hastalar ise hastalar \u00f6ncelikle tomografiye g\u00f6t\u00fcr\u00fclm\u00fc\u015f ve buradan ameliyathaneye g\u00f6nderilmi\u015f. Bu hastalar \u00e7al\u0131\u015fmadan \u00e7\u0131kar\u0131lm\u0131\u015f.<\/p>\r\n\r\n\r\n\r\n

    Hemorajik \u015fok geli\u015fen hastalara 1:1:1 protokol\u00fcne g\u00f6re ES, TDP ve platelet transf\u00fczyonu yap\u0131lm\u0131\u015f ve 24.saatte tekrar splenik Doppler RI \u00f6l\u00e7\u00fcm\u00fc yap\u0131lm\u0131\u015f.<\/p>\r\n\r\n\r\n\r\n

    Doppler \u00f6l\u00e7\u00fcmleri 3.5 MHz konveks prob kullan\u0131larak pulsewave ile IVC \u00f6l\u00e7\u00fcmleri ise 2-4 MHz sekt\u00f6r prob ile yap\u0131lm\u0131\u015f. Cihaz olarak GE Healthcare Loqic-e kullan\u0131lm\u0131\u015f. \u0130lk de\u011ferlendirmeden sonra, hastalar supin pozisyonda ya da sa\u011f yan\u0131na yat\u0131r\u0131larak koronal pencerede hilumu da viz\u00fcalize edecek \u015fekilde g\u00f6r\u00fcnt\u00fc elde edilerek dalak boyutu (alan\u0131) \u00f6l\u00e7\u00fclm\u00fc\u015f. Elde edilen ultrasonografik de\u011ferler abdominal BT\u2019de \u00f6l\u00e7\u00fclen de\u011ferler ile k\u0131yaslanm\u0131\u015f.<\/p>\r\n\r\n\r\n\r\n

    Renkli Doppler ile hilumdan 1 cm uzakta dalak i\u00e7indeki splenik arter ve ven belirlenmi\u015f. 30-60 derece a\u00e7\u0131 ile pik sistolik ve end-diastolik ak\u0131m h\u0131zlar\u0131 \u00f6l\u00e7\u00fclm\u00fc\u015f. \u00d6l\u00e7\u00fcmler dala\u011f\u0131n \u00fcst, orta veve alt pol\u00fcndenb\u00f6lgesinden yap\u0131lm\u0131\u015f ve elde edilen de\u011ferlerin ortalamas\u0131 al\u0131nm\u0131\u015f. Bu sayede intraobservervariabilite hesaba kat\u0131lm\u0131\u015f. Ek olarak bu \u00f6l\u00e7\u00fcmlerin birbirine k\u00f6r iki ayr\u0131 ultrasonograf taraf\u0131ndan ger\u00e7ekle\u015ftirilmesi ile interobserver variabilite de\u011ferlendirilmi\u015f.<\/p>\r\n\r\n\r\n\r\n

    Hastalar\u0131n vol\u00fcm durumunu belirlemek amac\u0131yla geleneksel \u015fekilde IVC \u00f6l\u00e7\u00fcmleri yap\u0131lm\u0131\u015f ve kollapsibilite indeksi hesaplanm\u0131\u015f.<\/p>\r\n\r\n\r\n\r\n

    \u00c7al\u0131\u015fma \u00f6ncesi yap\u0131lan g\u00fc\u00e7 analizinde her bir grup i\u00e7in gereken minimum \u00f6rneklem b\u00fcy\u00fckl\u00fc\u011f\u00fc 19 ila 8 hasta olarak hesaplanm\u0131\u015f. \u0130statistiksel anlaml\u0131l\u0131k i\u00e7in p<0,05 olarak belirlenmi\u015f.<\/p>\r\n\r\n\r\n\r\n

    T\u00fcm de\u011fi\u015fkenler SD veya y\u00fczde olarak belirtilmi\u015f. Her bir devaml\u0131 de\u011fi\u015fkenin normal da\u011f\u0131l\u0131m\u0131n\u0131 de\u011ferlendirmek amac\u0131yla D\u2019Agostino-Pearsonomnibus testi yap\u0131lm\u0131\u015f ve sadece splenik Doppler RI de\u011ferlerinin normal da\u011f\u0131l\u0131m g\u00f6sterdi\u011fi g\u00f6r\u00fclm\u00fc\u015f. T\u00fcm devaml\u0131 de\u011fi\u015fkenler Mann Whitney U testi ile, kategorik veriler ise Fisher testi ile test edilmi\u015f. Doppler RI, US alan, BT alan ve BT hacim de\u011ferleri aras\u0131ndaki korelasyon Spearman korelasyon katsay\u0131 hesaplamas\u0131 ile de\u011ferlendirilmi\u015f.<\/p>\r\n\r\n\r\n\r\n

    Hosmer-Lemeshow testi ile lojistik regresyon modellerinin istatistiksel a\u00e7\u0131dan anlaml\u0131l\u0131\u011fa ula\u015ft\u0131\u011f\u0131 g\u00f6sterilmi\u015f. \u00d6l\u00e7\u00fcmlerin tan\u0131sal do\u011fruluk oran\u0131, cut-off de\u011ferleri ve sensitivite ve spesifite de\u011ferleri ROC e\u011fri analizi ile belirlenmi\u015f. Intraobserver ve interobserver de\u011fi\u015fkenlik intraclasskorelasyon katsay\u0131s\u0131 (ICC) belirlenerek de\u011ferlendirilmi\u015f. Ek olarak, sonograflar aras\u0131 tutarl\u0131l\u0131\u011f\u0131n de\u011ferlendirilmesi amac\u0131yla Cronbach\u03b1 g\u00fcvenirlilik katsay\u0131s\u0131 hesaplanm\u0131\u015f.<\/p>\r\n\r\n\r\n\r\n

    \u0130statistiksel hesaplamalar sonucunda intraobserver ICC 0.986 (95% CI, 0.974-0.993; P<0.001), Cronbach\u03b1 g\u00fcvenirlilik katsay\u0131s\u0131 de\u011feri 0.973 olarak bulunmu\u015f. Interobserver ICC 0.962 (95% CI, 0.922-0.982; P<0.001) iken Cronbach\u03b1 g\u00fcvenirlilik katsay\u0131s\u0131 0.927 olarak hesaplanm\u0131\u015f.<\/p>\r\n\r\n\r\n\r\n

    Sonu\u00e7lar<\/strong><\/h3>\r\n\r\n\r\n\r\n

    Sonu\u00e7lara bak\u0131ld\u0131\u011f\u0131nda \u00e7al\u0131\u015fmaya dahil edilen 49 hastadan 22\u2019sinde 24 saat i\u00e7inde hemorajik \u015fok geli\u015fmi\u015f. Bu hastalardan \u00fc\u00e7\u00fc \u015f\u00fcpheli abdominal yaralanma nedeniyle eksploratif laparotomiye al\u0131nm\u0131\u015f. 11 hastaya ise anjiyografik giri\u015fim yap\u0131lm\u0131\u015f. Sekiz hastada ise konservatif y\u00f6ntemler uygulanm\u0131\u015f. Hemorajik \u015fokta olan hastalara ortalama olarak 6 \u00fcnite ES verilmi\u015f. Be\u015f hasta multi organ yetmezlikten dolay\u0131 kaybedilmi\u015f.<\/p>\r\n\r\n\r\n\r\n

    SplenikDoppler RI sensitivitesi %73,spesifitesi %74, PPV %70, NPV %77, cut-off de\u011feri 0.65 olarak hesaplanm\u0131\u015f.<\/p>\r\n\r\n\r\n\r\n

    Hemorajik \u015fokta olan hastalarda splenik Doppler RI de\u011feri belirgin olarak y\u00fcksek bulunmu\u015f. Ayr\u0131ca bu gruptaki hastalarda ISS\u2019un daha y\u00fcksek, standart baz a\u00e7\u0131\u011f\u0131n\u0131n daha d\u00fc\u015f\u00fck oldu\u011fu g\u00f6r\u00fclm\u00fc\u015f. Yine bu grupta yap\u0131lan etkili res\u00fcsitasyon yap\u0131ld\u0131ktan sonraki 24.saatte yap\u0131lan \u00f6l\u00e7\u00fcmlerde Doppler RI de\u011ferinde d\u00fc\u015fme izlenmi\u015f. Bu de\u011ferin hemorajik \u015foka girmeyen hasta grubunda de\u011fi\u015fmedi\u011fi g\u00f6r\u00fclm\u00fc\u015f. Di\u011fer klinik ve biyokimyasal parametreler de\u011ferlendirildi\u011finde dalak boyutu da dahil olmak \u00fczere iki grup aras\u0131nda anlaml\u0131 farkl\u0131l\u0131k g\u00f6zlenmemi\u015f. Hemorajik \u015fok grubunda res\u00fcsitasyon sonras\u0131 24.saatteki dalak boyutlar\u0131nda art\u0131\u015f izlense de iki grup aras\u0131nda anlaml\u0131 farkl\u0131l\u0131k izlenmemi\u015f.<\/p>\r\n\r\n\r\n\r\n

    Lojistik regresyon analizleri sonras\u0131nda splenik Doppler RI (OR, 1.37; P=0.001), ISS (OR, 1.15; P=0.002) ve standart baz a\u00e7\u0131\u011f\u0131 (OR, 0.77; P=0.032) parametrelerinin hemorajik \u015fok riski ile belirgin olarak ili\u015fkili oldu\u011fu g\u00f6sterilmi\u015f.<\/p>\r\n\r\n\r\n\r\n

    Bunun d\u0131\u015f\u0131nda, IVC \u00f6l\u00e7\u00fcmlerinde iki grup aras\u0131nda anlaml\u0131 farkl\u0131l\u0131k g\u00f6sterilememi\u015f. Yazarlar bu durumu, IVC \u00e7ap \u00f6l\u00e7\u00fcm\u00fcn\u00fcn hipovolemik hastalarda res\u00fcsitasyon sonras\u0131 \u015fokun rek\u00fcrrensini \u00f6n g\u00f6rmede kullan\u0131labilece\u011fini fakat, erken d\u00f6nemde hemodinamik a\u00e7\u0131dan stabil olan hastalarda devam eden kanamay\u0131 tespit etmedi\u011fini \u00f6ne s\u00fcrm\u00fc\u015fler.<\/p>\r\n\r\n\r\n\r\n

    Yazarlar \u00e7al\u0131\u015fmalar\u0131n\u0131n sonu\u00e7lar\u0131n\u0131 4 ana maddede \u00f6zetlemi\u015fler:<\/p>\r\n\r\n\r\n\r\n

      \r\n
    1. Ara\u015ft\u0131rma grubu hastalar\u0131nda acil servise ba\u015fvurular\u0131 s\u0131ras\u0131nda hemodinamik a\u00e7\u0131dan stabil olan politravmal\u0131 hastalar\u0131n neredeyse yar\u0131s\u0131 ok\u00fclt kanama nedeniyle takiplerinde hemorajik \u015foka girmi\u015f<\/li>\r\n
    2. Takip eden 24 saat i\u00e7inde hemorajik \u015foka giren hastalarda acil servise ba\u015fvuru s\u0131ras\u0131nda ok\u00fclt hemorajik \u015fokta olan hastalarda di\u011fer gruba k\u0131yasla daha y\u00fcksek splenikDoppler RI de\u011feri, ISS ve daha d\u00fc\u015f\u00fck standart baz a\u00e7\u0131\u011f\u0131 oldu\u011fu g\u00f6r\u00fclm\u00fc\u015f<\/li>\r\n
    3. Multivariate analizler sonucunda Splenik Doppler RI\u2019in ok\u00fclt hemorajik \u015fokun geli\u015fmesinde y\u00fcksek sensitivite ve spesifite ile birlikte tek ba\u015f\u0131na g\u00fc\u00e7l\u00fc bir ba\u011f\u0131ms\u0131z predikt\u00f6r oldu\u011fu \u00f6ne s\u00fcr\u00fclm\u00fc\u015f<\/li>\r\n
    4. Ayr\u0131ca, uygun res\u00fcsitasyona ra\u011fmen y\u00fcksek seyreden splenik Doppler RI de\u011ferlerinin mortalite ile ili\u015fkili oldu\u011fu g\u00f6sterilmi\u015f.<\/li>\r\n<\/ol>\r\n\r\n\r\n\r\n

      Yazar Katk\u0131s\u0131<\/strong><\/h3>\r\n\r\n\r\n\r\n

      \u00c7al\u0131\u015fman\u0131n zay\u0131f y\u00f6nlerine bak\u0131ld\u0131\u011f\u0131nda dalak yaralanmal\u0131 olgularda, post\u00fcr\u00fcn\u00fc de\u011fi\u015ftiremeyen ya da nefes tutma konusunda koopere olmayan hastalarda bu \u00f6l\u00e7\u00fcm y\u00f6ntemi sa\u011fl\u0131kl\u0131 sonu\u00e7lar vermeyebilir. Politravmal\u0131 ve acil res\u00fcsitasyon ihtiyac\u0131 olan hastalarda splenik Doppler RI \u00f6l\u00e7\u00fcm\u00fcn\u00fc res\u00fcsitatif \u00e7abalar\u0131 aksatmadan h\u0131zl\u0131 bir \u015fekilde yapabilmek i\u00e7in y\u00fcksek tecr\u00fcbe gerekli olmas\u0131 muhtemeldir. Ya\u015fl\u0131 ve kronik karaci\u011fer yetmezli\u011fi gibi altta yatan komorbiditeleri olan hastalar d\u0131\u015flanm\u0131\u015f oldu\u011fundan dolay\u0131 bu pop\u00fclasyonda Doppler \u00f6l\u00e7\u00fcm\u00fcn\u00fcn ne denli do\u011fru sonu\u00e7 verece\u011fi de muamma. Bu sebeplerden dolay\u0131 \u00e7al\u0131\u015fman\u0131n ger\u00e7ekle\u015ftirildi\u011fi pop\u00fclasyon k\u0131s\u0131tl\u0131 bir gruba indirgeniyor. Dolay\u0131s\u0131yla \u00e7al\u0131\u015fmadan elde edilen veriler \u0131\u015f\u0131\u011f\u0131nda bir genelleme yapmak m\u00fcmk\u00fcn de\u011fil.\u00a0 Ay\u0131rca yazarlar hemorajik \u015fokta olan hastalar\u0131 \u015fok s\u0131n\u0131flamas\u0131na g\u00f6re de\u011ferlendirmemi\u015fler. Dolay\u0131s\u0131yla evre 3 \u015foktaki bir hasta ile evre 2 \u015foktaki hasta aras\u0131nda \u00f6l\u00e7\u00fcm tutarl\u0131l\u0131\u011f\u0131n\u0131n de\u011fi\u015fip de\u011fi\u015fmedi\u011fini belirtmemi\u015fler.<\/p>\r\n\r\n\r\n\r\n

      Yazarlar hemorajik \u015foku \u00f6n g\u00f6recek RI e\u015fik de\u011ferinin sensitivite ve spesifitesinin hesaplanmas\u0131nda hastan\u0131n klinik durumu d\u0131\u015far\u0131da tuttu\u011fundan dolay\u0131 elde edilen sonu\u00e7lar\u0131n klinik a\u00e7\u0131dan ne anlama geldi\u011fi belirsizli\u011fini korumakta.<\/p>\r\n\r\n\r\n\r\n

      \u00c7al\u0131\u015fmay\u0131 okurken akla tak\u0131lan bir di\u011fer nokta da \u00f6l\u00e7\u00fcm yapan ki\u015filerle ilgili. \u0130lk isim yazar olan FC\u2019nin 15 y\u0131ll\u0131k Doppler deneyimi oldu\u011fu belirtilmi\u015fken \u00f6l\u00e7\u00fcmleri yapan di\u011fer yazar\u0131n (CB) ultrasonografi deneyiminden bahsedilmemi\u015f. Ek olarak, \u00f6l\u00e7\u00fcmlerin tamamland\u0131\u011f\u0131 s\u00fcre net olarak belirtilmemi\u015f. Bunun d\u0131\u015f\u0131nda splenik Doppler RI de\u011ferleri \u00fc\u00e7 \u00f6l\u00e7\u00fcm\u00fcn ortalamas\u0131 olarak al\u0131nd\u0131\u011f\u0131ndan verilerin ortalamaya daha da yakla\u015fmas\u0131na neden olmu\u015f. Dolay\u0131s\u0131yla gruplar\u0131n standart sapmas\u0131 d\u00fc\u015fm\u00fc\u015f, daha k\u00fc\u00e7\u00fck hasta pop\u00fclasyonu ile anlaml\u0131 sonu\u00e7lar elde edilmi\u015f.<\/p>\r\n\r\n\r\n\r\n

      Literat\u00fcre bak\u0131ld\u0131\u011f\u0131nda, Splenik Doppler RI \u00f6l\u00e7\u00fcm y\u00f6nteminin splenik steal sendromu\u00a0(6), sirozlu hastalarda splanknik arteriyel ak\u0131m\u00a0(7) incelemesi gibi \u00e7al\u0131\u015fmalarda incelenmi\u015f oldu\u011funu g\u00f6r\u00fcyoruz. \u0130nceledi\u011fimiz \u00e7al\u0131\u015fman\u0131n yazarlar\u0131 bu y\u00f6ntemi ilk kez acil servise ba\u015fvuran hastalarda test etmi\u015fler. Bundan dolay\u0131 bu ultrasonografik \u00f6l\u00e7\u00fcm y\u00f6nteminin acil servislerde dizayn edilecek yeni \u00e7al\u0131\u015fmalar\u0131n konusu olaca\u011f\u0131 kanaatindeyim.<\/p>\r\n\r\n\r\n\r\n

      Kaynak\u00e7a<\/em><\/h3>\r\n\r\n\r\n\r\n

      1. Spahn DR, Cerny V, Coats TJ, Duranteau J, Fernandez-Montejar E et al.TaskforceforadvancedBleedingCare in Trauma. Management of bleedingfollowingmajortrauma: a Europeanguideline. s.l.\u00a0: CritCare 24;11(2):414, 2007.<\/em><\/p>\r\n\r\n\r\n\r\n

      2. Theeffect of experimentalanaemia on the size of thespleen. TC, Shen. 74-80, s.l.\u00a0: JPhysiol, 2009, Vol. 3.<\/em><\/p>\r\n\r\n\r\n\r\n

      3. Observationsuponthe size of the size of thespleen. Barcroft J, Stephens JG. 1-22, s.l.\u00a0: JPyhsiol, 2010, Vol. 12.<\/em><\/p>\r\n\r\n\r\n\r\n

      4. Role of thespleen in integratedcontrol of splanchnicvasculartone:physiologyandpathopysiology. Hamza SM, Kaufmann S. 1-7, s.l.\u00a0: JPhysiolPharmacol, 2009, Vol. 87.<\/em><\/p>\r\n\r\n\r\n\r\n

      5. Changes in splenic size afterabdominaltrauma. Goodman LR, Aphramian C. 629, s.l.\u00a0: Radiol, 1990, Cilt 176.<\/em><\/p>\r\n\r\n\r\n\r\n

      6. Role of DopplerSonography in EarlyDetection of SplenicStealSyndrome. Li C, Quintini C, Hashimoto K, Fung J, Obuchowski NA, Sands MJ, Wang W. 7, s.l.\u00a0: JUltrasoundMed, 2016, Vol. 35, pp. 1393-1400.<\/em><\/p>\r\n\r\n\r\n\r\n

      7. Dopplerassessment of splanchnicarterialflow in patientswithlivercirrhosis: correlationwithammoniaplasmalevelsand MELD score. Gli\u0161i\u0107 TM, Peri\u0161i\u0107 MD, Dimitrijevic S, Juri\u0161i\u0107 V. 5, s.l.\u00a0: JClinUltrasound, 2014, Vol. 42, pp. 264-9.<\/em><\/p>\r\n","protected":false},"excerpt":{"rendered":"

      Giri\u015f Hemorajik \u015fok, politravmal\u0131 hastalarda en s\u0131k \u00f6l\u00fcm sebebi oldu\u011fundan erken tan\u0131nmas\u0131 bu hastalar\u0131n res\u00fcsitasyonunu y\u00f6nlendirmede anahtar rol oynamakta. Kaybedilen kan hacminin…<\/p>\n","protected":false},"author":1305,"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":[42,10031,10036],"class_list":["post-2179","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-literatur-ozetleri-surekli-yayinlar","category-surekli-yayinlar","tag-e-fast","tag-sok","tag-travma"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/posts\/2179","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\/1305"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/comments?post=2179"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/posts\/2179\/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=2179"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/categories?post=2179"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/tags?post=2179"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}