<\/p>\n
Acil Servise Kal\u00e7a K\u0131r\u0131\u011f\u0131 ile Ba\u015fvuran Ya\u015fl\u0131 Yeti\u015fkinler \u0130\u00e7in Ultrason K\u0131lavuzlu\u011funda Supra-\u0130nguinal Fasya Iliaka Kompartman Blo\u011fu: Randomize Kontroll\u00fc, \u00c7ift K\u00f6r Klinik \u00c7al\u0131\u015fma<\/strong><\/p>\n Fasya iliaka kompartman\u0131, \u00f6nde fasya iliaka ve arkada iliopsoas taraf\u0131ndan \u00e7evrelenen potansiyel bir bo\u015fluktur. Femoral siniri, obturator siniri ve lateral femoral kutan\u00f6z siniri i\u00e7erir. Femoral sinirin dallar\u0131 ve obturator sinir, kal\u00e7a ekleminden duyular\u0131 al\u0131r ve lateral femoral kutan\u00f6z sinirin dallar\u0131, lateral uyluktan duyular\u0131 al\u0131r. Fasya iliaka kompartman blo\u011fu (F\u0130KB), kal\u00e7a k\u0131r\u0131\u011f\u0131 olan hastalarda tatmin edici analjezi sa\u011flamak i\u00e7in femoral siniri, obturator siniri ve lateral femoral kutan\u00f6z siniri ayn\u0131 anda bloke edebilir.<\/p>\n Son y\u0131llarda F\u0130KB’yi ger\u00e7ekle\u015ftirmek i\u00e7in yeni bir y\u00f6ntem olarak ultrasonografi k\u0131lavuzlu\u011funda supra-inguinal yakla\u015f\u0131m \u00f6nerilmektedir. Klasik yakla\u015f\u0131mla kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda, supra-inguinal yakla\u015f\u0131m, ponksiyon i\u011fnesini ba\u015fa y\u00f6nlendirerek, sadece az miktarda ila\u00e7la daha kolay dif\u00fczyona ve daha iyi analjezik etkilere izin vermektedir. Bununla birlikte, \u00f6zellikle ya\u015fl\u0131 hastalarda, k\u0131r\u0131\u011f\u0131n erken evrelerinde suprainguinal F\u0130KB’nin analjezik etkileri \u00fczerine sadece s\u0131n\u0131rl\u0131 say\u0131da \u00e7al\u0131\u015fma mevcuttur. \u0130nceleyece\u011fimiz bu \u00e7al\u0131\u015fmada; acil servise kal\u00e7a k\u0131r\u0131\u011f\u0131 ile ba\u015fvuran ya\u015fl\u0131 hastalarda ultrasonografi k\u0131lavuzlu\u011funda supra-inguinal F\u0130KB’nin erken analjezik etkilerini de\u011ferlendirmek i\u00e7in randomize, kontroll\u00fc, \u00e7ift k\u00f6r bir klinik \u00e7al\u0131\u015fma ger\u00e7ekle\u015ftirilmi\u015ftir.<\/p>\n \u00a0<\/strong><\/p>\n Y\u00d6NTEM:<\/strong><\/p>\n \u00c7al\u0131\u015fma, Nisan-Temmuz 2021 tarihleri aras\u0131nda \u00c7in\u2019de Shengjing Hastanesinde ger\u00e7ekle\u015ftirilmi\u015f. Acil servise ba\u015fvuran hastalar \u00fczerinde randomize, kontroll\u00fc, \u00e7ift k\u00f6r bir klinik \u00e7al\u0131\u015fma y\u00fcr\u00fct\u00fclm\u00fc\u015f.<\/p>\n Akut kal\u00e7a k\u0131r\u0131\u011f\u0131 olan 65 ya\u015f ve \u00fcst\u00fc hastalar \u00e7al\u0131\u015fmaya dahil edilmi\u015f. D\u0131\u015flanan hastalar ise; ba\u015fka ciddi travmas\u0131 olan hastalar, koag\u00fclopatisi olan veya antikoag\u00fclan kullanan hastalar, kronik analjezik kullanan hastalar, lokal anesteziklere kar\u015f\u0131 alerji \u00f6yk\u00fcs\u00fc olan hastalar, F\u0130KB’nin uygulanaca\u011f\u0131 b\u00f6lgede bir enfeksiyon olmas\u0131 ve \u00f6nemli g\u00f6rme, i\u015fitme veya bili\u015fsel bozuklu\u011fa sahip olan hastalar olarak belirlenmi\u015f.<\/p>\n \u00c7al\u0131\u015fma Protokol\u00fc<\/strong><\/p>\n T\u00fcm \u00e7al\u0131\u015fma kat\u0131l\u0131mc\u0131lar\u0131, supra-inguinal yakla\u015f\u0131m grubuna (grup F) veya klasik yakla\u015f\u0131m grubuna (grup C) rastgele al\u0131nm\u0131\u015f. Hastalar acil servise ba\u015fvurduktan sonra monitorize edilmi\u015f, gerekli res\u00fcsitatif i\u015flemler uyguland\u0131ktan sonra F\u0130KB uygulanm\u0131\u015f.<\/p>\n Grup F’deki hastalara (supra-inguinal yakla\u015f\u0131m grubu) a\u015fa\u011f\u0131daki ad\u0131mlar uygulanm\u0131\u015f. 1) Hasta s\u0131rt\u00fcst\u00fc pozisyonda iken kas\u0131k b\u00f6lgesi dezenfekte edilmi\u015f ve uzun ekseni ligamente paralel olacak \u015fekilde inguinal ligamentin yan\u0131na steril ultrason probu yerle\u015ftirilmi\u015f. Femoral arter ve femoral sinir a\u00e7\u0131k\u00e7a belirlenmi\u015f. 2) Daha sonra prob, sartorius kas\u0131n\u0131 lokalize etmek i\u00e7in lateral olarak hareket ettirilmi\u015f. Sartorius kas\u0131n\u0131n g\u00f6r\u00fcnt\u00fcs\u00fc ekran\u0131n ortas\u0131na yerle\u015ftirilmi\u015f ve hipoekoik anterior superior iliak \u00e7\u0131k\u0131nt\u0131 kaybolana kadar prob sefale hareket ettirilmi\u015f. Ultrason probu, ekrandaki anterior superior iliak \u00e7\u0131k\u0131nt\u0131, iliak kas\u0131 ve kar\u0131n kaslar\u0131n\u0131 belirlemek i\u00e7in 90\u00b0 d\u00f6nd\u00fcr\u00fclm\u00fc\u015f. Daha sonra i\u011fne kaudad taraftan yerle\u015ftirilerek ba\u015fa y\u00f6nlendirilmi\u015f ve i\u011fne ucunun fasya iliaka kompartman\u0131na ula\u015fmas\u0131 i\u00e7in fasya iliakay\u0131 delmesine izin verilmi\u015f. 3) 5 mL salin enjekte edilerek i\u011fne ucunun do\u011fru \u015fekilde yerle\u015fiminin onaylanmas\u0131ndan sonra 30 mL %0,2 ropivakain uygulanm\u0131\u015f. \u0130la\u00e7 yay\u0131ld\u0131k\u00e7a iliyak fasyan\u0131n kastan ayr\u0131ld\u0131\u011f\u0131 g\u00f6r\u00fclm\u00fc\u015f. 4) Son olarak, i\u011fne \u00e7\u0131kar\u0131lm\u0131\u015f ve kanamay\u0131 durdurmak i\u00e7in b\u00f6lgeye 1 dakika kompresyon uygulanm\u0131\u015f ve steril bir bandajla pansuman yap\u0131lm\u0131\u015f.<\/p>\n Grup C’deki hastalara (klasik yakla\u015f\u0131m grubu) yukar\u0131da a\u00e7\u0131klanan 1., 3. ve 4. ad\u0131mlar uygulanm\u0131\u015f. Ancak 2. ad\u0131mda femoral sinirin lateralindeki fasya lata, fasya iliaka ve iliopsoas kas\u0131n\u0131n lokalizasyonu yap\u0131ld\u0131ktan sonra lateral olarak tek kullan\u0131ml\u0131k steril bir i\u011fne yerle\u015ftirilmi\u015f ve i\u00e7 tarafa do\u011fru y\u00f6nlendirilmi\u015f. \u0130\u011fnenin ucu fasya iliakay\u0131 delerek fasya iliaka kompart\u0131man\u0131na ula\u015f\u0131lm\u0131\u015f.<\/p>\n \u0130\u015flemden sonra hastalara her 12 saatte bir 50 mg flurbiprofen enjeksiyonu yap\u0131lm\u0131\u015f. Hasta \u015fiddetli a\u011fr\u0131dan \u015fikayet ederse oral oksikodon ve asetaminofen tablet verilmi\u015f.<\/p>\n \u00d6l\u00e7\u00fcmler<\/strong><\/p>\n Prosed\u00fcr s\u00fcreleri ve F\u0130KB’nin tamamlanmas\u0131ndan 30 dakika sonra duyusal bloklar de\u011ferlendirilmi\u015f. Etkili bir blok femoral, lateral femoral kutan\u00f6z ve obturator sinirler taraf\u0131ndan innerve edilen b\u00f6lgelerde i\u011fne batmas\u0131 hissi kayb\u0131 olarak tan\u0131mlanm\u0131\u015f. Bu ama\u00e7la femoral sinir i\u00e7in \u00f6n uyluk, lateral femoral kutan\u00f6z sinir i\u00e7in yan uyluk ve obturator sinir i\u00e7in i\u00e7 uyluk de\u011ferlendirilmi\u015f.<\/p>\n \u0130\u015flemden \u00f6nce ve i\u015flemden sonraki 30. dakika, 6. saat, 12. saat ve 24. saatte kan bas\u0131nc\u0131, nab\u0131z ve VAS skoruna g\u00f6re a\u011fr\u0131 de\u011ferlendirilmi\u015f. F\u0130KB sonras\u0131 ilk 24 saatte cerrahi uygulanan hastalar \u00e7al\u0131\u015fmadan \u00e7\u0131kar\u0131lm\u0131\u015f.<\/p>\n Randomizasyon ve K\u00f6rl\u00fck<\/strong><\/p>\n Ara\u015ft\u0131rmac\u0131lar hastalar\u0131 rastgele al\u0131m \u015feklinde randomize etmi\u015fler. Bunun i\u00e7in \u00fczerinde hasta numaras\u0131n\u0131n, i\u00e7inde ise uygulanacak y\u00f6ntemin yaz\u0131l\u0131 oldu\u011fu zarflar olu\u015fturulmu\u015f. Hasta tedavi odas\u0131na girdi\u011finde, F\u0130KB\u2019yi uygulayacak doktor, hastan\u0131n numaras\u0131na kar\u015f\u0131l\u0131k gelen zarf\u0131 a\u00e7arak hastan\u0131n ilgili gruba atanmas\u0131n\u0131 sa\u011flam\u0131\u015f ve ilgili F\u0130KB i\u015flemini uygulam\u0131\u015f. Hastalar\u0131n grupland\u0131r\u0131lmas\u0131n\u0131 sadece F\u0130KB\u2019yi uygulayan doktor biliyormu\u015f ve bu doktorlar istatistiksel analiz gibi \u00e7al\u0131\u015fman\u0131n geri kalan\u0131nda rol almam\u0131\u015flar. Takip ve veri toplamadan sorumlu doktorlar, hastalar\u0131n grupland\u0131r\u0131lmas\u0131n\u0131 bilmiyorlarm\u0131\u015f. Hastalar da kendilerine ne t\u00fcr F\u0130KB uyguland\u0131\u011f\u0131n\u0131 bilmiyorlarm\u0131\u015f.<\/p>\n SONU\u00c7LAR<\/strong><\/p>\n 51 hasta de\u011ferlendirilmeye al\u0131nm\u0131\u015f. D\u0131\u015flama kriterlerini kar\u015f\u0131layan 7 hasta ve randomizasyon sonras\u0131 d\u0131\u015flanan 6 hasta sonras\u0131nda supra-inguinal yakla\u015f\u0131m grubunda (F grubu) 18, klasik yakla\u015f\u0131m grubunda (C grubu) ise 20 hasta olmak \u00fczere toplam 38 hasta analiz edilmi\u015f.<\/p>\n Cinsiyet, ya\u015f, boy ve kilo gibi hasta karakteristikleri a\u00e7\u0131s\u0131ndan her iki grup aras\u0131nda istatistiksel bir fark saptanmam\u0131\u015f.<\/p>\n \u015eekil 1:<\/strong> \u00c7al\u0131\u015fma ak\u0131\u015f \u015femas\u0131<\/p>\n <\/p>\n <\/p>\n <\/p>\n F\u0130KB blo\u011fun uygulanma s\u00fcresi supra-inguinal yakla\u015f\u0131m grubunda daha uzun (10.5 \u00b1 1.5 dakika), klasik yakla\u015f\u0131m grubunda ise daha k\u0131sa (9.5 \u00b1 1.2 dakika) saptanm\u0131\u015f. Her iki grupta da t\u00fcm hastalarda femoral sinir blo\u011fu ba\u015far\u0131l\u0131 \u015fekilde ger\u00e7ekle\u015firken, lateral femoral kutan\u00f6z sinir blo\u011fu ve obturator sinir blo\u011fu supra-inguinal yakla\u015f\u0131m grubunda daha ba\u015far\u0131l\u0131 bulunmu\u015f (s\u0131ras\u0131yla 15\/18 hasta ve 10\/20 hasta). Klasik yakla\u015f\u0131m grubunda ise lateral femoral kutan\u00f6z sinir blo\u011fu ve obturator sinir blo\u011fu ba\u015far\u0131s\u0131 daha d\u00fc\u015f\u00fck saptanm\u0131\u015f (s\u0131ras\u0131yla 10\/20 hasta ve 5\/20 hasta).<\/p>\n \u0130\u015flemden sonraki 6. ve 12. saatlerde bak\u0131lan VAS skoru supra-inguinal yakla\u015f\u0131m grubunda daha d\u00fc\u015f\u00fck saptanm\u0131\u015f. \u0130\u015flem \u00f6ncesi, i\u015flemden sonraki 30. dakika ve 24. saattedeki VAS skorlar\u0131 a\u00e7\u0131s\u0131ndan her iki grup aras\u0131nda istatistiksel fark saptanmam\u0131\u015f.<\/p>\n Supra-inguinal yakla\u015f\u0131m grubunda i\u015flemden sonraki 6. saat ve 24. saatte daha d\u00fc\u015f\u00fck nab\u0131z de\u011ferleri \u00f6l\u00e7\u00fclm\u00fc\u015f. Ortalama arteryel bas\u0131n\u00e7 de\u011ferleri a\u00e7\u0131s\u0131ndan her iki grup aras\u0131nda istatistiksel fark saptanmam\u0131\u015f.<\/p>\n Oksikodon ve asetaminofen kullan\u0131m\u0131 a\u00e7\u0131s\u0131ndan her iki grup aras\u0131nda fark saptanmam\u0131\u015f. Her iki grupta da i\u015fleme ba\u011fl\u0131 herhangi bir komplikasyon geli\u015fmemi\u015f.<\/p>\n TARTI\u015eMA<\/strong><\/p>\n \u00c7al\u0131\u015fman\u0131n sonu\u00e7lar\u0131na bak\u0131ld\u0131\u011f\u0131nda kal\u00e7a k\u0131r\u0131\u011f\u0131 olan ya\u015fl\u0131 hastalarda ultrasonografi k\u0131lavuzlu\u011funda uygulanan supra-inguinal fasya iliaka kompartman blo\u011funun etkili analjezi sa\u011flad\u0131\u011f\u0131 ve klasik yakla\u015f\u0131mla kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda lateral femoral kutan\u00f6z siniri ve obturator siniri bloke etmede daha y\u00fcksek bir ba\u015far\u0131 sa\u011flad\u0131\u011f\u0131 g\u00f6r\u00fclmektedir.<\/p>\n Yap\u0131lan bir\u00e7ok \u00e7al\u0131\u015fma, inceledi\u011fimiz \u00e7al\u0131\u015fman\u0131n sonu\u00e7lar\u0131n\u0131 desteklemekte. Yap\u0131lan bir \u00e7al\u0131\u015fmada supra-inguinal F\u0130KB uygulanan hastalarda sadece pre-operatif d\u00f6nemde de\u011fil, ayn\u0131 zamanda post-operatif d\u00f6nemde de daha az a\u011fr\u0131 hissettiklerini ortaya koymu\u015ftur. B\u00f6ylece acil serviste uygulanan F\u0130KB sayesinde uzun d\u00f6nemde de hastalar\u0131n analjezik ihtiyac\u0131 azalm\u0131\u015ft\u0131r.<\/p>\n Sinir bloklar\u0131 acil servislerde nadiren kullan\u0131lmaktad\u0131r. Bu durum muhtemelen ilgili teknik ve becerilerin anla\u015f\u0131lmamas\u0131ndan ve hastalar\u0131n acil serviste k\u0131sa s\u00fcre kalmas\u0131ndan kaynaklanmaktad\u0131r. Fakat ultrasonografi k\u0131lavuzlu\u011funda uygulanan supra-inguinal fasya iliaka kompartman blo\u011funun ya\u015fl\u0131 hastalarda erken ve efektif analjezi sa\u011flad\u0131\u011f\u0131 unutulmamal\u0131d\u0131r.<\/p>\n <\/p>\n KISITLILIKLAR<\/strong><\/p>\n Hastalar k\u0131r\u0131k geli\u015fen kal\u00e7ay\u0131 hareket ettiremedikleri i\u00e7in \u00e7al\u0131\u015fmada F\u0130KB’den sonra kas g\u00fcc\u00fc de\u011ferlendirilmemi\u015f. Bu nedenle, yaln\u0131zca F\u0130KB i\u015flemi sonras\u0131 24 saat i\u00e7inde ameliyat olmayan hastalar \u00e7al\u0131\u015fmaya dahil edilmi\u015f. Yazarlar, bu se\u00e7imin yanl\u0131l\u0131\u011f\u0131na neden olmu\u015f olabilece\u011fini belirtmi\u015fler.<\/p>\n <\/p>\n TATDUS yazar\u0131n\u0131n \u00e7al\u0131\u015fma i\u00e7in yorumlar\u0131;<\/strong><\/p>\n Kal\u00e7a k\u0131r\u0131\u011f\u0131 olan ya\u015fl\u0131 hastalarda a\u011fr\u0131 kontol\u00fc i\u00e7in non-steroid antiiflmatuar ila\u00e7 (NSA\u0130\u0130) ve opioid kullan\u0131m\u0131 yayg\u0131n bir yakla\u015f\u0131m. Fakat NSA\u0130\u0130\u2019lerin yeterli analjezi sa\u011flamamas\u0131, peptik \u00fclser ve akut b\u00f6brek yetmezli\u011fi a\u00e7\u0131s\u0131ndan risk ta\u015f\u0131malar\u0131; opioidlerin de bulant\u0131, kusma, kab\u0131zl\u0131k, idrar retansiyonu, hipotansiyon ve solunum depresyonu a\u00e7\u0131s\u0131ndan risk ta\u015f\u0131malar\u0131 birer dezavantaj. Ultrasonografi k\u0131lavuzlu\u011funda uygulanacak sinir bloklar\u0131 bu riskleri azaltmak a\u00e7\u0131s\u0131ndan \u00f6nem ta\u015f\u0131makta.<\/p>\n Bu \u00e7al\u0131\u015fma \u00f6zelinde yorumlayacak olur isek; \u00e7al\u0131\u015fmada i\u015flemi kimin veya kimlerin yapt\u0131\u011f\u0131 belirtilmemi\u015f. Ayr\u0131ca deneyim d\u00fczeyinden de bahsedilmemi\u015f. Dolay\u0131s\u0131yla \u00e7al\u0131\u015fmada verilen sonu\u00e7lar\u0131n deneyim d\u00fczeyinden ba\u011f\u0131ms\u0131z i\u015flemi yapan ki\u015finin ba\u015far\u0131s\u0131 m\u0131 yoksa i\u015flemin ba\u015far\u0131s\u0131 m\u0131 oldu\u011fundan kesin olarak bahsedemeyiz. Bu durum \u00e7al\u0131\u015fmada bir limitasyon olu\u015fturmakta. Deneyim d\u00fczeyini kapsayacak \u015fekilde daha iyi planlanm\u0131\u015f \u00e7al\u0131\u015fmalar yap\u0131labilir. Fakat hem bu \u00e7al\u0131\u015fma hem de literat\u00fcr ultrasonografi k\u0131lavuzlu\u011funda uygulanan F\u0130KB\u2019nin ba\u015far\u0131s\u0131n\u0131n olduk\u00e7a y\u00fcksek oldu\u011funu g\u00f6stermekte. Acil t\u0131p uzmanlar\u0131 olarak bu konudaki deneyimimizi artt\u0131rmam\u0131z gerekti\u011fini d\u00fc\u015f\u00fcnmekteyim.<\/p>\n <\/p>\n <\/p>\n","protected":false},"excerpt":{"rendered":" Kal\u00e7a k\u0131r\u0131\u011f\u0131 yeti\u015fkin hastalarda geli\u015fen k\u0131r\u0131klar\u0131n %20\u2019sini olu\u015fturmaktad\u0131r ve ya\u015fl\u0131 n\u00fcfusun giderek artmas\u0131ndan dolay\u0131 insidans\u0131 artmaktad\u0131r. Kal\u00e7a k\u0131r\u0131klar\u0131ndan kaynaklanan a\u011fr\u0131 olduk\u00e7a yo\u011fundur…<\/p>\n","protected":false},"author":3140,"featured_media":4242,"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":[3,19,12,10014],"tags":[10046,10045],"class_list":["post-4241","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-egitim","category-literatur-ozetleri-surekli-yayinlar","category-surekli-yayinlar","category-akademik-blog-yazisi","tag-fasya-iliaka-kompartman-blogu","tag-femoral-sinir-blogu"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/posts\/4241","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\/3140"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/comments?post=4241"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/posts\/4241\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/media\/4242"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/media?parent=4241"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/categories?post=4241"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/tags?post=4241"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}![\"\"](\"https:\/\/tatd.org.tr\/tatdus\/wp-content\/uploads\/sites\/5\/2022\/04\/3465ee99903045b0cb7b99d99dc1720f.png\")
<\/p>\n