Karın Ağrısında Analjezi İlkeleri
Özet
Karın ağrısı, acil serviste en sık karşılaşılan başvuru nedenlerinden biridir. Hayatı tehdit edici nedenlerden acil olmayan durumlara kadar uzanan geniş bir etiyolojiye sahiptir. Bu hasta grubunda analjezi uygulaması, uzun yıllar boyunca fizik muayene bulgularını maskeleyebileceği ve cerrahi tanıyı geciktirebileceği endişesiyle ertelenmiştir. Bu yaklaşım, acil tıp pratiğinde yaygın biçimde benimsenmiş, ancak güçlü bilimsel kanıtlarla desteklenmemiştir. Mevcut kanıtlar, analjezi uygulanan hastalarda cerrahi karar verme süreçlerinin olumsuz etkilenmediğini, aksine hasta konforunun artmasıyla daha güvenilir bir klinik değerlendirmenin mümkün olduğunu göstermiştir. Karın ağrısının patofizyolojisi iyi bilinmeli ve ağrı şiddeti sistematik olarak değerlendirilmelidir. Karın ağrısında analjezi uygulamaları, ağrının şiddeti ve hastanın klinik özellikleri dikkate alınarak bireyselleştirilmelidir. Analjezik tedavide temel amaç, yeterli ağrı kontrolü sağlarken yan etkileri en aza indirmektir. Bu doğrultuda uygun ilaç seçimi, doz titrasyonu ve yakın klinik izlem önem taşımaktadır. Farklı etki mekanizmalarına sahip analjeziklerin birlikte kullanımı, daha dengeli ve sürdürülebilir bir ağrı kontrolü sağlamaktadır. Ağrının kontrol altına alınması etik ve hasta merkezli bakım anlayışının temelini oluşturmaktadır.
Abdominal pain is one of the most common reasons for presentation to the emergency department. It encompasses a broad etiological spectrum, ranging from life-threatening causes to non-urgent conditions. In this patient population, the administration of analgesia has long been delayed due to concerns that it might mask physical examination findings and delay surgical diagnosis. This approach has been widely adopted in emergency medicine practice; however, it lacks strong scientific evidence. Current evidence indicates that analgesia does not adversely affect surgical decision-making processes; on the contrary, improved patient comfort may allow for a more reliable clinical evaluation. A thorough understanding of the pathophysiology of abdominal pain is essential, and pain severity should be assessed systematically. Analgesic management in abdominal pain should be individualized based on pain severity and the patient’s clinical characteristics. The primary goal of analgesic therapy is to achieve adequate pain control while minimizing adverse effects. Accordingly, appropriate drug selection, dose titration, and close clinical monitoring are paramount. The combined use of analgesics with different mechanisms of action provides more balanced and sustainable pain control. Effective pain management constitutes a fundamental component of ethical and patient-centered care.
Referanslar
Thomas SH, Silen W. Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain. British Journal of Surgery. 2003;90(1):5–9. doi:10.1002/bjs.4009
Gallagher EJ, Esses D, Lee C, et al. Randomized clinical trial of morphine in acute abdominal pain. Annals of Emergency Medicine. 2006;48(2):150-160. doi:10.1016/j.annemergmed.2005.11.020
Ranji SR, Goldman LE, Simel DL, et al. Do opiates affect the clinical evaluation of patients with acute abdominal pain? Journal of the American Medical Association. 2006;296(14):1764–1774. doi:10.1001/jama.296.14.1764
Manterola C, Vial M, Moraga J, et al. Analgesia in patients with acute abdominal pain. Cochrane Database of Systematic Reviews. 2011; 2011(1):CD005660. doi:10.1002/14651858.CD005660.pub3
Thomas SH, Silen W, Cheema F, et al. Effects of morphine analgesia on diagnostic accuracy in emergency department patients with abdominal pain: a prospective, randomized trial. Journal of the American College of Surgeons. 2003;196(1):18–31. doi:10.1016/s1072-7515(02)01480-1
Brennan F, Carr DB, Cousins M. Pain management: a fundamental human right. Anesthesia & Analgesia. 2007;105(1):205–221. doi:10.1213/01.ane.0000268145.52345.55
Falch C, Vicente D, Häberle H, et al. Treatment of acute abdominal pain in the emergency room: a systematic review of the literature. European Journal of Pain. 2014;18(7): 902–913. doi:10.1002/j.1532-2149.2014.00456.x
Masneri D.A., O’Brien M.C. Acute Abdominal Pain. In: Tintinalli JE (eds.) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9 th ed. New York: McGraw-Hill Education; 2020. p. 473-475.
Lax Y, Singh A. Referred abdominal pain. Pediatrics in Review. 2020;41(8):430-433. doi:10.1542/pir.2019-0221
Ducharme J. Acute Pain Management. In: Tintinalli JE (eds.) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9 th ed. New York: McGraw-Hill Education; 2020. p. 229-236.
Hachimi-Idrissi S, Coffey F, Dobias V, et al. Guidelines for the Management of Acute Pain in Emergency Situations. Brussels: European Society for Emergency Medicine (EUSEM); 2020.
Bielewicz J, Daniluk B, Kamieniak P. VAS and NRS, Same or Different? Are Visual Analog Scale Values and Numerical Rating Scale Equally Viable Tools for Assessing Patients after Microdiscectomy? Pain Research and Management. 2022; 2022:5337483. doi:10.1155/2022/5337483
Breivik H, Borchgrevink PC, Allen SM, et al. Assessment of pain. British Journal of Anaesthesia. 2008;101(1);17-24. doi:10.1093/bja/aen103
Hawker GA, Mian S, Kendzerska T, et al. Measures of adult pain: Visual Analog Scale for Pain, Numeric Rating Scale for Pain, McGill Pain Questionnaire. Arthritis Care & Research. 2011;63(S11):240–252. doi:10.1002/acr.20543
Kumar P, Tripathi L. Challenges in pain assessment: pain intensity scales. Indian Journal of Pain. 2014;28(2):61–70. doi: 10.4103/0970-5333.132841
Tytgat, G.N. Hyoscine butylbromide – a review on its parenteral use in acute abdominal spasm and as an aid in abdominal diagnostic and therapeutic procedures. Current Medical Research and Opinion, 2008;24(11):3159-3173. doi:10.1185/03007990802472700
Janczura M, Kobus-Moryson M, Sip S, et al. Fixed-Dose Combination of NSAIDs and Spasmolytic Agents in the Treatment of Different Types of Pain—A Practical Review. Journal of Clinical Medicine. 2021;10(14):3118. doi:10.3390/jcm10143118
Motov S, Rockoff B, Cohen V, et al. Intravenous subdissociative-dose ketamine versus morphine for analgesia in the emergency department: a randomized controlled trial. Annals of Emergency Medicine. 2015;66(3):222–229.
Sin B, Ternas T, Motov S, et al. The use of subdissociative-dose ketamine for acute pain in the emergency department. Academic Emergency Medicine. 2015;22(3):251–257. doi:10.1111/acem.12604
Motov S, Fassassi C, Drapkin J, et al. Comparison of intravenous lidocaine/ketorolac combination to either analgesic alone for suspected renal colic pain in the emergency department. The American Journal of Emergency Medicine. 2020;38(2):165-172. doi:10.1016/j.ajem.2019.01.048
Chinn E, Friedman BW, Naeem F, et al. Randomized trial of intravenous lidocaine versus hydromorphone for acute abdominal pain in the emergency department. Annals of Emergency Medicine. 2019;74(2):233-240. doi:10.1016/j.annemergmed.2019.01.021
Referanslar
Thomas SH, Silen W. Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain. British Journal of Surgery. 2003;90(1):5–9. doi:10.1002/bjs.4009
Gallagher EJ, Esses D, Lee C, et al. Randomized clinical trial of morphine in acute abdominal pain. Annals of Emergency Medicine. 2006;48(2):150-160. doi:10.1016/j.annemergmed.2005.11.020
Ranji SR, Goldman LE, Simel DL, et al. Do opiates affect the clinical evaluation of patients with acute abdominal pain? Journal of the American Medical Association. 2006;296(14):1764–1774. doi:10.1001/jama.296.14.1764
Manterola C, Vial M, Moraga J, et al. Analgesia in patients with acute abdominal pain. Cochrane Database of Systematic Reviews. 2011; 2011(1):CD005660. doi:10.1002/14651858.CD005660.pub3
Thomas SH, Silen W, Cheema F, et al. Effects of morphine analgesia on diagnostic accuracy in emergency department patients with abdominal pain: a prospective, randomized trial. Journal of the American College of Surgeons. 2003;196(1):18–31. doi:10.1016/s1072-7515(02)01480-1
Brennan F, Carr DB, Cousins M. Pain management: a fundamental human right. Anesthesia & Analgesia. 2007;105(1):205–221. doi:10.1213/01.ane.0000268145.52345.55
Falch C, Vicente D, Häberle H, et al. Treatment of acute abdominal pain in the emergency room: a systematic review of the literature. European Journal of Pain. 2014;18(7): 902–913. doi:10.1002/j.1532-2149.2014.00456.x
Masneri D.A., O’Brien M.C. Acute Abdominal Pain. In: Tintinalli JE (eds.) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9 th ed. New York: McGraw-Hill Education; 2020. p. 473-475.
Lax Y, Singh A. Referred abdominal pain. Pediatrics in Review. 2020;41(8):430-433. doi:10.1542/pir.2019-0221
Ducharme J. Acute Pain Management. In: Tintinalli JE (eds.) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9 th ed. New York: McGraw-Hill Education; 2020. p. 229-236.
Hachimi-Idrissi S, Coffey F, Dobias V, et al. Guidelines for the Management of Acute Pain in Emergency Situations. Brussels: European Society for Emergency Medicine (EUSEM); 2020.
Bielewicz J, Daniluk B, Kamieniak P. VAS and NRS, Same or Different? Are Visual Analog Scale Values and Numerical Rating Scale Equally Viable Tools for Assessing Patients after Microdiscectomy? Pain Research and Management. 2022; 2022:5337483. doi:10.1155/2022/5337483
Breivik H, Borchgrevink PC, Allen SM, et al. Assessment of pain. British Journal of Anaesthesia. 2008;101(1);17-24. doi:10.1093/bja/aen103
Hawker GA, Mian S, Kendzerska T, et al. Measures of adult pain: Visual Analog Scale for Pain, Numeric Rating Scale for Pain, McGill Pain Questionnaire. Arthritis Care & Research. 2011;63(S11):240–252. doi:10.1002/acr.20543
Kumar P, Tripathi L. Challenges in pain assessment: pain intensity scales. Indian Journal of Pain. 2014;28(2):61–70. doi: 10.4103/0970-5333.132841
Tytgat, G.N. Hyoscine butylbromide – a review on its parenteral use in acute abdominal spasm and as an aid in abdominal diagnostic and therapeutic procedures. Current Medical Research and Opinion, 2008;24(11):3159-3173. doi:10.1185/03007990802472700
Janczura M, Kobus-Moryson M, Sip S, et al. Fixed-Dose Combination of NSAIDs and Spasmolytic Agents in the Treatment of Different Types of Pain—A Practical Review. Journal of Clinical Medicine. 2021;10(14):3118. doi:10.3390/jcm10143118
Motov S, Rockoff B, Cohen V, et al. Intravenous subdissociative-dose ketamine versus morphine for analgesia in the emergency department: a randomized controlled trial. Annals of Emergency Medicine. 2015;66(3):222–229.
Sin B, Ternas T, Motov S, et al. The use of subdissociative-dose ketamine for acute pain in the emergency department. Academic Emergency Medicine. 2015;22(3):251–257. doi:10.1111/acem.12604
Motov S, Fassassi C, Drapkin J, et al. Comparison of intravenous lidocaine/ketorolac combination to either analgesic alone for suspected renal colic pain in the emergency department. The American Journal of Emergency Medicine. 2020;38(2):165-172. doi:10.1016/j.ajem.2019.01.048
Chinn E, Friedman BW, Naeem F, et al. Randomized trial of intravenous lidocaine versus hydromorphone for acute abdominal pain in the emergency department. Annals of Emergency Medicine. 2019;74(2):233-240. doi:10.1016/j.annemergmed.2019.01.021
