Yanık Tedavisinde Kullanılan İlaçlar ve Yan Etkileri
Özet
Yanık hastalarının tedavisinde enfeksiyon kontrolü, sıvı replasmanı, antisepsi kuralları, sedasyon ve analjezi hayati önem taşımaktadır. Yanmış ciltteki mikrosirkülasyon hasarı nedeniyle sistemik antibiyotikler yetersiz kaldığından topikal antimikrobiyal ilaçlar tercih edilir. En sık kullanılan ajanlardan gümüş sülfadiazin geniş spektrumlu ve ucuz bir standart bakım ürünü olmakla birlikte, reepitelizasyonu engelleyebilir ve geçici lökopeniye yol açabilir. Gümüş nitrat, direnç geliştirmeyen ancak çevreyi siyaha boyayan bir alternatiftir. Gümüş içermeyen ajanlardan mafenid asetat skar dokusuna iyi penetre olur fakat geniş alanlarda metabolik asidoz ve ağrı yapabilir. Basitrasin, mupirosin, polimiksin ve nitrofurazon gibi diğer topikal ajanlar da belirli patojenlere karşı etkilidir ancak sistemik emilim durumunda nefrotoksisite riskine dikkat edilmelidir. Yanık ağrısının kontrolünde non-opioidler (parasetamol, NSAİİ'ler) opioid ihtiyacını azaltmak için sinerjistik olarak kullanılır. Orta ve şiddetli ağrılarda morfin, fentanil, hidromorfon, oksikodon ve metadon gibi güçlü opioidler iv yol veya hasta kontrollü analjezi (PCA) ile kişiselleştirilerek uygulanır. Uzun süreli opioid kullanımı tolerans ve hiperaljeziye neden olabilir. Ayrıca dirençli ağrılarda NMDA reseptör antagonisti ketamin ile nöropatik semptomlar için antiepileptikler ve antidepresanlar tedaviye eklenmektedir.
In the treatment of burn patients, infection control, fluid replacement, antisepsis rules, sedation, and analgesia are of vital importance. Since systemic antibiotics are insufficient due to damaged microcirculation in burned skin, topical antimicrobial drugs are preferred. Among the most commonly used agents, silver sulfadiazine is a broad-spectrum and inexpensive standard care product, but it can inhibit re-epithelialization and cause transient leukopenia. Silver nitrate is an alternative that does not develop resistance but stains the surroundings black. Among silver-free agents, mafenide acetate penetrates scar tissue well but can cause metabolic acidosis and pain in large areas. Other topical agents like bacitracin, mupirocin, polymyxin, and nitrofurazone are also effective against specific pathogens, but the risk of nephrotoxicity should be considered in case of systemic absorption. In burn pain management, non-opioids (paracetamol, NSAIDs) are used synergistically to reduce opioid requirements. For moderate to severe pain, strong opioids such as morphine, fentanyl, hydromorphone, oxycodone, and methadone are administered via iv route or patient-controlled analgesia (PCA) by being individualized. Prolonged opioid use may cause tolerance and hyperalgesia. Additionally, ketamine, an NMDA receptor antagonist for resistant pain, and antiepileptics and antidepressants for neuropathic symptoms are added to the treatment.
Referanslar
Nakamura Y, Daya M. Use of appropriate antimicrobials in wound management. Emerg Med Clin North Am. 2007;25(1):159–76.
Lansdown AB. Silver 1. Its antibacterial properties and mechanism of action. J Wound Care 2002;11:125-130.
Caffee, H. H. & Bingham, H. G. 1982. Leukopenia and silver sulfadiazine. J Trauma, 22, 586–7.
Fuller FW, Engler PE. Leukopenia in non-septic burn patients receiving topical 1% silver sulfadiazine cream therapy: a survey. J Burn Care Rehabil 1988;9:606-609.
Fong, J. & Wood, F. 2006. Nanocrystalline silver dressings in wound management: A review. Int J Nanomedicine, 1, 441–9.
Boyce ST, Supp AP, Swope VB, et al. Topical Sulfamylon reduces engraftment of cultured skin substitutes on athymic mice. J Burn Care Rehabil 1999;20:33-36.
Shuck, J. M. & Moncrief, J. A. 1969. Safeguards in the use of topical mafenide (Sulfamylon) in burned patients. Am J Surg, 118, 864–70.
Monafo WW, West MA. Current treatment recommendations for topical burn therapy. Drugs 1990;40:364-373.
Acikel C, Oncul O, Ulkur E, et al. Comparison of silver sulfadiazine 1%, mupirocin 2%, and fusidic acid 2% for topical antibacterial effect in methicillin-resistant staphylococci infected full-skin thickness rat burn wounds. J Burn Care Rehabil 2003;24:37-41.
Dai T, Huang YY, Sharma SK, Hashmi JT, Kurup DB, Hamblin MR. Topical antimicrobials for burn wound infections. Recent Pat Antiinfect Drug Discov. 2010 Jun;5(2):124-51.
Norman G, Christie J, Liu Z, et al. Antiseptics for burns. Cochrane Database Syst Rev 2017; 7:CD011821.
Vermeulen H, Westerbos SJ, Ubbink DT. Benefit and harm of iodine in wound care: a systematic review. J Hosp Infect 2010; 76:191.
Jull AB, Cullum N, Dumville JC, et al. Honey as a topical treatment for wounds. Cochrane Database Syst Rev 2015; :CD005083.
Ahmed N, Shahzad MN, Qureshi KH, et al. Effectiveness of 0.025% dakin's solution versus 1% silver sulphadiazine for treatment of partial thickness burns. Ann Pak Inst Med Sci 2011; 7:127.
Dauber A, Osgood PF, Breslau AJ et al (2002) Chronic persistent pain after severe burns: a survey of 358 burn survivors. Pain Med 3: 6 –17.
Ratcliff SL, Brown A, Rosenberg L et al (2006) The effectiveness of a pain and anxiety protocol to treat the acute pediatric burn patient. Burns 32(5): 554 – 562.
Pallua N (2009) Kompendium der Schmerztherapie bei Verbrennungen. Deutsche Gesellschaft für Verbrennungsmedizin und Deutsche Gesellschaft zum Studium des Schmerzes. URL: http://www.dgss.org/filead min/pdf/Schmerz_KompendiumVerbrennung0901.
Koppert W, Wehrfritz A, Korber N et al (2004) The cyclo oxygenase isoenzyme inhibitors parecoxib and paracetamol reduce central hyperalgesia in humans. Pain 108: 148 – 153.
James DL, Jowza M. Principles of Burn Pain Management. Clin Plast Surg. 2017 Oct;44(4):737-747.
Marret E. Effects of nonsteroidal antiinflammatory drugs on patient-controlled analgesia morphine side effects: meta-analysis of controlled trials. Anesthesiology 2005;102:1249–60.
McGettigan P, Henry D (2006) Cardiovascular risk and inhibition of cyclooxygenase. A systematic review of the oberservational studies of selective and nonselective inhibitors of cyclooxygenase2. JAMA 296(13):1633– 1644.
Gregorian RS, Kavanagh S. Importance of side effects in opioid treatment: a trade off analysis with patients and physicians. J Pain 2010;11:1095–108.
Wibbenmeyer L, Eid A, Kluesner K, et al. An evaluation of factors related to postoperative pain control in burn patients. J Burn Care Res 2015;36:580–6.
Choiniere M, Grenier R, Paquette C. Patient controlled analgesia: a double-blind study in burn patients. Anaesthesia 1992;47:467–72.
Marc G. Jeschke et al. (eds.), Handbook of Burns. Springer-Verlag/Wien 2012. Pain management after burn trauma pp 339-360.
Linneman PK, Terry BE, Burd RS (2000) The efficacy and safety of fentanyl for the management of severe procedural pain in patients with burn injuries. J Burn Care Rehabil 21(6): 519 – 522.
Ong EC (2008) Controlled-release oxycodone in the treatment of neuropathic pain of nonmalignant and malignant causes. Oncology 74(1): 72 – 75.
Novick DM, Kreek MJ, Fanizza AM, et al. Methadone disposition in patients with chronic liver disease. Clin Pharmacol Ther 1981;30(3):353–62.
Andrews CM, Krantz MJ, Wedam EF, et al. Methadone- induced mortality in the treatment of chronic pain: role of QT prolongation. Cardiol J 2009;16(3):210–7.
Concilus R, Denson DD, Knarr D, et al. Continuous intravenous infusion of methadone for control of burn pain. J Burn Care Rehabil 1989;10(5):406–9.
Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med 2006;144:127–34.
McGuinness SK, Wasiak J, Cleland H, et al. A systematic review of ketamine as an analgesic agent in adult burn injuries. Pain Med 2011;12:1551–8.
Cuignet O. Effects of gabapentin on morphine consumption and pain in severely burned patients. Burns 2007;33:81–6.
Gray P. Pregabalin in severe burn injury pain: a double-blind, randomized placebo-controlled trial. Pain 2011;152:1279–88.
