Turkiye Klinikleri Journal of Anesthesiology Reanimation

.: REVIEW
Genel Anestezide Analjezi Düzeyinin Monitörizasyonu: Geleneksel Derleme
Monitoring of Analgesia Level During General Anesthesia: Traditional Review
Ayşe Hande ARPACIa , Berrin IŞIKb
aDepartment of Oral and Maxillofacial Surgery, Ankara University Faculty of Dentistry, Ankara, Türkiye
bDepartment of Anesthesiology and Reanimation, Gazi University Faculty of Medicine, Ankara, Türkiye
Turkiye Klinikleri J Anest Reanim. 2023;21(2):74-83
doi: 10.5336/anesthe.2022-95151
Article Language: TR
Full Text
ÖZET
 Genel anestezi uygulamaları ile hastalarda hipnoz, analjezi ve değişen derecelerde kas gevşemesinin sağlanması hedeflenmektedir. Böylece tanı ve tedavi amaçlı girişimlerde ağrı kontrol altına alınmakta, planlanan işlem başarıyla gerçekleştirilebilmekte ve hasta konforu sağlanmaktadır. Güncel monitörizasyon yöntemleri ile hipnoz durumu ve kas gevşeticilerin etkinliği sırasıyla elektroensefalogram ve sinir kas kavşağının uyarana yanıtı üzerinden oldukça güvenli monitörizasyon yöntemleri ile takip edilebilmektedir. Anesteziklerle sağlanan bilinç kaybı ve kas gevşeticilerle sağlanan paralizi altındaki bir hastada ağrının takibi ise çeşitli güçlükleri de beraberinde getirmektedir. Genel anestezi altındaki hastaların ağrı takibinde konvansiyonel olarak kalp atım hızı, kalp ritmi, kan basıncı, cildin görünüşü, cilt rengi, pupil çapı, göz yaşarması, terleme gibi otonomik değişiklikler izlense de hiçbiri tek başına yeterli olmamaktadır. Ayrıca otonomik değişkenler ağrı dışında endojen ve ekzojen pek çok faktörden de etkilenmektedir. Anestezi altında analjezinin değerlendirmesinde tüm hasta gruplarında güvenle kullanılabilecek, etkinliği konusunda üzerinde uzlaşılmış ağrı takip metodu henüz yoktur. Ancak otonomik değişkenler üzerinden ağrının değerlendirilmeye çalışıldığı monitörizasyon metodları bulunmaktadır. Bu nedenle genel anestezi altında ağrının objektif ve güvenilir yöntemlerle değerlendirilmesine ihtiyaç duyulmakta, bu konuda araştırma geliştirme çalışmaları devam etmektedir. Günümüzde tek ya da birden çok parametre ile nosisepsiyonu değerlendiren monitörler kullanılmaktadır. Bu monitörlerin genel anestezi altındaki hastaların ağrı takibinde etkinliklerini ortaya koymada çeşitli avantaj ve kısıtlılıkları bulunmaktadır. Bu derlemede, anestezistin deneyimi dışında objektif olarak intraoperatif analjezi düzeyini saptamada kullanılan mevcut izlem metodları ve bu metodların değerlendirdiği parametrelerin özellikleri sunularak, konunun güncel literatür bilgileri ışığında tartışılması amaçlanmıştır.

Anahtar Kelimeler: Analjezi; nosisepsiyon; monitörizasyon; genel anestezi
ABSTRACT
 General anesthesia is aimed to provide hypnosis, analgesia and varying degrees of muscle relaxation in patients. Thus, pain is controlled in diagnostic and therapeutic interventions, the planned procedure can be performed successfully and patient comfort is provided. With current monitoring methods, the state of hypnosis and the effectiveness of muscle relaxants can be followed by quite reliable monitoring methods over electroencephalogram and neuromuscular junction response to stimulus, respectively. The loss of consciousness provided by anesthetics and the follow-up of pain in a patient under paralysis with muscle relaxants bring along various challenges. Although autonomic changes such as heart rate, heart rhythm, blood pressure, skin appearance, skin color, pupil diameter, tearing, sweating are conventionally followed in the pain follow-up of patients underwent general anesthesia, none of them alone is sufficient. In addition to pain, autonomic variables are also affected by many endogenous and exogenous factors. There is no pain followup method that can be used safely in all patient groups in the evaluation of analgesia whose patients are underwent general anesthesia, and effectiveness of it agreed upon. However, there are monitoring methods that aim to evaluate pain over autonomic variables. For this reason, evaluation of pain, under general anesthesia, is needed with objective and reliable methods, and research and development studies continue on this subject. Today, monitors that evaluate nociception with one or more parameters are used. These monitors have several advantages and limitations in demonstrating their effectiveness in pain monitoring of patients under general anesthesia. In this review, it is aimed to discuss the subject in the light of current literature by presenting the current monitoring methods used to determine the level of intraoperative analgesia objectively, apart from the anesthetist's experience, and the characteristics of the parameters evaluated by these methods.

Keywords: Analgesia; nociception; monitoring; general anesthesia
REFERENCES:
  1. Martinez-Vazquez P, Jensen EW. Different perspectives for monitoring nociception during general anesthesia. Korean J Anesthesiol. 2022;75(2):112-23. [Crossref]  [PubMed]  [PMC] 
  2. Ledowski T. Objective monitoring of nociception: a review of current commercial solutions. Br J Anaesth. 2019;123(2):e312-21. [Crossref]  [PubMed]  [PMC] 
  3. Ghanty I, Schraag S. The quantification and monitoring of intraoperative nociception levels in thoracic surgery: a review. J Thorac Dis. 2019;11(9):4059-71. [Crossref]  [PubMed]  [PMC] 
  4. Brown EN, Lydic R, Schiff ND. General anesthesia, sleep, and coma. N Engl J Med. 2010;363(27):2638-50. [Crossref]  [PubMed]  [PMC] 
  5. Büget İM, Orhan Sungur M. Anestezi derinliği ve analjezi ölçümü [Depth of anesthesia and analgesia monitoring]. Turkiye Klinikleri J Anest Reanim-Special Topics. 2015;8(1):57-64. [Link] 
  6. Vanluchene AL, Vereecke H, Thas O, Mortier EP, Shafer SL, Struys MM. Spectral entropy as an electroencephalographic measure of anesthetic drug effect: a comparison with bispectral index and processed midlatency auditory evoked response. Anesthesiology. 2004;101(1):34-42. [Crossref]  [PubMed] 
  7. Markle A, Graf N, Horn K, Welter JE, Dullenkopf A. Neuromuscular monitoring using TOF-Cuff® versus TOF-Scan®: an observational study under clinical anesthesia conditions. Minerva Anestesiol. 2020;86(7):704-11. [Crossref]  [PubMed] 
  8. Klein AA, Meek T, Allcock E, Cook TM, Mincher N, Morris C, et al. Recommendations for standards of monitoring during anaesthesia and recovery 2021: Guideline from the Association of Anaesthetists. Anaesthesia. 2021;76(9):1212-23. [Crossref]  [PubMed] 
  9. Funcke S, Sauerlaender S, Pinnschmidt HO, Saugel B, Bremer K, Reuter DA, et al. Validation of innovative techniques for monitoring nociception during general anesthesia: a clinical study using tetanic and intracutaneous electrical stimulation. Anesthesiology. 2017;127(2):272-83. [Crossref]  [PubMed] 
  10. Nitzschke R, Fischer M, Funcke S. [Nociception monitoring: method for intraoperative opioid control?]. Anaesthesist. 2021;70(9):735-52. [Crossref]  [PubMed] 
  11. Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020;161(9):1976-82. [Crossref]  [PubMed]  [PMC] 
  12. 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 Res Manag. 2022;2022:5337483. [Crossref]  [PubMed]  [PMC] 
  13. Crellin D, Harrison D, Santamaria N, Babl FE. Comparison of the psychometric properties of the FLACC scale, the MBPS and the observer applied visual analogue scale used to assess procedural pain. J Pain Res. 2021;14:881-92. [Crossref]  [PubMed]  [PMC] 
  14. Cividjian A, Petitjeans F, Liu N, Ghignone M, de Kock M, Quintin L. Do we feel pain during anesthesia? A critical review on surgery-evoked circulatory changes and pain perception. Best Pract Res Clin Anaesthesiol. 2017;31(4):445-67. [Crossref]  [PubMed] 
  15. von Dincklage F. [Monitoring of pain, nociception, and analgesia under general anesthesia: Relevance, current scientific status, and clinical practice]. Anaesthesist. 2015;64(10):758-64. [Crossref]  [PubMed] 
  16. Loeser JD, Treede RD. The Kyoto protocol of IASP basic pain terminology. Pain. 2008;137(3):473-7. [Crossref]  [PubMed] 
  17. Sahinovic MM, Eleveld DJ, Kalmar AF, Heeremans EH, De Smet T, Seshagiri CV, et al. Accuracy of the composite variability index as a measure of the balance between nociception and antinociception during anesthesia. Anesth Analg. 2014;119(2):288-301. [Crossref]  [PubMed] 
  18. Julius D, Basbaum AI. Molecular mechanisms of nociception. Nature. 2001;413(6852):203-10. [Crossref]  [PubMed] 
  19. Jiao Y, He B, Tong X, Xia R, Zhang C, Shi X. Intraoperative monitoring of nociception for opioid administration: a meta-analysis of randomized controlled trials. Minerva Anestesiol. 2019;85(5):522-30. [Crossref]  [PubMed] 
  20. Gruenewald M, Ilies C. Monitoring the nociception-anti-nociception balance. Best Pract Res Clin Anaesthesiol. 2013;27(2):235-47. [Crossref]  [PubMed] 
  21. Fields HL, Heinricher MM. Anatomy and physiology of a nociceptive modulatory system. Philos Trans R Soc Lond B Biol Sci. 1985;308(1136):361-74. [Crossref]  [PubMed] 
  22. Jeanne M, Clément C, De Jonckheere J, Logier R, Tavernier B. Variations of the analgesia nociception index during general anaesthesia for laparoscopic abdominal surgery. J Clin Monit Comput. 2012;26(4):289-94. [Crossref]  [PubMed] 
  23. Boselli E, Daniela-Ionescu M, Bégou G, Bouvet L, Dabouz R, Magnin C, et al. Prospective observational study of the non-invasive assessment of immediate postoperative pain using the analgesia/nociception index (ANI). Br J Anaesth. 2013;111(3):453-9. [Crossref]  [PubMed] 
  24. De Jonckheere J, Rommel D, Nandrino JL, Jeanne M, Logier R. Heart rate variability analysis as an index of emotion regulation processes: interest of the Analgesia Nociception Index (ANI). Annu Int Conf IEEE Eng Med Biol Soc. 2012;2012:3432-5. [Crossref]  [PubMed] 
  25. Julien-Marsollier F, Rachdi K, Caballero MJ, Ayanmanesh F, Vacher T, Horlin AL, et al. Evaluation of the analgesia nociception index for monitoring intraoperative analgesia in children. Br J Anaesth. 2018;121(2):462-8. [Crossref]  [PubMed] 
  26. Soral M, Altun GT, Dinçer PÇ, Arslantaş MK, Aykaç Z. Effectiveness of the analgesia nociception index monitoring in patients who undergo colonoscopy with sedo-analgesia. Turk J Anaesthesiol Reanim. 2020;48(1):50-7. [Crossref]  [PubMed]  [PMC] 
  27. Theerth KA, Sriganesh K, Reddy KM, Chakrabarti D, Umamaheswara Rao GS. Analgesia Nociception Index-guided intraoperative fentanyl consumption and postoperative analgesia in patients receiving scalp block versus incision-site infiltration for craniotomy. Minerva Anestesiol. 2018;84(12):1361-18. [Crossref]  [PubMed] 
  28. Daccache G, Caspersen E, Pegoix M, Monthé-Sagan K, Berger L, Fletcher D, et al. A targeted remifentanil administration protocol based on the analgesia nociception index during vascular surgery. Anaesth Crit Care Pain Med. 2017;36(4):229-32. [Crossref]  [PubMed] 
  29. Upton HD, Ludbrook GL, Wing A, Sleigh JW. Intraoperative "Analgesia Nociception Index"-guided fentanyl administration during sevoflurane anesthesia in lumbar discectomy and laminectomy: a randomized clinical trial. Anesth Analg. 2017;125(1):81-90. [Crossref]  [PubMed] 
  30. İnan G, Şatırlar ZÖ. Kraniotomide Analjezi Nosisepsiyon İndeks Kılavuzluğunda anestezi yönetimi [Analgesia Nociception Index-Guided anesthesia management in craniotomy]. Turkiye Klinikleri J Anest Reanim. 2021;19(1):8-16. [Crossref] 
  31. Ledowski T, Tiong WS, Lee C, Wong B, Fiori T, Parker N. Analgesia nociception index: evaluation as a new parameter for acute postoperative pain. Br J Anaesth. 2013;111(4):627-9. [Crossref]  [PubMed] 
  32. Le Gall L, David A, Carles P, Leuillet S, Chastel B, Fleureau C, et al. Benefits of intraoperative analgesia guided by the Analgesia Nociception Index (ANI) in bariatric surgery: An unmatched case-control study. Anaesth Crit Care Pain Med. 2019;38(1):35-9. [Crossref]  [PubMed] 
  33. Storm H, Myre K, Rostrup M, Stokland O, Lien MD, Raeder JC. Skin conductance correlates with perioperative stress. Acta Anaesthesiol Scand. 2002;46(7):887-95. [Crossref]  [PubMed] 
  34. Storm H. Changes in skin conductance as a tool to monitor nociceptive stimulation and pain. Curr Opin Anaesthesiol. 2008;21(6):796-804. [Crossref]  [PubMed] 
  35. Ledowski T, Ang B, Schmarbeck T, Rhodes J. Monitoring of sympathetic tone to assess postoperative pain: skin conductance vs surgical stress index. Anaesthesia. 2009;64(7):727-31. [Crossref]  [PubMed] 
  36. Storm H, Shafiei M, Myre K, Raeder J. Palmar skin conductance compared to a developed stress score and to noxious and awakening stimuli on patients in anaesthesia. Acta Anaesthesiol Scand. 2005;49(6):798-803. [Crossref]  [PubMed] 
  37. Ledowski T, Pascoe E, Ang B, Schmarbeck T, Clarke MW, Fuller C, et al. Monitoring of intra-operative nociception: skin conductance and surgical stress index versus stress hormone plasma levels. Anaesthesia. 2010;65(10):1001-6. [Crossref]  [PubMed] 
  38. Sabourdin N, Arnaout M, Louvet N, Guye ML, Piana F, Constant I. Pain monitoring in anesthetized children: first assessment of skin conductance and analgesia-nociception index at different infusion rates of remifentanil. Paediatr Anaesth. 2013;23(2):149-55. [Crossref]  [PubMed] 
  39. Choo EK, Magruder W, Montgomery CJ, Lim J, Brant R, Ansermino JM. Skin conductance fluctuations correlate poorly with postoperative self-report pain measures in school-aged children. Anesthesiology. 2010;113(1):175-82. [Crossref]  [PubMed] 
  40. Loewenfeld IE. The light reflex. Pupillary reflex pathways. The Pupil: Anatomy, Physiology and Clinical Applications. 2nd ed. Oxford: Butterworth-Heinemann; 1999. p.198-240.
  41. Vide S, Castro A, Antunes P, Lima D, Larson M, Gambús P, et al. Pharmacodynamic modelling of the effect of remifentanil using the Pupillary Pain Index. J Clin Monit Comput. 2020;34(2):319-24. [Crossref]  [PubMed] 
  42. Sabourdin N, Meniolle F, Chemam S, Rigouzzo A, Hamza J, Louvet N, et al. Effect of different concentrations of propofol used as a sole anesthetic on pupillary diameter: a randomized trial. Anesth Analg. 2020;131(2):510-7. [Crossref]  [PubMed] 
  43. Sabourdin N, Peretout JB, Khalil E, Guye ML, Louvet N, Constant I. Influence of depth of hypnosis on pupillary reactivity to a standardized tetanic stimulus in patients under propofol-remifentanil target-controlled infusion: a crossover randomized pilot study. Anesth Analg. 2018;126(1):70-7. [Crossref]  [PubMed] 
  44. Constant I, Nghe MC, Boudet L, Berniere J, Schrayer S, Seeman R, et al. Reflex pupillary dilatation in response to skin incision and alfentanil in children anaesthetized with sevoflurane: a more sensitive measure of noxious stimulation than the commonly used variables. Br J Anaesth. 2006;96(5):614-9. [Crossref]  [PubMed] 
  45. Sabourdin N, Diarra C, Wolk R, Piat V, Louvet N, Constant I. Pupillary pain index changes after a standardized bolus of alfentanil under sevoflurane anesthesia: first evaluation of a new pupillometric index to assess the level of analgesia during general anesthesia. Anesth Analg. 2019;128(3):467-74. [Crossref]  [PubMed] 
  46. Sabourdin N, Barrois J, Louvet N, Rigouzzo A, Guye ML, Dadure C, et al. Pupillometry-guided intraoperative remifentanil administration versus standard practice influences opioid use: a randomized study. Anesthesiology. 2017;127(2):284-92. [Crossref]  [PubMed] 
  47. Aissou M, Snauwaert A, Dupuis C, Atchabahian A, Aubrun F, Beaussier M. Objective assessment of the immediate postoperative analgesia using pupillary reflex measurement: a prospective and observational study. Anesthesiology. 2012;116(5):1006-12. [Crossref]  [PubMed] 
  48. Kantor E, Montravers P, Longrois D, Guglielminotti J. Pain assessment in the postanaesthesia care unit using pupillometry: a cross-sectional study after standard anaesthetic care. Eur J Anaesthesiol. 2014;31(2):91-7. [Crossref]  [PubMed] 
  49. von Dincklage F, Hackbarth M, Schneider M, Baars JH, Rehberg B. Introduction of a continual RIII reflex threshold tracking algorithm. Brain Res. 2009;1260:24-9. [Crossref]  [PubMed] 
  50. Jakuscheit A, Weth J, Lichtner G, Jurth C, Rehberg B, von Dincklage F. Intraoperative monitoring of analgesia using nociceptive reflexes correlates with delayed extubation and immediate postoperative pain: a prospective observational study. Eur J Anaesthesiol. 2017;34(5):297-305. [Crossref]  [PubMed] 
  51. Skljarevski V, Ramadan NM. The nociceptive flexion reflex in humans--review article. Pain. 2002;96(1-2):3-8. [Crossref]  [PubMed] 
  52. Struys MM, Sahinovic M, Lichtenbelt BJ, Vereecke HE, Absalom AR. Optimizing intravenous drug administration by applying pharmacokinetic/pharmacodynamic concepts. Br J Anaesth. 2011;107(1):38-47. [Crossref]  [PubMed] 
  53. Thee C, Ilies C, Gruenewald M, Kleinschmidt A, Steinfath M, Bein B. Reliability of the surgical Pleth index for assessment of postoperative pain: a pilot study. Eur J Anaesthesiol. 2015;32(1):44-8. [Crossref]  [PubMed] 
  54. Bergmann I, Göhner A, Crozier TA, Hesjedal B, Wiese CH, Popov AF, et al. Surgical pleth index-guided remifentanil administration reduces remifentanil and propofol consumption and shortens recovery times in outpatient anaesthesia. Br J Anaesth. 2013;110(4):622-8. [Crossref]  [PubMed] 
  55. Won YJ, Lim BG, Kim YS, Lee M, Kim H. Usefulness of surgical pleth index-guided analgesia during general anesthesia: a systematic review and meta-analysis of randomized controlled trials. J Int Med Res. 2018;46(11):4386-98. [Crossref]  [PubMed]  [PMC] 
  56. Ledowski T, Sommerfield D, Slevin L, Conrad J, von Ungern-Sternberg BS. Surgical pleth index: prediction of postoperative pain in children? Br J Anaesth. 2017;119(5):979-83. [Crossref]  [PubMed] 
  57. Park JH, Lim BG, Kim H, Lee IO, Kong MH, Kim NS. Comparison of surgical pleth index-guided analgesia with conventional analgesia practices in children: a randomized controlled trial. Anesthesiology. 2015;122(6):1280-7. [Crossref]  [PubMed] 
  58. Bonhomme V, Uutela K, Hans G, Maquoi I, Born JD, Brichant JF, et al. Comparison of the surgical Pleth Index? with haemodynamic variables to assess nociception-anti-nociception balance during general anaesthesia. Br J Anaesth. 2011;106(1):101-11. [Crossref]  [PubMed] 
  59. Gruenewald M, Willms S, Broch O, Kott M, Steinfath M, Bein B. Sufentanil administration guided by surgical pleth index vs standard practice during sevoflurane anaesthesia: a randomized controlled pilot study. Br J Anaesth. 2014;112(5):898-905. [Crossref]  [PubMed] 
  60. Colombo R, Raimondi F, Rech R, Castelli A, Fossali T, Marchi A, et al. Surgical Pleth Index guided analgesia blunts the intraoperative sympathetic response to laparoscopic cholecystectomy. Minerva Anestesiol. 2015;81(8):837-45. [PubMed] 
  61. Jensen EW, Valencia JF, López A, Anglada T, Agustí M, Ramos Y, et al. Monitoring hypnotic effect and nociception with two EEG-derived indices, qCON and qNOX, during general anaesthesia. Acta Anaesthesiol Scand. 2014;58(8):933-41. [Crossref]  [PubMed] 
  62. Pantalacci T, Allaouchiche B, Boselli E. Relationship between ANI and qNOX and between MAC and qCON during outpatient laparoscopic cholecystectomy using remifentanil and desflurane without muscle relaxants: a prospective observational preliminary study. J Clin Monit Comput. 2023;37(1):83-91. [Crossref]  [PubMed] 
  63. Rogozov V, Vanek T, Maly M, Rocek J, Kacer P. The nociceptive response during adult cardiac surgery measured by the qNOX index: a feasibility study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2022 Nov 2. [Crossref]  [PubMed] 
  64. Ledowski T, Schmitz-Rode I. Predicting acute postoperative pain by the Qnox score at the end of surgery: a prospective observational study. Br J Anaesth. 2020;124(2):222-6. [Crossref]  [PubMed] 
  65. Tantri AR, Sukmono RB, Lumban Tobing SDA, Natali C. Comparing the effect of classical and modified thoracolumbar interfascial plane block on postoperative pain and IL-6 level in posterior lumbar decompression and stabilization surgery. Anesth Pain Med. 2022;12(2):e122174. [Crossref]  [PubMed]  [PMC] 
  66. Bollag L, Jelacic S, Delgado Upegui C, Wu C, Richebe P. The nociception level index (NOL) response to intubation and incision in patients undergoing video-assisted thoracoscopic surgery (VATS) with and without thoracic epidural analgesia. A pilot study. F1000Res. 2018;7:875. [Crossref]  [PubMed]  [PMC] 
  67. Martini CH, Boon M, Broens SJ, Hekkelman EF, Oudhoff LA, Buddeke AW, et al. Ability of the nociception level, a multiparameter composite of autonomic signals, to detect noxious stimuli during propofol-remifentanil anesthesia. Anesthesiology. 2015;123(3):524-34. [Crossref]  [PubMed] 
  68. Meijer F, Honing M, Roor T, Toet S, Calis P, Olofsen E, et al. Reduced postoperative pain using Nociception Level-guided fentanyl dosing during sevoflurane anaesthesia: a randomised controlled trial. Br J Anaesth. 2020;125(6):1070-8. [Crossref]  [PubMed]  [PMC] 
  69. Meijer FS, Martini CH, Broens S, Boon M, Niesters M, Aarts L, et al. Nociception-guided versus standard care during remifentanil-propofol anesthesia: a randomized controlled trial. Anesthesiology. 2019;130(5):745-55. [Crossref]  [PubMed] 
  70. Espitalier F, Idrissi M, Fortier A, Bélanger MÈ, Carrara L, Dakhlallah S, et al. Impact of Nociception Level (NOL) index intraoperative guidance of fentanyl administration on opioid consumption, postoperative pain scores and recovery in patients undergoing gynecological laparoscopic surgery. A randomized controlled trial. J Clin Anesth. 2021;75:110497. [Crossref]  [PubMed] 
  71. Renaud-Roy E, Morisson L, Brulotte V, Idrissi M, Godin N, Fortier LP, et al. Effect of combined intraoperative use of the Nociception Level (NOL) and bispectral (BIS) indexes on desflurane administration. Anaesth Crit Care Pain Med. 2022;41(3):101081. [Crossref]  [PubMed] 
  72. Niebhagen F, Golde C, Koch T, Hübler M. [Does NoL monitoring affect opioid consumption during da Vinci prostatectomy?]. Anaesthesiologie. 2022;71(9):683-8. [Crossref]  [PubMed]  [PMC] 
  73. Fuica R, Krochek C, Weissbrod R, Greenman D, Freundlich A, Gozal Y. Reduced postoperative pain in patients receiving nociception monitor guided analgesia during elective major abdominal surgery: a randomized, controlled trial. J Clin Monit Comput. 2023;37(2):481-91. [Crossref]  [PubMed]  [PMC] 

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2.3. LINK: A link enabling to access to another website through the "SITE", the files, the context or through another website to the "SITE", the files and the context.

2.4. CONTEXT: Any visual, literary and auditory images published in the "Turkiye Klinikleri", "SITE" and/or any website or any accessible information, file, picture, number/figures, price, etc.

2.5. "USER CONTRACT": An electronically signed contract between a natural or a legal identity benefiting from special services "Turkiye Klinikleri" will provide and "Turkiye Klinikleri".

3. SCOPE OF THE SERVICES

3.1. "Turkiye Klinikleri" is completely free to determine the scope and quality of the services via the "SITE".

3.2. To benefit the services of "Turkiye Klinikleri" "SITE", the "USER" must deliver the features that will be specified by "Turkiye Klinikleri". "Turkiye Klinikleri" may change this necessity any time single-sided.

3.3. Not for a limited number, the services "Turkiye Klinikleri" will provide through the "SITE" for a certain price or for free are;

- Providing scientific articles, books and informative publications for health industry.

- Providing structural, statistical and editorial support to article preparation stage for scientific journals.

4. GENERAL PROVISIONS

4.1. "Turkiye Klinikleri" is completely free to determine which of the services and contents provided in the "SITE" will be charged.

4.2. People benefiting from the services provided by "Turkiye Klinikleri" and using the website can use the "SITE" only according to the law and only for personal reasons. Users have the criminal and civil liability for every process and action they take in the "SITE". Every USER agrees, declares and undertakes that they will not proceed by any function or action infringement of rights of "Turkiye Klinikleri"s and/or other third parties', they are the exclusive right holder on usage, processing, storage, made public and revealing any written, visual or auditory information reported to Turkiye Klinikleri" and/or "SITE" to the third parties. "USER" agrees and undertakes that s/he will not duplicate, copy, distribute, process, the pictures, text, visual and auditory images, video clips, files, databases, catalogs and lists within the "SITE", s/he will not be using these actions or with other ways to compete with "Turkiye Klinikleri", directly or indirectly.

4.3. The services provided and the context published within the "SITE" by third parties is not under the responsibility of "Turkiye Klinikleri", institutions collaborated with "Turkiye Klinikleri", "Turkiye Klinikleri" employee and directors, "Turkiye Klinikleri" authorized salespeople. Commitment to accuracy and legality of the published information, context, visual and auditory images provided by any third party are under the full responsibility of the third party. "Turkiye Klinikleri" does not promise and guarantee the safety, accuracy and legality of the services and context provided by a third party.

4.4. "USER"s cannot act against "Turkiye Klinikleri", other "USER"s and third parties by using the "SITE". "Turkiye Klinikleri" has no direct and/or indirect responsibility for any damage a third party suffered or will suffer regarding "USER"s actions on the "SITE" against the rules of the hereby "Terms of Use" and the law.

4.5. "USER"s accept and undertake that the information and context they provided to the "SITE" are accurate and legal. "Turkiye Klinikleri" is not liable and responsible for promising and guaranteeing the verification of the information and context transmitted to "Turkiye Klinikleri" by the "USER"s, or uploaded, changed and provided through the "SITE" by them and whether these information are safe, accurate and legal.

4.6. "USER"s agree and undertake that they will not perform any action leading to unfair competition, weakening the personal and commercial credit of "Turkiye Klinikleri" and a third party,  encroaching and attacking on personal rights within the "SITE" in accordance with the Turkish Commercial Code Law.

4.7. "Turkiye Klinikleri" reserves the right to change the services and the context within the "SITE"  anytime. "Turkiye Klinikleri" may use this right without any notification and timelessly. "USER"s have to make the changes and/or corrections "Turkiye Klinikleri" required immediately. Any changes and/or corrections that are required by "Turkiye Klinikleri", may be made by "Turkiye Klinikleri" when needed. Any harm, criminal and civil liability resulted or will result from changes and/or corrections required by "Turkiye Klinikleri" and were not made on time by the "USER"s belongs completely to the users.

4.8. "Turkiye Klinikleri" may give links through the "SITE" to other websites and/or "CONTEXT"s and/or folders that are outside of their control and owned and run by third parties. These links are provided for ease of reference only and do not hold qualification for support the respective web SITE or the admin or declaration or guarantee for the information inside. "Turkiye Klinikleri" does not hold any responsibility over the web-sites connected through the links on the "SITE", folders and context, the services or products on the websites provided through these links or their context.

4.9. "Turkiye Klinikleri" may use the information provided to them by the "USERS" through the "SITE" in line with the terms of the "PRIVACY POLICY" and "USER CONTRACT". It may process the information or classify and save them on a database. "Turkiye Klinikleri" may also use the USER's or visitor's identity, address, e-mail address, phone number, IP number, which sections of the "SITE" they visited, domain type, browser type, date and time information to provide statistical evaluation and customized services.

5. PROPRIETARY RIGHTS

5.1. The information accessed through this "SITE" or provided by the users legally and all the elements (including but not limited to design, text, image, html code and other codes) of the "SITE" (all of them will be called as studies tied to "Turkiye Klinikleri"s copyrights) belongs to "Turkiye Klinikleri". Users do not have the right to resell, process, share, distribute, display or give someone permission to access or to use the "Turkiye Klinikleri" services, "Turkiye Klinikleri" information and the products under copyright protection by "Turkiye Klinikleri". Within hereby "Terms of Use" unless explicitly permitted by "Turkiye Klinikleri" nobody can reproduce, process, distribute or produce or prepare any study from those under "Turkiye Klinikleri" copyright protection.

5.2. Within hereby "Terms of Use", "Turkiye Klinikleri" reserves the rights for "Turkiye Klinikleri" services, "Turkiye Klinikleri" information, the products associated with "Turkiye Klinikleri" copyrights, "Turkiye Klinikleri" trademarks, "Turkiye Klinikleri" trade looks or its all rights for other entity and information it has through this website unless it is explicitly authorized by "Turkiye Klinikleri".

6. CHANGES IN THE TERMS OF USE

"Turkiye Klinikleri" in its sole discretion may change the hereby "Terms of Use" anytime announcing within the "SITE". The changed terms of the hereby "Terms of Use" will become valid when they are announced. Hereby "Terms of Use" cannot be changed by unilateral declarations of users.

7. FORCE MAJEURE

"Turkiye Klinikleri" is not responsible for executing late or never of this hereby "Terms of Use", privacy policy and "USER Contract" in any situation legally taken into account as force majeure. Being late or failure of performance or non-defaulting of this and similar cases like this will not be the case from the viewpoint of "Turkiye Klinikleri", and "Turkiye Klinikleri" will not have any damage liability for these situations. "Force majeure" term will be regarded as outside of the concerned party's reasonable control and any situation that "Turkiye Klinikleri" cannot prevent even though it shows due diligence. Also, force majeure situations include but not limited to natural disasters, rebellion, war, strike, communication problems, infrastructure and internet failure, power cut and bad weather conditions.

8. LAW AND AUTHORISATION TO FOLLOW

Turkish Law will be applied in practicing, interpreting the hereby "Terms of Use" and managing the emerging legal relationships within this "Terms of Use" in case of finding element of foreignness, except for the rules of Turkish conflict of laws. Ankara Courts and Enforcement Offices are entitled in any controversy happened or may happen due to hereby contract.

9. CLOSING AND AGREEMENT

Hereby "Terms of Use" come into force when announced in the "SITE" by "Turkiye Klinikleri". The users are regarded to agree to hereby contract terms by using the "SITE". "Turkiye Klinikleri" may change the contract terms and the changes will be come into force by specifying the version number and the date of change on time it is published in the "SITE".

 

30.03.2014

Privacy Policy

We recommend you to read the terms of use below before you visit our website. In case you agree these terms, following our rules will be to your favor. Please read our Terms of Use thoroughly.

www.turkiyeklinikleri.com website belongs to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. and is designed in order to inform physicians in the field of health

www.turkiyeklinikleri.com cannot reach to user’s identity, address, service providers or other information. The users may send this information to the website through forms if they would like to. However, www.turkiyeklinikleri.com may collect your hardware and software information. The information consists of your IP address, browser type, operating system, domain name, access time, and related websites. www.turkiyeklinikleri.com cannot sell the provided user information (your name, e-mail address, home and work address, phone number) to the third parties, publish it publicly, or keep it in the website. Gathered information has a directing feature to be a source for the website’s visitor profile, reporting and promotion of the services.

www.turkiyeklinikleri.com uses the taken information:

-To enhance, improve and maintain the quality of the website

-To generate visitor’s profile and statistical data

-To determine the tendency of the visitors on using our website

-To send print publications/correspondences

-To send press releases or notifications through e-mail

-To generate a list for an event or competition

By using www.turkiyeklinikleri.com you are considered to agree that;

-Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. cannot be hold responsible for any user’s illegal and immoral behavior,

-Terms of use may change from time to time,

-It is not responsible for other websites’ contents it cannot control or the harms they may cause although it uses the connection they provided.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. may block the website to users in the following events:

-Information with wrong, incomplete, deceiving or immoral expressions is recorded to the website,

-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

info@turkiyeklinikleri.com