{"id":23245,"date":"2021-08-27T08:00:58","date_gmt":"2021-08-27T05:00:58","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=23245"},"modified":"2021-08-26T17:34:31","modified_gmt":"2021-08-26T14:34:31","slug":"olasiliga-dayali-surveyans","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2021\/08\/27\/olasiliga-dayali-surveyans\/","title":{"rendered":"Kal\u00e7a Protezi Ameliyatlar\u0131na Y\u00f6nelik Bir \u00d6neri: Olas\u0131l\u0131\u011fa Dayal\u0131 S\u00fcrveyans"},"content":{"rendered":"

G\u0130R\u0130\u015e<\/b><\/h2>\n

\u00dclkemizde, Ulusal Sa\u011fl\u0131k Hizmeti \u0130li\u015fkili \u0130nfeksiyonlar (SH\u0130\u0130) S\u00fcrveyans\u0131, Yatakl\u0131 Tedavi Kurumlar\u0131 \u0130nfeksiyon Kontrol Y\u00f6netmeli\u011fi\u2019nin 2005 y\u0131l\u0131nda yay\u0131mlanmas\u0131 ile birlikte t\u00fcm yatakl\u0131 tedavi kurumlar\u0131nda uygulanmaya ba\u015flanm\u0131\u015ft\u0131r. 2007 y\u0131l\u0131ndan itibaren s\u00fcrveyans verileri Ulusal Sa\u011fl\u0131k Hizmeti \u0130li\u015fkili \u0130nfeksiyonlar S\u00fcrveyans A\u011f\u0131 (USH\u0130\u0130SA)\u2019na kaydedilmektedir (1). Cerrahi alan infeksiyonu (CA\u0130) s\u00fcrveyans\u0131 ise toplanan veriler, hastalar\u0131n izlemi ve analizi gibi \u00e7e\u015fitli \u00f6zellikleri a\u00e7\u0131s\u0131ndan SH\u0130\u0130 s\u00fcrveyans\u0131n\u0131n bir bile\u015feni olarak farkl\u0131l\u0131k g\u00f6stermektedir. CA\u0130 s\u00fcrveyans\u0131nda farkl\u0131 olarak, infeksiyon geli\u015fen ve geli\u015fmeyen t\u00fcm hastalar\u0131n ameliyat verileri (yara s\u0131n\u0131f\u0131, ASA skoru, anestezi t\u00fcr\u00fc gibi) kaydedilir. CA\u0130 s\u00fcrveyans\u0131n\u0131 ay\u0131ran en \u00f6nemli \u00f6zellik ise taburculuk sonras\u0131 s\u00fcrveyanst\u0131r. Ameliyat olan hastalar, ameliyat t\u00fcr\u00fcne g\u00f6re belirlenen 30 veya 90 g\u00fcnl\u00fck CA\u0130 s\u00fcrveyans s\u00fcresinin \u00e7ok b\u00fcy\u00fck bir k\u0131sm\u0131n\u0131 hastane d\u0131\u015f\u0131nda ge\u00e7irmekte olup CA\u0130\u2019lerin \u00e7o\u011fu bu d\u00f6nemde ger\u00e7ekle\u015fmektedir. Taburculuk sonras\u0131 geli\u015fen bu infeksiyonlar\u0131n tespitinde, hastalar\u0131n ba\u015fka hastaneye ba\u015fvurmas\u0131, ayakta tan\u0131 almas\u0131 ve tespit eden hekimin bildirim yapmamas\u0131 gibi nedenlerle g\u00fc\u00e7l\u00fckler ya\u015fanmaktad\u0131r (2-7). Bu nedenle CA\u0130 s\u00fcrveyans\u0131 emek yo\u011fun ve zaman al\u0131c\u0131d\u0131r.<\/p>\n

\u00dclkemizde, y\u0131ll\u0131k 50 ve \u00fczeri kal\u00e7a protezi ameliyat\u0131 yap\u0131lan hastanelerde, bu ameliyat kategorisi i\u00e7in CA\u0130 s\u00fcrveyans\u0131 yap\u0131lmas\u0131 zorunludur (8). S\u00fcrveyansta t\u00fcm verilerin toplanmas\u0131 ve t\u00fcm hastalar\u0131n 90 g\u00fcn izlemlerinin tamamlanmas\u0131, di\u011fer bir ifade ile s\u00fcrveyans\u0131n taml\u0131\u011f\u0131, hastaneye yeniden yatan hastalar\u0131n, poliklini\u011fe veya ba\u015fka hastaneye ba\u015fvuranlar\u0131n tespit edilebilmesi ile do\u011frudan ili\u015fkilidir. Dolay\u0131s\u0131yla\u00a0 <\/span>hastanelerin s\u00fcrveyans kapasiteleri, hesaplanan CA\u0130 h\u0131zlar\u0131n\u0131n do\u011frulu\u011funu belirler. Ameliyat say\u0131lar\u0131n\u0131n fazlal\u0131\u011f\u0131 ve yo\u011fun i\u015f y\u00fck\u00fc nedeniyle hastalar\u0131n telefonla aranmas\u0131, poliklinik izlemlerine \u00e7a\u011f\u0131r\u0131lmas\u0131 gibi \u00f6nerilerin uygulanmas\u0131 \u00e7o\u011funlukla m\u00fcmk\u00fcn olmamaktad\u0131r. Ulusal raporlar, \u00fclkemizde kal\u00e7a protezi ameliyatlar\u0131nda CA\u0130\u2019lerin s\u00fcrekli bir azalma e\u011filiminde oldu\u011funu g\u00f6stermekle birlikte CA\u0130 s\u00fcrveyans\u0131n\u0131n\u00a0 <\/span>y\u00fcr\u00fct\u00fclmesindeki bu g\u00fc\u00e7l\u00fckler nedeniyle ger\u00e7ek insidans\u0131n daha y\u00fcksek oldu\u011fu tahmin edilmektedir (2-7).\u00a0<\/span><\/p>\n

\u0130deal olan, ameliyat olan t\u00fcm hastalar\u0131n 90 g\u00fcn boyunca aktif olarak izlenmesi olsa da bunun m\u00fcmk\u00fcn olmad\u0131\u011f\u0131 a\u00e7\u0131kt\u0131r. T\u00fcm hastalar yerine y\u00fcksek riskli hastalar\u0131n izlem s\u00fcresi boyunca aktif izlemi, i\u015f y\u00fck\u00fcnden kazan\u00e7 elde ederek s\u00fcrveyans\u0131n mevcut duruma g\u00f6re daha do\u011fru ve g\u00fcvenilir olmas\u0131n\u0131 sa\u011flayabilir. Bu \u00e7al\u0131\u015fmada, kal\u00e7a protezi ameliyatlar\u0131nda CA\u0130 geli\u015fimi y\u00fcksek riskli hastalar\u0131n belirlenmesi i\u00e7in bir model geli\u015ftirilmesi ve geli\u015ftirilen model kullan\u0131larak belirlenen y\u00fcksek riskli hastalar\u0131n s\u00fcrveyans\u0131na odaklanarak farkl\u0131 CA\u0130 y\u00fck\u00fc ve s\u00fcrveyans kapasitesi olan hastaneler i\u00e7in tahminde bulunulmas\u0131 ama\u00e7lanm\u0131\u015ft\u0131r.<\/p>\n

\"\"<\/a>

Tablo 1.<\/strong> Y\u00fcksek Riskli Hastalara Odaklanman\u0131n Faydas\u0131n\u0131 De\u011ferlendirmek \u0130\u00e7in
Kullan\u0131lan \u00d6l\u00e7\u00fctler<\/p><\/div>\n

\"\"<\/a>

Tablo 2.<\/strong> Ameliyatlara Ait De\u011fi\u015fkenlerin Da\u011f\u0131l\u0131m\u0131<\/p><\/div>\n

\"\"<\/a>

\u015eekil 1.<\/strong> ROC analizinin sonu\u00e7lar\u0131.
E\u011frinin alt\u0131nda kalan alan riskli hastalar\u0131 ay\u0131rmada olu\u015fturulan modelin g\u00fcc\u00fcn\u00fc g\u00f6stermektedir. E\u011frinin alt\u0131nda kalan alan 0.50\u2019den ne kadar b\u00fcy\u00fckse modelin g\u00fcc\u00fc de o kadar b\u00fcy\u00fckt\u00fcr. P de\u011ferinin ise <0.05 olmas\u0131 e\u011frinin alt\u0131nda kalan alan\u0131n 0.50\u2019den istatistiksel olarak anlaml\u0131 d\u00fczeyde farkl\u0131 oldu\u011funu g\u00f6stermektedir.<\/p><\/div>\n

 <\/p>\n

\"\"<\/a>

\u015eekil 2.<\/strong> Modele g\u00f6re hastalar\u0131n CA\u0130 geli\u015fimi olas\u0131l\u0131\u011f\u0131 da\u011f\u0131l\u0131m\u0131.
Olas\u0131l\u0131k modelden elde edilen form\u00fcl g\u00f6re her hastan\u0131n CA\u0130 geli\u015fme olas\u0131l\u0131\u011f\u0131n\u0131 ifade etmektedir.<\/p><\/div>\n

\"\"<\/a>

Tablo 3.<\/strong> CA\u0130 Geli\u015fimi \u0130\u00e7in Tek De\u011fi\u015fkenli Analiz Sonu\u00e7lar\u0131<\/p><\/div>\n

\"\"<\/a>

Tablo 4.<\/strong> Lojistik Regresyon Analizinin Sonu\u00e7lar\u0131<\/p><\/div>\n

\"\"<\/a>

Tablo 5.<\/strong> Bootstrap Analizinin Sonu\u00e7lar\u0131<\/p><\/div>\n

\"\"<\/a>

\u015eekil 3.<\/strong> Modelde yer alan de\u011fi\u015fkenlere g\u00f6re hastalar\u0131n CA\u0130 geli\u015fimi olas\u0131l\u0131\u011f\u0131 da\u011f\u0131l\u0131m\u0131.
Olas\u0131l\u0131k modelden elde edilen form\u00fcle g\u00f6re her hastan\u0131n CA\u0130 geli\u015fme olas\u0131l\u0131\u011f\u0131n\u0131 ifade etmektedir. Kutunun ortas\u0131ndaki \u00e7izgi ortanca de\u011feri, \u00fcst ve alt s\u0131n\u0131r\u0131 3. ve 1. ceyreklik de\u011ferini ifade eder. Hata \u00e7ubuklar\u0131n\u0131n \u00fcst ve alt \u00e7izgileri s\u0131ras\u0131yla en b\u00fcy\u00fck ve en k\u00fc\u00e7\u00fck de\u011feri, + simgesi u\u00e7 de\u011ferleri g\u00f6stermektedir.<\/p><\/div>\n

\"\"<\/a>

\u015eekil 4.<\/strong> Hastanelerin s\u00fcrveyans kapasitesi ve CA\u0130 h\u0131z\u0131na g\u00f6re hesaplanan CA\u0130
h\u0131z\u0131ndaki fark\u0131n da\u011f\u0131l\u0131m\u0131.
CA\u0130 h\u0131z\u0131= CA\u0130 say\u0131s\u0131 \/ ameliyat say\u0131s\u0131 x 100
S\u00fcrveyans duyarl\u0131l\u0131\u011f\u0131, s\u00fcrveyans\u0131n ger\u00e7ek CA\u0130\u2019leri tespit edebilme oran\u0131d\u0131r. S\u00fcrveyans\u0131n y\u00fcksek riskli hastalarda geli\u015fen CA\u0130\u2019leri tespit edebilme g\u00fcc\u00fcn\u00fc ifade eder.<\/p><\/div>\n

\"\"<\/a>

Tablo 6.<\/strong> Fakl\u0131 CA\u0130 H\u0131z\u0131 ve S\u00fcrveyans Duyarl\u0131l\u0131\u011f\u0131 Olan Hastaneler \u0130\u00e7in \u00d6l\u00e7\u00fctler<\/p><\/div>\n

Y\u00d6NTEMLER<\/b><\/h2>\n

\u00c7al\u0131\u015fmaya 2018 y\u0131l\u0131nda USH\u0130\u0130SA\u2019ya kaydedilen kal\u00e7a protezi ameliyat\u0131 olan hastalar al\u0131nm\u0131\u015ft\u0131r. Ya\u015f verisi eksik hastalar, <18 ya\u015f ve >109 ya\u015f olan hastalar \u00e7al\u0131\u015fmaya al\u0131nmam\u0131\u015ft\u0131r. Ameliyat s\u00fcresi kesme noktas\u0131 olarak da adland\u0131r\u0131lan IQR 5 (5 \u00e7eyrekler aras\u0131 aral\u0131k) ameliyat s\u00fcreleri i\u00e7in uygunsuz bir u\u00e7 de\u011fer g\u00f6stergesi olarak kullan\u0131l\u0131r. IQR 5, 75. y\u00fczdelik dilimin \u00fczerine \u00e7eyrekler aras\u0131 aral\u0131\u011f\u0131n (Q1-Q3) be\u015f kat\u0131 eklenerek hesaplan\u0131r (9). \u00c7al\u0131\u015fmada bu de\u011fer 435 dakika olarak hesaplanm\u0131\u015ft\u0131r. Bu nedenle ameliyat s\u00fcresi <5 dakika ve >435 dakika olan hastalar \u00e7al\u0131\u015fmadan d\u0131\u015flanm\u0131\u015ft\u0131r. CA\u0130 geli\u015fimi i\u00e7in risk fakt\u00f6rleri olarak
\nUSH\u0130\u0130SA\u2019 da yer alan ya\u015f, cinsiyet, hastane t\u00fcr\u00fc, ASA skoru, yara s\u0131n\u0131f\u0131, ameliyat s\u00fcresi, elektif-acil operasyon, risk indeksi ve profilaktik antibiyotik uygunlu\u011fu de\u011fi\u015fkenleri incelenmi\u015ftir.\u00a0<\/span><\/p>\n

Hastalar\u0131n CA\u0130 geli\u015fme riskini belirlemek i\u00e7in olu\u015fturulan lojistik regresyon modelinden elde edilen form\u00fcl ile her hasta i\u00e7in bireysel CA\u0130 geli\u015fme olas\u0131l\u0131\u011f\u0131 belirlenmi\u015ftir. Modelin istikrar\u0131 Bootstrap yeniden \u00f6rnekleme y\u00f6ntemiyle test edilmi\u015ftir. Y\u00fcksek riskli hastalar\u0131 ay\u0131rmada kullan\u0131lacak e\u015fik olas\u0131l\u0131k ROC analizi ile belirlenmi\u015ftir. Farkl\u0131 CA\u0130 h\u0131zlar\u0131 olan hastaneler ve CA\u0130\u2019leri yakalama kapasitesi (s\u00fcrveyans duyarl\u0131l\u0131\u011f\u0131) farkl\u0131 olan hastaneler i\u00e7in Tablo 1\u2019de yer alan \u00f6l\u00e7\u00fctler kullan\u0131larak \u00e7al\u0131\u015fmada belirlenen e\u015fik olas\u0131l\u0131ktan y\u00fcksek olas\u0131l\u0131\u011fa sahip y\u00fcksek riskli hastalara odaklanman\u0131n faydas\u0131 de\u011ferlendirilmi\u015ftir.<\/p>\n

Veriler, SPSS 20.0 paket program\u0131 kullan\u0131larak analiz edilmi\u015ftir. T\u00fcm testler i\u00e7in \u00f6nemlilik s\u0131n\u0131r\u0131 (p de\u011feri) 0.05 olarak al\u0131nm\u0131\u015ft\u0131r.\u00a0<\/span><\/p>\n

USH\u0130\u0130SA verilerinin kullan\u0131m\u0131 i\u00e7in Sa\u011fl\u0131k Bakanl\u0131\u011f\u0131\u2019ndan izin al\u0131nm\u0131\u015ft\u0131r.\u00a0<\/span><\/p>\n

BULGULAR<\/b><\/h2>\n

\u00c7al\u0131\u015fmaya toplam 29 336 ameliyat dahil edilmi\u015ftir. Hastalar\u0131n ya\u015f ortalamas\u0131 68.1\u00b115.5 y\u0131l ve ortalama ameliyat s\u00fcresi 112.6\u00b149.6 dakikad\u0131r. Ameliyatlara ait de\u011fi\u015fkenlerin da\u011f\u0131l\u0131m\u0131 Tablo 2\u2019de g\u00f6sterilmi\u015ftir.\u00a0<\/span><\/p>\n

Bu ameliyatlarda toplam 429 CA\u0130 tespit edilmi\u015f olup CA\u0130 h\u0131z\u0131 1.44 bulunmu\u015ftur. CA\u0130\u2019lerin %24.0 (n=103)\u2019\u0131 primer y\u00fczeyel insizyonel CA\u0130, %46.2 (n=198)\u2019si primer derin insizyonel CA\u0130 ve %29.8 (n=128)\u2019i organ-bo\u015fluk tipi CA\u0130\u2019dir. CA\u0130 geli\u015fimi i\u00e7in tek de\u011fi\u015fkenli analizlerin sonu\u00e7lar\u0131 Tablo 3\u2019de g\u00f6sterilmi\u015ftir.<\/p>\n

CA\u0130 geli\u015fimi i\u00e7in kad\u0131n cinsiyet, ameliyat s\u00fcresinin 75. y\u00fczdelik dilimden uzun olmas\u0131, ASA skorunun 4-5 olmas\u0131, \u226565 ya\u015fta olmak ve \u00f6zel hastanelere g\u00f6re di\u011fer hastaneler risk fakt\u00f6r\u00fc olarak belirlenmi\u015ftir (Tablo 4 ve 5).\u00a0<\/span><\/p>\n

Her hasta i\u00e7in CA\u0130 geli\u015fme olas\u0131l\u0131\u011f\u0131 (p<\/i>\u0302) modelden elde edilen parametre tahminleri (B) kullan\u0131larak hesaplanm\u0131\u015ft\u0131r:\u00a0<\/span><\/p>\n

p<\/i>\u0302 = p<\/i>\u0302 logit (p<\/i>\u0302) \/ (1 + p<\/i>\u0302 logit (p<\/i>\u0302))<\/p>\n

logit (p<\/i>\u0302) = [-5.874 -0.416 (Cinsiyet = Erkek) + 0.277 (Ameliyat s\u00fcresi = 75. y\u00fczdelik dilimden uzun) + 0.743 (ASA skoru = 4-5) + 0.724 (Ya\u015f = \u226565) + 1.149 (Hastane t\u00fcr\u00fc = Devlet hastanesi) + 1.348 (Hastane t\u00fcr\u00fc = AEH) + 1.175 (Hastane t\u00fcr\u00fc = \u00dcniversite)]<\/p>\n

ROC analizi ile 0.76 duyarl\u0131l\u0131k ve 0.46 \u00f6zg\u00fcll\u00fck kapsam\u0131nda, CA\u0130 geli\u015fimi a\u00e7\u0131s\u0131ndan y\u00fcksek riskli hastalar\u0131 ay\u0131rmak i\u00e7in e\u015fik olas\u0131l\u0131k 0.0119893 (%1.2) bulunmu\u015ftur (\u015eekil 1). E\u015fik de\u011ferin \u00fczerinde bireysel olas\u0131l\u0131\u011f\u0131 olan hastalar y\u00fcksek riskli olarak kabul edilmi\u015ftir. T\u00fcm hastalar\u0131n, 16 044 (%54.6)\u2019\u00fc CA\u0130 geli\u015fimi a\u00e7\u0131s\u0131ndan y\u00fcksek riskli bulunmu\u015ftur. Modele g\u00f6re belirlenen olas\u0131l\u0131k da\u011f\u0131l\u0131mlar\u0131 \u015eekil 2 ve 3\u2019te g\u00f6sterilmi\u015ftir.<\/p>\n

S\u00fcrveyans kapasitesi ve CA\u0130 y\u00fck\u00fc farkl\u0131 olan hastaneler i\u00e7in yap\u0131lan sim\u00fclasyon ve hesaplanan \u00f6l\u00e7\u00fctler Tablo 6\u2019da g\u00f6sterilmektedir. Fakl\u0131 CA\u0130 h\u0131z\u0131 ve s\u00fcrveyans duyarl\u0131l\u0131\u011f\u0131na g\u00f6re hesaplanan h\u0131z fark\u0131 \u015eekil 4\u2019te g\u00f6sterilmektedir. Hastalar\u0131n modele g\u00f6re hesaplanan olas\u0131l\u0131k da\u011f\u0131l\u0131m\u0131 ile risk indeksi da\u011f\u0131l\u0131m\u0131 aras\u0131nda pozitif y\u00f6nde zay\u0131f korelasyon saptanm\u0131\u015ft\u0131r (Spearman\u2019\u0131n s\u0131ralama korelasyon katsay\u0131s\u0131 (rho)=0.257, p<0.001).<\/p>\n

\u0130RDELEME<\/b><\/h2>\n

\u00c7al\u0131\u015fmada olu\u015fturulan model kullan\u0131larak belirlenen y\u00fcksek riskli hastalar\u0131n s\u00fcrveyans\u0131na odaklan\u0131ld\u0131\u011f\u0131nda bir hastanenin ger\u00e7ek CA\u0130 h\u0131z\u0131 y\u00fckseldik\u00e7e, 1 CA\u0130 daha tespit edilmesi i\u00e7in ula\u015f\u0131lmas\u0131 gereken hasta say\u0131s\u0131 belirgin \u015fekilde azalmaktad\u0131r. S\u00fcrveyans duyarl\u0131l\u0131\u011f\u0131 azald\u0131k\u00e7a elde edilen yeni h\u0131z eski h\u0131zdan daha b\u00fcy\u00fck farkl\u0131l\u0131k g\u00f6stermi\u015f ve ger\u00e7ek CA\u0130 h\u0131z\u0131na yakla\u015fma miktar\u0131 artm\u0131\u015ft\u0131r. CA\u0130 h\u0131z\u0131 artt\u0131k\u00e7a pozitif ve negatif prediktif de\u011fer, genel uyum, d\u0131\u015flanan hasta say\u0131s\u0131 ve d\u0131\u015flanma oran\u0131nda belirgin farkl\u0131l\u0131k g\u00f6zlenmezken fazladan tespit edilen CA\u0130 say\u0131s\u0131 katlanarak artm\u0131\u015ft\u0131r.<\/p>\n

Kad\u0131n cinsiyet, 65 ya\u015f\u0131n \u00fczerinde olmak, ameliyat s\u00fcresinin 75. y\u00fczdelik dilimden uzun olmas\u0131, ASA skorunun 3\u2019\u00fcn \u00fczerinde olmas\u0131 ve ameliyat\u0131n \u00f6zel hastane d\u0131\u015f\u0131 bir hastanede yap\u0131lm\u0131\u015f olmas\u0131 kal\u00e7a protezi ameliyatlar\u0131nda CA\u0130 geli\u015fimi i\u00e7in ba\u011f\u0131ms\u0131z risk fakt\u00f6rleri olarak bulunmu\u015ftur. Risk erkeklerde kad\u0131nlara g\u00f6re %34 daha az bulunurken, 65 ya\u015f ve \u00fczerinde olanlarda risk 2 kattan fazla artmaktad\u0131r. Ameliyat s\u00fcresinin uzam\u0131\u015f oldu\u011fu hastalarda risk %31 daha fazla olup ASA skoru 4 ve 5 olan hastalarda risk 2 kattan fazla artm\u0131\u015ft\u0131r. Devlet hastanelerinde \u00f6zel hastanelere g\u00f6re risk 3.15 kat, e\u011fitim ve ara\u015ft\u0131rma hastanelerinde 3.69 kat ve \u00fcniversite hastanelerinde 4.36 kat fazla bulunmu\u015ftur. \u00d6zel hastanelerde riskin daha d\u00fc\u015f\u00fck olmas\u0131 di\u011fer hastanelere g\u00f6re daha d\u00fc\u015f\u00fck riskli hastalar\u0131n ameliyat ediliyor olmas\u0131 ile a\u00e7\u0131klanabilir. Risk fakt\u00f6rleri aras\u0131nda risk indeksine dahil olan ASA skoru ve ameliyat s\u00fcresi yer al\u0131rken, yara s\u0131n\u0131f\u0131 risk fakt\u00f6r\u00fc olarak saptanmam\u0131\u015ft\u0131r. Bunun nedeni yara s\u0131n\u0131f\u0131n\u0131n protez ameliyatlar\u0131nda fazla de\u011fi\u015fkenlik g\u00f6stermemesi olabilir.<\/p>\n

Benzer \u015fekilde Amerika Birle\u015fik Devletleri\u2019nde Hastal\u0131k \u00d6nleme ve Kontrol Merkezi (Centers for Disease Control ve Prevention – CDC)\u2019nin y\u00fczeyel, derin ve organ-bo\u015fluk tipi CA\u0130\u2019lerin dahil edildi\u011fi eri\u015fkin hastalar i\u00e7in standardize infeksiyon oran\u0131 (SIR) modelinde ya\u015f, ameliyat s\u00fcresi ve ASA skoru, kal\u00e7a protezi ameliyatlar\u0131nda CA\u0130 geli\u015fimi i\u00e7in risk fakt\u00f6r\u00fc olarak bulunurken, cinsiyet ve hastane t\u00fcr\u00fc risk fakt\u00f6r\u00fc olarak bulunmam\u0131\u015ft\u0131r. Ancak CDC\u2019nin modelinde bu risk fakt\u00f6rleri d\u0131\u015f\u0131nda diyabet, travma, v\u00fccut kitle indeksi, anestezi, prosed\u00fcr tipi ve yara s\u0131n\u0131f\u0131 gibi bireysel de\u011fi\u015fkenler ile hastane yatak kapasitesi risk fakt\u00f6r\u00fc olarak modelde yer alm\u0131\u015ft\u0131r. \u00dclkemizdeki SH\u0130\u0130 s\u00fcrveyans\u0131 kapsam\u0131nda diyabet, v\u00fccut kitle indeksi, travma gibi bireysel de\u011fi\u015fkenlerin takip edilmemesi bu farkl\u0131l\u0131\u011f\u0131 a\u00e7\u0131klayabilir. S\u00fcrveyans y\u00f6ntemimiz geli\u015ftik\u00e7e ve toplanan veri miktar\u0131 artt\u0131k\u00e7a daha iyi modeller elde edilebilir. CDC\u2019nin pediatrik hastalar i\u00e7in geli\u015ftirdi\u011fi modellerde ise incelenen de\u011fi\u015fkenlerden hi\u00e7biri risk fakt\u00f6r\u00fc olarak saptanmam\u0131\u015ft\u0131r (9).<\/p>\n

Brezilya\u2019da ise kal\u00e7a protezi ameliyatlar\u0131n\u0131n da dahil oldu\u011fu ortopedik ameliyatlar i\u00e7in geli\u015ftirilen lojistik regresyon modelinin risk indeksi yakla\u015f\u0131m\u0131na g\u00f6re tahmin performans\u0131n\u0131n daha iyi oldu\u011fu bildirilmi\u015ftir. ROC analizinde, \u00e7al\u0131\u015fmam\u0131zdakine yak\u0131n \u015fekilde e\u011frinin alt\u0131nda kalan alan 0.75 olarak saptanm\u0131\u015f; genel anestezi, anestezi s\u00fcresi, yara s\u0131n\u0131f\u0131, hastane t\u00fcr\u00fc, ameliyat s\u0131ras\u0131ndaki cerrahi ekipteki ki\u015fi say\u0131s\u0131, ASA skoru ve protez ameliyat\u0131 olmak risk fakt\u00f6r\u00fc olarak bulunmu\u015ftur (10). \u00a0<\/span><\/p>\n

T\u00fcrkiye\u2019de kal\u00e7a protezi ve diz protezi ameliyatlar\u0131nda risk indeksi kategorilerine g\u00f6re d\u00fczeltilmi\u015f ulusal standardize CA\u0130 oranlar\u0131n\u0131n CA\u0130 h\u0131zlar\u0131n\u0131n d\u00fczeltilmesinde \u00e7ok etkili olmad\u0131\u011f\u0131 g\u00f6r\u00fclm\u00fc\u015ft\u00fcr. Bu da mevcut risk indeksi yakla\u015f\u0131m\u0131n\u0131n protez ameliyatlar\u0131nda yeterli olmad\u0131\u011f\u0131n\u0131 desteklemektedir (11).\u00a0<\/span><\/p>\n

Risk indeksi, CDC taraf\u0131ndan olu\u015fturulmu\u015f ve d\u00fcnya genelinde yayg\u0131n olarak kullan\u0131lmakta olan bir tabakalama y\u00f6ntemidir. Bu yakla\u015f\u0131mda, CA\u0130 h\u0131zlar\u0131 e\u015fit a\u011f\u0131rl\u0131kl\u0131 \u00fc\u00e7 fakt\u00f6rden olu\u015fan risk indeksinin 4 tabakas\u0131nda sunulmaktad\u0131r. Bu fakt\u00f6rler ASA skoru, yara s\u0131n\u0131f\u0131 ve ameliyat s\u00fcresidir. ASA skoru 1,2 ise s\u0131f\u0131r puan, 3,4,5 ise bir puan; yara s\u0131n\u0131f\u0131 temiz, temiz-kontamine ise s\u0131f\u0131r puan; kontamine, kirli-infekte ise 1 puan; operasyon s\u00fcresi daha \u00f6nceden belirlenen y\u00fczdelik da\u011f\u0131l\u0131m\u0131na g\u00f6re 75. y\u00fczdelik dilim ve alt\u0131na denk d\u00fc\u015f\u00fcyorsa s\u0131f\u0131r puan, 75. y\u00fczdelik dilimin \u00fcst\u00fcndeyse 1 puan verilerek risk indeksi belirlenir. B\u00f6ylece risk indeksi 0, 1, 2 veya 3 olabilir. T\u00fcm ameliyat t\u00fcrleri i\u00e7in kabul edilen bu \u00fc\u00e7 fakt\u00f6r\u00fcn risk indeksine katk\u0131s\u0131 ayn\u0131 oranda olup fakt\u00f6rler aras\u0131nda bir etki a\u011f\u0131rl\u0131kland\u0131rmas\u0131 yap\u0131lmamaktad\u0131r. Baz\u0131 prosed\u00fcrler i\u00e7in risk indeksinde yer alan de\u011fi\u015fkenlerin CA\u0130 riski ile ili\u015fkili olmad\u0131\u011f\u0131 g\u00f6sterilmi\u015ftir. Bunun anlam\u0131 baz\u0131 ameliyatlarda risk indeksi artt\u0131k\u00e7a CA\u0130 h\u0131zlar\u0131nda belirgin art\u0131\u015f g\u00f6zlenmedi\u011fidir. Baz\u0131 ameliyatlar i\u00e7inse bu de\u011fi\u015fkenlerin etkisi ayn\u0131 a\u011f\u0131rl\u0131kta olmayabilir. \u00d6rne\u011fin bir ameliyat i\u00e7in yara s\u0131n\u0131f\u0131, CA\u0130 riski ile daha fazla ili\u015fkiliyken prosed\u00fcr s\u00fcresi ayn\u0131 oranda ili\u015fkili olmayabilir. Ayr\u0131ca risk indeksi di\u011fer pek \u00e7ok ba\u015fka fakt\u00f6r\u00fc i\u00e7ermedi\u011fi i\u00e7in yap\u0131lan d\u00fczeltme eksik kalmaktad\u0131r. Di\u011fer bir ifade ile hasta pop\u00fclasyonlar\u0131 aras\u0131ndaki farkl\u0131l\u0131klar yaln\u0131zca yara s\u0131n\u0131f\u0131, ASA skoru ve ameliyat s\u00fcresi ile a\u00e7\u0131klanamamaktad\u0131r. Bu \u00fc\u00e7 fakt\u00f6r bir cerrah veya hastane i\u00e7in ayn\u0131 olsa da ba\u015fka fakt\u00f6rler hasta pop\u00fclasyonlar\u0131n\u0131n CA\u0130 riski a\u00e7\u0131s\u0131ndan farkl\u0131 olabilmesine neden olmaktad\u0131r (2). \u00c7al\u0131\u015fmadaki model risk indeksi tabakaland\u0131rma i\u00e7in kullan\u0131ld\u0131\u011f\u0131nda 64 farkl\u0131 tabaka elde edilmektedir. Bu durumda en y\u00fcksek risk tabakas\u0131nda, \u00fcniversite hastanesinde 75. y\u00fczdelik dilimin \u00fczerinde s\u00fcren bir ameliyat olan, ASA skoru 4-5 olan ve 65 ya\u015f ve \u00fczerindeki kad\u0131n hastalar yer al\u0131r. En d\u00fc\u015f\u00fck risk tabakas\u0131nda ise \u00f6zel bir hastanede 75. y\u00fczdelik dilimden k\u0131sa s\u00fcren bir ameliyat olan, ASA skoru 1-2-3 olan ve 65 ya\u015f alt\u0131ndaki erkek hastalar yer al\u0131r. Tabakalardaki olas\u0131l\u0131k % 0.18 ile % 6.56 aras\u0131nda de\u011fi\u015fmektedir.<\/p>\n

Bu nedenlerle risk indeksi yakla\u015f\u0131m\u0131 art\u0131k yerini \u00e7ok de\u011fi\u015fkenli regresyon modelleri kullan\u0131larak hesaplanan SIR\u2019a b\u0131rakmaya ba\u015flam\u0131\u015ft\u0131r. Bu y\u00f6ntem istatistiksel olarak daha iyi bir d\u00fczeltme sa\u011flamakta ve her bir ameliyat i\u00e7in farkl\u0131 de\u011fi\u015fkenlerin risk d\u00fczeltmesine kat\u0131labilmesine olanak tan\u0131maktad\u0131r. T\u00fcrkiye\u2019de SIR \u00f6l\u00e7\u00fct\u00fc ilk kez yo\u011fun bak\u0131m \u00fcnitelerinde invaziv ara\u00e7 ili\u015fkili infeksiyonlar i\u00e7in 2016 y\u0131l\u0131 ulusal verilerinden hesaplanm\u0131\u015ft\u0131r (12, 13). CA\u0130\u2019ler i\u00e7inse hen\u00fcz SIR hesaplamalar\u0131 yapmaya uygun ulusal modeller bulunmamaktad\u0131r. Ayn\u0131 y\u00f6ntem, \u00fclkemizde \u00fcriner kateter ili\u015fkili idrar yolu infeksiyonlar\u0131nda \u00f6l\u00fcm ile ili\u015fkili fakt\u00f6rlerin incelenmesi amac\u0131yla\u00a0 <\/span>USH\u0130\u0130SA verilerine de uygulanm\u0131\u015ft\u0131r (14).<\/p>\n

\u00c7al\u0131\u015fmada, CA\u0130 say\u0131s\u0131n\u0131n g\u00f6reli az olmas\u0131 nedeniyle CA\u0130 t\u00fcr\u00fcne g\u00f6re ayr\u0131m yap\u0131lamam\u0131\u015ft\u0131r. Ayr\u0131ca verilerin do\u011frulu\u011fu ve taml\u0131\u011f\u0131 hastaneler aras\u0131nda farkl\u0131l\u0131k g\u00f6steriyor olabilir. Ancak olu\u015fturulan modelin ulusal s\u00fcrveyans verilerine dayanmas\u0131, \u00e7al\u0131\u015fman\u0131n T\u00fcrkiye\u2019deki t\u00fcm hastaneleri kapsamas\u0131 nedeniyle \u00f6rnek b\u00fcy\u00fckl\u00fc\u011f\u00fcn\u00fcn geni\u015f olmas\u0131 ve CA\u0130\u2019lerin infeksiyon kontrol ekiplerince ulusal k\u0131lavuzlara g\u00f6re tespit edilmi\u015f olmas\u0131 bu k\u0131s\u0131tl\u0131l\u0131klar\u0131n\u0131n etkisini azaltmaktad\u0131r. Model s\u00fcrveyansta toplanan de\u011fi\u015fkenler artt\u0131k\u00e7a ve CA\u0130 tan\u0131 kriterlerinde \u00f6nemli de\u011fi\u015fiklikler olduk\u00e7a yenilenmelidir.<\/p>\n

\u00d6zetle, \u00e7al\u0131\u015fmada belirlenen 5 risk fakt\u00f6r\u00fcn\u00fc e\u015f zamanl\u0131 olarak hesaba katan lojistik regresyon modelinden elde edilen form\u00fcl ile bireysel CA\u0130 geli\u015fme olas\u0131l\u0131\u011f\u0131 belirlenerek y\u00fcksek riskli hastalar ayr\u0131lm\u0131\u015ft\u0131r.
\nUSH\u0130\u0130SA\u2019ya bu model entegre edildi\u011finde hastaneler ek veri giri\u015f y\u00fck\u00fc olmadan otomatik olarak y\u00fcksek riskli hastalar\u0131 ay\u0131rabilirler ve bu hastalar\u0131n s\u00fcrveyans\u0131na odaklanmak mevcut duruma g\u00f6re daha ger\u00e7ek\u00e7i CA\u0130 h\u0131zlar\u0131 elde etmeyi sa\u011flayabilir. Bu \u015fekilde izlenecek hasta say\u0131s\u0131 yar\u0131ya yak\u0131n azalmakta, bu da i\u015f g\u00fcc\u00fcnden ve zamandan tasarruf sa\u011flamaktad\u0131r. Bu modelin kullan\u0131lmas\u0131 \u00f6zellikle CA\u0130 h\u0131z\u0131 y\u00fcksek ve s\u00fcrveyans duyarl\u0131l\u0131\u011f\u0131 d\u00fc\u015f\u00fck hastaneler i\u00e7in daha fazla yarar sa\u011flayacakt\u0131r. Sonu\u00e7 olarak bu form\u00fcl, ulusal s\u00fcrveyans sistemine entegre edilmeli, b\u00f6ylelikle y\u00fcksek riskli hastalar\u0131n belirlenmesi kolayla\u015ft\u0131r\u0131lmal\u0131d\u0131r. Di\u011fer ameliyatlar i\u00e7in de modelleme yaparak y\u00fcksek riskli hastalar\u0131 belirlemek faydal\u0131 olabilir.\u00a0<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

G\u0130R\u0130\u015e \u00dclkemizde, Ulusal Sa\u011fl\u0131k Hizmeti \u0130li\u015fkili \u0130nfeksiyonlar (SH\u0130\u0130) S\u00fcrveyans\u0131, Yatakl\u0131 Tedavi Kurumlar\u0131 \u0130nfeksiyon Kontrol Y\u00f6netmeli\u011fi\u2019nin 2005 y\u0131l\u0131nda yay\u0131mlanmas\u0131 ile birlikte t\u00fcm yatakl\u0131 tedavi kurumlar\u0131nda uygulanmaya ba\u015flanm\u0131\u015ft\u0131r. 2007 y\u0131l\u0131ndan itibaren s\u00fcrveyans verileri Ulusal Sa\u011fl\u0131k Hizmeti \u0130li\u015fkili \u0130nfeksiyonlar S\u00fcrveyans A\u011f\u0131 (USH\u0130\u0130SA)\u2019na kaydedilmektedir (1). Cerrahi alan infeksiyonu (CA\u0130) s\u00fcrveyans\u0131 ise toplanan veriler, hastalar\u0131n izlemi ve analizi gibi \u00e7e\u015fitli […]<\/p>\n","protected":false},"author":3,"featured_media":23553,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5129],"tags":[3046,5234,5235,3665],"class_list":["post-23245","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ozgun-arastirma","tag-cerrahi-alan-infeksiyonu","tag-kalca-protez-ameliyati","tag-olasilik","tag-surveyans"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/23245","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/comments?post=23245"}],"version-history":[{"count":3,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/23245\/revisions"}],"predecessor-version":[{"id":23516,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/23245\/revisions\/23516"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media\/23553"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=23245"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=23245"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=23245"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}