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Anesthesia methods used by anesthetic experts for circumcision cases: national survey study
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ABSTRACT
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Objective: To state the anesthesiologist’s choice for anesthesia techniques and drugs in circumcision
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and determine the preoperative examination, intraoperative monitoring techniques, postoperative
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analgesia methods and common complications among anesthesiologists working in our country.
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Methods: This cross-sectional study was conducted in Bülent Ecevit University Hospital, Zonguldak,
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Turkey, between 15 May to 01 July 2012. Survey data were obtained by survey forms through
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electronic data over the web. Questionnaire consists of twenty questions. These questions included
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demograhic data, methods of anesthesia for circumcision, postoperative analgesia methods,
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monitorization methods. Descriptive statistics were expressed as number and percentage. Differences
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and relationships between variables were analyzed by chi-square test between the groups.
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Results: The datas were obtained from 206 anesthesiologist who accept to participate to survey.
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Circumcision was performed most frequently in the age group of 3-6 year. It was detected that 47% of
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routine preoperative laboratory tests were coagulation parameters and complete blood count tests. The
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most frequently method of anesthesia was laryngeal mask and the frequency of administration of
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regional anesthesia is 37.4%, caudal block is more preferable. Bupivacaine as a local anesthetic in
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regional anesthesia and midazolam and ketamine were most preferred agents in sedoanalgesia. During
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regional anesthesia ultrasound is used by anesthesiologists (31.6%). In circumcision most preferred
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monitorization was standard monitoring.
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Conclusion: Ambulatory anesthesia protocols which are also needed in circumcision can be improved
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with international recommendation and these protocols could be conformed to sociocultural structure
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in societies. This study should be regarded as preliminary study to attrack attention about anesthesia
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techniques in circumcision.
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INTRODUCTION
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Male circumcision is the surgical removal of the foreskin (prepuce) of the human penis.. It is a
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very common surgical procedure, performed traditionally for many years1
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Children are ideal patients for outpatient day surgery. With full medical assessment, appropriate
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surgery and anesthesia method, the majority of pediatric patients can undergo outpatient
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interventions. The appropriate anesthetic method should reduce complications and ease recovery
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and discharge. The most important point is that the outpatient approach should reduce disruption
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to the child's daily life and should ensure a positive experience for other surgical interventions.2
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The number of outpatient operations increase in light of a variety of indications. The most
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common outpatient surgeries for children are minor surgeries like inguinal hernia and
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circumcision. These types of surgery in infants and children are carried out with regional
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anesthesia, sedation or general anesthesia.3 The anesthetic method for circumcision operations
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varies according to the patient's situation, available opportunities of the hospital, occupational
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skills and attitude of the physician.4
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In our study we aimed to research the attitude and behavior of anesthetic experts about anesthesia
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methods they use for circumcision cases. With this survey we aimed to determine the chosen
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anesthetic techniques, medications used and complications, preoperative tests, intraoperative
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monitoring and postoperative analgesia methods used by anesthesia experts in our country for
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circumcision operations.
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Methods: After receiving permission from Bülent Ecevit University Research Ethics Committee
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(Meeting decision no: 2012/10, date: 02.05.2012), this cross-sectional study was conducted in
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Bülent Ecevit University Hospital, Zonguldak, Turkey, between 15 May to 01 July 2012. The
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created survey questions were read by 15 individuals not participating in the research for clarity
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and preliminary study.
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Data Collection Method: Survey data were obtained using a web-based electronic data form. The
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survey was sent to the known email addresses of 700 anesthetic experts a total of three times at 10
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day intervals and those who had participated were reminded not to participate again. The answered
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surveys were checked for repeat participation.
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Survey Form: The survey form comprised 20 questions. Section A included 5 questions on
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demographic information of participants, section B included 13 questions about circumcision,
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section C included 1 question about postoperative analgesia and section D included 1 question
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about routine monitoring methods used during circumcision operations. As it was stated that
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participants could give more than one answer to the questions, different combinations of survey
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results were obtained. These different and multi-variable answers that were only chosen by some
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of the 206 anesthetic experts were evaluated within the group "other chosen methods". Similarly,
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some questions were left semi open-ended and participants were presented with the option of
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choosing "other" without any request for an explanation.
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Statistical Analysis: Statistical evaluation was completed using the SPSS 18.0 (Statistical Package
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For Social Sciences. Chicago. IL. USA) program. Descriptive statistics are given as number and
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percentage. Differences between the groups and correlations between variables were investigated
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with the chi-square test. Results were assessed at the 95% confidence interval and p<0.05 was
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accepted as statistically significant.
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Results: With our survey sent by electronic mail, 206 anesthetic experts responded to the survey
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and were included in the study. Demographic data of anesthetic experts participating in the study
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are shown in (Table 1). When the organizations the survey participants currently were employed in
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was questioned, 49.5% (n=102) worked in university hospitals, 24.3% (n=50) worked in state
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hospitals, 16% (n=33) worked in education and research hospitals and 10.2% (n=21) worked in
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private hospitals. When the branch performing circumcision was examined, generally more than
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one branch performed circumcision and most were performed by pediatric surgery-urology 21.8%
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(n=45), 10.2% by pediatric surgery (n=21), 7.3% by urology (n=15) and 1.0% by general surgery
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departments (n=2). Additionally the operation was performed in pediatric urology and plastic
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surgery departments. Concerning preoperative laboratory tests, 41.7% (n=86) requested complete
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blood count pluscoagulation, 19.9% (n=41) complete blood count, and 9.2% (n=19) coagulation
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and additionally hepatitis markers and other biochemical tests.
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circumcision was identified as 9.7% laryngeal mask (n=20), 8.3% laryngeal mask plus caudal
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block (n=17) and 7.3% face mask (n=15) (Table 2). In addition to general anesthesia and
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sedoanalgesia, regional anesthesia methods were used 37.4% of the time, 6.8% did not use it at all.
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Seventy eight (37.9%) used caudal and 56 (27.2%) dorsal penile nerve block (Table 3). When
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ultra-sound guidance (USG) use for caudal or penile block was questioned, 141 (68.4%) did not
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use it, 46 (22.3%) stated their organization did not have it, 13 (6.3%) stated the organization had it
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but they did not need to use it, 1 (0.5%) used it and 5 (2.4%) selected the "other*" answer. For
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circumcision operations 93.7% of dorsal penile block was administered by surgeons and 6.3% by
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anesthesiologists. For circumcision operations the most common local anesthetics used for caudal
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block were: 81 (39.3%) bupivacaine, 30 (14.6%)
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(11.2%) levobupivacaine with lidocaine and prilocaine also among the choices. For dorsal nerve
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block, the most common local anesthetics chosen by anesthesiologists were: 43 (20.9%)
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bupivacaine, 28 (13.6%) , prilocaine,27 (13.1%), lidocaine, 7 (3.4%) levobupivacaine and a
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variety of combinations of these medications. Sedoanalgesia administration for circumcision
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operations most frequently used midazolam plus ketamine (11.7%) (Table 4). The most common
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complications after circumcision were hemorrhage (22.3%), bronchospasm or laryngospasm
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(17%) and severe pain (7.8%). The methods and/or medication chosen for analgesia after
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circumcision was most commonly paracetamol (17.5%) (Table 5). When monitoring methods
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for circumcision operations were assessed, there was a high rate use of the combination of pulse
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oximeter, electrocardiography, blood pressure, heart rate, end tidal carbon dioxide (20.4%) (Table
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6).
The anesthetic method for
bupivacaine plus levobupivacaine and 23
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Discussion: Anesthesiologists frequently choose laryngeal mask, and the regional anesthesia
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method of caudal block for circumcision operations and 31.6% use USG for the block. The most
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frequently observed complication appears to be hemorrhage. Paracetamol is frequently used for
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postoperative analgesia after circumcision.
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Though publications related to circumcision training and applications by surgeons were found
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from Turkey and the world, we did not encounter any publication investigating the attitude and
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behavior of anesthetic experts in our country to circumcision applications. In a survey study to
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determine the level of knowledge of practitioner clinicians in Turkey about circumcision by
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Cankorkmaz et al5 200 clinicians were reached by post and 178 people (72%) responded to the
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survey. A postal survey to assess clinical applications by anesthesiologists for outpatient pediatric
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surgery in England had a 74% response rate.6 Our study reached 580 anesthesiologists by
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electronic mail and received a response from 206 (35.5%). We believe the reason for the low
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participation rate for survey studies in the electronic environment in our country is that these types
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of studies are relatively new and infrequently performed.
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A study by Yıldız et al7 researching the attitude and behavior of anesthetic experts to anesthetic
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administration outside the operating room stated that highest participation was from university
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hospitals (31.7%). In our study the reason for the highest response rate coming from university
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hospitals (49.5%) may be linked to the active role played by universities in education and
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research..
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A survey study by Şahin et al8 found that of 1235 children circumcision was performed by
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traditional circumciser for 13.3% and by pediatric surgeons or neurologists? for the remainder.
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Yakıncı et al9 in a study of 1880 circumcised primary school children living in different socio-
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economic regions requested parents to complete a circumcision form. Evaluation of the data
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showed that when the occupation of the person performing the circumcision is examined; 66%
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were health officials with diplomas, 13.2% were personnel other than health officials, 8.8% were
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urologists, 6.2% were practicing clinicians, 2.9% were general surgeons and 2.8% were pediatric
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surgeons. When the same study evaluated the rate of complications of circumcision, traditional
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circumciser were first with 17.7% and expert clinicians were last with 3.4% rate. When the
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relationship between family income and education level and the person performing circumcision is
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investigated, as economic situation and education level increased they stated there was an increase
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in the rate of licensed individuals performing circumcision. İn the United States, circumcision is
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performed mainly by paediatricians, family practitioners and obstetricians.10 In our study in
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general more than one branch performed circumcision and the highest rate was 21.8% pediatric
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surgery plus urology, 10.2% pediatric surgery, 7.3% urology and 1.0% general surgery
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departments.
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If no problem is identified in history or physical examination, the view that routine laboratory tests
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are not required, especially for minor surgical interventions, is becoming more common. 11 Roy et
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al12 grouped 2000 pediatric patients by age group and found that anemia with no symptoms was
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more common in the under 5 age group compared to the group above the age of 5; they stated this
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affects care after anesthesia and may even be a reason to postpone minor surgery. Johnson et al13
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reported routine preoperative tests (complete blood count, urea, electrolytes and glucose) affected
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anesthesia planning for only 0.2% of patients and that reorganizing tests according to requirements
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could reduce hospital costs by £50,000 yearly. In our country, according to the preoperative
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guidelines published by the Turkish Association of Anesthesia and Reanimation in 2005, for minor
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surgery under the age of 16 such as circumcision, preoperative testing hemoglobin/hematocrit is
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sufficient.11 In our study it appeared 41.7% requested complete blood count plus coagulation,
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19.9% requested complete blood count and 9.2% requested coagulation. We think that
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preoperative history and physical examination can avoid unnecessary expenses and ensure labor
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savings.
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Debates about the age for circumcision still continue. In some African tribes circumcision is
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performed at birth, in Jewish tradition it is performed in the first days after birth. 14 To prevent
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negative issues like castration phobia, it is recommended that circumcision not be performed
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between the ages of 3 and 6.15 Aydur et al16 observed that 11% of Turkish children were
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circumcised in the age interval 0-2, 27,1% from 3-5 years and 61.7% from 6-12 years. Cüceloğlu
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et al17 determined that circumcision after the age of 7 carried more risk in terms of early
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ejaculation than before the age of 7 so circumcision should be performed under the age of 7. They
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stated that as the 3-7 year interval appeared to be the "phallic period", the ideal age may be 0-3
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years. In our study it appeared that most circumcision operations were performed from 3-6 years
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(31.6%) with least completed in the newborn period (1%). We believe parents need to be informed
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about the phallic period and clinicians need to expend more energy so circumcision is performed
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in the appropriate age interval.
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Unless necessary, laryngeal mask should be chosen instead of endotracheal intubation to secure
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the airway for outpatient surgeries. This is because it does not require muscle relaxation or
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laryngoscopy, is easier and less traumatic to insert, provides reliable airway, ensures hemodynamic
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stability during intubation and extubation, has short recovery and discharge times and does not
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have negative effects like throat pain.18 In anesthesia for outpatient pediatric surgery in
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England, it appears the laryngeal mask is much more common than tracheal intubation with
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a rate of 85%.6 In our study we found the laryngeal mask was the anesthetic method used for
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circumcision operations.
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Kazak et al19 found that dorsal penile nerve block by urologists for circumcision operations
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provided longer term analgesia for postoperative pain management than caudal block by
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anesthesiologist, however as the time to first walking was significantly longer they stated there
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was a higher risk of motor block. In our study in addition to general anesthesia and sedoanalgesia,
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regional anesthesia methods were performed in 37.4% of the patients, with caudal block being
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the most common (37.9%) used method, followed by dorsal penile nerve block (27.2%) .
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Faraoni et al20 in a study comparing the efficacy of dorsal penile nerve block techniques
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accompanied by USG or by anatomic estimation found that while there was no difference in terms
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of failure rates, there was a significant difference in terms of postoperative pain scores and
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additional paracetamol administration time for block given with USG. They showed that the use of
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USG was more efficient. In our study when the frequency of USG use was examined, 68.4% of
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anesthesiologists did not use USG, while 22.3% stated that their organization did not have a USG
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device.
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Erbüyün et al21 stated that USG for caudal block applications would neither increase nor decrease
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the success of the treatment and should be needed in cases where the detection of sacral anatomy
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is difficult, especially by palpations.
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Comparing bupivacaine and levobupivacaine for caudal block administration, a study found that
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due to cardiovascular and central nervous system side effects of high doses of bupivacaine,
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levobupivacaine was more reliable.22 Locatelli et al23 reported that for caudal block administration
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bupivacaine provided longer duration analgesic effect and higher motor block incidence that
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ropivacaine and levobupivacaine, while two cases developed sinus bradycardia.
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As a result they considered that levobupivacaine was more reliable for pediatric surgery. In our
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study bupivacaine was observed to be the most common choice for block administration. We
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believe the reason for levobupivacaine being chosen less often may be due to this medication not
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being available in our country.
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The use of propofol and ketamine together for sedoanalgesia for short term interventions has
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become more common.24 Özkan et al25 retrospectively investigated the use of midazolam for
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premedication, ketamine for sedation and bupivacaine as infiltrative agent for 2720 children
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undergoing minor urological surgery (69% circumcision) and stated that the majority were
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discharged in a short time and serious side effects were not observed. With ketamine nausea,
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vomiting and negative effects on hemodynamic parameters were observed less and they stated it
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may be an effective agent for sedation during outpatient pediatric surgeries. In our study for
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sedoanalgesia administration the combination of midazolam + ketamine (11.7%) was chosen most
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often, and we believe this is due to providing better hemodynamic stability and surgical
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conditions.
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In developed countries where circumcisions are performed by professionals the rate of
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development of complications is 5%, in developing countries where circumcisions are performed
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by health technicians it is 10% and for circumcisions performed by traditional circumciser the rate
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reaches 85%.26 In our country a survey study determined 93.1% of complications occurring after
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circumcision were after circumcisions performed by circumcisionists, 4.4% of complications were
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after those by practicing clinicians and 2.5% occurred after those by expert clinicians. 27 After
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circumcision in the early period complications such as hemorrhage, wound infection, secondary
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phimosis, urethra and glans penis injury, urine retention and complications linked to anesthesia are
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reported. In the later period meatal stenosis together with too little or much foreskin removed,
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buried penis, adhesion of glans to penis skin, shape disorders of penis, secondary hypospadias, bad
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wound healing and granuloma, skin bridges and psychological disorders developing after
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mistimed or collective circumcision.26 Respiratory infections were encountered by patients without
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preoperative evaluation by anesthesiologists before circumcision with laryngospasm incidence
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rates increased 2-7 times with mask anesthesia.28 In our study complications after circumcision
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included hemorrhage (22.3%) and bronchospasm or laryngospasm (17%).
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Many clinics use local anesthetics, opioids, non steroidal anti-inflammatory drugs (NSAIDs) and
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paracetamol for analgesia after circumcision. Especially for outpatient surgeries, the combination
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of NSAIDs and regional anesthesia provide effective analgesia.29 In recent years the use of iv
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paracetamol administration is increasing. The paracetamol iv dose for pediatric patients is
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determined as 15 mg/kg used at most 4 times per day.30 In our study for postoperative analgesia,
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the choices of anesthesiologist varied, with the most common being paracetamol (17.5%).
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In our study monitoring of circumcision cases was according to standards in the ASA guidelines
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for 20.2% (pulse oximeter plus electrocardiography , blood pressure, heart rate and end-tidal
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carbon dioxide). We believe that in the healthy patient group, this is reliable and sufficient for
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outpatient anesthesia.
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Anesthesiologists most frequently used laryngeal mask, general anesthesia and sedoanalgesia
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administration in addition to regional anesthesia methods for circumcision cases and caudal block
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was most frequently chosen. For caudal or dorsal penile nerve block administration USG was not
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commonly used and for both blocks bupivacaine was chosen as local anesthetic.
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For sedoanalgesia administration the combination of midazolam + ketamine was used, with
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paracetamol chosen for postoperative analgesia. The majority requested preoperative routine
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laboratory tests of complete blood count + coagulation, with variations observed in intraoperative
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monitoring. Hemorrhage, bronchospasm and laryngospasm were frequently encountered
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postoperative complications. This survey, when the participation is noted, is an insufficient study
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of the anesthetic methods administered to circumcision cases, but is accepted as a preliminary
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study to draw attention to the topic. We believe that we have to develop standard anesthesia
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protocols within the frame of international recommendations for circumcision operations, the most
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commonly performed outpatient surgical procedure.
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REFERENCES
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7. Yıldız M, İyilikçi L, Duru S. Türkiye’de Anesteziyoloji ve Reanimasyon Uzmanlarının
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9. Yakıncı CY, Şahin S, Paç FA, Karabiber H, Balbay MD, Yoloğlu S. Circumcision Investigation In
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10. Stang HJ, Snellman LW.
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13. Johnson RK, Mortimer AJ. Routine preoperative blood testing: is it necessary? Anaesthesia
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14. Rivzi SA, Naqvi SA, Hussain M, Hasan AS. Regilious circumcision: a Muslim view. BJU İnt
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15. Oztürk OM. Ritual circumcision and castration anxiety. Psychiatry 1973; 36: 49-60.
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16. Aydur E, Gungor S, Ceyhan ST, Taiimaz L, Baser I. Effects of childhood circumcision age on
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18. Joshi GP, Inagaki Y, White PF, Kennedy LT, Wat LI, Gevirtz C, et al. Use of Laryngeal Mask
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19. Kazak BZ, Ekmekci P, Hakan HA. Levobupivacaine for postoperative pain management
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22. Morrison SG, Dominguez JJ, Frascarolo P, Reiz S. A comparison of the electrocardiographic
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Table - Demographic data of anesthesia experts (n=206)
Participants
n
%
Female/Male
90/116
43.7 / 56.3
Below 30
4
1.9
31-40 years
98
47.6
41-50 years
90
43.7
51-60 years
8
3.9
61 years and above
6
2.9
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Table 2- Frequency of anesthetic methods administered for circumcision operations (n=206)
Anesthesia Methods
n
%
Laryngeal mask
Laryngeal mask+Caudal block
Face mask
Face mask+Sedoanalgesia
Laryngeal mask+Face mask
Laryngeal mask+Dorsal penile nerve block
Face mask+Local Infiltration Anesthesia+DPNB
Sedoanalgesia
Sedoanalgesia+DPNB
Face mask+Caudal block
Face mask+Sedoanalgesia+Local Infiltration Anesthesia
Laryngeal mask+Sedoanalgesia
Laryngeal mask+Face mask+Caudal block
Laryngeal mask+Face mask+Sedoanalgesia
Laryngeal mask+Sedoanalgesia+DPNB
Face mask+ Local Infiltration Anesthesia
Face mask+Sedoanalgesia+DPNB
Face mask+Sedoanalgesia+DPNB +Caudal block
Face mask+Sedoanalgesia+Local Infiltration Anesthesia
Sedoanalgesia+Local Infiltration Anesthesia
Face mask+DPNB
Face mask+DPNB+Caudal block
Face mask+Sedoanalgesia+DPNB+Local Infiltration Anesthesia
20
17
15
12
9
8
7
7
6
6
6
5
5
5
4
4
4
4
3
3
3
3
3
9.7
8.3
7.3
5.8
4.4
3.9
3.4
3.4
2.9
2.9
2.9
2.4
2.4
2.4
1.9
1.9
1.9
1.9
1.5
1.5
1.5
1.5
1.5
Face mask+Sedoanalgesia+Local Infiltration Anesthesia+Caudal block
2
1.0
Sedoanalgesia+DPNB+Local Infiltration Anesthesia
2
1.0
Sedoanalgesia+Caudal block
2
1.0
Laryngeal mask+Face mask+Sedoanalgesia+Caudal block
2
1.0
Laryngeal mask+Face mask+DPNB
2
1.0
Laryngeal mask+Sedoanalgesia+Caudal block
2
1.0
Laryngeal mask+Local Infiltration Anesthesia
2
1.0
Caudal block
2
1.0
Endotracheal Intubation+Face mask
2
1.0
Laryngeal mask+Sedoanalgesia+Caudal block+DPNB
2
1.0
*Other method(s) chosen
27
13.1
314
*Other method(s) chosen: different combinations of laryngeal mask, face mask, local infiltration
315
anesthesia, dorsal penile nerve block, caudal block, sedoanalgesia
316
317
Table 3- Frequency of regional anesthesia in addition to general anesthesia and sedoanalgesia (n=206)
Regional Anesthesia Methods
n
%
Caudal block
78
37.9
DPNB
56
27.2
Local infiltration anesthesia
35
17.0
DPNB+Caudal block
10
4.9
DPNB+Local infiltration anesthesia
6
2.9
I do not use additional regional anesthesia methods
4
1.9
DPNB+Local infiltration anesthesia+Caudal block
3
1.5
Local infiltration anesthesia+Caudal block
2
1.0
*Other
12
5.8
318
*Other was presented as an alternative answer, different to the options, with no explanation requested
319
from participants.
320
321
Table 4- Frequency of agents for sedoanalgesia administration (n=206)
Sedoanalgesic agent(s)
Midazolam+Ketamine
Midazolam+Ketamine+Fentanyl
Propofol+Midazolam+Ketamine+Fentanyl
Propofol+Midazolam+Ketamine
Propofol+Midazolam+Fentanyl
Propofol+Midazolam
Midazolam
Propofol+Fentanyl
Propofol+Midazolam+Ketamine+Remifentanil+Fentanyl
Propofol+Alfentanil
n
24
22
22
18
14
14
8
7
6
5
%
11.7
10.7
10.7
8.8
6.8
6.8
3.9
3.4
2.9
2.4
322
Ketamine
4
1.9
Propofol+Ketamine
4
1.9
Midazolam+Fentanyl
3
1.5
Propofol
3
1.5
Propofol+Ketamine+Fentanyl
3
1.5
Propofol+Midazolam+Ketamine+Pentotal
3
1.5
Propofol+Midazolam+Ketamine+Remifentanil
3
1.5
Fentanyl
2
1.0
Propofol+Remifentanil
2
1.0
Propofol+Midazolam+Remifentanil
2
1.0
Propofol+Midazolam+Ketamine+Remifentanil+Fentanyl+Pentot
2
1.0
Propofol+Midazolam+Ketamine+Alfentanil
2
1.0
Aaaaal+Alfentanil
Propofol+Midazolam+Remifentanil+Fentanyl
2
1.0
Propofol+Midazolam+Fentanyl+Pentotal
2
1.0
Propofol+Midazolam+Alfentanil
2
1.0
Propofol+Ketamine+Pentotal
2
1.0
Midazolam+Ketamine+Alfentanil
2
1.0
*Other
6
2.9
**Other chosen methods
16
7.7
*Other was presented as an alternative answer, different to the options, with no explanation requested
323
from participants.
324
**Other chosen methods: different combinations of propofol, midazolam, ketamine, fentanyl, and
325
remifentanil
326
Table 5- Methods and/or medication use for postoperative analgesia (n=206)
Analgesia Methods
n
%
Paracetamol
Paracetamol+Caudal block+DPNB
Paracetamol+Local infiltration anesthesia
Paracetamol+Caudal block
Paracetamol+ DPNB
Paracetamol+Local infiltration anesthesia+ DPNB
Paracetamol+Local infiltration anesthesia+Caudal block
Caudal block
Paracetamol+Local infiltration anesthesia+Caudal block+DPNB
36
17
15
12
9
9
9
8
8
17.5
8.3
7.3
5.8
4.4
4.4
4.4
3.9
3.9
Paracetamol+Local infiltration anesthesia+NSAID
4
1.9
Paracetamol+Meperidine+Caudal block
Paracetamol+ NSAID
Paracetamol+Local infiltration anesthesia+NSAID+DPNB
4
4
3
1.9
1.9
1.5
Paracetamol+Meperidine+Local infiltration anesthesia
Paracetamol+Meperidine+Tramadol+DPNB
Paracetamol+ NSAID+Caudal block+DPNB
3
3
3
1.5
1.5
1.5
Paracetamol+Tramadol
Paracetamol+Tramadol+DPNB
3
3
1.5
1.5
Paracetamol+Tramadol+Local infiltration anesthesia+Caudal block+DPNB
3
1.5
Local infiltration anesthesia
Tramadol
Caudal block+DPNB
Local infiltration anesthesia+Caudal block
Caudal block+Meperidine
Paracetamol+Meperidine+DPNB +Caudal block
Paracetamol+Meperidine+Caudal block+NSAID
2
2
2
2
2
2
2
1.0
1.0
1.0
1.0
1.0
1.0
1.0
327
Paracetamol+Caudal block+Tramadol
2
1.0
Paracetamol+Tramadol+Caudal block+DPNB
2
1.0
*Other
5
2.4
**Other chosen methods
27
13.1
*Other was presented as an alternative answer, different to the options, with no explanation requested
328
from participants.
329
**Other chosen methods included different combinations of paracetamol, local infiltration anesthesia,
330
non-steroidal anti-inflammatory drugs, dorsal penile nerve block, caudal block, tramadol, and
331
meperidine.
332
333
Table 6- Frequency of monitoring methods for circumcision cases (n=206)
Monitoring methods
n
%
Pulse oximeter+EKG+Blood pressure+Heart rate+ETCO2
42
20.4
Pulse oximeter+EKG+Heart rate+ETCO2
35
17
Pulse oximeter+EKG +Heart rate
27
13.1
Pulse oximeter+EKG
24
11.7
Pulse oximeter+EKG+ETCO2
14
6.8
Pulse oximeter+EKG+Blood pressure
9
4.4
Pulse oximeter+EKG+Blood pressure+Heart rate
9
4.4
Pulse oximeter+Heart rate
6
2.9
Pulse oximeter+EKG+ETCO2+temperature
6
2.9
Pulse oximeter+EKG+ETCO2+Blood pressure
5
2.4
Pulse oximeter
5
2.4
Pulse oximeter+Heart rate+ETCO2
4
1.9
Pulse oximeter+EKG+Blood pressure+Heart rate
3
1.5
Pulse oximeter+EKG+Blood pressure+ETCO2+temperature
1
0.5
Pulse oximeter+EKG+Blood pressure+temperature
1
0.5
Pulse oximeter+EKG+Blood pressure+Heart rate+temperature
1
0.5
Pulse oximeter+ETCO2
1
0.5
Pulse oximeter+Blood pressure+Heart rate
1
0.5
Pulse oximeter+Heart rateı+ETCO2+temperature
1
0.5
*Other
3
1.5
334
* Other was presented as an alternative answer, different to the options, with no explanation requested
335
from participants.
336
337
338
339
340
341
342
343
344
345
346
347
348
349
350
351
352
353