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1 Anesthesia methods used by anesthetic experts for circumcision cases: national survey study 2 3 ABSTRACT 4 Objective: To state the anesthesiologist’s choice for anesthesia techniques and drugs in circumcision 5 and determine the preoperative examination, intraoperative monitoring techniques, postoperative 6 analgesia methods and common complications among anesthesiologists working in our country. 7 Methods: This cross-sectional study was conducted in Bülent Ecevit University Hospital, Zonguldak, 8 Turkey, between 15 May to 01 July 2012. Survey data were obtained by survey forms through 9 electronic data over the web. Questionnaire consists of twenty questions. These questions included 10 demograhic data, methods of anesthesia for circumcision, postoperative analgesia methods, 11 monitorization methods. Descriptive statistics were expressed as number and percentage. Differences 12 and relationships between variables were analyzed by chi-square test between the groups. 13 Results: The datas were obtained from 206 anesthesiologist who accept to participate to survey. 14 Circumcision was performed most frequently in the age group of 3-6 year. It was detected that 47% of 15 routine preoperative laboratory tests were coagulation parameters and complete blood count tests. The 16 most frequently method of anesthesia was laryngeal mask and the frequency of administration of 17 regional anesthesia is 37.4%, caudal block is more preferable. Bupivacaine as a local anesthetic in 18 regional anesthesia and midazolam and ketamine were most preferred agents in sedoanalgesia. During 19 regional anesthesia ultrasound is used by anesthesiologists (31.6%). In circumcision most preferred 20 monitorization was standard monitoring. 21 Conclusion: Ambulatory anesthesia protocols which are also needed in circumcision can be improved 22 with international recommendation and these protocols could be conformed to sociocultural structure 23 in societies. This study should be regarded as preliminary study to attrack attention about anesthesia 24 techniques in circumcision. 25 INTRODUCTION 26 Male circumcision is the surgical removal of the foreskin (prepuce) of the human penis.. It is a 27 very common surgical procedure, performed traditionally for many years1 28 Children are ideal patients for outpatient day surgery. With full medical assessment, appropriate 29 surgery and anesthesia method, the majority of pediatric patients can undergo outpatient 30 interventions. The appropriate anesthetic method should reduce complications and ease recovery 31 and discharge. The most important point is that the outpatient approach should reduce disruption 32 to the child's daily life and should ensure a positive experience for other surgical interventions.2 33 The number of outpatient operations increase in light of a variety of indications. The most 34 common outpatient surgeries for children are minor surgeries like inguinal hernia and 35 circumcision. These types of surgery in infants and children are carried out with regional 36 anesthesia, sedation or general anesthesia.3 The anesthetic method for circumcision operations 37 varies according to the patient's situation, available opportunities of the hospital, occupational 38 skills and attitude of the physician.4 39 In our study we aimed to research the attitude and behavior of anesthetic experts about anesthesia 40 methods they use for circumcision cases. With this survey we aimed to determine the chosen 41 anesthetic techniques, medications used and complications, preoperative tests, intraoperative 42 monitoring and postoperative analgesia methods used by anesthesia experts in our country for 43 circumcision operations. 44 Methods: After receiving permission from Bülent Ecevit University Research Ethics Committee 45 (Meeting decision no: 2012/10, date: 02.05.2012), this cross-sectional study was conducted in 46 Bülent Ecevit University Hospital, Zonguldak, Turkey, between 15 May to 01 July 2012. The 47 created survey questions were read by 15 individuals not participating in the research for clarity 48 and preliminary study. 49 Data Collection Method: Survey data were obtained using a web-based electronic data form. The 50 survey was sent to the known email addresses of 700 anesthetic experts a total of three times at 10 51 day intervals and those who had participated were reminded not to participate again. The answered 52 surveys were checked for repeat participation. 53 Survey Form: The survey form comprised 20 questions. Section A included 5 questions on 54 demographic information of participants, section B included 13 questions about circumcision, 55 section C included 1 question about postoperative analgesia and section D included 1 question 56 about routine monitoring methods used during circumcision operations. As it was stated that 57 participants could give more than one answer to the questions, different combinations of survey 58 results were obtained. These different and multi-variable answers that were only chosen by some 59 of the 206 anesthetic experts were evaluated within the group "other chosen methods". Similarly, 60 some questions were left semi open-ended and participants were presented with the option of 61 choosing "other" without any request for an explanation. 62 Statistical Analysis: Statistical evaluation was completed using the SPSS 18.0 (Statistical Package 63 For Social Sciences. Chicago. IL. USA) program. Descriptive statistics are given as number and 64 percentage. Differences between the groups and correlations between variables were investigated 65 with the chi-square test. Results were assessed at the 95% confidence interval and p<0.05 was 66 accepted as statistically significant. 67 Results: With our survey sent by electronic mail, 206 anesthetic experts responded to the survey 68 and were included in the study. Demographic data of anesthetic experts participating in the study 69 are shown in (Table 1). When the organizations the survey participants currently were employed in 70 was questioned, 49.5% (n=102) worked in university hospitals, 24.3% (n=50) worked in state 71 hospitals, 16% (n=33) worked in education and research hospitals and 10.2% (n=21) worked in 72 private hospitals. When the branch performing circumcision was examined, generally more than 73 one branch performed circumcision and most were performed by pediatric surgery-urology 21.8% 74 (n=45), 10.2% by pediatric surgery (n=21), 7.3% by urology (n=15) and 1.0% by general surgery 75 departments (n=2). Additionally the operation was performed in pediatric urology and plastic 76 surgery departments. Concerning preoperative laboratory tests, 41.7% (n=86) requested complete 77 blood count pluscoagulation, 19.9% (n=41) complete blood count, and 9.2% (n=19) coagulation 78 and additionally hepatitis markers and other biochemical tests. 79 circumcision was identified as 9.7% laryngeal mask (n=20), 8.3% laryngeal mask plus caudal 80 block (n=17) and 7.3% face mask (n=15) (Table 2). In addition to general anesthesia and 81 sedoanalgesia, regional anesthesia methods were used 37.4% of the time, 6.8% did not use it at all. 82 Seventy eight (37.9%) used caudal and 56 (27.2%) dorsal penile nerve block (Table 3). When 83 ultra-sound guidance (USG) use for caudal or penile block was questioned, 141 (68.4%) did not 84 use it, 46 (22.3%) stated their organization did not have it, 13 (6.3%) stated the organization had it 85 but they did not need to use it, 1 (0.5%) used it and 5 (2.4%) selected the "other*" answer. For 86 circumcision operations 93.7% of dorsal penile block was administered by surgeons and 6.3% by 87 anesthesiologists. For circumcision operations the most common local anesthetics used for caudal 88 block were: 81 (39.3%) bupivacaine, 30 (14.6%) 89 (11.2%) levobupivacaine with lidocaine and prilocaine also among the choices. For dorsal nerve 90 block, the most common local anesthetics chosen by anesthesiologists were: 43 (20.9%) 91 bupivacaine, 28 (13.6%) , prilocaine,27 (13.1%), lidocaine, 7 (3.4%) levobupivacaine and a 92 variety of combinations of these medications. Sedoanalgesia administration for circumcision 93 operations most frequently used midazolam plus ketamine (11.7%) (Table 4). The most common 94 complications after circumcision were hemorrhage (22.3%), bronchospasm or laryngospasm 95 (17%) and severe pain (7.8%). The methods and/or medication chosen for analgesia after 96 circumcision was most commonly paracetamol (17.5%) (Table 5). When monitoring methods 97 for circumcision operations were assessed, there was a high rate use of the combination of pulse 98 oximeter, electrocardiography, blood pressure, heart rate, end tidal carbon dioxide (20.4%) (Table 99 6). The anesthetic method for bupivacaine plus levobupivacaine and 23 100 Discussion: Anesthesiologists frequently choose laryngeal mask, and the regional anesthesia 101 method of caudal block for circumcision operations and 31.6% use USG for the block. The most 102 frequently observed complication appears to be hemorrhage. Paracetamol is frequently used for 103 postoperative analgesia after circumcision. 104 Though publications related to circumcision training and applications by surgeons were found 105 from Turkey and the world, we did not encounter any publication investigating the attitude and 106 behavior of anesthetic experts in our country to circumcision applications. In a survey study to 107 determine the level of knowledge of practitioner clinicians in Turkey about circumcision by 108 Cankorkmaz et al5 200 clinicians were reached by post and 178 people (72%) responded to the 109 survey. A postal survey to assess clinical applications by anesthesiologists for outpatient pediatric 110 surgery in England had a 74% response rate.6 Our study reached 580 anesthesiologists by 111 electronic mail and received a response from 206 (35.5%). We believe the reason for the low 112 participation rate for survey studies in the electronic environment in our country is that these types 113 of studies are relatively new and infrequently performed. 114 A study by Yıldız et al7 researching the attitude and behavior of anesthetic experts to anesthetic 115 administration outside the operating room stated that highest participation was from university 116 hospitals (31.7%). In our study the reason for the highest response rate coming from university 117 hospitals (49.5%) may be linked to the active role played by universities in education and 118 research.. 119 A survey study by Şahin et al8 found that of 1235 children circumcision was performed by 120 traditional circumciser for 13.3% and by pediatric surgeons or neurologists? for the remainder. 121 Yakıncı et al9 in a study of 1880 circumcised primary school children living in different socio- 122 economic regions requested parents to complete a circumcision form. Evaluation of the data 123 showed that when the occupation of the person performing the circumcision is examined; 66% 124 were health officials with diplomas, 13.2% were personnel other than health officials, 8.8% were 125 urologists, 6.2% were practicing clinicians, 2.9% were general surgeons and 2.8% were pediatric 126 surgeons. When the same study evaluated the rate of complications of circumcision, traditional 127 circumciser were first with 17.7% and expert clinicians were last with 3.4% rate. When the 128 relationship between family income and education level and the person performing circumcision is 129 investigated, as economic situation and education level increased they stated there was an increase 130 in the rate of licensed individuals performing circumcision. İn the United States, circumcision is 131 performed mainly by paediatricians, family practitioners and obstetricians.10 In our study in 132 general more than one branch performed circumcision and the highest rate was 21.8% pediatric 133 surgery plus urology, 10.2% pediatric surgery, 7.3% urology and 1.0% general surgery 134 departments. 135 If no problem is identified in history or physical examination, the view that routine laboratory tests 136 are not required, especially for minor surgical interventions, is becoming more common. 11 Roy et 137 al12 grouped 2000 pediatric patients by age group and found that anemia with no symptoms was 138 more common in the under 5 age group compared to the group above the age of 5; they stated this 139 affects care after anesthesia and may even be a reason to postpone minor surgery. Johnson et al13 140 reported routine preoperative tests (complete blood count, urea, electrolytes and glucose) affected 141 anesthesia planning for only 0.2% of patients and that reorganizing tests according to requirements 142 could reduce hospital costs by £50,000 yearly. In our country, according to the preoperative 143 guidelines published by the Turkish Association of Anesthesia and Reanimation in 2005, for minor 144 surgery under the age of 16 such as circumcision, preoperative testing hemoglobin/hematocrit is 145 sufficient.11 In our study it appeared 41.7% requested complete blood count plus coagulation, 146 19.9% requested complete blood count and 9.2% requested coagulation. We think that 147 preoperative history and physical examination can avoid unnecessary expenses and ensure labor 148 savings. 149 Debates about the age for circumcision still continue. In some African tribes circumcision is 150 performed at birth, in Jewish tradition it is performed in the first days after birth. 14 To prevent 151 negative issues like castration phobia, it is recommended that circumcision not be performed 152 between the ages of 3 and 6.15 Aydur et al16 observed that 11% of Turkish children were 153 circumcised in the age interval 0-2, 27,1% from 3-5 years and 61.7% from 6-12 years. Cüceloğlu 154 et al17 determined that circumcision after the age of 7 carried more risk in terms of early 155 ejaculation than before the age of 7 so circumcision should be performed under the age of 7. They 156 stated that as the 3-7 year interval appeared to be the "phallic period", the ideal age may be 0-3 157 years. In our study it appeared that most circumcision operations were performed from 3-6 years 158 (31.6%) with least completed in the newborn period (1%). We believe parents need to be informed 159 about the phallic period and clinicians need to expend more energy so circumcision is performed 160 in the appropriate age interval. 161 Unless necessary, laryngeal mask should be chosen instead of endotracheal intubation to secure 162 the airway for outpatient surgeries. This is because it does not require muscle relaxation or 163 laryngoscopy, is easier and less traumatic to insert, provides reliable airway, ensures hemodynamic 164 stability during intubation and extubation, has short recovery and discharge times and does not 165 have negative effects like throat pain.18 In anesthesia for outpatient pediatric surgery in 166 England, it appears the laryngeal mask is much more common than tracheal intubation with 167 a rate of 85%.6 In our study we found the laryngeal mask was the anesthetic method used for 168 circumcision operations. 169 Kazak et al19 found that dorsal penile nerve block by urologists for circumcision operations 170 provided longer term analgesia for postoperative pain management than caudal block by 171 anesthesiologist, however as the time to first walking was significantly longer they stated there 172 was a higher risk of motor block. In our study in addition to general anesthesia and sedoanalgesia, 173 regional anesthesia methods were performed in 37.4% of the patients, with caudal block being 174 the most common (37.9%) used method, followed by dorsal penile nerve block (27.2%) . 175 Faraoni et al20 in a study comparing the efficacy of dorsal penile nerve block techniques 176 accompanied by USG or by anatomic estimation found that while there was no difference in terms 177 of failure rates, there was a significant difference in terms of postoperative pain scores and 178 additional paracetamol administration time for block given with USG. They showed that the use of 179 USG was more efficient. In our study when the frequency of USG use was examined, 68.4% of 180 anesthesiologists did not use USG, while 22.3% stated that their organization did not have a USG 181 device. 182 Erbüyün et al21 stated that USG for caudal block applications would neither increase nor decrease 183 the success of the treatment and should be needed in cases where the detection of sacral anatomy 184 is difficult, especially by palpations. 185 Comparing bupivacaine and levobupivacaine for caudal block administration, a study found that 186 due to cardiovascular and central nervous system side effects of high doses of bupivacaine, 187 levobupivacaine was more reliable.22 Locatelli et al23 reported that for caudal block administration 188 bupivacaine provided longer duration analgesic effect and higher motor block incidence that 189 ropivacaine and levobupivacaine, while two cases developed sinus bradycardia. 190 As a result they considered that levobupivacaine was more reliable for pediatric surgery. In our 191 study bupivacaine was observed to be the most common choice for block administration. We 192 believe the reason for levobupivacaine being chosen less often may be due to this medication not 193 being available in our country. 194 The use of propofol and ketamine together for sedoanalgesia for short term interventions has 195 become more common.24 Özkan et al25 retrospectively investigated the use of midazolam for 196 premedication, ketamine for sedation and bupivacaine as infiltrative agent for 2720 children 197 undergoing minor urological surgery (69% circumcision) and stated that the majority were 198 discharged in a short time and serious side effects were not observed. With ketamine nausea, 199 vomiting and negative effects on hemodynamic parameters were observed less and they stated it 200 may be an effective agent for sedation during outpatient pediatric surgeries. In our study for 201 sedoanalgesia administration the combination of midazolam + ketamine (11.7%) was chosen most 202 often, and we believe this is due to providing better hemodynamic stability and surgical 203 conditions. 204 In developed countries where circumcisions are performed by professionals the rate of 205 development of complications is 5%, in developing countries where circumcisions are performed 206 by health technicians it is 10% and for circumcisions performed by traditional circumciser the rate 207 reaches 85%.26 In our country a survey study determined 93.1% of complications occurring after 208 circumcision were after circumcisions performed by circumcisionists, 4.4% of complications were 209 after those by practicing clinicians and 2.5% occurred after those by expert clinicians. 27 After 210 circumcision in the early period complications such as hemorrhage, wound infection, secondary 211 phimosis, urethra and glans penis injury, urine retention and complications linked to anesthesia are 212 reported. In the later period meatal stenosis together with too little or much foreskin removed, 213 buried penis, adhesion of glans to penis skin, shape disorders of penis, secondary hypospadias, bad 214 wound healing and granuloma, skin bridges and psychological disorders developing after 215 mistimed or collective circumcision.26 Respiratory infections were encountered by patients without 216 preoperative evaluation by anesthesiologists before circumcision with laryngospasm incidence 217 rates increased 2-7 times with mask anesthesia.28 In our study complications after circumcision 218 included hemorrhage (22.3%) and bronchospasm or laryngospasm (17%). 219 Many clinics use local anesthetics, opioids, non steroidal anti-inflammatory drugs (NSAIDs) and 220 paracetamol for analgesia after circumcision. Especially for outpatient surgeries, the combination 221 of NSAIDs and regional anesthesia provide effective analgesia.29 In recent years the use of iv 222 paracetamol administration is increasing. The paracetamol iv dose for pediatric patients is 223 determined as 15 mg/kg used at most 4 times per day.30 In our study for postoperative analgesia, 224 the choices of anesthesiologist varied, with the most common being paracetamol (17.5%). 225 In our study monitoring of circumcision cases was according to standards in the ASA guidelines 226 for 20.2% (pulse oximeter plus electrocardiography , blood pressure, heart rate and end-tidal 227 carbon dioxide). We believe that in the healthy patient group, this is reliable and sufficient for 228 outpatient anesthesia. 229 Anesthesiologists most frequently used laryngeal mask, general anesthesia and sedoanalgesia 230 administration in addition to regional anesthesia methods for circumcision cases and caudal block 231 was most frequently chosen. For caudal or dorsal penile nerve block administration USG was not 232 commonly used and for both blocks bupivacaine was chosen as local anesthetic. 233 For sedoanalgesia administration the combination of midazolam + ketamine was used, with 234 paracetamol chosen for postoperative analgesia. The majority requested preoperative routine 235 laboratory tests of complete blood count + coagulation, with variations observed in intraoperative 236 monitoring. Hemorrhage, bronchospasm and laryngospasm were frequently encountered 237 postoperative complications. This survey, when the participation is noted, is an insufficient study 238 of the anesthetic methods administered to circumcision cases, but is accepted as a preliminary 239 study to draw attention to the topic. We believe that we have to develop standard anesthesia 240 protocols within the frame of international recommendations for circumcision operations, the most 241 commonly performed outpatient surgical procedure. 242 243 244 REFERENCES 245 1. Koo HP, Duckett JW. Circumcision–Quo Vadis? In: Williams DL, Etker S editors. Contemporary 246 Issues in Paediatric Urology. İn memorian Herbet B Logos, İstanbul, 1996; p.149 -154. 247 2. Bogetz MS. Anesthesia for pediatric outpatient surgery. Pediatrician 1989;16:45-55. 248 3. Gunter JB. Benefit and risks of local anesthetics in infants and children. Paediatr Drugs 2002;4: 249 250 251 252 253 254 255 649-672. 4. Rosow C, Manberg PJ. Bispectral index monitoring. Anesthesiol Clin North America 2001;19: 947-966. 5. Cankorkmaz L, Cetinkaya S, Koyluoğlu G. General Practitioner Knowledge Levels About Circumcision. Balkan Med J 2011;28:264-268. 6. Payne K, Moore WE, Elliott R.A, Moore JK, McHugh GA. Anaesthesia for day case surgery: a survey of paediatric clinical practice in the UK. Eur J Anaesthesiol 2003;21:325-330. 256 7. Yıldız M, İyilikçi L, Duru S. Türkiye’de Anesteziyoloji ve Reanimasyon Uzmanlarının 257 Ameliyathane Dışı Anestezi Uygulamalarındaki Tutum ve Davranışları: Bir Anket Çalışması. Turk 258 J Anaesth Reanim 2014; 42: 196-213. 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 8. Sahin F, Beyazova U, Akturk A. Attitudes and practices regarding circumcision in Turkey. Child Care Health Dev 2003;29:275–280. 9. Yakıncı CY, Şahin S, Paç FA, Karabiber H, Balbay MD, Yoloğlu S. Circumcision Investigation In Malatya. T Klin J Pediatr 1996;5:64-67. 10. Stang HJ, Snellman LW. Circumcision practice patterns in the United State. Pediatrics 1998;101:e5. 11. Anestezi Uygulama Kılavuzları (Preoperatif Hazırlık).Türk Anesteziyoloji ve Reanimasyon Derneği http://www.tard.org.tr/kilavuz/3.pdf [Kasım 2005]. 12. Roy WL, Lerman J, McIntyre BG. Is preoperative haemoglobin testing justified in children undergoing minorelective surgery? Can J Anaesth 1991;38:700-703. 13. Johnson RK, Mortimer AJ. Routine preoperative blood testing: is it necessary? Anaesthesia 2002;57:914-917. 14. Rivzi SA, Naqvi SA, Hussain M, Hasan AS. Regilious circumcision: a Muslim view. BJU İnt 1999; 83:13-16. 15. Oztürk OM. Ritual circumcision and castration anxiety. Psychiatry 1973; 36: 49-60. 274 275 276 277 16. Aydur E, Gungor S, Ceyhan ST, Taiimaz L, Baser I. Effects of childhood circumcision age on adult male sexual functions. Int J Impot Res 2007;19:424-431. 17. Cüceloğlu AE, Hoşrik EM, Ak M, Bozkurk A. Sünnet Yaşının Erken Boşalma Üzerindeki Etkisi. Türk Psikiyatri Dergisi 2012; 23:99-107. 278 18. Joshi GP, Inagaki Y, White PF, Kennedy LT, Wat LI, Gevirtz C, et al. Use of Laryngeal Mask 279 Airway as an Alternative to the tracheal tube during ambulatory anesthesia. Anesth Analg 280 1997;85:573-577. 281 282 283 284 285 286 19. Kazak BZ, Ekmekci P, Hakan HA. Levobupivacaine for postoperative pain management incircumcision: caudal blocks or dorsal penile nerve block. Ağrı 2012;24:180-186. 20. Faraoni D, Gilbeau A, Lingier P, Barvais L, Engelman E, Hennart D. Does ultrasound guidance improve the efficacy of dorsal penile nerve block in children? Paediatr Anaesth 2010;20:931–936. 21. Erbüyün K, Açıkgöz B, Ok G, Yılmaz Ö, Temeltaş G, Tekin I, et al. The role of ultrasound guidance in pediatric caudal block. Saudi Med J 2016; 37: 147-150. 287 22. Morrison SG, Dominguez JJ, Frascarolo P, Reiz S. A comparison of the electrocardiographic 288 cardiotoxic effects of racemic bupivacaine, levobupivacaine, and ropivacaine in anesthetized 289 swine. Anesth Analg 2000;90:1308-1314. 290 23. Locatelli B, Ingelmo P, Sonzogni V, Zanella A, Gatti V, Spotti A, et al. Randomized, double-blind, 291 phase III, controlled trial comparing levobupivacaine 0.25%, ropivacaine 0.25% and bupivacaine 292 0.25% by the caudal route in children. Br J Anaesth 2005;94:366-371. 293 24. Willman EV, Andolfatto G. Prospective Evaluation of “Ketofol” (Ketamine/Propofol 294 Combination) for Procedural Sedastion and Analgesia in the Emergency Department. Ann Emerg 295 Med 2007;49:23-30. 296 297 298 299 25. Ozkan A, Okur M, Kaya M, Kaya E, Küçük A, Erbas M, et al. Sedoanalgesia in pediatric daily surgery. Int J Clin Exp Med. 2013;6:576-582. 26. Özdemir E. Significantly increased complication risks with mass circumcisions. Br J Urol 1997;80:136-139. 300 27. Benli E, Koca O. Circumcision research in Bingol province. The New J Urol 2011;6:22-25. 301 28. Başaklar AC. Bebek ve Çocukların Cerrahi ve Ürolojik Hastalıkları. Palme Yayıncılık, Ankara 302 2006;59. 303 29. Zavras N, Tsamoudaki S, Christianakis E, Schizas D, Pikoulis E, Kyritsi H, et al. Ring block with 304 levobupivacaine 0.25% and paracetamol vs. paracetamol alone in children submitted to three 305 different surgical techniques of circumcision: A prospective randomized study. Saudi J Anaesth 306 307 308 2014;8:45-50. 30. Anderson BJ. What we don’t know about paracetamol in children. Paediat Anaesth. 1998;8:451460. 309 310 311 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 2.9 312 313 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