Turkiye Klinikleri Journal of Anesthesiology Reanimation

.: ORIGINAL RESEARCH
Comparison Of Dexmedetomidine and Morphine For Postoperative Pain and Sedation Management in Pediatric Patients Undergoing Congenital Cardiac Surgery: A Retrospective Study
Konjenital Kalp Cerrahisi Geçiren Pediatrik Hastalarda Postoperatif Ağrı ve Sedasyon Yönetimi İçin Deksmedetomidin Ve Morfinin Karşılaştırılması: Retrospektif Çalışma
Dilek ALTUNa, Ahmet ARNAZb, Abdullah DOĞANc, Ayda TÜRKÖZd
aDepartment of Anesthesiology and Reanimation, Acıbadem Mehmet Ali Aydınlar University, İstanbul, Türkiye
bDepartment of Cardiovascular Surgery, Acıbadem Mehmet Ali Aydınlar University, Medical Faculty, İstanbul, Türkiye
cClinical of Cardiovascular Surgery, Acıbadem Bakırköy Hospital, İstanbul, Türkiye
dDepartment of Anesthesiology and Reanimation,Bezmialem University Medical Faculty Hospital, İstanbul, Türkiye
Turkiye Klinikleri J Anest Reanim. 2020;18(2):35-43
doi: 10.5336/anesthe.2020-75419
Article Language: EN
Full Text
ABSTRACT
 Objective: In this retrospective study, it was aimed to compare the effects of dexmedetomidine and morphine on postoperative pain, sedation, extubation time and hemodynamics in patients who underwent congenital cardiac surgery. Material and Methods: From December 2012 to December 2013, 46 patients between 1 to 5 years of age, who underwent congenital cardiac surgery were included and divided into two groups based on the sedative regimen used in the postoperative period. Twenty-three patients (Group Morp) received morphine at an infusion dose of 0.01 to 0.04 mg/kg/h; 23 patients (Group Dex) received dexmedetomidine at an infusion dose of 0.05 to 0.5 mcg/kg/h. Pain scores were measured using Children's Hospital Eastern Ontario Pain Scale (CHEOPS); sedation scores with the Ramsay Sedation Scale (RSS); and hemodynamic parameters were recorded with these measured values. Sedation debth was monitored by using the Bispectral Index (BIS). In this retrospective study, postoperative pain, sedation and hemodynamic effects of intravenous dexmedetomidine in pediatric patients undergoing congenital cardiac surgery, and the effects of mechanical ventilation duration and length of intensive care unit (ICU) stay were compared with morphine. Results: Mean doses of morphine and dexmedetomidine infused were 7.04±3.94 mg/24 h and 94.33±48.38 mcg/24 h, respectively. BIS values were higher in Group Dex than Group Morp (p<0.01). Mechanical ventilation duration was shorter in Group Dex compared to Group Morp 5.74±1.98 hours vs 7.83±3.08 hours) (p<0.05). The length of ICU stay and other outcome measurements between the two groups were similar. Heart rate was lower in the group Dex only in the first two hours (p<0.01). CHEOPS pain scores were similar in two groups (p> 0.05). RSS scores at 1st, 2nd, 3rd, 4th hours were higher in Group Dex than Group Morp (p <0.01); however, there was no difference between the groups in terms of RSS scores at the 12th, 16th, 20th and 24th hours (p> 0.05). There was no difference between the groups in terms of the frequency of side effects (p> 0.05). Conclusion: With regard to our study findings, dexmedetomidine can provide effective analgesia and sedation with shorter mechanical ventilation duration without adverse reaction compared to morphine in pediatric patients undergoing congenital cardiac surgery.

Keywords: Dexmedetomidine; morphine; postoperative pain; cardiac surgical procedures; pediatrics
ÖZET
 Amaç: Bu retrospektif çalışmada konjenital kalp cerrahisi uygulanan hastalarda deksmedetomidin ve morfinin postoperatif ağrı, sedasyon, ekstübasyon süresi ve hemodinami üzerine etkilerinin karşılaştırılması hedeflenmiştir. Gereç ve Yöntemler: Aralık 2012 - Aralık 2013 tarihleri arasında konjenital kalp ameliyatı geçirmiş 1-5 yaş arası 46 hasta dahil edildi ve ameliyat sonrası dönemde kullanılan sedasyon rejimine göre iki gruba ayrıldı. Yirmi üç hasta (Morp grubu) 0.01-0.04 mg/kg/saat infüzyon dozunda morfin alırken ; 23 hasta (Dex grubu) 0.05-0.5 mcg/kg/saat intravenöz infüzyon dozunda deksmedetomidin almıştır. Ağrı skorları, Children's Hospital Eastern Ontario Ağrı Ölçeği kullanılarak; sedasyon skorları Ramsay Sedasyon Ölçeği ile ölçülmüştür; ve bu ölçülen değerler ile hemodinamik parametreler kaydedilmiştir. Sedasyon derinliği Bispectral Index kullanılarak izlenmiştir. Bu retrospektif çalışmada konjenital kalp cerrahisi geçiren pediyatrik hastalarda intravenöz deksmedetomidinin postoperatif ağrı, sedasyon ve hemodinamik etkileri ile mekanik ventilasyon süresi ile yoğun bakımda kalış süresine olan etkileri morfin ile karşılaştırılmıştır. Bulgular: İnfüze edilen ortalama morfin ve deksmedetomidin dozları sırasıyla 7.04±3.94 mg/24 saat ve 94.33±48.38 mcgµg/24 saat idi. BIS değerleri Dex grubunda Morp grubundan daha yüksekti (p<0.01). Dex grubunda mekanik ventilasyon süresi Morp grubuna göre daha kısaydı (morfin: 7,83±3,08 saat; deksmedetomidin: 5,74±1,98 saat) (p<0.05). İki grup arasında YBÜ'de kalış süresi ve diğer sonuç ölçümleri benzerdi. Kalp hızı deksmedetomidin grubunda sadece ilk iki saatte düşüktü (p<0.01). CHEOPS ağrı skorları iki grupta benzerdi (p>0.05). RSS skorları 1., 2., 3., 4. saatlerde Dex grubunda Morp grubundan daha yüksekti (p<0.01); bununla birlikte 12., 16., 20. ve 24. saatlerde RSS skorları bakımından gruplar arasında fark yoktu (p>0.05). Yan etki görülme sıklığı bakımından da gruplar arasında fark yoktu (p>0.05). Sonuç: Çalışma bulgularımıza göre, deksmedetomidin, konjenital kalp ameliyatı geçiren pediyatrik hastalarda morfine kıyasla yan etki olmadan daha kısa mekanik ventilasyon süresi ile etkili analjezi ve sedasyon sağlayabilmiştir.

Anahtar Kelimeler: Deksmedetomidin; morfin; postoperatif ağrı; kardiyak cerrahi işlemler; pediatri
REFERENCES:
  1. Ostermann ME, Keenan SP, Seiferling RA, Sibbald WJ. Sedation in the intensive care unit: a systematic review. JAMA. 2000;283(11):1451-9. [Crossref]  [PubMed] 
  2. Maze M, Scarfini C, Cavaliere F. New agents for sedation in the intensive care unit. Crit Care Clin. 2001;17(4):881-97. [Crossref]  [PubMed] 
  3. Chrysostomou C, De Toledo JS, Avolio T, Motoa MV, Berry D, Morell VO, et al. Dexmedetomidine use in a pediatric cardiac intensive care unit: can we use it in infants after cardiac surgery? Pediatr Crit Care Med. 2012;13(3):373. [Crossref]  [PubMed] 
  4. Venn RM, Bryant A, Hall GM, Grounds RM. Effects of dexmedetomidine on adrenocortical function, and the cardiovascular, endocrine and inflammatory responses in post-operative patients needing sedation in the intensive care unit. Br J Anaesth. 2001;86(5):650-6. [Crossref]  [PubMed] 
  5. Pollak U, Serraf A. Pediatric cardiac surgery and pain management: after 40 years in the desert, have we reached the promised land? World J Pediatr Congenit Heart Surg. 2018;9(3):315-25. [Crossref]  [PubMed] 
  6. Zeilmaker-Roest GA, Wildschut ED, van Dijk M, Anderson BJ, Breatnach C, Bogers AJJC, et al; Paediatric Analgesia after Cardiac Surgery consortium. An international survey of management of pain and sedation after paediatric cardiac surgery. BMJ Paediatr Open. 2017;1(1):e000046. [Crossref]  [PubMed]  [PMC] 
  7. McGrath PJ, Johnson G, Goodman JT, Dunn J, Chapman J. CHEOPS: a behavioral scale for rating postoperative pain in children. In: Fields HL, Dubner R, Cervero F, eds. Advances in Pain Research and Therapy. Vol. 9. New York: Raven Press; 1985. p.395-402.
  8. Rosen DA, Rosen KR, Steelman RJ. Is the BIS monitor vital in children undergoing cardiothoracic surgery. Anesthesiol. 1999;91:1244.
  9. Lynn A, Nespeca MK, Bratton SL, Strauss SG, Shen DD. Clearance of morphine in postoperative infants during intravenous infusion: the influence of age and surgery. Anesth Analg. 1998;86(5):958-63. [Crossref]  [PubMed] 
  10. Liu RZ, Li BT, Zhao GQ. Efficacy of different analgesic or sedative drug therapies in pediatric patients with congenital heart disease undergoing surgery: a network meta-analysis. World J Pediatr. 2019;15(3):235-45. [Crossref]  [PubMed] 
  11. Jacobs JP, Jacobs ML, Maruszewski B, Lacour-Gayet FG, Tchervenkov CI, Tobota Z, et al. Initial application in the EACTS and STS Congenital Heart Surgery Databases of an empirically derived methodology of complexity adjustment to evaluate surgical case mix and results. Eur J Cardiothorac Surg. 2012;42(5):775-9. [Crossref]  [PubMed]  [PMC] 
  12. Sottas CE, Anderson BJ. Dexmedetomidine: the new all-in-one drug in paediatric anaesthesia? Curr Opin Anesthesiol. 2017;30(4):441-51. [Crossref]  [PubMed] 
  13. Tobias JD. Dexmedetomidine: applications in pediatric critical care and pediatric anesthesiology. Pediatr Crit Care Med. 2007;8(2):115-31. [Crossref]  [PubMed] 
  14. Liu Y, Bian W, Liu P, Zang X, Gu X, Chen W. Dexmedetomidine improves the outcomes in paediatric cardiac surgery: a meta-analysis of randomized controlled trials. Interact Cardiovasc Thorac Surg. 2018;26(5):852-8. [Crossref]  [PubMed] 
  15. Nasr VG, DiNardo JA. Sedation and analgesia in pediatric cardiac critical care. Pediatr Crit Care Med. 2016;17(8 Suppl 1):S225-31. [Crossref]  [PubMed] 
  16. Chrysostomou C, De Toledo JS, Avolio T, Motoa MV, Berry D, Morell VO, et al. Dexmedetomidine use in a pediatric cardiac intensive care unit: can we use it in infants after cardiac surgery? Pediatr Crit Care Med. 2009;10(6):654-60. [Crossref]  [PubMed] 
  17. Abd Aziz N, Chue MC, Yong CY, Hassan Y, Awaisu A, Hassan J, et al. Efficacy and safety of dexmedetomidine versus morphine in post-operative cardiac surgery patients. Int J Clin Pharm. 2011;33(2):150-4. [Crossref]  [PubMed] 
  18. Jiang L, Ding S, Yan H, Li Y, Zhang L, Chen X, et al. A retrospective comparison of dexmedetomidine versus midazolam for pediatric patients with congenital heart disease requiring postoperative sedation. Pediatr Cardiol. 2015;36(5):993-9. [Crossref]  [PubMed] 
  19. Prasad SR, Simha PP, Jagadeesh AM. Comparative study between dexmedetomidine and fentanyl for sedation during mechanical ventilation in post-operative paediatric cardiac surgical patients. Indian J Anaesth. 2012;56(6):547-52. [Crossref]  [PubMed]  [PMC] 
  20. Triltsch AE, Welte M, von Homeyer P, Grosse J, Genähr A, Moshirzadeh M, et al. Bispectral index-guided sedation with dexmedetomidine in intensive care: a prospective, randomized, double blind, placebo-controlled phase II study. Crit Care Med. 2002;30(5):1007-14. [Crossref]  [PubMed] 
  21. Chen Z, Shao DH, Hang LH. Effects of dexmedetomidine on performance of bispectral index as an indicator of loss of consciousness during propofol administration. Swiss Med Wkly. 2013;143:w13762. [Crossref]  [PubMed] 
  22. Pan W, Wang Y, Lin L, Zhou G, Hua X, Mo L. Outcomes of dexmedetomidine treatment in pediatric patients undergoing congenital heart disease surgery: a meta-analysis. Pediatr Anesth. 2016;26(3):239-48. [Crossref]  [PubMed] 
  23. Achuff BJ, Nicolson SC, Elci OU, Zuppa AF. Intraoperative dexmedetomidine reduces postoperative mechanical ventilation in infants after open heart surgery. Pediatr Crit Care Med. 2015;16(5):440-7. [Crossref]  [PubMed] 
  24. Tobias JD, Berkenbosch JW. Sedation during mechanical ventilation in infants and children: dexmedetomidine versus midazolam. South Med J. 2004;97(5):451-5. [Crossref]  [PubMed] 
  25. Wang G, Niu J, Li Z, Lv H, Cai H. The efficacy and safety of dexmedetomidine in cardiac surgery patients: a systematic review and meta-analysis. PLoS One. 2018;13(9):e0202620. [Crossref]  [PubMed]  [PMC] 

.: Up To Date

.: Process List

Login

 Forgot your password?

 New Registration  

Contact

Ortadoğu Reklam Tanıtım Yayıncılık Turizm Eğitim İnşaat Sanayi ve Ticaret A.Ş.

.: Address

Turkocagi Caddesi No:30 06520 Balgat / ANKARA
Phone: +90 312 286 56 56
Fax: +90 312 220 04 70
E-mail: info@turkiyeklinikleri.com

.: Manuscript Editing Department

Phone: +90 312 286 56 56/ 2
E-mail: yaziisleri@turkiyeklinikleri.com

.: English Language Redaction

Phone: +90 312 286 56 56/ 145
E-mail: tkyayindestek@turkiyeklinikleri.com

.: Marketing Sales-Project Department

Phone: +90 312 286 56 56/ 142
E-mail: reklam@turkiyeklinikleri.com

.: Subscription and Public Relations Department

Phone: +90 312 286 56 56/ 118
E-mail: abone@turkiyeklinikleri.com

.: Customer Services

Phone: +90 312 286 56 56/ 118
E-mail: satisdestek@turkiyeklinikleri.com

1. TERMS OF USE

1.1. To use the web pages with http://www.turkiyeklinikleri.com domain name or the websites reached through the sub domain names attached to the domain name (They will be collectively referred as "SITE"), please read the conditions below. If you do not accept these terms, please cease to use the "SITE." "SITE" owner reserves the right to change the information on the website, forms, contents, the "SITE," "SITE" terms of use anytime they want.

1.2. The owner of the "SITE" is Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. (From now on it is going to be referred as "Turkiye Klinikleri", shortly) and it resides at Turkocagi cad. No:30, 06520 Balgat Ankara. The services in the "SITE" are provided by "Turkiye Klinikleri."

1.3. Anyone accessing the "SITE" with or without a fee whether they are a natural person or a legal identity is considered to agree these terms of use. In this contract hereby, "Turkiye Klinikleri" may change the stated terms anytime. These changes will be published in the "SITE" periodically and they will be valid when they are published. Any natural person or legal identity benefiting from and reaching to the "SITE" are considered to be agreed to any change on hereby contract terms done by "Turkiye Klinikleri."

1.4. The "Terms of Use" hereby is published in the website with the last change on March 30th 2014 and the "SITE" is activated by enabling the access to everyone. The "Terms of Use" hereby is also a part of the any "USER Contract" was and/or will be done with the users using "Turkiye Klinikleri" services with or without a fee an inseparable.

2. DEFINITIONS

2.1. "SITE": A website offering different kind of services and context with a certain frame determined by "Turkiye Klinikleri" and it is accessible on-line on http://www.turkiyeklinikleri.com domain name and/or subdomains connected to the domain name.

2.2. USER: A natural person or a legal identity accessing to the "SITE" through online settings.

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

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

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

3. SCOPE OF THE SERVICES

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

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

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

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

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

4. GENERAL PROVISIONS

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

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

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

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

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

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

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

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

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

5. PROPRIETARY RIGHTS

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

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

6. CHANGES IN THE TERMS OF USE

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

7. FORCE MAJEURE

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

8. LAW AND AUTHORISATION TO FOLLOW

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

9. CLOSING AND AGREEMENT

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

 

30.03.2014

Privacy Policy

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

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

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

www.turkiyeklinikleri.com uses the taken information:

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

-To generate visitor’s profile and statistical data

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

-To send print publications/correspondences

-To send press releases or notifications through e-mail

-To generate a list for an event or competition

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

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

-Terms of use may change from time to time,

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

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

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

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

-During various attacks to the website,

-Disruption of the website because of a virus.

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

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

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

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

info@turkiyeklinikleri.com