Turkiye Klinikleri Journal of Anesthesiology Reanimation

.: REVIEW
COVID-19, Anesthesia and Liver: Traditional Review
COVID-19, Anestezi ve Karaciğer: Geleneksel Derleme
Ayşe Hande ARPACIa , Berrin IŞIKb
aDepartment of Oral and Maxillofacial Surgery, Ankara University Faculty of Dentistry, Ankara, Türkiye
bDepartment of Anesthesiology and Reanimation, Gazi University Faculty of Medicine, Ankara, Türkiye
Turkiye Klinikleri J Anest Reanim. 2023;21(2):68-73
doi: 10.5336/anesthe.2022-94630
Article Language: EN
Full Text
ABSTRACT
 In the coronavirus disease-2019 (COVID-19) pandemic, which started in 2019 and was caused by the severe acute respiratory syndrome-coronavirus-2 virus, the clinical course of the infection was observed in a wide range from very mild symptoms to death. Although the respiratory system and lungs are mostly affected in COVID-19 infection, other organs and systems are also affected. The most common symptoms in COVID-19 are fever, cough, fatigue, difficulty breathing, anosmia, and loss of taste. In cases where clinical symptoms are more severe, acute respiratory distress syndrome, cytokine storms, multiple organ failure, sepsis and thrombosis are seen. Liver involvement has an important place in the course of COVID-19 apart from lung involvement, some patients with COVID-19 infection and cooperation difficulties require general anesthesia during computed tomography imaging procedures or intensive care treatments. Again, the need for urgent surgical intervention during infection causes them to be exposed to general anesthetics. The negative effects of general anesthesia agents on organ systems, especially on the liver, is an important issue that is frequently emphasized in the literature. Liver enzymes should be monitored in the clinical follow-up and estimation of mortality in patients with a diagnosis of COVID-19. Non-emergency surgeries of patients with a diagnosis of COVID-19 should be postponed or if anesthesia applications are necessary, non-hepatotoxic or minimally hepatotoxic methods should be performed. In this review, it is aimed to share information on anesthesia applications in terms of COVID-19 and liver functions by examining the relationship of COVID-19 with the liver.

Keywords: COVID-19; anesthesia; liver
ÖZET
 2019 yılında başlayan, şiddetli akut solunum sendromu-koronavirüs-2 virüsünün etken olduğu koronavirüs hastalığı-2019 [coronavirus disease-2019 (COVID-19)] pandemisinde, enfeksiyonun klinik seyri çok hafif belirtilerden ölüme varan geniş bir yelpazede izlenmiştir. COVID-19 enfeksiyonunda daha çok solunum sistemi ve akciğerler etkilenmekle birlikte, diğer organ ve sistemler de etkilenmektedir. COVID-19'da en sık görülen semptomlar ateş, öksürük, yorgunluk, nefes almakta zorluk, anosmi ve tat alma duyusunda kayıptır. Klinik belirtilerin daha ağır seyrettiği olgularda ise akut solunum sıkıntısı sendromu, sitokin fırtınaları, çoklu organ yetersizliği, sepsis ve trombozlar görülmektedir. COVID-19 seyrinde solunum sistemi ve akciğer dışı organ hasarlarında karaciğer tutulumu önemli bir yer tutmaktadır. COVID-19 enfeksiyonu geçiren ve uyum sorunu olan bazı hastalara bilgisayarlı tomografi görüntüleme işlemleri ya da yoğun bakım tedavileri sırasında genel anestezi uygulamaları gerekmektedir. Yine enfeksiyon sırasında acil cerrahi müdahale gerekmesi genel anesteziklere maruz kalmalarına neden olmaktadır. Genel anestezi ajanlarının organ sistemleri üzerine, özellikle de karaciğer üzerine olumsuz etkileri literatürde sıklıkla vurgulanan önemli bir konudur. COVID-19 tanılı hastaların klinik takibinde ve mortalite tahmininde karaciğer enzimleri izlenmelidir. COVID-19 tanılı hastaların acil olmayan cerrahileri ertelenmeli, anestezi uygulamaları hepatotoksik olmayan ya da en az hepatotoksik olan yöntemlerle yapılmalıdır. Bu derlemede, COVID-19'un karaciğer ile ilişkisi irdelenerek, COVID-19 ve karaciğer fonksiyonları açısından anestezi uygulamaları konusunda bilgi paylaşılması amaçlanmıştır.

Anahtar Kelimeler: COVID-19; anestezi; karaciğer
REFERENCES:
  1. Su WL, Lu KC, Chan CY, Chao YC. COVID-19 and the lungs: a review. J Infect Public Health. 2021;14(11):1708-14. [Crossref]  [PubMed]  [PMC] 
  2. Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS, et al. Extrapulmonary manifestations of COVID-19. Nat Med. 2020;26(7):1017-32. [Crossref]  [PubMed] 
  3. Jothimani D, Venugopal R, Abedin MF, Kaliamoorthy I, Rela M. COVID-19 and the liver. J Hepatol. 2020;73(5):1231-40. [Crossref]  [PubMed]  [PMC] 
  4. Fan Z, Chen L, Li J, Cheng X, Yang J, Tian C, et al. Clinical features of COVID-19-related liver functional abnormality. Clin Gastroenterol Hepatol. 2020;18(7):1561-6. [Crossref]  [PubMed]  [PMC] 
  5. Kumar MP, Mishra S, Jha DK, Shukla J, Choudhury A, Mohindra R, et al. Coronavirus disease (COVID-19) and the liver: a comprehensive systematic review and meta-analysis. Hepatol Int. 2020;14(5):711-22. [Crossref]  [PubMed]  [PMC] 
  6. Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW; the Northwell COVID-19 Research Consortium; Barnaby DP, Becker LB, Chelico JD, Cohen SL, Cookingham J, Coppa K, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized With COVID-19 in the New York City area. JAMA. 2020;323(20):2052-9. Erratum in: JAMA. 2020;323(20):2098. [Crossref]  [PubMed]  [PMC] 
  7. Xu L, Liu J, Lu M, Yang D, Zheng X. Liver injury during highly pathogenic human coronavirus infections. Liver Int. 2020;40(5):998-1004. [Crossref]  [PubMed]  [PMC] 
  8. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al; China Medical Treatment Expert Group for Covid-19. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382(18):1708-20. [PubMed]  [PMC] 
  9. Gordon DE, Jang GM, Bouhaddou M, Xu J, Obernier K, White KM, et al. A SARS-CoV-2 protein interaction map reveals targets for drug repurposing. Nature. 2020;583(7816):459-68. [PubMed]  [PMC] 
  10. Amin M. COVID-19 and the liver: overview. Eur J Gastroenterol Hepatol. 2021;33(3):309-11. [Crossref]  [PubMed]  [PMC] 
  11. Ding ZY, Li GX, Chen L, Shu C, Song J, Wang W, et al; Tongji Multidisciplinary Team for Treating COVID-19 (TTTC). Association of liver abnormalities with in-hospital mortality in patients with COVID-19. J Hepatol. 2021;74(6):1295-302. [PubMed]  [PMC] 
  12. Cai Q, Huang D, Yu H, Zhu Z, Xia Z, Su Y, et al. COVID-19: abnormal liver function tests. J Hepatol. 2020;73(3):566-74. [Crossref]  [PubMed]  [PMC] 
  13. Hartl L, Haslinger K, Angerer M, Jachs M, Simbrunner B, Bauer DJM, et al. Age-adjusted mortality and predictive value of liver chemistries in a Viennese cohort of COVID-19 patients. Liver Int. 2022;42(6):1297-307. [Crossref]  [PubMed]  [PMC] 
  14. Zhao S, Lin Q, Ran J, Musa SS, Yang G, Wang W, et al. Preliminary estimation of the basic reproduction number of novel coronavirus (2019-nCoV) in China, from 2019 to 2020: A data-driven analysis in the early phase of the outbreak. Int J Infect Dis. 2020;92:214-7. [Crossref]  [PubMed]  [PMC] 
  15. Rahman A, Niloofa R, Jayarajah U, De Mel S, Abeysuriya V, Seneviratne SL. Hematological abnormalities in COVID-19: a narrative review. Am J Trop Med Hyg. 2021;104(4):1188-201. [Crossref]  [PubMed]  [PMC] 
  16. Nardo AD, Schneeweiss-Gleixner M, Bakail M, Dixon ED, Lax SF, Trauner M. Pathophysiological mechanisms of liver injury in COVID-19. Liver Int. 2021;41(1):20-32. [Crossref]  [PubMed]  [PMC] 
  17. Kaltschmidt B, Fitzek ADE, Schaedler J, Förster C, Kaltschmidt C, Hansen T, et al. Hepatic vasculopathy and regenerative responses of the liver in fatal cases of COVID-19. Clin Gastroenterol Hepatol. 2021;19(8):1726-9.e3. [Crossref]  [PubMed]  [PMC] 
  18. Vishwajeet V, Purohit A, Kumar D, Vijayvergia P, Tripathi S, Kanchan T, et al. Evaluation of liver histopathological findings of coronavirus disease 2019 by minimally invasive autopsies. J Clin Exp Hepatol. 2022;12(2):390-7. [Crossref]  [PubMed]  [PMC] 
  19. Hammoud H, Bendari A, Bendari T, Bougmiza I. Histopathological findings in COVID-19 cases: a systematic review. Cureus. 2022;14(6):e25573. [Crossref]  [PubMed]  [PMC] 
  20. Elsoukkary SS, Mostyka M, Dillard A, Berman DR, Ma LX, Chadburn A, et al. Autopsy findings in 32 patients with COVID-19: a single-institution experience. Pathobiology. 2021;88(1):56-68. [Crossref]  [PubMed]  [PMC] 
  21. Lax SF, Skok K, Zechner P, Kessler HH, Kaufmann N, Koelblinger C, et al. Pulmonary arterial thrombosis in COVID-19 with fatal outcome: results from a prospective, single-center, clinicopathologic case series. Ann Intern Med. 2020;173(5):350-61. [Crossref]  [PubMed]  [PMC] 
  22. Díaz LA, Idalsoaga F, Cannistra M, Candia R, Cabrera D, Barrera F, et al. High prevalence of hepatic steatosis and vascular thrombosis in COVID-19: a systematic review and meta-analysis of autopsy data. World J Gastroenterol. 2020;26(48):7693-706. [Crossref]  [PubMed]  [PMC] 
  23. Saini RK, Saini N, Ram S, Soni SL, Suri V, Malhotra P, et al. COVID-19 associated variations in liver function parameters: a retrospective study. Postgrad Med J. 2022;98(1156):91-7. [Crossref]  [PubMed] 
  24. Melquist S, Estepp K, Aleksandrovich Y, Lee A, Beiseker A, Hamedani FS, et al. COVID-19 presenting as fulminant hepatic failure: a case report. Medicine (Baltimore). 2020;99(43):e22818. [Crossref]  [PubMed]  [PMC] 
  25. Teschke R, Méndez-Sánchez N, Eickhoff A. Liver injury in COVID-19 Patients with drugs as causatives: a systematic review of 996 DILI cases published 2020/2021 based on RUCAM as causality assessment method. Int J Mol Sci. 2022;23(9):4828. [Crossref]  [PubMed]  [PMC] 
  26. Zhang R, Wang Q, Yang J. Impact of liver functions by repurposed drugs for COVID-19 treatment. J Clin Transl Hepatol. 2022;10(4):748-56. [Crossref]  [PubMed]  [PMC] 
  27. Yoon E, Babar A, Choudhary M, Kutner M, Pyrsopoulos N. Acetaminophen-induced hepatotoxicity: a comprehensive update. J Clin Transl Hepatol. 2016;4(2):131-42. [Crossref]  [PubMed]  [PMC] 
  28. COVIDSurg Collaborative; GlobalSurg Collaborative. Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study. Anaesthesia. 2021;76(6):748-58. [Crossref]  [PubMed]  [PMC] 
  29. Thampi S, Yap A, Fan L, Ong J. Special considerations for the management of COVID-19 pediatric patients in the operating room and pediatric intensive care unit in a tertiary hospital in Singapore. Paediatr Anaesth. 2020;30(6):642-6. [Crossref]  [PubMed]  [PMC] 
  30. Greenland JR, Michelow MD, Wang L, London MJ. COVID-19 infection: implications for perioperative and critical care physicians. Anesthesiology. 2020;132(6):1346-61. Erratum in: Anesthesiology. 2020;133(3):693. [Crossref]  [PubMed]  [PMC] 
  31. Geng-Ramos G, Cronin J, Challa C, Brennan M, Matisoff A, Delaney M, et al. Anesthesia and surgery for positive COVID-19 asymptomatic pediatric patients: how long should we wait? Paediatr Anaesth. 2021;31(6):730-2. [Crossref]  [PubMed]  [PMC] 
  32. Ramsey PS, Ramin KD. Pneumonia in pregnancy. Obstet Gynecol Clin North Am. 2001;28(3):553-69. [Crossref]  [PubMed] 
  33. Wong SF, Chow KM, Leung TN, Ng WF, Ng TK, Shek CC, et al. Pregnancy and perinatal outcomes of women with severe acute respiratory syndrome. Am J Obstet Gynecol. 2004;191(1):292-7. [Crossref]  [PubMed]  [PMC] 
  34. Chen R, Zhang Y, Huang L, Cheng BH, Xia ZY, Meng QT. Safety and efficacy of different anesthetic regimens for parturients with COVID-19 undergoing cesarean delivery: a case series of 17 patients. Can J Anaesth. 2020;67(6):655-63. [Crossref]  [PubMed]  [PMC] 
  35. Vlachodimitropoulou Koumoutsea E, Vivanti AJ, Shehata N, Benachi A, Le Gouez A, Desconclois C, et al. COVID-19 and acute coagulopathy in pregnancy. J Thromb Haemost. 2020;18(7):1648-52. [Crossref]  [PubMed]  [PMC] 
  36. Basukala S, Rijal S, Karki S, Basukala B, Gautam AR. Spontaneous gallbladder perforation in patient with COVID-19-a case report and review of literature. J Surg Case Rep. 2021;2021(11):rjab496. [Crossref]  [PubMed]  [PMC] 
  37. Yohanathan L, Campioli CC, Mousa OY, Watt K, Friedman DZP, Shah V, et al. Liver transplantation for acute liver failure in a SARS-CoV-2 PCR-positive patient. Am J Transplant. 2021;21(8):2890-4. [Crossref]  [PubMed]  [PMC] 
  38. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. 2020;396(10243):27-38. Erratum in: Lancet. 2020 Jun 9. [PubMed]  [PMC] 
  39. Hanje AJ, Patel T. Preoperative evaluation of patients with liver disease. Nat Clin Pract Gastroenterol Hepatol. 2007;4(5):266-76. Erratum in: Nat Clin Pract Gastroenterol Hepatol. 2007;4(7):409. [Crossref]  [PubMed] 
  40. Ünüvar A. COVID-19 and coagulopathy. Journal of Advanced Research in Health Sciences. 2020;3(1):52-62. [Link] 
  41. Keegan MT, Plevak DJ. Preoperative assessment of the patient with liver disease. Am J Gastroenterol. 2005;100(9):2116-27. [Crossref]  [PubMed] 
  42. Wiklund RA. Preoperative preparation of patients with advanced liver disease. Crit Care Med. 2004;32(4 Suppl):S106-15. [Crossref]  [PubMed] 
  43. Remchuk SL, Levine WC. Spesific considerations with liver disease. In: Dunn PF, ed. Clinical Anesthesia Procedures of the Massachusetts General Hospital. 7th ed. Massachusett: Lippincott Williams & Wilkins: 2007. p.64-75.
  44. O'Leary JG, Yachimski PS, Friedman LS. Surgery in the patient with liver disease. Clin Liver Dis. 2009;13(2):211-31. [Crossref]  [PubMed] 
  45. Nelson PD, Ferguson CN, Jones RM. Anaesthetic organ toxicity: is it really a problem? Curr Opin Anaesthesiol. 1998;11(4):399-401. [Crossref]  [PubMed] 
  46. Cohen EN. Toxicity of inhalation anaesthetic agents. Br J Anaesth. 1978;50(7):665-75. [Crossref]  [PubMed] 
  47. Eghtesadi-Araghi P, Sohrabpour A, Vahedi H, Saberi-Firoozi M. Halothane hepatitis in Iran: a review of 59 cases. World J Gastroenterol. 2008;14(34):5322-6. [Crossref]  [PubMed]  [PMC] 
  48. Côté G, Bouchard S. Hepatotoxicity after desflurane anesthesia in a 15-month-old child with Mobius syndrome after previous exposure to isoflurane. Anesthesiology. 2007;107(5):843-5. [Crossref]  [PubMed] 
  49. Jones RM. Clinical comparison of inhalation anaesthetic agents. Br J Anaesth. 1984;56 Suppl 1:57S-69S. [PubMed] 
  50. Stark RD, Binks SM, Dutka VN, O'Connor KM, Arnstein MJ, Glen JB. A review of the safety and tolerance of propofol ('Diprivan'). Postgrad Med J. 1985;61 Suppl 3:152-6. [PubMed] 
  51. Servin F, Desmonts JM, Haberer JP, Cockshott ID, Plummer GF, Farinotti R. Pharmacokinetics and protein binding of propofol in patients with cirrhosis. Anesthesiology. 1988;69(6):887-91. [Crossref]  [PubMed] 
  52. Soleimanpour H, Safari S, Shahsavari Nia K, Sanaie S, Alavian SM. Opioid drugs in patients with liver disease: a systematic review. Hepat Mon. 2016;16(4):e32636. [Crossref]  [PubMed]  [PMC] 
  53. Moore EW, Hunter JM. The new neuromuscular blocking agents: do they offer any advantages? Br J Anaesth. 2001;87(6):912-25. [Crossref]  [PubMed] 
  54. Hölscher AH. Patient, surgeon, and health care worker safety during the COVID-19 pandemic. Ann Surg. 2021;274(5):681-7. Erratum in: Ann Surg. 2021;274(6):e665. [Crossref]  [PubMed]  [PMC] 
  55. Suri A, Sindwani G. Ketamine use in the COVID-19 era: be cautious! Korean J Anesthesiol. 2020;73(6):568-9. [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