Travmatik Beyin Hasarı Olan Erişkin Hastalarda Yoğun Bakım Yönetimi
Özet
Travmatik beyin hasarı (TBH), dünya genelinde mortalite ve morbiditenin en önemli nedenlerinden biridir. Yoğun bakım yönetiminde temel amaç, sekonder beyin hasarını önlemek ve intrakraniyal basıncı (ICP) kontrol altında tutmaktır. Hastaların nörolojik durumunu değerlendirmek için Glasgow Koma Skalası (GKS) standart bir yöntem olarak kullanılırken, GKS skoru 9'un altındaki vakalar şiddetli TBH olarak tanımlanır. Tedavi sürecinde övoleminin korunması için normal salin tercih edilmeli; beyin ödemini tetikleyebilecek hipotonik sıvılardan ve mortaliteyi artırabilen albüminden kaçınılmalıdır. Kan basıncı yönetiminde, yaş gruplarına göre belirlenmiş sistolik eşiklerin (100-110 mmHg) korunması ve serebral perfüzyon basıncının 60-70 mmHg seviyesinde tutulması kritiktir. Solunum desteği alan hastalarda hiperkarbi ve hipokarbiden kaçınmak için end-tidal karbondioksit monitörizasyonu yapılmalıdır. Nöbet profilaksisinde sıklıkla levetirasetam kullanılırken, venöz tromboembolizm riskine karşı mekanik ve stabilize hastalarda farmakolojik önlemler alınmalıdır. Ayrıca kan şekeri (140-180 mg/dL) ve vücut ısısının (normotermi) titizlikle yönetilmesi gerekir. ICP takibi için eksternal ventriküler drenaj en güvenilir yöntemdir ve hedef basınç ≤ 22 mmHg'dir. Dirençli vakalarda dekompresif kraniektomi, barbitürat koması veya hipotermi gibi ileri tedaviler uygulanabilir. Şiddetli TBH sonrası uzun vadeli prognoz genellikle zayıftır ve iyileşme süreci hipoksik iskemik hasarın boyutuna bağlıdır.
Traumatic brain injury (TBI) is one of the leading causes of mortality and morbidity worldwide. The primary goal of intensive care management is to prevent secondary brain injury and maintain control over intracranial pressure (ICP). The Glasgow Coma Scale (GCS) is used as a standard method to assess neurological status, with scores below 9 defined as severe TBI. During treatment, normal saline should be preferred to maintain euvolemia; hypotonic fluids that may trigger cerebral edema and albumin, which can increase mortality, should be avoided. In blood pressure management, maintaining systolic thresholds (100-110 mmHg) based on age groups and keeping cerebral perfusion pressure at 60-70 mmHg is critical. End-tidal carbon dioxide monitoring is essential for patients on respiratory support to avoid hypercarbia and hypocarbia. Levetiracetam is frequently used for seizure prophylaxis, while mechanical and, in stabilized patients, pharmacological measures should be taken against the risk of venous thromboembolism. Additionally, blood glucose (140-180 mg/dL) and body temperature (normothermia) must be meticulously managed. External ventricular drainage is the most reliable method for ICP monitoring, with a target pressure of ≤ 22 mmHg. In refractory cases, advanced treatments such as decompressive craniectomy, barbiturate coma, or hypothermia may be applied. The long-term prognosis after severe TBI is generally poor, and the recovery process depends on the extent of hypoxic-ischemic damage.
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