COVID-19’lu Yoğun Bakım Hastalarında Trakeostomi
Özet
COVID-19 pandemisinde yoğun bakım hastalarında uzun süreli endotrakeal entübasyonun ses teli paralizisi ve larenks hasarı gibi komplikasyonlarını önlemek amacıyla trakeostomi uygulanması önem taşımaktadır. Yoğun bakım ünitelerinde, yatak başında kolayca uygulanabilmesi, ameliyathaneye transfer gerektirmemesi ve daha az komplikasyon riski barındırması nedeniyle perkütan trakeostomi (PT) cerrahi trakeostomiye göre daha sık tercih edilmektedir. COVID-19 hastalarında trakeostomi zamanlaması belirlenirken hastanın klinik durumu ve bulaş riski bireysel olarak değerlendirilmeli, işlem öncesinde ise hastanın hemodinamik stabilitesi ile koagülasyon parametreleri kontrol edilerek mutlaka onam alınmalıdır. İşlem sırasında aerosol ve damlacık yayılımını en aza indirmek için sağlık çalışanlarının tam kişisel koruyucu ekipman (N95/FFP2 veya N99/FFP3 maske, siperlik, çift eldiven, önlük) kullanması, odada deneyimli ve minimum sayıda personel bulundurulması kritik öneme sahiptir. Ultrasonografi ve tek kullanımlık bronkoskopi gibi görüntüleme yöntemlerinin rehberliğinde gerçekleştirilen tekli dilatasyon tekniği, işlemin güvenliğini artırıp süresini kısaltarak bulaş riskini minimize eder. İşlem esnasında solunumun kapalı devrede tutulması, derin nöromusküler blokaj uygulanması, trakea lümenine girilmeden hemen önce mekanik ventilatörün durdurulması ve kafın hızla şişirilmesi gibi koruyucu yaklaşımlar enfeksiyon yayılımını önlemektedir. Trakeostominin en sık görülen erken komplikasyonları kanama ve hipoksemi iken, geç dönemde granülom formasyonu ve trakea stenozu gibi durumlar gelişebilir. Sonuç olarak, her hastanın ihtiyacına göre hazırlanan kontrol listeleri eşliğinde, deneyimli ekiplerce koruyucu basamaklar takip edilerek yapılan perkütan trakeostomi, yoğun bakımdaki COVID-19 hastalarında güvenli ve etkin bir havayolu yönetimi sağlamaktadır.
During the COVID-19 pandemic, performing a tracheostomy in intensive care patients has become crucial to prevent complications of prolonged endotracheal intubation, such as vocal cord paralysis and laryngeal injury. In intensive care units, percutaneous tracheostomy (PT) is preferred over surgical tracheostomy because it can be performed at the bedside, does not require transfer to the operating room, and carries lower complication rates. When determining the timing of tracheostomy in COVID-19 patients, the patient's clinical status and the risk of transmission must be evaluated individually, and consent must be obtained after checking hemodynamic stability and coagulation parameters. During the procedure, it is critical for healthcare workers to use full personal protective equipment (N95/FFP2 or N99/FFP3 masks, visors, double gloves, gowns) and to keep a minimum number of experienced personnel in the room to minimize aerosol and droplet dissemination. The single dilatation technique guided by imaging methods such as ultrasonography and disposable bronchoscopy increases safety, shortens the procedure time, and minimizes exposure risk. Protective approaches—such as maintaining closed-circuit ventilation, administering deep neuromuscular blockade, stopping mechanical ventilation immediately before entering the tracheal lumen, and rapidly inflating the cuff—prevent the spread of infection. While bleeding and hypoxemia are the most common early complications of tracheostomy, late-stage complications such as granuloma formation and tracheal stenosis may occur. In conclusion, percutaneous tracheostomy performed by experienced teams utilizing checklists tailored to individual patient needs and adhering to protective steps provides safe and effective airway management for COVID-19 patients in intensive care.
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