Topikalizasyon Tekniği ile Artırılmış Hasta Konforu: Uyanık Entübasyon Sürecinden Bir Olgu Sunumu
Özet
Zor havayolu yönetimi, anesteziyologlar için hem klinik başarıyı hem de hasta güvenliğini doğrudan etkileyen kritik bir alandır. Özellikle daha önce entübasyon başarısızlığı yaşamış olgularda, uyanık trakeal entübasyon (UTE) gibi rehber temelli stratejiler, komplikasyon riskini minimize etmede hayati rol oynar. Bu olgu sunumunda, geçmişte entübasyon başarısızlığı öyküsü bulunan ve ASA (Amerikan Anesteziyoloji Derneği) II sınıfında değerlendirilen 62 yaşındaki bir erkek hastada uygulanan UTE deneyimi aktarılmaktadır. Uygulamanın merkezinde ise topikalizasyonun sistematik ve çok aşamalı şekilde planlanması yer almaktadır. DAS (Difficult Airway Society) 2019 Yetişkinlerde Uyanık Trakeal Entübasyon Rehberinin ve ASA 2022 Zor Havayolu Yönetimi Uygulama Kılavuzunun önerileri doğrultusunda; topikal anestezi süreci, yalnızca lokal ajanın uygulanmasıyla sınırlı kalmamış, aynı zamanda minimal sedasyonun titre edilerek yönetilmesiyle desteklenmiştir. Öncelikle %2’lik lidokain çözeltisi 5 mL nebulizasyon yoluyla uygulanmıştır. Ardından, %10’luk lidokain sprey üçer puf olacak şekilde sağ ve sol dil köküne, üçer puf orta hatta ve ikişer puf sağ ve sol nazal kavitelere uygulanarak orofarenks, nazal kaviteler, tonsiller ve dil kökü anestezisi sağlanmıştır. Vokal kordlar geçilerek subglottik bölge fiberoptik bronkoskopi eşliğinde %2’lik lidokain 5 mL ile anestezi edilmiştir. İşlem süresince hastanın tamamen oryante, koopere ve anksiyeteden uzak olduğu gözlenmiştir. Minimal sedasyon altında yürütülen UTE işlemi sırasında, hastada öğürme, öksürük ve gag refleksleri gözlenmemiş; entübasyon başarılı, güvenli ve konforlu biçimde tamamlanmıştır. Rehberlerde sıkça vurgulandığı üzere, yetersiz topikalizasyon sedasyonla telafi edilemez ve bunun ihlali ciddi komplikasyonlara neden olabilir. Bu olgu, topikalizasyonun yalnızca teknik bir adım değil; UTE’nin başarısını belirleyen temel klinik bileşen olduğunu güçlü biçimde ortaya koymaktadır. Rehber temelli yaklaşım, ekip koordinasyonu ve hasta merkezli planlama ile topikalizasyonun UTE’deki vazgeçilmez rolü bir kez daha gözler önüne serilmiştir.
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