Fatma ÖZKAN SİPAHİOLU, Mehmet Murat SAYIN

Tetraplejik-Ventilatör Bağımlı Hastada Trakeaözofageal Fistül Tanı ve Tedavisi: Olgu Sunumu

Edinilmiş trakea-özofageal fistül (TÖF), yoğun bakım ünitelerinde unutulmaması gereken nadir bir komplikasyondur. TÖF’ün benign nedenleri arasında en yaygın olanı kaf ilişkili trakeal tüp hasarı- dır. Bu olgu sunumunda ventilatör bağımlı tetraplejik bir hastada gelişen TÖF tanı ve tedavisi tartışılmaktadır. Trafik kazası sonrası yüksek seviye servikal fraktür nedeniyle tetrapleji gelişmiş 45 yaşında hasta, trakeotomi ile ventilatörde takip edildiği başka bir merkezden yoğun bakım ünitemize kabul edil- di. Stabil seyreden hastanın trakeotomili 37. gününde genel durumunda ani bir bozulma görüldü. Hastada yeterli havalanmaya rağmen, CO 2 retansiyonu oldu. Abdominal distansiyon gelişti ve nazogastrik sondada hava görüldü. Bilgisayarlı tomografide TÖF görüntülendi. Kesin tanı için endoskopi yapıldı. Trakea duvarından özofagusa geçiş yapmış kaf balonu görüntülendi. Hastanın akciğerini korumak amacıyla trakeotomi kanülü endotrakeal tüp ile değiştirildi ve balon fistülden uzakta şişirildi. Primer onarım cerrahisi planlanan hasta yaklaşık 1 hafta sonra başarıyla opere edildi. Postoperatif dönemde hastanın takibine ayarlanabilen trakeotomi kanülü ile devam edildi. Hasta halen yoğun bakımımızda takip edilmektedir. Trakeaözofageal fistül trakeotomi geç komplikasyonlarından biridir. Erken tanı hastayı olası fatal pulmoner komplikasyonlardan korumak için önemlidir. Trakeal sekresyon artışı, gastrik içerik aspirasyonu, havalandırma zorluğu, abdominal distansiyon veya nazogastrik sondaya hava dol- ması bizi TÖF açısından uyarmalıdır. Trakeaözofageal fistül ventilatöre bağımlı hastalarda hemen fark edilemeyebilir. Özel durumlarda ayarlanabilir trakeotomi kanülleri düşünülmelidir.

Diagnosis and Treatment of Tracheoesophageal Fistula in Tetraplegic-Ventilator Dependent Patient: Case Report

Acquired tracheoesophageal fistula (TEF) is a rare complication that should not be forgotten in intensive care units (ICUs). Cuff -related tracheal damage is the most common cause among the benign causes of TEF. In this case presentation, the diagnosis and treatment of TEF in a mechan- ically ventilated tetraplegic patient are discussed. A 45-year-old patient with tetraplegia due to high cervical fracture after a traffic accident was admitted to our ICU from another center where he was followed up with tracheostomy and mechanical ventilation. There was a sudden deterioration in patient’s general health condition while he was stable on the 37 th day of tracheostomy. Despite adequate ventilation, the patient had CO 2 retention. Abdominal distention developed and air was observed in nasogastric drainage tube. Computerized tomography revealed a TEF. Endoscopy was performed for definitive diagno- sis. Endotracheal tube cuff that entered into the esophagus was visualized. Tracheostomy can- nula was replaced by an endotracheal tube and the balloon was inflated distally from the fistula. The patient underwent a primary repair surgery successfully one week later. In the postoperative period the patient was followed-up with an adjustable tracheostomy cannula. The patient is still being followed up by us in our intensive care unit. Tracheoesophageal fistula is one of the late complications of tracheostomy. Early diagnosis is important to protect the patient from possible fatal pulmonary complications. Increased tracheal secretions, aspiration of gastric contents, ventilation difficulties, abdominal distention or filling of air into the nasogastric tube should alert us for TEF. Tracheoesophageal fistula may not be recognized immediately in ventilator-dependent patients. Adjustable tracheostomy tubes should be considered in special cases.

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