Estudo transversal retrospectivo das infecções odontogênicas em um hospital universitário público / Retrospective cross-sectional study of dental infections in a public university hospital

Infecções odontogênicas são quadros clínicos que podem se agravar quando não tratados no tempo e da forma adequada. A disseminação do processo infeccioso para os tecidos e espaços fasciais adjacentes leva a internação hospitalar e pode provocar com frequência grande morbidade, mas raramente óbitos. Propusemo-nos a analisar por um estudo retrospectivo dados de prontuários de pacientes com infecções odontogênicas no período de janeiro de 2010 a janeiro de 2021 em um hospital universitário público para verificar possíveis associações de fatores clínicos e laboratoriais no aumento do tempo de internação. Uma amostra aleatória de 220 prontuários conforme a Classificação Internacional de Doenças (CID-10) em K-047 (abscesso periapical) e K-122 (celulite e abscesso da boca) foi selecionada para coleta de dados. 43% dos prontuários (n=99) continham a maioria das informações para coleta das variáveis como: sexo, idade, regiões anatômicas envolvidas, comorbidades, resultados de exames laboratoriais quando presentes (contagem de leucócitos, proteína C-reativa e hemoglobina), origem da infecção, tratamento, período de internação, antibióticos administrados, relato ou outras medicações quando descritas. Os dados foram distribuídos quanto a média e desvio padrão, medidas de frequência e foram submetidos a teste de associação (qui-quadrado ou exato de Fisher) para algumas variáveis relacionadas a gravidade e alongamento do tempo de hospitalização. A maioria dos casos foi de celulite e abscessos da boca (K-122)sendo os mais graves em homens com idade entre os 27 a 32 anos. Não foramreportados óbitos. Os casos de menor gravidade foram abscesso periapical (K-047) envolveram igualmente homens e mulheres na sua maioria crianças entre 12 e 13 anos. A região mais acometida em toda a amostra foi o espaço submandibular. Houve evolução para mediastinite em cinco casos e em 14 para angina de Ludwig. O período de internação para os casos de menor gravidade foi de 3 dias em média enquanto para os casos de maior gravidade ultrapassaram 7 dias. Encontramos associação significativa na amostra total vinculando alongamento da permanência hospitalar por mais do que 3 dias (72h) com os casos de maior gravidade incluindo 6 os registros de celulite e abscesso da boca (K-122), (p=0.003) e quando múltiplos espaços estivessem acometidos (p<0.001). Não foi possível verificar associação significativa entre os resultados dos exames laboratoriais e o alongamento da permanência hospitalar (>72h) porém nos casos de maior gravidade os níveis de PCR se confirmaram significativamente mais elevados. Para os de menor gravidade, periapical (K-047), a penicilina e derivados foram os antibióticos de escolha. Para os casos de maior gravidade a associação de ceftriaxona e clindamicina foi a mais utilizada. Concluímos que os dados corroboram com os dados da literatura internacional. Um estudo prospectivo com maior amostra deve ser conduzido para sugerir fatores preditores clínicos e laboratoriais de gravidade e alongamento de permanência hospitalar.

Manejo de la hipoxia durante ventilación unipulmonar en un paciente con absceso mediastinal y mediastinitis para toracotomía abierta. Reporte de caso / Hypoxia Management during One-Lung Ventilation in a Patient with Mediastinal Abscess and Mediastinitis for Open Thoracotomy. Case Report

Introducción: la mayoría de los pacientes que se someten a cirugía torácica pueden ser clasificados en el grupo de alto riesgo para hipoxia, especialmente cuando se decide por una ventilación unipulmonar, debido al desequilibrio V/Q; por lo tanto, se han desa-rrollado nuevas estrategias ventilatorias y maniobras de rescate para hipoxia. Curso clínico: presentamos una paciente de 85 años de edad sin comorbilidades programada para toracotomía abierta y manejada con ventilación unipulmonar. Durante el mane-jo anestésico, se presenta hipoxia secundaria a desequilibrio V/Q y choque hipovolémi-co hemorrágico, con respuesta positiva a las maniobras de rescate para hipoxia. Con-clusión: es importante prevenir en la medida de lo posible la hipoxia en la ventilación unipulmonar, siguiendo las nuevas estrategias ventilatorias. Sin embargo, cuando se presenta una crisis, no debemos retrasar las maniobras de rescate de forma moderna. (AU)

Introduction: most of the patients undergoing thoracic surgery fit in the high risk group for hypoxia, especially when deciding to use one-lung ventilation due to the V/Q mis-match; therefore, new ventilation strategies and hypoxia rescue manoeuvres have been developed. Clinical course: we present an 85-year old female with no major co-morbidities scheduled for open thoracotomy and managed with one-lung ventilation. During the course of the anaesthetic management, hypoxia presents secondary to V/Q mismatch and haemorrhagic hypovolemic shock, with a positive response to hypoxia rescue manoeuvres. Conclusion: it is important to prevent as much as we can the hy-poxia in a one-lung ventilation following the new ventilation strategies. Although when facing a crisis, proper hypoxia management with a modern approach should not be de-layed. (AU)

Clinical management and prognosis for descending necrotizing mediastinitis / 中华耳鼻咽喉头颈外科杂志

Objective: To investigate the clinical characteristics, treatment experiences and prognostic factors for descending necrotizing mediastinitis (DNM). Methods: A retrospective analysis was performed on the data of 22 patients with DNM diagnosed and treated in Henan Provincial People's Hospital from January 2016 to August 2022, including 16 males and 6 females, aged 29-79 years. After admission, all patients underwent CT scanning of the maxillofacial, cervical, and thoracic regions to confirm their diagnoses. Emergency incision and drainage were performed. The neck incision was treated with continuous vacuum sealing drainage. According to the prognoses, the patients were divided into cure group and death group, and the prognostic factors were analyzed. SPSS 25.0 software was used to analyze the clinical data. Rusults: The main complaints were dysphagia (45.5%, 10/22) and dyspnea (50.0%, 11/22). Odontogenic infection accounted for 45.5% (10/22) and oropharyngeal infection accounted for 54.5% (12/22). There were 16 cases in the cured group and 6 cases in the death group, with a total mortality rate of 27.3%. The mortality rates of DNM typeⅠand typeⅡwere respectively 16.7% and 40%. Compared with the cured group, the death group had higher incidences for diabetes, coronary heart disease and septic shock (all P<0.05). There were statistically significant differences between the cure group and the death group in procalcitonin level (50.43 (137.64) ng/ml vs 2.92 (6.33) ng/ml, M(IQR), Z=3.023, P<0.05) and acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) score (16.10±2.40 vs 6.75±3.19, t=6.524, P<0.05). Conclution: DNM is rare, with high mortality, high incidence of septic shock, and the increased procalcitonin level and APACHE Ⅱ score combined diabetes and coronary heart disease are the poor prognostic factors for DNM. Early incision and drainage combined with continuous vacuum sealing drainage technique is a better way to treat DNM.

Mediastinitis descendente en el contexto de la angina de Ludwig. Artículo de revisión / Descending mediastinitis in the context of Ludwig's Angina. Article review

Introducción: la mediastinitis se define como el proceso inflamatorio usualmente infeccioso del tejido conectivo mediastinal y los órganos que este rodea. Específicamente, la mediastinitis descendente corresponde a una complicación rara por infección de los espacios profundos del cuello, la orofaringe o la cavidad oral, que se extiende a través de los espacios fasciales del cuello y los diseca. De forma infrecuente, esta patología puede originarse a partir de la parotiditis, las infecciones de la piel del cuello o la epiglotitis. También, de manera menos frecuente, puede generarse en el contexto de un traumatismo del cuello o la cavidad oral. En este estudio se pretende llamar la atención, en particular, sobre los aspectos que involucran al especialista otorrinolaringólogo en el manejo de los pacientes con infecciones profundas del cuello y su rol en el diagnóstico y tratamiento eficaz de la mediastinitis descendente, como la principal causa de mortalidad en estos casos. Metodología: se llevó a cabo una búsqueda con las palabras clave "Airway" "Ludwig's angina" en PubMed, no se efectuó filtración por fecha ni tipo de estudio. Se encontró un total de 147 artículos. Se realizó lectura de los resúmenes por los autores y se seleccionaron 50. Se realizó lectura crítica del texto completo de los 50 artículos resultantes de la búsqueda y se extrajo la información relevante. Conclusión: esta patología de marcada severidad conlleva a un aumento significativo de la mortalidad. Su tratamiento, aunque permanece controversial en ciertas circunstancias, debe ser agresivo y oportuno, con un enfoque en el rol del otorrinolaringólogo en 4 pilares de tratamiento: el drenaje quirúrgico, la antibioticoterapia de amplio espectro, el soporte hemodinámico y la seguridad de la vía aérea.

Introduction: Mediastinitis is defined as the usually infectious inflammatory process of the mediastinal connective tissue and the organs it surrounds. Specifically, descending mediastinitis corresponds to a rare complication, an infection of deep spaces of the neck, oropharynx, or oral cavity, which extends through the facial spaces of the neck, dissecting. Less frequent, this pathology can originate from parotiditis, skin infections of the neck or epiglottitis. Also, less frequent it can be generated in the context of trauma to the neck or oral cavity. This study intends to draw attention to the aspects that involve the ENT specialist in the management of patients with deep neck infections and their role in the diagnosis and effective treatment of descending mediastinitis as the main cause of mortality in these patients. Methodology: A search was carried out with the keywords "Airway" "Ludwig's angina" in PubMed, no filtering was performed by date or type of study, finding a total of 147 articles, abstracts were read by the authors, selecting 50. A critical reading of the 50 articles full texts is carried out and the relevant information is extracted. Conclusion: This pathology of marked severity, carries a significant increase in mortality and its treatment, although it remains controversial in certain circumstances, it must be aggressive and timely, focusing the role of the otorhinolaryngologist on 4 pillars of treatment: surgical drainage, antibiotic therapy, hemodynamic support, and airway safety.

Risco de mediastinite no pós-operatório de cirurgia de revascularização do miocárdio / Risk of mediastinitis in the postoperative period of myocardial revascularization surgery / Riesgo de mediastinitis en el postoperatorio de cirugía de revascularización miocárdica

Objetivo: classificar os pacientes segundo o risco de desenvolvimento de mediastinite no pós-operatório de cirurgia de revascularização do miocárdio. Método: estudo observacional, transversal, realizado na Unidade de Terapia Intensiva Pós-Operatória de um hospital universitário no interior paulista. Amostra consecutiva e não probabilística foi constituída por pacientes adultos, submetidos à revascularização do miocárdio. A coleta de dados foi realizada na alta da Terapia Intensiva, utilizando o Escore de Risco Multivariável para Mediastinite. Para a obtenção do escore foram realizadas análises estatística descritivas. Resultados: participaram do estudo 50 pacientes, 68% do sexo masculino, com média de idade de 62,7 anos. Nenhum paciente foi reoperado ou apresentava doença pulmonar obstrutiva crônica; 26,0% eram obesos; 12,0% apresentaram angina instável e 4,0% foram politransfundidos no pós-operatório. Segundo o escore, 58,0% apresentaram baixo e 42,0% médio risco de desenvolvimento de mediastinite. Conclusão: a maior parte dos pacientes apresentava baixo risco de desenvolvimento de mediastinite

Objective: to classify patients according to the risk of developing mediastinitis in the postoperative period of myocardial revascularization surgery. Method: observational, cross-sectional study, carried out in the Post-Operative Intensive Care Unit of a university hospital in the interior of São Paulo. Consecutive and non-probabilistic sample consisted of adult patients who underwent myocardial revascularization. Data collection was performed at discharge from the Intensive Care, using the Multivariable Risk Score for Mediastinitis. To obtain the score, descriptive statistical analyzes were performed. Results: the50 patients participated in the study, 68% were male, with a mean age of 62.7 years. No patient was reoperated or had chronic obstructive pulmonary disease; 26.0% were obese; 12.0% had unstable angina and 4.0% were transfused in the postoperative period. According to the score, 58.0% had a low and 42.0% medium risk of developing mediastinitis. Conclusion: most patients were at low risk of developing mediastinitis

Objetivo: clasificar a los pacientes según el riesgo de desarrollar mediastinitis en el postoperatorio de cirugía de revascularización miocárdica. Método: estudio observacional, transversal, realizado en la Unidad de Cuidados Intensivos Posoperatorios de un hospital universitario del interior de São Paulo. La muestra consecutiva y no probabilística estuvo constituida por pacientes adultos sometidos a revascularización miocárdica. La recolección de datos se realizó al alta de la Unidad de Cuidados Intensivos, utilizando el Multivariable Risk Score para Mediastinitis. Para obtener la puntuación se realizaron análisis estadísticos descriptivos. Resultados: participaron en el estudio 50 pacientes, el 68% eran varones, con una edad media de 62,7 años. Ningún paciente fue reintervenido ni presentó enfermedad pulmonar obstructiva crónica; El 26,0% eran obesos; El 12,0% presentó angina inestable y el 4,0% recibió transfusión en el postoperatorio. Según el puntaje, el 58.0% tenía un riesgo bajo y el 42.0% medio de desarrollar mediastinitis. Conclusión: la mayoría de los pacientes tenían un riesgo bajo de desarrollar mediastinitis

Short-term efficacy and perioperative safety of catheter-based intervention for pulmonary vein stenosis caused by fibrosing mediastinitis / 中华心血管病杂志

Objective: To evaluate the short-term efficacy and perioperative safety of catheter-based intervention in patients with pulmonary vein stenosis caused by fibrosing mediastinitis (FM). Methods: It was a case series study. Consecutive patients with pulmonary vein stenosis caused by FM, who underwent percutaneous pulmonary vein angioplasty in Gansu Provincial Hospital from January 2018 to June 2020, were retrospective enrolled. The baseline characteristics, comorbidities, exercise capacity and hemodynamic data before and after treatment were compared, and the procedural related complications were evaluated. Results: A total of 30 patients ((64.3±7.1) years, 15 males) were included. Sixty-three pulmonary vein stenosis were treated by 32 percutaneous pulmonary vein angioplasty procedures. Forty-four stents were implanted in 41 pulmonary veins after balloon angioplasty, and the diameter of implanted stents was (8.3±1.2)mm. Balloon angioplasty was performed on 22 pulmonary vein stenosis, the mean balloon diameter was (4.2±2.1)mm. The pulmonary vein diameter increased from (2.6±1.3) to (6.6±2.6) mm (P<0.001) and the pressure gradient across the pulmonary vein stenotic segment reduced from 19 (12, 29) to 2 (0, 4) mmHg (1 mmHg=0.133 kPa) (P<0.001) immediately post procedure. The pulmonary vein flow grade was significantly improved compared with baseline (P<0.001). The most common operation related complications were lung injury (44.0% (11/25)) and hemoptysis (18.8% (6/32)), which did not need special treatment. During the 2.0 (1.3, 3.2) months follow-up, the WHO functional class was significantly improved (P<0.05), the 6-minute walking distance increased from (254.8±114.5) m to (342.8±72.4)m (P<0.05), the mean pulmonary arterial pressure decreased from (40.9±8.3) mmHg to (35.4±7.7) mmHg (P<0.01), 17 out of 19 patients with refractory pleural effusion experienced total remission during the follow-up period (P<0.001). CT pulmonary venography was repeated in 17 patients. The incidence of in-stent restenosis of pulmonary vein was 24.0% (6/25). Conclusions: Percutaneous pulmonary vein angioplasty is effective for the treatment of pulmonary vein stenosis caused by fibrosing mediastinitis. However, it's not so safe, procedural related complication should be paid attention to and the rate of in-stent restenosis is relative high during the short-term follow-up.

Treatment and Chest Reconstruction for Mediastinitis Following Sternotomy for Cardiac Surgery at the Heart Institute of the University of São Paulo Medical School

Abstract This study presents the method used for chest reconstruction and treatment of mediastinitis following cardiac surgery at the Heart Institute of the University of São Paulo Medical School. After infection control with antibiotic therapy associated with aggressive surgical debridement and negative pressure wound therapy, chest reconstruction is performed using flaps. The advantages and disadvantages of negative pressure wound therapy are discussed, as well as options for flap-based chest reconstruction according to the characteristics of the patient and sternum. Further studies are needed to provide evidence to support the decisions when facing this great challenge.

Mediastinitis necrotizante descendente de origen odontogénico / Descending necrotizing mediastinitis of odontogenic origin

Resumen Introducción: El tratamiento inoportuno e ineficaz de las infecciones odontogénicas puede causar complicaciones potencialmente mortales como la mediastinitis necrotizante descendente (MND). La MDN es una infección grave que afecta al cuello-tórax, con una alta tasa de mortalidad por sepsis e insuficiencia orgánica si no se trata de manera rápida y efectiva. Objetivo: Describir un caso de MND de origen odontogénico y su manejo médico-quirúrgico. Caso clínico: Presentamos un paciente de sexo masculino de 34 años que ingresa con un cuadro infeccioso agudo de origen odontogénico, que compromete espacios de la cabeza, cuello y tórax (mediastino superior), el cual se trata exitosamente. Discusión: Las infecciones odontogénicas son generalmente localizadas y que se pueden tratar mediante terapias convencionales. A pesar de esto, si estas infecciones no pueden controlarse, ya sea por no realización de tratamientos oportunos o por estados inmunosuprimidos del paciente, se pueden desarrollar diferentes complicaciones como la MND. Conclusión: Un diagnóstico rápido, el tratamiento quirúrgico agresivo, la terapia antibiótica adecuada y la atención de apoyo son los pilares fundamentales para el manejo de la MND.

Introduction: Inappropriate and ineffective treatment of odontogenic infections can cause life-threatening complications such as Descending Necrotizing Mediastinitis (MND). MDN is a serious infection that affects the neck-thorax, with a high mortality rate from sepsis and organ failure if it is not treated quickly and effectively. Aim: To describe a case of MND of odontogenic origin and its medical-surgical management. Case report: We present a 34-year-old male patient who is admitted with an acute infectious condition of odontogenic origin, which compromises spaces of the head, neck and thorax (upper mediastinum), which is treated successfully. Discussion: Odontogenic infections are generally localized and can be treated by conventional therapies. In spite of this, if these infections cannot be controlled, either by not carrying out appropriate treatments or by immunosuppressed states of the patient, different complications such as MND can develop. Conclusion: A rapid diagnosis, aggressive surgical treatment, adequate antibiotic therapy and supportive care are the fundamental pillars for the management of MND.

Mediastinitis necrotizante descendente de origen odontogénico / Descending necrotizing mediastinitis of odontogenic origin

Introducción: las infecciones odontogénicas afectan al 80 %-90 % de la población y pueden dar lugar a complicaciones potencialmente mortales como la mediastinitis necrotizante descendente, una infección polimicrobiana aguda en el mediastino con una tasa de mortalidad entre el 11 % y 40 %. Su detección precoz y el tratamiento adecuado con manejo antibiótico y drenaje quirúrgico a cargo de un equipo multidisciplinario representan factores influyentes en el pronóstico de la enfermedad. Objetivo: en este artículo presentamos un caso de mediastinitis necrotizante descendente en un paciente masculino de 34 años, que se originó por una infección odontogénica que requirió un procedimiento dental. El paciente fue hospitalizado por el empeoramiento del estado clínico a pesar de la profilaxis antibiótica. La tomografía axial computarizada (TAC) confirmó la extensión de la infección al mediastino, y el paciente fue tratado con éxito con antibioterapia intravenosa y múltiples drenajes quirúrgicos intraorales, cervicotomía y toracoscopia. Materiales y métodos: se realizó una búsqueda en bases de datos globales y se seleccionaron los artículos por los siguientes términos MeSH y DeCS: "mediastinitis necrotizante descendente", "angina de Ludwig", "absceso", "toracoscopia" y sus respectivos en inglés, priorizando los referentes a la mediastinitis necrotizante descendente de origen odontogénico. Conclusiones: en la mediastinitis necrotizante descendente, la combinación de diagnóstico precoz, tratamiento antibiótico de amplio espectro, mantenimiento de la vía aérea y drenaje quirúrgico amplio y a cargo de un equipo multidisciplinario mejora de manera importante el pronóstico de la enfermedad.

Introduction: Odontogenic infections affect 80%-90% of the population and can lead to life-threatening complications such as descending necrotizing mediastinitis. Is an acute polymicrobial infection in the mediastinum with a mortality rate of 11%-40%. Its early detection and adequate treatment with antibiotic management and surgical drainage by a multidisciplinary team represent influential factors in the prognosis of the disease. Objective: In this article, we present a case of descending necrotizing mediastinitis in a 34-year-old male patient that originated from an odontogenic infection that required a dental procedure. The patient was hospitalized for worsening clinical status despite antibiotic prophylaxis. Computed axial tomography confirmed the extension of the infection to the mediastinum and the patient was successfully treated with intravenous antibiotherapy and multiple intraoral, cervicotomy, and thoracoscopic surgical drains. Materials and methods: A search was made in global databases, articles were selected by the following MeSH and DeCS terms: "descending necrotizing mediastinitis", "Ludwig's angina", "abscess", "thoracoscopy", and their respective English terms, prioritizing those referring to descending necrotizing mediastinitis of odontogenic origin. Conclusions: In descending necrotizing mediastinitis, the combination of early diagnosis, broad-spectrum antibiotic treatment, airway maintenance, and extensive surgical drainage by a multidisciplinary team significantly improves the prognosis of the disease.

Intervenções a pacientes com mediastinite pós-esternotomia: revisão integrativa da literatura / Intervenciones para pacientes con mediastinitis post-esternotomía: una revisión bibliográfica integradora / Interventions for patients with post-sternotomy mediastinitis: an integrative literature review

Objetivo: analisar as evidências disponíveis na literatura sobre as intervenções a pacientes com mediastinite pós-esternotomia. Método: Revisão integrativa com busca dos estudos primários nas bases de dados LILACS, MEDLINE (via PUBMED), CINAHL e BDENF, publicados em inglês, português e espanhol. Resultados: Os oito artigos analisados mostram que, na maioria deles, a intervenção mais utilizada foi terapia por pressão negativa, associada ou não a antibioticoterapia e cirurgia reconstrutora. Conclusão: As evidências científicas geradas fornecem subsídios para a tomada de decisão quanto às intervenções para pacientes pós-cirurgia cardíaca com mediastinite, bem como a identificação de lacunas do conhecimento, para a condução de novas pesquisas com o propósito de implementar intervenções de enfermagem a esses pacientesa(AU)

Objective: To analyze information available in the literature on interventions for patients with mediastinitis after a cardiac surgery. Method: an integrative review of primary studies in the databases LILACS, MEDLINE (via PUBMED), CINAHL and BDENF, published in English, Portuguese, and Spanish. Results: Most of the eight analyzed articles show that the most used intervention was negative pressure therapy, whether or not associated with antibiotic therapy and reconstructive surgery. Conclusion: the scientific evidence analyzed supports decision-making processes regarding interventions for patients with mediastinitis after cardiac surgery. It also allows the identification of knowledge gaps to conduct new research and implement nursing interventions for these patients(AU)

Objetivo: Analizar las evidencias disponibles en la literatura sobre intervenciones en pacientes con mediastinitis después de la cirugía cardíaca. Método: Revisión integradora con búsqueda de estudios primarios en las bases de datos LILACS, MEDLINE (vía PUBMED), CINAHL y BDENF, publicados en inglés, portugués y español. Resultados: Los ocho artículos analizados muestran que en la mayoría de ellos la intervención más utilizada fue la terapia de presión negativa, asociada o no con la terapia con antibióticos y la cirugía reconstructiva. Conclusión: La evidencia científica generada respalda la toma de decisiones con respecto a las intervenciones en pacientes después de una cirugía cardíaca con mediastinitis, así como la identificación de lagunas de conocimiento para realizar nuevas investigaciones con el propósito de implementar intervenciones de enfermería para estos pacientes(AU)

Angina de ludwig de foco amigdaliano evoluindo para mediastinite - Um caso de sucesso / Amigdalian focus of ludwig's angina expanding to mediastinitis - A success case

Objetivo: relatar e descrever a evolução satisfatória de uma Angina de Ludwig decorrente de uma infecção amigdaliana, que evoluiu para mediastinite e choque séptico. O trabalho visa detalhar os aspectos clínicos e diagnósticos desta grave doença, além da terapêutica empregada neste caso. Método: as informações foram obtidas do prontuário do paciente, bem como dos laudos dos exames de imagem realizados. A revisão da literatura foi feita na base de dados PUBMED. Considerações finais: o caso estudado relata um raro desfecho favorável de uma Angina de Ludwig que evoluiu para mediastinite, cuja taxa de mortalidade é de até 50% dos casos. A abordagem cirúrgica combinada com antibioticoterapia precoce se mostra ser a melhor conduta para estes casos.

Objective: report and describe the satisfactory evolution of Ludwig's Angina due to a tonsillary infection, which evolved to mediastinitis and sept shock. The work aims to detail the clinical and diagnostic aspects of this serious illness, in addition to the therapy used in this case. Method: the information was obtained from the patient's medical record, as well as from the reports of the imaging tests performed. The literature review was carried out in the PUBMED database. Final considerations: the case studied has great importance for the medical community, since it reports a rare favorable outcome for a case of Ludwig's Angina complicated with an mediastinitis, whose mortality is described up to 50% of the cases. The surgical approach combined with early antibiotic therapy is shown to be the best approach for these cases.

Mediastinitis necrotizante descendente de origen dental: revisión de la literatura y presentación de un caso / Descending necrotizing mediastinitis of dental origin: a case study and review of the literature

La mediastinitis se define como una inflamación aguda severa de los tejidos conectivos ubicados en la cavidad torácica media, en la que 20% de los casos puede implicar una infección difusa y polimicrobiana del mediastino denominada mediastinitis necrotizante descendente (MND), secundaria a la propagación de una infección grave desde los tejidos bucofaríngeos o cervicales tales como infecciones odontogénicas (de 36 a 47%), faríngeas (de 33 a 45%), cervicales (15%) y otras infecciones de cabeza y cuello (5%). Clínicamente, los pacientes presentan aumento de volumen, temblores, trismus, odinofagia con disnea, disfagia, hipotensión, dolor de cuerpo y del ángulo de la mandíbula. Puede observarse signo de Hamman (crepitación mediastinal con el latido cardiaco) y enfisema subcutáneo. El manejo quirúrgico de las infecciones odontogénicas, sin importar su severidad, consta de dos principios: eliminar el foco etiológico y el vaciamiento quirúrgico de los espacios anatómicos comprometidos con la instalación de un drenaje adecuado. Se presenta el caso de un masculino de 60 años con diagnóstico de mediastinitis necrotizante descendente de origen dental (AU)

Mediastinitis is defined as a severe acute inflammation of the connective tissues affected in the middle thoracic cavity, in which 20% of cases may involve a diffuse and polymicrobial infection of the mediastinum, descending necrotizing mediastinitis (MND), secondary to the spread of a serious infection from the oropharyngeal or cervical tissues, stories such as odontogenic infections (36 to 47%), pharyngeal (33 to 45%), cervical (15%) and other head and neck infections (5%). Clinically, patients present with increased volume, tremors, trismus, odynophagia with dyspnea, dysphagia, hypotension, pain in the body and in the angle of the jaw. Hamman sign (mediastinal crepitus with heartbeat) and subcutaneous emphysema may be observed. The surgical management of odontogenic infections, regardless of their severity, consists of two principles: eliminate the etiological focus and the surgical emptying of the anatomical spaces compromised with the installation of adequate drainage. We present the case of a 60-year-old man diagnosed with descending necrotizing (AU)

Diseño y validación de la escala pronóstica cubana PREDICMED para estratificar el riesgo de mediastinitis postoperatoria / Design and validation of the Cuban prognostic scale PREDICMED to stratify the risk of postoperative mediastinitis

RESUMEN Introducción: La predicción de fenómenos en las ciencias médicas mediante escalas pronósticas constituye una herramienta valiosa en la actualidad y deben incluirse en el proceso de toma de decisiones. Pronosticar la mediastinitis postoperatoria permite disponer de recursos para su prevención. Objetivo: Construir una escala pronóstica para estratificar el riesgo de padecer mediastinitis postoperatoria. Método: Se realizó un estudio de casos y controles para los factores de riesgo de mediastinitis postoperatoria en el Cardiocentro Ernesto Guevara de Santa Clara, Cuba. Luego de la regresión logística se obtuvo el modelo y, a partir de este, se incluyeron y ponderaron los predictores para obtener la escala cubana pronóstica de mediastinitis postoperatoria: PREDICMED, que se validó por diversos métodos. Resultados: Esta escala se obtuvo con seis predictores y dos estratos de riesgo. Se analizó su rendimiento mediante ajuste, calibración y determinación de su poder discriminante, con buenos resultados. Se realizó validación interna por el método de división de datos y se comparó su capacidad en ambos subconjuntos (desarrollo y validación) sin diferencias. Se probó su buena validez de constructo, al no existir diferencias entre las probabilidades predichas y las observadas. También se analizó su validez de contenido mediante expertos. Por último, se determinó su validez de criterio al comparar con otra escala similar (MEDSCORE). PREDICMED presentó muy buena capacidad discriminatoria (área bajo la curva 0,962) y elevados valores de sensibilidad (84,62%) y especificidad (92,31%). Conclusiones: La escala pronóstica cubana PREDICMED, para estratificar el riesgo de mediastinitis postoperatoria, mostró buenos parámetros de validación y logró estratificar el riesgo en no alto y alto.

ABSTRACT Introduction: Phenomena prediction through prognostic scales is a valuable tool in medical sciences nowadays and it should be included in the decision-making process. Predicting postoperative mediastinitis allows to count on resources for its prevention. Objective: To build a prognostic scale to stratify the risk of suffering from postoperative mediastinitis. Method: A case-control study for the risk factors of postoperative mediastinitis was carried out at the Cardiocentro Ernesto Guevara from Santa Clara, Cuba. After the logistic regression, the model was obtained and from it, the predictors to obtain the Cuban prognostic scale of postoperative mediastinitis PREDICMED were included and weighted, which was validated through several methods. Results: This scale was obtained, counting on six predictors and two risk strata. Its performance was analyzed through adjustment, calibration and determination of its discriminating capacity, showing good results. Internal validation was carried out through the data division method and its capacity was compared in both subsets (development and validation) showing no differences. Its good construct validity was demonstrated, since there were no differences between the predicted and the observed probabilities. Its contents validity was also analyzed by experts. Finally, its criteria validity was determined when compared with another similar scale (Medscore). PREDICMED showed a very good discriminatory capacity (area under the curve 0.962) as well as high values of sensitivity (84.62%) and specificity (92.31%). Conclusions: The Cuban prognostic scale PREDICMED, to stratify the risk of postoperative mediastinitis showed good validation parameters and it was able to stratify the risk in not high and high.

Fatores de riscos para mediastinite no pós-operatório de cirurgia cardíaca / Risk factors for mediastinitis in the post-operative period of heart surgery / Factores de riesgo para mediastinitis en el período postoperatorio de cirugía cardíaca

Objetivos: Identificar os fatores de risco pré e pós-operatórios relacionados ao desenvolvimento de mediastinite entre pacientes submetidos à cirurgia cardíaca em um hospital da cidade do Rio de Janeiro, caracterizar a população estudada e analisar a relação entre os fatores de risco e a incidência de mediastinite nos pacientes submetidos à cirurgia cardíaca. Método: Estudo descritivo, abordagem quantitativa, em que foram identificados os fatores de risco para mediastinite em pacientes que realizaram cirurgia cardíaca em um hospital do Rio de Janeiro. Resultados: Obteve-se um n de 192 pacientes, de maioria homens, na faixa etária de 50 a 69 anos e em sobrepeso. Diabetes mellitus e tabagismo foram as comorbidades mais frequentes, e CRVMC a cirurgia mais realizada, 4 pacientes apresentaram mediastinite. Conclusão: A identificação destes fatores contribui para elaboração de estratégias de prevenção para mediastinite, e na implementação de cuidados de enfermagem no pré e pós-operatório de cirurgias cardíacas

Objectives: To identify pre and postoperative risk factors related to the development of mediastinitis among patients submitted to cardiac surgery at a hospital in the city of Rio de Janeiro, to characterize the study population and to analyze the relationship between risk factors and the incidence of mediastinitis in patients undergoing cardiac surgery. Method: descriptive study, quantitative approach, in which the risk factors for mediastinitis were identified in patients who underwent cardiac surgery in a hospital in Rio de Janeiro. Results: a n of 192 patients, mostly males, aged 50 to 69 years and overweight were obtained. Diabetes mellitus and smoking were the most frequent comorbidities, and CRVMC the most performed surgery, 4 patients had mediastinitis. Conclusion: the identification of these factors contributes to the elaboration of prevention strategies for mediastinitis, and the implementation of nursing care in the pre and postoperative period of cardiac surgeries

Objetivos: Identificar los factores de riesgo pre y postoperatorios relacionados al desarrollo de mediastinitis entre pacientes sometidos a la cirugía cardiaca en un hospital de la ciudad de Río de Janeiro, caracterizar a la población estudiada y analizar la relación entre los factores de riesgo y la incidencia de mediastinitis en los pacientes sometidos a la cirugía cardiaca. Método: Estudio descriptivo, abordaje cuantitativo, en que se identificaron los factores de riesgo para la mediastinitis en pacientes que realizaron una intervención cardiaca en un hospital de Río de Janeiro. Resultados: Se obtuvo un n de 192 pacientes, de mayoría hombres, en el grupo de edad de 50 a 69 años y en sobrepeso. La diabetes mellitus y el tabaquismo fueron las comorbilidades más frecuentes, y CRVMC la cirugía más realizada, 4 pacientes presentaron mediastinitis. Conclusión: La identificación de estos factores contribuye a la elaboración de estrategias de prevención para la mediastinitis, y en la implementación de cuidados de enfermería en el pre y postoperatorio de cirugías cardíacas

Mediastinite descendente necrosante pós-angina de Ludwig: relato de caso / Descending necrotizing mediastinitis after Ludwig's angina: case report

Introdução: a mediastinite necrosante descendente é um processo infeccioso grave do mediastino e pode ser originária de uma infecção odontogênica, apresentando; alta taxa de mortalidade. O cirurgião-dentista deve buscar estratégias para prevenir focos infecciosos, diminuindo a incidência de infecções odontogênicas graves que se disseminem pelos espaços cervicofaciais e torácicos. Objetivo: relatar caso de um paciente com diagnóstico de mediastinite necrosante pós-angina de Ludwig, descrever suas manifestações clínicas e a conduta terapêutica odontológica adotada. Relato de caso: paciente, 31 anos, sexo masculino, foi admitido referindo sintomatologia dolorosa no dente 3.8, que evoluiu para aumento de volume em região cervical, associado à febre e disfagia progressiva. Ao exame físico extraoral, observam-se sinais de disseminação para os espaços cervicofaciais e torácicos. Após exames complementares, o diagnóstico revela a infecção, associada à angina de Ludwig, secundária à pericoronarite. O tratamento foi analgesia e antibioticoterapia por via venosa. Após remissão dos sintomas, o paciente recebeu alta hospitalar em bom estado e foi realizada exodontia do dente 3.8. Conclusão: a mediastinite necrosante é uma patologia rara que pode levar a óbito, se não tratada adequadamente. O cirurgiãodentista deve estar consciente da possibilidade de disseminação pelos espaços faciais e mediastinais dos processos infecciosos de origem odontogênica e estar apto para tratar corretamente os casos antes, que eles acarretem grande risco à vida dos pacientes.

Introduction: descending necrotizing mediastinitis (DNM) is a severe infectious process of the mediastinum and may originate from an odontogenic infection; having a high mortality rate. The dentist should seek strategies to prevent infections that spread through the cervicofacial and thoracic spaces. Objective: to report a case of a patient with a diagnosis of DNM after Ludwig's angina, to describe its clinical manifestations and the adopted dental treatment. Case report: a thirty-one year old male patient was admitted with painful 3.8 tooth symptoms that evolved to swelling in the cervical regions, associated with fever and progressive dysphagia. Extraoral physical examination shows signs of spread to the cervicofacial and thoracic spaces. After further examination, the diagnosis was DNM associated with Ludwig's angina secondary to pericoronitis. Treatment was intravenous analgesia and antibiotic therapy. After remission of symptoms, the patient was discharged from hospital in good condition and 3.8 tooth extraction. Conclusion: DNM is a rare condition that can lead to death if not treated properly. The dentist should be aware of the possibility of spreading through the facial and mediastinal spaces of infectious processes of odontogenic origin, being able to correctly treat the cases, before they pose a great risk to patients' lives.

Perfil clínico-cirúrgico de pacientes com mediastinite pós-cirurgia cardíaca: estudo transversal retrospectivo / Clinical-surgical profile of patients with post-cardiac mediastinitis: retrospective cross-sectional study / Perfil clínico-quirúrgico de pacientes con mediastinitis post-cirugía cardíaca: estudio transversal retrospectivo

Objetivo: Descrever o perfil dos pacientes que desenvolveram mediastinite no pós-operatório de cirurgia cardíaca em um hospital de alta complexidade, analisando o desfecho, relacionado ao tempo de internação, à necessidade de reinternação, à antibioticoterapia instituída e a óbito. Método: Estudo transversal, com coleta de dados retrospectiva, por meio de consulta a 86 prontuários de pacientes que desenvolveram mediastinite no ano de 2015. Os dados foram coletados desde o pré-operatório até 90 dias após a alta hospitalar, o diagnóstico de mediastinite ou o óbito. Resultados: O diagnóstico de mediastinite ocorreu em 45,3% dos casos durante a internação e 54,7% após a alta hospitalar, dos quais 14,9% foram tratados ambulatorialmente e 85,1% necessitaram de reinternação. O tempo médio de internação foi de 31,8 dias. O tempo médio para o diagnóstico de mediastinite foi de 21,2 dias (desvio padrão ­ DP±11,48). O tratamento foi baseado principalmente em quinolonas (43%) e glicopeptídeos (39,5%). Conclusão: Considerando a frequência de identificação de casos após a alta hospitalar, a vigilância pós-alta de infecções do sítio cirúrgico entre pacientes submetidos a cirurgias cardíacas deve ser um objetivo compartilhado pela equipe multiprofissional.

Objectives: Describe the profile of patients who developed mediastinitis in the postoperative period of cardiac surgery in a hospital of high complexity, analyzing the outcome, related to the time of hospitalization, the need for reinternation, instituted antibiotic therapy and death. Method: Cross-sectional study, with retrospective data collection, through consultation with 86 medical records of patients who developed mediastinitis in the year 2015. Data were collected from the preoperative period up to 90 days after hospital discharge, the diagnosis of Mediastinitis or death. Results: The diagnosis of mediastinitis occurred in 45.3% of the cases during hospitalization and 54.7% after hospital discharge, of which 14.9% were treated ambulatory and 85.1% required reinternation. The mean hospitalization time was 31.8 days. The mean time for the diagnosis of Mediastinitis was 21.2 days (Standard deviation ­ SD ± 11,48). Treatment was mainly based on Quinolones (43%) and Glycopeptides (39.5%). Conclusion: Considering the frequency of identification of cases after hospital discharge, postoperative surveillance of surgical site infections among patients submitted to cardiac surgeries should be an objective shared by the multiprofessional team.

Objetivos: Describir el perfil de los pacientes que desarrollaron mediastinitis en el postoperatorio de cirugía cardíaca en un hospital de alta complejidad, analizando el resultado, relacionado con el tiempo de internación, la necesidad de reinternación, antibioticoterapia instituida y la muerte. Método: Estudio transversal, con recolección de datos retrospectiva, por medio de consulta a 86 historiales de pacientes que desarrollaron mediastinitis en el año 2015. Los datos fueron recogidos desde el preoperatorio, hasta 90 días después del alta hospitalaria, el diagnóstico de mediastinitis o el óbito. Resultados: El diagnóstico de mediastinitis ocurrió en 45,3% de los casos durante la internación y 54,7% después de alta hospitalaria, de los cuales, 14,9% fueron tratados ambulatorialmente y 85,1% necesitaron reinternación. El tiempo medio de internación fue de 31,8 días. El tiempo medio para el diagnóstico de mediastinitis fue de 21,2 días (desviación estándar ­ DP 11,48). El tratamiento se basó principalmente en quinolonas (43%) y glicopéptidos (39,5%). Conclusión: Considerando la frecuencia de identificación de casos tras el alta hospitalaria, la vigilancia postalta de infecciones del sitio quirúrgico entre pacientes sometidos a cirugías cardíacas debe ser un objetivo compartido por el equipo multiprofesional.

Assistência fisioterapêutica a um paciente submetido à cirurgia de revascularização do miocárdio com evolução de mediastinite como complicação pós-operatória / Physiotherapeutic assistance to a patient submitted to coronary artery bypass grafting with mediastinitis as postoperative complication

A fisioterapia integra os cuidados do paciente submetido à cirurgia cardíaca. Porém são escassos estudos que relacionam esta ciência a pacientes que desenvolveram mediastinite pós-operatória. O objetivo do estudo foi relatar o acompanhamento fisioterapêutico em um caso clínico de mediastinite associada à Cirurgia de Revascularização Miocárdica realizada no Hospital Universitário Cassiano Antônio de Moraes (HUCAM). Desenvolveu-se um estudo de caso relatando a abordagem fisioterapêutica realizada ao paciente durante o período de internação hospitalar. O tratamento fisioterapêutico do paciente do estudo ocorreu duas vezes ao dia com os objetivos de restabelecer as funções pulmonares e a mobilidade para o retorno às atividades funcionais. As condutas aplicadas, junto às abordagens clínicas, visaram à melhora rápida e a alta hospitalar precoce. Conclui-se que a diversidade dessas situações e a existência de poucos estudos sobre a atuação fisioterapêutica nesses casos mostram uma lacuna de conhecimento nesta área da saúde e a possibilidade de explorar o assunto para ampliar a atuação deste profissional em futuros casos semelhantes. (AU)

Physical therapy integrates the care of patients submitted to cardiac surgery. However, there are few studies that relate this science to patients who developed postoperative mediastinitis. The objective of the study was to report the physiotherapeutic follow-up in a clinical case of mediastinitis associated with myocardial revascularization surgery (MRS) performed at the Hospital Universitário Cassiano Antônio de Moraes (HUCAM). A case study was developed reporting the physiotherapeutic approach performed during the period of hospital stay. The physiotherapeutic treatment of the study patient occurred twice a day and the objectives were to restore mobility and pulmonary functions aiming the returning to functional activities. The physiotherapeutic conducts together with the clinical approaches aimed a rapid recovery and early hospital discharge. It is concluded that the diversity of these situations and the existence of few studies on physiotherapeutic performance in these cases shows a knowledge gap in this area of health and the possibility of exploring the subject to expand the performance of this professional in future similar cases. (AU)

A simple modification of the conventional figure-of-eight sternal closure technique

Abstract Objective: To describe a new technique of sternal closure, modified from the conventional figure-of-eight approach, which can provide a secure closure and prevent sternal complications. Methods: The modified technique is based on the intercalation of the caudal portion of each steel wire passed along the sternum. This is a retrospective analysis of patients operated with this modified technique at our institution between January 2014 and December 2016. Results: One hundred and forty-three patients underwent sternal closure with the modified technique. In-hospital mortality rate was 1.4% (n=2). No sternal instability was observed at 30 days postoperatively. Two patients developed mediastinitis that required extraction of the wires. Conclusion: Short-term results have shown that the modified sternal closure technique can be used safely and effectively, with complications rates being consistent with worldwide experience.

Sclerosing mediastinitis causing unilateral pulmonary edema due to left atrial and pulmonary venous compression. a case report and literature review

Abstract Sclerosing mediastinitis (SM), previously named chronic fibrosing mediastinitis, is an inflammatory process that in its end-stage results to sclerosis around the mediastinal structures. SM is quite rare and has been correlated with inflammatory and autoimmune diseases, as well as malignancy. SM may either present in a mild form, with minor symptoms and a benign course or in a more aggressive form with severe pulmonary hypertension and subsequent higher morbidity and mortality. The diagnosis of SM may be difficult and quite challenging, as symptoms depend on the mediastinal structure that is mainly involved; quite often the superior vena cava. However, practically any mediastinal structure may be involved by the fibrotic process, such as the central airways, as well as the pulmonary arteries and veins, leading to obstruction or total occlusion. The latter may be impossible to undergo proper surgical excision of the lesion, and is considered to be a real challenge to the surgeon. We herein report a case of SM that presented with arterial and venous compression. The imaging appearance was that of unilateral pulmonary edema, associated with lung collapse. The case is supplemented by a non-systematic review of the relevant literature.