Airway management in Ludwig's angina - a challenge: case report / Manejo da via aérea na angina de Ludwig - um desafio: relato de caso

Abstract Background Ludwig's angina (LA) is an infection of the submandibular space, first described by Wilhelm Frederick von Ludwig in 1836. It represents an entity difficult to manage due to the rapid progression and difficulty in maintaining airway patency, a major challenge in medical practice, resulting in asphyxia and death in 8-10% of patients. Objective Describe a case of a patient with Ludwig's angina undergoing surgery, with emphasis on airway management, in addition to reviewing the articles published in the literature on this topic. Case report Male patient, 21 years, drug addict, admitted by the emergency department and diagnosed with LA. Difficult airway was identified during the anesthetic examination. In additional tests, significant deviation from the tracheal axis was seen. Undergoing bilateral thoracoscopic pleural drainage, we opted for airway management through tracheal intubation using fiberoptic bronchoscopy, and balanced general anesthesia was proposed. There were no complications during the surgical-anesthetic act. After the procedure, the patient remained intubated and mechanically ventilated in the intensive care unit. Conclusions Airway management in patients with Ludwig's angina remains challenging. The choice of the safest technique should be based on clinical signs, technical conditions available, and the urgent need to preserve the patient's life.

Resumo Justificativa A angina de Ludwig (AL) constitui uma infecção do espaço submandibular, primeiramente descrita por Wilhelm Frederick von Ludwig em 1836. Representa uma entidade de difícil manejo devido à rápida progressão e dificuldade na manutenção da via aérea pérvia, um importante desafio na prática médica, que culmina em asfixia e morte em 8-10% dos pacientes. Objetivo Descrever o caso clínico de um paciente com angina de Ludwig submetido a procedimento cirúrgico, com ênfase no manejo da via aérea, além de revisar os artigos disponíveis na literatura médica a respeito desse tema. Relato de caso Paciente masculino, 21 anos, drogadito, admitido pelo pronto socorro e diagnosticado com AL. Na propedêutica anestésica constatou-se via aérea difícil. Nos exames complementares foi possível observar importante desvio do eixo traqueal. Submetido à toracoscopia bilateral com drenagem pleural, optou-se pelo manejo da via aérea através de intubação nasotraqueal por fibrobroncoscopia e foi proposta anestesia geral balanceada. Não houve intercorrência durante o ato cirúrgico-anestésico. Após procedimento paciente permaneceu intubado e em ventilação mecânica na Unidade de Terapia Intensiva. Conclusões O manejo da via aérea nos pacientes com angina de Ludwig permanece desafiador. A escolha da técnica mais segura deve ser embasada no quadro clínico, nas condições técnicas disponíveis e na necessidade premente de preservação da vida do paciente.

[Airway management in Ludwig's angina - a challenge: case report]. / Manejo da via aérea na angina de Ludwig ­ um desafio: relato de caso.

BACKGROUND: Ludwig's angina (LA) is an infection of the submandibular space, first described by Wilhelm Frederick von Ludwig in 1836. It represents an entity difficult to manage due to the rapid progression and difficulty in maintaining airway patency, a major challenge in medical practice, resulting in asphyxia and death in 8-10% of patients. OBJECTIVE: Describe a case of a patient with Ludwig's angina undergoing surgery, with emphasis on airway management, in addition to reviewing the articles published in the literature on this topic. CASE REPORT: Male patient, 21 years, drug addict, admitted by the emergency department and diagnosed with LA. Difficult airway was identified during the anesthetic examination. In additional tests, significant deviation from the tracheal axis was seen. Undergoing bilateral thoracoscopic pleural drainage, we opted for airway management through tracheal intubation using fiberoptic bronchoscopy, and balanced general anesthesia was proposed. There were no complications during the surgical-anesthetic act. After the procedure, the patient remained intubated and mechanically ventilated in the intensive care unit. CONCLUSIONS: Airway management in patients with Ludwig's angina remains challenging. The choice of the safest technique should be based on clinical signs, technical conditions available, and the urgent need to preserve the patient's life.

[Antimicrobial resistance of uropathogens among outpatients, 2000-2004]. / Resistência antimicrobiana dos uropatógenos em pacientes ambulatoriais, 2000-2004.

A retrospective study based on the electronic database of a university hospital was carried out to investigate the prevalence of etiological agents and their susceptibilities to antibiotics, among adult outpatients (> 18 years old) with urinary tract infections. Nine hundred and fifty-seven positive urine cultures were identified between January 2000 and December 2004. Escherichia coli, Proteus mirabilis and Klebsiella sp were the three principal bacterial etiological agents. Trimethoprim-sulfamethoxazole presented the highest prevalence of bacterial resistance (46.9%), followed by cefalotin (46.7%), nalidixic acid (27.6%) and nitrofurantoin (22.3%). Over the study period, nalidixic acid presented annual increases of 5.9% in the rate of bacterial resistance (p = 0.02). Ciprofloxacin also showed an increasing trend, of 3.3% per year (p = 0.07). This study demonstrated that the antibiotics that are widely recommended for empirical treatment of urinary tract infection in adults presented high rates of bacterial resistance among the population studied.

Resistência antimicrobiana dos uropatógenos em pacientes ambulatoriais, 2000-2004 / Antimicrobial resistance of uropathogens among outpatients, 2000-2004

Foi realizado um estudo retrospectivo, baseado no banco de dados eletrônico de um hospital universitário, com objetivo de investigar a prevalência dos germes causadores e suas suscetibilidades aos antibióticos em adultos (idade >18 anos), com infecção do trato urinário atendidos ambulatorialmente. Foram identificados 957 exames de urocultura positiva no período entre janeiro de 2000 e dezembro de 2004. Escherichia coli, Proteus mirabillis e Klebsiella sp foram três principais bactérias causadoras. Sulfametoxazol-trimetropim apresentou a maior (46,9 por cento) prevalência de resistência bacteriana seguida por cefalotina (46,7 por cento), ácido nalidíxico (27,6 por cento) e nitrofurantoína (22,3 por cento). Durante o período estudado, o ácido nalidíxico apresentou um aumento anual de 5,9 por cento na taxa de resistência bacteriana (p= 0,02). Ciprofloxacina mostrou também a tendência de aumento, com um crescimento anual de 3,3 por cento (p= 0,07). Este estudo demonstrou que os antibióticos amplamente recomendados no tratamento empírico da infecção do trato urinário em adultos apresentaram altas taxas de resistência bacteriana na população estudada.

A retrospective study based on the electronic database of a university hospital was carried out to investigate the prevalence of etiological agents and their susceptibilities to antibiotics, among adult outpatients (> 18 years old) with urinary tract infections. Nine hundred and fifty-seven positive urine cultures were identified between January 2000 and December 2004. Escherichia coli, Proteus mirabilis and Klebsiella sp were the three principal bacterial etiological agents. Trimethoprim-sulfamethoxazole presented the highest prevalence of bacterial resistance (46.9 percent), followed by cefalotin (46.7 percent), nalidixic acid (27.6 percent) and nitrofurantoin (22.3 percent). Over the study period, nalidixic acid presented annual increases of 5.9 percent in the rate of bacterial resistance (p = 0.02). Ciprofloxacin also showed an increasing trend, of 3.3 percent per year (p = 0.07). This study demonstrated that the antibiotics that are widely recommended for empirical treatment of urinary tract infection in adults presented high rates of bacterial resistance among the population studied.