[The ulm emergency algorithm for the acute treatment of drug-induced, bradykinin-mediated angioedema]. / Ulmer Notfallalgorithmus: die Akuttherapie von medikamenteninduzierten bradykininvermittelten Angioödemen.

BACKGROUND: Bradykinin-mediated, drug-induced edema like ACE-inhibitor-induced angioedema (ACEi AE) is almost exclusively located in the head and neck region and is potentially life threatening. To date, there are no guidelines or officially-approved treatments available for this pathology. OBJECTIVES: We sought to provide a structured therapeutic algorithm for the acute treatment of drug-induced bradykinin-mediated angioedema. MATERIALS AND METHODS: We analyzed data (especially the course of disease and therapy) of all patients with acute angioedema, who presented to the Department of Otorhinolaryngology, Head and Neck Surgery at the University of Ulm (2010-2015). We also conducted a literature review on PubMed with the terms "acute angioedema", "angioedema emergency", "ACE angioedema", "bradykinin angioedema" and "angioedema therapy". Other fundamental references were the recent German guidelines "hereditary angioedema", "anaphylaxis" and "airway management". RESULTS: An emergency algorithm was generated as a flowchart for the acute therapy of bradykinin-mediated drug-induced angioedema was generated. We focused on the decision criteria for intubation/airway management and pharmacological therapy: antihistamines and glucocorticoids versus anti-bradykinin treatment. Furthermore, recommendations for inpatient monitoring have been derived. CONCLUSION/DISCUSSION: To date, therapy of drug-induced bradykinin-mediated angioedema is performed according to an "off-label" use and without officially-approved guidelines. The presented emergency algorithm provides a first approach for a structured therapeutic concept for a potentially life-threatening pathology.

Infections and edema.

Infectious and inflammatory conditions of the head and neck may present with impaired airways. An understanding of the pathophysiology will allow for accurate diagnosis and prompt intervention. Preintervention discussion and planning by members of the airway team are crucial in developing a primary and backup plans for safely securing the airway.

Evaluación perioperatoria de una paciente con un angioedema grave para una cirugía de coordinación

RESUMEN Introducción: el angioedema es una enfermedad caracterizada por episodios de edema subcutáneo o submucoso, recurrente y autolimitado, pudiendo comprometer la vía aérea de forma grave y en diferentes momentos de la intervención. El diagnóstico de su etiología es esencial para el tratamiento y la prevención. Objetivos: presentar la evaluación preoperatoria de una paciente con diagnóstico de angioedema que será sometida a una cirugía de coordinación, centrado en la valoración etiológica y perioperatorio. Caso clínico: paciente de sexo femenino, 32 años, coordinada para colecistectomía con exploración radiológica de vía biliar principal. Angioedema diagnosticado en 2009, caracterizado por episodios recurrentes de edema de extremidades, cara, labios, lengua y úvula, asociado a dificultad respiratoria, sintomatología abdominal, con múltiples consultas, tratada con corticoides, antihistamínicos y adrenalina inhalatoria, con buena respuesta. No existen antecedentes familiares de angioedema. Se descartaron enfermedades autoinmunes (lupus y artiris reumatoidea). Fibrogastroscopía con biopsia, negativa para Helicobacter pylori. Prick tests positivos para ácaros, polvo y variados alimentos. Discusión: C1 inhibidor y C4 fueron normales, descartándose en primer lugar déficit de C1 inhibidor hereditario y adquirido, así como causas autoinmunes, e infección por Helycobacter pylori. Se descartan causas farmacológicas. Dado su terreno atópico y prick test positivos el planteo diagnóstico es de angioedema alérgico o pseudoalérgico. Se plantea la siguiente profilaxis preoperatoria: anthistamínicos 5 a 7 días y corticoides 2 a 3 días vía oral. Conclusiones: se presenta un caso clínico de muy baja frecuencia donde el uso de un algoritmo diagnóstico es fundamental para la profilaxis de complicaciones anestésicas graves.

SUMMARY Introduction: angioedema is a disease characterized by recurrent, self-limited episodes of subcutaneous or submucosal edema, that may seriously affect the airway during different stages of the surgery. The diagnosis of its etiology is essential for treatment and prevention. Objectives: to present the preoperative evaluation of a patient diagnosed with angioedema who will be subject to a scheduled surgery, with a focus on the etiologic assessment and the preoperative period. Clinical case: female patient, 32 years of age, with scheduled surgery for cholecystectomy with radiological exploration of main biliary tract, diagnosed with angioedema in 2009, characterized by recurrent episodes of edema in extremities, face, lips, tongue and uvula, associated to respiratory distress, abdominal symptoms; she consulted in several occasions, and was treated with corticosteroids, antihistamines and adrenaline by inhalation, with good response. There is no family history of angioedema. Autoimmune diseases were discarded (lupus and rheumatoid arthritis). Fibrogastroscopy with negative biopsy for Helicobacter pylori. Prick tests positive for mite, dust and different types food. Discussion: C4 and C1 inhibitor were normal, therefore, hereditary and acquired C1 inhibitor deficiency was discarded in the first place, as well as autoimmune diseases and Helicobacter pylori infection. Pharmacological causes were discarded. Due to the atopic field and positive prick tests, the diagnosis presented was allergic or pseudoallergic angioedema. Planned preoperative prophylaxis: antihistamines 5 to 7 days and corticosteroids 2 to 3 days, orally. Conclusions: we present a clinical case with very low frequency where the use of a diagnostic algorithm is fundamental for the prophylaxis of severe anesthetic complications.

RESUMO Introdução: o angioedema é uma doença caracterizada por episódios de edema subcutâneo ou submucoso, recorrente e autolimitado, podendo comprometer a via aérea de forma grave em diferentes momentos da intervenção cirúrgica. O diagnostico de sua etiologia é essencial para o tratamento e a prevenção. Objetivos: apresentar a avaliação pré-operatória de uma paciente com diagnostico de angioedema que será submetida a uma cirurgia eletiva, centrado na avaliação etiológica e perioperatoria. Caso clinico: paciente do sexo feminino, 32 anos, marcada para realização de uma colecistectomia com exploração radiológica da via biliar principal. Angioedema diagnosticado em 2009, caracterizado por episódios recorrentes de edema de extremidades, face, lábios, língua e úvula , associada a dificuldade respiratória, sintomatologia abdominal, com múltiplas consultas, tratada com corticóides, antihistaminicos e adrenalina inalatoria, com boa resposta. Não existem antecedentes familiares de angioedema. Descarta-se doenças autoimunes (lúpus e artrite reumatoide). Fibrogastroscopia com biopsia, negativa para Helicobacter pylori. Prick test positivo para ácaros, pó e varios alimentos. Discussão: C1 inibidor e C 4 foram normais , descartando-se em primeiro lugar déficit de C1 inibidor hereditário e adquirido, assim como causas autoimunes,ou infecção por Helycobacter pylori. Descartam-se causas farmacológicas. Pelos seus antecedentes e prick teste positivo foi cogitado o diagnostico de angioedema alérgico ou pseudoalergico. Foi planejada a seguinte profilaxia pré-operatória: antihistaminicos 5 a 7 dias e corticóides 2 a 3 dias via oral. Conclusões: apresenta-se um caso clinico de baixa frequência onde a utilização de um algorritmo diagnostico é fundamental para a profilaxia de complicações anestésicas graves.