Systemic air embolism after cardiopulmonary resuscitation in a preterm infant

Bedside Ultrasound Detection of Systemic Air Embolism Secondary to Fulminant Necrotizing Enterocolitis in a Neonate With Congenital Heart Disease: A Case Report

Systemic air embolism is a rarely reported complication of necrotizing enterocolitis in the neonatal population. It carries significant morbidity and mortality. We report a 6-day-old, term female neonate with a duct-dependent (systemic) congenital heart disease (interrupted aorta with patent ductus arteriosus and ventricular septal defect) who presented in extremis. The neonate was successfully resuscitated, mechanically ventilated, and put on intravenous prostaglandins in paediatric intensive care unit. She clinically improved but later she developed necrotizing enterocolitis which was complicated by systemic air embolism; both of which were identified by bedside ultrasound. Her condition deteriorated and she succumbed due to these complications.

Thrombosis after umbilical venous catheterisation: prospective study with serial ultrasound

BACKGROUND

Umbilical venous catheters (UVCs) are associated with thrombus formation. Most studies on thrombosis in infants with UVCs focus on only one part of the route, and none assessed a control group of infants without UVCs.

OBJECTIVE

To determine the incidence and location of thrombi in infants after umbilical catheterisation and compare this with a control group of infants without umbilical catheters.

DESIGN

Prospective observational study with serial ultrasonography of the UVC route from the umbilico-portal confluence to the heart. Ultrasonography was performed until day 14 after catheterisation in cases and day 14 after birth in controls.

RESULTS

Thrombi in the UVC route were detected in 75% (30/40) of infants with UVCs in the study group, whereas no thrombi were detected in the control group of infants without UVCs (0/20) (p<0.001). Six thrombi (20%) were located in the right atrium. Most of these were also partly present in the ductus venosus. Six thrombi (20%) were located in the ductus venosus only, and in 12 infants (40%), the thrombus was at least partly located in the umbilico-portal confluence. Thrombi persisted after UVC removal in 25/30 cases. Two infants with thrombotic events were treated with low-molecular-weight heparin and resolution was found. In the other 23 infants managed expectantly, 2 died due to necrotising enterocolitis, 1 was lost to follow-up and in 20 spontaneous regression was seen.

CONCLUSIONS

Thrombotic events occur frequently in infants after umbilical catheterisation. Most thrombi were asymptomatic and regressed spontaneously with expectant management. Routine screening for thrombi in UVCs is therefore not advised.

Inferior vena cava syndrome in neonates: An evidence-based systematic review of the literature

Neonatal inferior vena cava syndrome (IVCS), though uncommon, is associated with significant morbidity and mortality. Information on risk factors, diagnosis, treatment, and outcomes is limited. This review comprised 61 neonates across 33 reports. Thrombosis occurred in 98% and 42% involved a central venous catheter. Diagnosis was mainly established by ultrasound in 82%. Therapeutically, heparin was employed in 36% and thrombolysis in 18% of the cases. The overall mortality was 23%. An algorithm of clinical signs, investigation, and management is presented. Well-designed prospective studies are needed to establish a concrete investigational approach to neonatal IVCS and institute safe, evidence-based treatment.

Vascular air embolism: A silent hazard to patient safety

PURPOSE

To narratively review published information on prevention, detection, pathophysiology, and appropriate treatment of vascular air embolism (VAE).

MATERIALS AND METHODS

MEDLINE, SCOPUS, Cochrane Central Register and Google Scholar databases were searched for data published through October 2016. The Manufacturer and User Facility Device Experience (MAUDE) database was queried for "air embolism" reports (years 2011-2016).

RESULTS

VAE may be introduced through disruption in the integrity of the venous circulation that occurs during insertion, maintenance, or removal of intravenous or central venous catheters. VAE impacts pulmonary circulation, respiratory and cardiac function, systemic inflammation and coagulation, often with serious or fatal consequences. When VAE enters arterial circulation, air emboli affect cerebral blood flow and the central nervous system. New medical devices remove air from intravenous infusions. Early recognition and treatment reduce the clinical sequelae of VAE. An organized team approach to treatment including clinical simulation can facilitate preparedness for VAE. The MAUDE database included 416 injuries and 95 fatalities from VAE. Data from the American Society of Anesthesiologists Closed Claims Project showed 100% of claims for VAE resulted in a median payment of $325,000.

CONCLUSIONS

VAE is an important and underappreciated complication of surgery, anesthesia and medical procedures.

Appearance of gas collections after scuba diving death: a computed tomography study in a porcine model

INTRODUCTION

Postmortem computed tomography can easily demonstrate gas collections after diving accidents. Thus, it is often used to support the diagnosis of air embolism secondary to barotrauma. However, many other phenomenons (putrefaction, resuscitation maneuvers, and postmortem tissue offgassing) can also cause postmortem gas effusions and lead to a wrong diagnosis of barotrauma.

OBJECTIVES

The aim of this study is to determine topography and time of onset of postmortem gas collections respectively due to putrefaction, resuscitation maneuvers, and tissue offgassing.

MATERIALS AND METHODS

A controlled experimental study was conducted on nine pigs. Three groups of three pigs were studied postmortem by CT from H0 to H24: one control group of nonresuscitated nondivers, one group of divers exposed premortem to an absolute maximal pressure of 5 b for 16 min followed by decompression procedures, and one group of nondivers resuscitated by manual ventilation and thoracic compression for 20 min. The study of intravascular gas was conducted using CT scan and correlated with the results of the autopsy.

RESULTS

The CT scan reveals that, starting 3 h after death, a substantial amount of gas is observed in the venous and arterial systems in the group of divers. Arterial gas appears 24 h after death for the resuscitated group and is absent for the first 24 h for the control group. Concerning the putrefaction gas, this provokes intravenous and portal gas collections starting 6 h after death. Subcutaneous emphysema was observed in two of the three animals from the resuscitated group, corresponding to the thoracic compression areas.

CONCLUSION

In fatal scuba diving accidents, offgassing appears early (starting from the first hour after death) in the venous system then spreads to the arterial system after about 3 h. The presence of intra-arterial gas is therefore not specific to barotrauma. To affirm a death by barotrauma followed by a gas embolism, a postmortem scanner should be conducted very early. Subcutaneous emphysema should not be mistaken as diagnostic criteria of barotrauma because it can be caused by the resuscitation maneuvers.

Intravascular gas distribution in the upper abdomen of non-traumatic in-hospital death cases on postmortem computed tomography

OBJECTIVES

To investigate the occurrence of intravascular gas in the liver, kidneys, spleen, and pancreas by postmortem computed tomography (PMCT) in cases of non-traumatic in-hospital deaths and elucidate the relationship between the PMCT data and clinical information or autopsy results.

METHODS

The study included 45 cadavers of patients who died while receiving treatment in our academic tertiary-care hospital between April and December 2009. All subjects underwent PMCT and conventional autopsy. The appearance of postmortem gas in the liver, kidney, spleen, and pancreas was assessed using PMCT and scored using a subjective scale (liver, L0-L3; kidney, K0-K2; spleen, S0-S1; and pancreas, P0-P1), and the distribution of gases in the vessels of the liver (arteries, veins, and portal veins) was analyzed. The relationship between the gas score and time elapsed since death, cardiopulmonary resuscitation (CPR), administration of antibiotics, a history of bacteremia, or cause of death was assessed statistically.

RESULTS

Positive correlations were found between administration of CPR and liver and kidney gas scores (P=0.008 and 0.002, respectively), but not with spleen and pancreas gas (P=0.291 and 0.535, respectively). No significant relationship between distribution of gas in the vessels of the liver and CPR was found. No other significant correlations between gas and any of the other parameters described above were found. While significant correlations were detected in no-CPR cases between liver gas, kidney gas, spleen gas, and pancreas gas (P<0.001 for all six combinations), no correlation between these parameters was detected in the CPR cases.

CONCLUSIONS

The present study was the first statistical analysis of intravascular gas in the liver, kidneys, spleen, and pancreas by using PMCT in non-traumatic in-hospital death cases. The results showed that PMCT in the presence and absence of CPR reveals differences in intraorgan gas distribution. In addition, the detection of intraorgan gas on PMCT cannot be used to predict time elapsed since death, and it is not affected by the administration of antibiotics, a history of bacteremia, and cause of death. Awareness of these postmortem changes is important for the accurate interpretation of PMCT results.

Intravascular gas in multiple organs detected by postmortem computed tomography: effect of prolonged cardiopulmonary resuscitation on organ damage in patients with cardiopulmonary arrest

A 76-year-old woman was found in cardiopulmonary arrest with her head submerged in water in a bathtub. Despite cardiopulmonary resuscitation (CPR) for over 1 h by professional emergency technicians and medical doctors, the patient died. Postmortem computed tomography revealed not only pulmonary edema associated with drowning but also the presence of intravascular gas in the pulmonary artery, liver, kidneys, heart (right ventricle), and brain. It was speculated that intravascular gas was generated and spread to multiple organs during CPR procedures via the alimentary tract and lungs, which had been damaged by ischemia after cardiopulmonary arrest. Prolonged CPR procedures may involve the risk of additional organ damage and systemic air emboli.