Arterial gas embolism: a review of cases at Prince of Wales Hospital, Sydney, 1996 to 2006

Systemic arterial gas embolism (SAGE) as a complication of bronchoscopic lung biopsy: a case report and systematic literature review

Background

Systemic arterial gas embolism (SAGE) is a rare yet serious and underrecognized complication of bronchoscopic procedures. A recent case of presumed SAGE after transbronchial needle aspiration prompted a systematic literature review of SAGE after biopsy procedures during flexible bronchoscopy.

Methods

We performed a systematic database search for case reports and case series pertaining to SAGE after bronchoscopic lung biopsy; reports or series involving only bronchoscopic laser therapy or argon plasma coagulation (APC) were excluded. Patient data were extracted directly from published reports.

Results

A total of 29 unique patient reports were assessed for patient demographics, specifics of the procedure, clinical manifestations, diagnostic findings, and clinical outcomes. Cases of SAGE occurred after multiple types of bronchoscopic biopsy and under both positive and negative pressure ventilation. The most common clinical findings were neurologic, followed by cardiac manifestations; temporal patterns included acute onset of cardiac or neurologic emergencies immediately after biopsy, or delayed awakening post-procedure. There was a high mortality rate among cases (28%), with residual neurologic deficits also common (24%).

Discussion

SAGE is an underrecognized but severe adverse effect of bronchoscopic lung biopsy, which often presents with acute coronary or cerebral ischemia or delayed awakening from sedation. It is important for all physicians who perform bronchoscopic biopsies to be aware of the clinical manifestations and therapeutic management of SAGE in order to mitigate morbidity and mortality among patients undergoing these procedures.

Cerebral arterial gas embolism proven by computed tomography following transthoracic echocardiography using bubble contrast

A 75 year-old male developed features of an acute stroke following bubble contrast echocardiography, which was shown on emergent computed tomography scanning to be a result of cerebral arterial gas embolism (CAGE) to the left middle cerebral artery. Ischaemic stroke symptoms have previously been reported as a rare complication of bubble contrast echocardiography. Radiologically proven CAGE from bubble contrast echocardiography had not been reported at the time this case occurred. Immediate provision of 100% oxygen and administration of hyperbaric oxygen are recommended treatments for CAGE and were associated with a substantial recovery for this patient.

Hyperbaric oxygen therapy for iatrogenic arterial gas embolism after CT-guided lung biopsy : A case report

Iatrogenic arterial gas embolism (AGE) can be life-threatening. The only causal treatment is immediate hyperbaric oxygen therapy (HBOT). This article reports on a case of a 74-year-old male patient who underwent computed tomography (CT)-guided lung biopsy of suspect nodules after squamous cell carcinoma of the tonsils. During puncture, sudden cardiovascular arrest occurred. The CT scan documented severe arterial gas embolism in the aorta, spinal canal, left heart ventricle, and brain. The patient was then transferred to our hospital for HBOT. After the first HBOT, an additional CT scan showed regression of all gas inclusions. In the treatment of gas embolism, HBOT is considered the gold standard and is indispensable. It is primarily used to reduce acute bubble effects and to avoid secondary bubble effects. Unfortunately, the long persisting gas occlusions and perfusion deficits led to severe hypoxic brain damage and a poor prognosis for the patient. In this case report we present the management of (iatrogenic) arterial gas embolism and point out the necessity of immediate HBOT. Furthermore, we discuss the pathophysiology leading to arterial gas embolism on the basis of the gas laws.

Hyperbaric oxygen therapy of air embolus in the cerebral venous sinuses after intracranial surgery: a case report

A case with cerebral venous air embolism (CVAE) after neurosurgery and treated with hyperbaric oxygen therapy (HBOT) is presented. This is a rare and potentially fatal complication that neurosurgeons should be aware of. A 52-year-old male was diagnosed with an intracerebral hematoma. An emergency evacuation of the hematoma was performed with a craniotomy and the postoperative CT scan showed a complete evacuation of the hematoma, but it also revealed a CVAE. The patient was immediately referred to HBOT and received three sessions within 48 h. The CT scan after the first HBOT showed no CVAE, venous thrombosis, or new hematoma.

Diagnosis of arterial gas embolism in SCUBA diving: modification suggestion of autopsy techniques and experience in eight cases

The purpose of this study was to suggest modifications of autopsy techniques in order to improve post-mortem diagnosis of arterial gas embolism (AGE) based on multidisciplinary investigation of SCUBA diving fatalities. Five adult human cadavers from the voluntary donation program of the Human Anatomy Laboratory, and eight judicial autopsied bodies of SCUBA divers from the Forensic Pathology Service were assessed. Before performing any autopsies, we accessed the diving plan and the divers' profiles for each case. We then introduced a new dissection procedure that included identification, isolation, and manipulation of carotid, vertebral and thoracic arterial systems. The dissected vascular structures that allowed optimall isolation of the systemic arterial circulation were identified and ligated. In three of the eight judicial cases, we had a strongly suggestive history of arterial gas embolism following pulmonary barotrauma (PBt/AGE). In these cases, the additional arterial dissection allowed us to clearly diagnose AGE in one of them. The autopsy of the rest of the cases showed other causes of death such as asphyxia by drowning and heart attack. In all cases we were able to reject decompression sickness, and in some of them we showed the presence of artefacts secondary to decomposition and resuscitation maneuvers. These results allow us to suggest a specific autopsy technique divided into four steps, aimed at confirming or excluding some evidence of dysbaric disorders according to a re-enactment of the incident. We have demonstrated the presence of large volumes of intravascular air, which is typical of PBt/AGE.

Neurologic complications of acute environmental injuries

Environmental injuries can result in serious neurologic morbidity. This chapter reviews neurologic complications of thermal burns, smoke inhalation, lightning strikes, electric injury, near drowning, decompression illness, as well as heat stroke and accidental hypothermia. Knowing the pathophysiology and clinical presentation of such injuries is essential to proper management of primary and secondary medical complications. This chapter highlights the most frequently encountered neurologic injuries secondary to common environmental hazards, divided into the topics: injuries related to fire, electricity, water, and the extremes of temperature.

Neurology and diving

Diving exposes a person to the combined effects of increased ambient pressure and immersion. The reduction in pressure when surfacing can precipitate decompression sickness (DCS), caused by bubble formation within tissues due to inert gas supersaturation. Arterial gas embolism (AGE) can also occur due to pulmonary barotrauma as a result of breath holding during ascent or gas trapping due to disease, causing lung hyperexpansion, rupture and direct entry of alveolar gas into the blood. Bubble disease due to either DCS or AGE is collectively known as decompression illness. Tissue and intravascular bubbles can induce a cascade of events resulting in CNS injury. Manifestations of decompression illness can vary in severity, from mild (paresthesias, joint pains, fatigue) to severe (vertigo, hearing loss, paraplegia, quadriplegia). Particularly as these conditions are uncommon, early recognition is essential to provide appropriate management, consisting of first aid oxygen, targeted fluid resuscitation and hyperbaric oxygen, which is the definitive treatment. Less common neurologic conditions that do not require hyperbaric oxygen include rupture of a labyrinthine window due to inadequate equalization of middle ear pressure during descent, which can precipitate vertigo and hearing loss. Sinus and middle ear overpressurization during ascent can compress the trigeminal and facial nerves respectively, causing temporary facial hypesthesia and lower motor neuron facial weakness. Some conditions preclude safe diving, such as seizure disorders, since a convulsion underwater is likely to be fatal. Preventive measures to reduce neurologic complications of diving include exclusion of individuals with specific medical conditions and safe diving procedures, particularly related to descent and ascent.

Air embolism: an unusual cause of delayed death following gunshot wound to the chest

A 29-year-old man was shot in the chest twice sustaining extensive contusion of the right lung. He was, however, clinically stable with no major vessel injury or significant blood loss. Unexpected cardiac arrest occurred hours after hospital admission due to left coronary artery air embolism. Lung parenchymal damage from the passage of two projectiles within the chest wall close to the pleural cavity had occurred, with disruption of the capillary-alveolar interface and passage of air into the pulmonary venous circulation. While tangential gunshot wounds to the chest wall may rarely cause air embolism, symptoms are usually immediate. The present case demonstrates, however, that death may occur unexpectedly some time after the initial trauma in an individual who is considered clinically stable.