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Arstikyte K, Vitkute G, Traskaite-Juskeviciene V, Macas A. Disseminated intravascular coagulation following air embolism during orthotropic liver transplantation: is this just a coincidence? BMC Anesthesiol 2021; 21:264. [PMID: 34717530 PMCID: PMC8557023 DOI: 10.1186/s12871-021-01476-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 10/15/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND During orthotopic liver transplantation, venous air embolism may occur due to iatrogenic injury of the inferior vena cava. However, venous air embolism followed by coagulopathy is a rare event. In this case report, we discuss a possible connection between venous air embolism and disseminated intravascular coagulation. CASE PRESENTATION A 37-year-old male patient with chronic hepatitis B- and C-induced liver cirrhosis was admitted for orthotopic liver transplantation. During the dissection phase of the surgery, arterial blood pressure, heart rate, saturation and end-tidal carbon dioxide levels suddenly decreased, indicating the occurrence of venous air embolism. After stabilizing the patient's condition, various coagulation issues started developing. Venous air embolism-induced coagulopathy was handled by administering transfusions of various blood products. However, the patient's condition continued to deteriorate leading to a complete asystole. CONCLUSIONS This is a rare case of venous air embolism-induced disseminated intravascular coagulation. The real connection remains unclear as disseminated intravascular coagulation for end-stage liver disease patients can be induced by various causes during different stages of liver transplantation. Certainly, both venous air embolism and coagulopathy were significant and led to an unfavorable outcome. Further studies are needed to better understand the possible mechanisms and correlation between these two life-threatening complications.
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Affiliation(s)
- Karolina Arstikyte
- Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
- , Wakefield, UK.
| | - Gintare Vitkute
- Department of Anaesthesiology, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
| | - Vilma Traskaite-Juskeviciene
- Department of Anaesthesiology, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
| | - Andrius Macas
- Department of Anaesthesiology, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
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Serfozo K, Tarnal V. Anesthetic Management of Patients Undergoing Open Suboccipital Surgery. Anesthesiol Clin 2021; 39:93-111. [PMID: 33563388 DOI: 10.1016/j.anclin.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The posterior cranial fossa with its complex anatomy houses key pathways regulating consciousness, autonomic functions, motor and sensory pathways, and cerebellar centers regulating balance and gait. The most common posterior fossa pathologies for which neurosurgical intervention may be necessary include cerebellopontine angle tumors, aneurysms, and metastatic lesions. The posterior cranial fossa can be accessed from variations of the supine, lateral, park-bench, prone, and sitting positions. Notable complications from positioning include venous air embolism, paradoxic air embolism, tension pneumocephalus, nerve injuries, quadriplegia, and macroglossia. An interdisciplinary approach with careful planning, discussion, and clinical management contributes to improved outcomes and reduced complications.
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Affiliation(s)
- Kelsey Serfozo
- Department of Anesthesiology, University Hospital, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5048, USA
| | - Vijay Tarnal
- Department of Anesthesiology, University Hospital, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5048, USA.
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Intraoperative Management of Large Resuscitation-Associated Venous Air Embolism (VAE) for Emergent Neurological Surgery. Case Rep Anesthesiol 2020; 2020:8868037. [PMID: 32566316 PMCID: PMC7294353 DOI: 10.1155/2020/8868037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 11/17/2022] Open
Abstract
Venous air embolism (VAE) is a well-described phenomenon that may have life-threatening cardiopulmonary and neurological consequences. Accidental administration of air during resuscitation while using a rapid infuser is rare. Furthermore, there is a paucity of published data describing the intraoperative management of VAE during emergent nonseated neurological surgery. We report a 22-year-old previously healthy female who experienced a motor vehicle accident with severe facial and head trauma, and mixed subdural and epidural hematomas with an 8 mm midline shift. Computed tomography revealed significant air entrainment in the right heart and main pulmonary artery, with venous air tracking from the right axillary vein. Given her age, lack of preexisting cardiac comorbidities, hemodynamic stability, and critical cerebral herniation risk, further cardiac evaluation was deferred, and the patient was transferred to the operating room for emergent decompressive craniotomy. Intraoperatively, she experienced acute decrease in mean arterial pressure and end-expiratory carbon-dioxide with loss of pulse oximetry waveform concerning for obstructive VAE physiology. She was responsive to fluid resuscitation and epinephrine administration and did not experience any recurrence of obstructive VAE. This challenging case report describes positive neurologic and hemodynamic outcomes after resuscitation-associated VAE and cardiopulmonary collapse during emergency neurosurgery. Comprehensive evaluation of risk, urgency of procedure, and need for diagnostic monitoring and treatment should be personalized.
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Urgent Repositioning After Venous Air Embolism During Intracranial Surgery in the Seated Position: A Case Series. J Neurosurg Anesthesiol 2020; 31:413-421. [PMID: 30148744 DOI: 10.1097/ana.0000000000000534] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Venous air embolism (VAE) is a well-described complication of neurosurgical procedures performed in the seated position. Although most often clinically insignificant, VAE may result in hemodynamic or neurological compromise resulting in urgent change to a level position. The incidence, intraoperative course, and outcome in such patients are provided in this large retrospective study. METHODS Patients undergoing a neurosurgical procedure in the seated position at a single institution between January 2000 and October 2013 were identified. Corresponding medical records, neurosurgical operative reports, and computerized anesthetic records were searched for intraoperative VAE diagnosis. Extreme VAE was defined as a case in which urgent seated to level position change was performed for patient safety. Detailed examples of extreme VAE cases are described, including their intraoperative course, VAE management, and postoperative outcomes. RESULTS There were 8 extreme VAE (0.47% incidence), 6 during suboccipital craniotomy (1.5%) and 2 during deep brain stimulator implantation (0.6%). VAE-associated end-expired CO2 and mean arterial pressure reductions rapidly normalized following position change. No new neurological deficits or cardiac events associated with extreme VAE were observed. In 5 of 8, surgery was completed. Central venous catheter placement and aspiration during VAE played no demonstrable role in patient outcome. CONCLUSIONS Extreme VAE during seated intracranial neurosurgical procedures is infrequent. Extreme VAE-associated CO2 exchange and hemodynamic consequences from VAE were transient, recovering quickly back to baseline without significant neurological or cardiopulmonary morbidity.
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Nates JL, Cattano D, Costa FS, Chelly JE, Doursout MF. Thromboelastographic assessment of the impact of mexiletine on coagulation abnormalities induced by air or normal saline intravenous injections in conscious rats. Diving Hyperb Med 2017; 47:228-232. [PMID: 29241232 PMCID: PMC6706339 DOI: 10.28920/dhm47.4.228-232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/11/2017] [Indexed: 11/05/2022]
Abstract
BACKGROUND Thromboelastography (TEG) in venous air embolism (VAE) has been poorly studied. We induced coagulation abnormalities by VAE in a rat model, assessed by TEG with and without mexiletine, a lidocaine analogue local anesthetic. METHODS Twenty-three Sprague Dawley rats instrumented under isoflurane anesthesia and allowed to recover five days prior to the experiments were randomized into three experimental groups: 1) VAE (n = 6); 2) VAE and mexiletine (n = 9); and 3) normal saline (NS) alone (control group, n = 8). Blood samples were collected at baseline, one hour (h) and 24 h in all groups and analyzed by TEG to record the R, K, angle α and MA parameters. RESULTS In Group 1, VAE decreased significantly R at 1 h (31%), K at 1 h (59%) and 24 h (34%); α increased significantly at 1 h (30%) and 24 h (22%). While R returned to baseline values within 24 h, K, MA and α did not. In group-2 (Mexiletine + VAE), K and R decreased at 1 h (48% and 29%, respectively) and at 24 h the changes were non-significant. Angle α increased at 1 h (28%) and remained increased for 24 h (25%). In group 3 (NS), only R was temporarily affected. MA increased significantly at 24 h only in the VAE alone group. CONCLUSION As expected, VAE produced a consistent and significant hypercoagulable response diagnosed/confirmed by TEG. Mexiletine prevented the MA elevation seen with VAE and corrected R and K time at 24 h, whereas angle α remained unchanged. Mexiletine seemed to attenuate the hypercoagulability associated with VAE in this experiment. These results may have potential clinical applications and deserve further investigation.
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Affiliation(s)
- Joseph L Nates
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 112, Houston, TX 77030, USA,
| | - Davide Cattano
- Department of Anesthesiology, The University of Texas Medical School at Houston, Houston, Texas, USA
| | | | - Jacques E Chelly
- Department of Anesthesiology, The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Marie-Francoise Doursout
- Department of Anesthesiology, The University of Texas Medical School at Houston, Houston, Texas, USA
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Himes BT, Mallory GW, Abcejo AS, Pasternak J, Atkinson JLD, Meyer FB, Marsh WR, Link MJ, Clarke MJ, Perkins W, Van Gompel JJ. Contemporary analysis of the intraoperative and perioperative complications of neurosurgical procedures performed in the sitting position. J Neurosurg 2016; 127:182-188. [PMID: 27494821 DOI: 10.3171/2016.5.jns152328] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Historically, performing neurosurgery with the patient in the sitting position offered advantages such as improved visualization and gravity-assisted retraction. However, this position fell out of favor at many centers due to the perceived risk of venous air embolism (VAE) and other position-related complications. Some neurosurgical centers continue to perform sitting-position cases in select patients, often using modern monitoring techniques that may improve procedural safety. Therefore, this paper reports the risks associated with neurosurgical procedures performed in the sitting position in a modern series. METHODS The authors reviewed the anesthesia records for instances of clinically significant VAE and other complications for all neurosurgical procedures performed in the sitting position between January 1, 2000, and October 8, 2013. In addition, a prospectively maintained morbidity and mortality log of these procedures was reviewed for instances of subdural or intracerebral hemorrhage, tension pneumocephalus, and quadriplegia. Both overall and specific complication rates were calculated in relation to the specific type of procedure. RESULTS In a series of 1792 procedures, the overall complication rate related to the sitting position was 1.45%, which included clinically significant VAE, tension pneumocephalus, and subdural hemorrhage. The rate of any detected VAE was 4.7%, but the rate of VAE requiring clinical intervention was 1.06%. The risk of clinically significant VAE was highest in patients undergoing suboccipital craniotomy/craniectomy with a rate of 2.7% and an odds ratio (OR) of 2.8 relative to deep brain stimulator cases (95% confidence interval [CI] 1.2-70, p = 0.04). Sitting cervical spine cases had a comparatively lower complication rate of 0.7% and an OR of 0.28 as compared with all cranial procedures (95% CI 0.12-0.67, p < 0.01). Sitting cervical cases were further subdivided into extradural and intradural procedures. The rate of complications in intradural cases was significantly higher (OR 7.3, 95% CI 1.4-39, p = 0.02) than for extradural cases. The risk of VAE in intradural spine procedures did not differ significantly from sitting suboccipital craniotomy/craniectomy cases (OR 0.69, 95% CI 0.09-5.4, p = 0.7). Two cases (0.1%) had to be aborted intraoperatively due to complications. There were no instances of intraoperative deaths, although there was a single death within 30 days of surgery. CONCLUSIONS In this large, modern series of cases performed in the sitting position, the complication rate was low. Suboccipital craniotomy/craniectomy was associated with the highest risk of complications. When appropriately used with modern anesthesia techniques, the sitting position provides a safe means of surgical access.
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Giraldo M, Lopera LM, Arango M. Venous air embolism in neurosurgery. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rcae.2014.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Venous air embolism in neurosurgery☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1097/01819236-201543001-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Heng HG, Ruth JD, Lee K. Venous air embolism detected on computed tomography of small animals. J Small Anim Pract 2014; 55:420-3. [PMID: 24889199 DOI: 10.1111/jsap.12238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe the prevalence, location and clinical significance of abnormal gas accumulations in dogs and cats detected on computerised tomography images. METHODS Retrospective evaluation of all canine and feline computed tomography examinations (292 pre-contrast and 219 post-contrast) performed in a 12-month time period. All studies were evaluated for the presence of venous air emboli. The location of intravenous gas was noted and the volume of intravenous air emboli was estimated visually. The medical records of animals with venous air embolism were reviewed for signs of cardiopulmonary complications. RESULTS The overall prevalence of air embolism on pre- and incidence on post-contrast images was 4 · 5 and 2 · 3%, respectively. The prevalence of air embolism on pre-contrast and incidence on post-contrast thoracic images was 35 · 7 and 14 · 2%, respectively. The volume of venous air was generally small and the most common was in an axillary vein. None of the animals had any cardiopulmonary complications. CLINICAL SIGNIFICANCE The presence of small volume venous air embolism on routine computed tomography examinations is a frequent incidental finding that does not appear to cause cardiopulmonary complications.
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Affiliation(s)
- H G Heng
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, IN, 47906, USA
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