Acute management of vascular air embolism

Cerebral air embolism: neurologic manifestations, prognosis, and outcome

Background

Cerebral air embolism (CAE) is an uncommon medical emergency with a potentially fatal course. We have retrospectively analyzed a set of patients treated with CAE at our comprehensive stroke center and a hyperbaric medicine center. An overview of the pathophysiology, causes, diagnosis, and treatment of CAE is provided.

Results

We retrospectively identified 11 patients with cerebral venous and arterial air emboli that highlight the diversity in etiologies, manifestations, and disease courses encountered clinically. Acute-onset stroke syndrome and a progressive impairment of consciousness were the two most common presentations in four patients each (36%). Two patients (18%) suffered from an acute-onset coma, and one (9%) was asymptomatic. Four patients (36%) were treated with hyperbaric oxygen therapy (HBTO), high-flow oxygen therapy without HBOT was started in two patients (18%), two patients (18%) were in critical care at the time of diagnosis and three (27%) received no additional treatment. CAE was fatal in five cases (46%), caused severe disability in two (18%), mild disability in three (27%), and a single patient had no lasting deficit (9%).

Conclusion

Cerebral air embolism is a dangerous condition that necessitates high clinical vigilance. Due to its diverse presentation, the diagnosis can be missed or delayed in critically ill patients and result in long-lasting or fatal neurological complications. Preventative measures and a proper diagnostic and treatment approach reduce CAE's incidence and impact.

Intraoperative Challenge: Managing Venous Air Embolism During Sitting Craniotomy

Venous air embolism (VAE) represents a rare yet potentially life-threatening complication encountered during neurosurgical procedures, particularly craniotomy. Here, we present a case of a 30-year-old male undergoing excision of a cerebellar abscess who developed VAE midway through the procedure. Immediate recognition and intervention were paramount in managing the embolism effectively, ensuring a favorable surgical outcome. Vigilant monitoring, prompt cessation of the procedure, and implementation of preventive measures such as oxygen therapy and venous air aspiration were pivotal in mitigating the embolism's effects. This study underscores the critical importance of intraoperative vigilance, preparedness, and multidisciplinary teamwork in addressing rare but potentially catastrophic complications during neurosurgical interventions.

Investigation of air bubble behaviour after gas embolism events induced in a microfluidic network mimicking microvasculature

Gas embolism is a medical condition that occurs when gas bubbles are present in veins or arteries, decreasing blood flow and potentially reducing oxygen delivery to vital organs, such as the brain. Although usually reported as rare, gas embolism can lead to severe neurological damage or death. However, presently, only limited understanding exists regarding the microscale processes leading to the formation, persistence, movement, and resolution of gas emboli, as modulated by microvasculature geometrical features and blood properties. Because gas embolism is initially a physico-chemical-only process, with biological responses starting later, the opportunity exists to fully study the genesis and evolution of gas emboli using in vitro microfluidic networks mimicking small regions of microvasculature. The microfluidics networks used in this study, which aim to mimic microvasculature geometry, comprise linear channels with T-, or Y-junction air inlets, with 20, 40, and 60 μm widths (arterial or venous), and a 30 μm width honeycombed network (arterial) with three bifurcation angles (30°, 60°, and 90°). Synthetic blood, equivalent to 46% haematocrit concentrations, and water were used to study the modulation of gas embolism-like events by liquid viscosity. Our study shows that (i) longer bubbles with lower velocity occur in narrower channels, e.g., with 20 μm width; (ii) the resistance of air bubbles to the flow increases with the higher haematocrit concentration; and lastly (iii) the propensity of gas embolism-like events in honeycomb architectures increases for more acute, e.g., 30°, bifurcation angles. A dimensionless analysis using Euler, Weber, and capillary numbers demarcated the conditions conducive to gas embolism. This work suggests that in vitro experimentation using microfluidic devices with microvascular tissue-like structures could assist medical guidelines and management in preventing and mitigating the effects of gas embolism.

Effects of different fractions of inspired oxygen on gas embolization during hysteroscopic surgery: A double-blind, randomized, controlled trial

OBJECTIVE

Gas embolism is a common complication of hysteroscopic surgery that causes serious concern among gynecologists and anesthesiologists due to the potential risk to patients. The factors influencing gas embolism in hysteroscopic surgery have been extensively studied. However, the effect of the oxygen concentration inhaled by patients on gas embolism during hysteroscopic surgery remains elusive. Therefore, we designed a double-blind, randomized, controlled trial to determine whether different inhaled oxygen concentrations influence the occurrence of gas embolism during hysteroscopic surgery.

METHODS

This trial enrolled 162 adult patients undergoing elective hysteroscopic surgery who were randomly divided into three groups with inspired oxygen fractions of 30%, 50%, and 100%. Transthoracic echocardiography (four-chamber view) was used to evaluate whether gas embolism occurred. Before the start of surgery, the four-chamber view was continuously monitored.

RESULTS

The number of gas embolisms in the 30%, 50%, and 100% groups was 36 (69.2%), 30 (55.6%), and 24 (44.4%), respectively. The incidence of gas embolism gradually decreased with increasing inhaled oxygen concentration (P = 0.031).

CONCLUSION

In hysteroscopic surgery, a higher oxygen concentration inhaled by patients may reduce the incidence of gas embolism, indicating that a higher inhaled oxygen concentration, especially 100%, could be recommended for patients during hysteroscopic surgery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (https://www.chictr.org.cn/showproj.html?proj=53779, Registration number: ChiCTR2000033202).

Iatrogenic air embolism: pathoanatomy, thromboinflammation, endotheliopathy, and therapies

Iatrogenic vascular air embolism is a relatively infrequent event but is associated with significant morbidity and mortality. These emboli can arise in many clinical settings such as neurosurgery, cardiac surgery, and liver transplantation, but more recently, endoscopy, hemodialysis, thoracentesis, tissue biopsy, angiography, and central and peripheral venous access and removal have overtaken surgery and trauma as significant causes of vascular air embolism. The true incidence may be greater since many of these air emboli are asymptomatic and frequently go undiagnosed or unreported. Due to the rarity of vascular air embolism and because of the many manifestations, diagnoses can be difficult and require immediate therapeutic intervention. An iatrogenic air embolism can result in both venous and arterial emboli whose anatomic locations dictate the clinical course. Most clinically significant iatrogenic air emboli are caused by arterial obstruction of small vessels because the pulmonary gas exchange filters the more frequent, smaller volume bubbles that gain access to the venous circulation. However, there is a subset of patients with venous air emboli caused by larger volumes of air who present with more protean manifestations. There have been significant gains in the understanding of the interactions of fluid dynamics, hemostasis, and inflammation caused by air emboli due to in vitro and in vivo studies on flow dynamics of bubbles in small vessels. Intensive research regarding the thromboinflammatory changes at the level of the endothelium has been described recently. The obstruction of vessels by air emboli causes immediate pathoanatomic and immunologic and thromboinflammatory responses at the level of the endothelium. In this review, we describe those immunologic and thromboinflammatory responses at the level of the endothelium as well as evaluate traditional and novel forms of therapy for this rare and often unrecognized clinical condition.

Air Medical Transport of a 12-Year-Old Girl With Cerebral Gas Embolism Due to Helium Inhalation

This case report describes the initial care and transport considerations of a pediatric patient who suffered from cerebral gas embolism sustained after inhalation of helium from a pressurized tank. The patient demonstrated neurologic symptoms necessitating hyperbaric oxygen therapy and required fixed wing air transport across a mountain range from a rural community hospital to a tertiary center for the treatment. We review the pathophysiology of cerebral gas embolism and strategies for transporting patients with cerebral gas embolism and other trapped gas.

Spontaneous Cerebral Air Embolism-An Unusual Scenario

The introduction of air into cerebral venous or arterial circulation known as cerebral air embolism (CAE) is a rare clinical entity. CAE is commonly iatrogenic secondary to central venous catheter (CVC) placement or removal, various endoscopic procedures, or trauma or surgical scenarios. Here we report a case of spontaneous CAE in an unusual scenario. A 71-year-old male presented to emergency after developing giddiness following a yoga session. His MRI showed air embolism in the posterior fossa along cerebellar folia, prepontine, and suprasellar cisterns and tracking superiorly along the tentorium cerebelli. CAE is a rare clinical entity. Our case had CAE as a complication of cholesteatoma and possibly got triggered due to change in air pressor dynamics during yoga session.

Intraoperative air embolism diagnosis and treatment using hyperbaric oxygen therapy after craniotomy: illustrative case

BACKGROUND

This report describes the use of hyperbaric oxygen therapy for the acute management of an intraoperative air embolism encountered during a neurosurgical procedure. Furthermore, the authors highlight the concomitant diagnosis of tension pneumocephalus requiring evacuation prior to hyperbaric therapy.

OBSERVATIONS

A 68-year-old male developed acute ST-segment elevation and hypotension during elective disconnection of a posterior fossa dural arteriovenous fistula. The semi-sitting position had been used to minimize cerebellar retraction, raising the concern for acute air embolism. Intraoperative transesophageal echocardiography was utilized to establish the diagnosis of air embolism. The patient was stabilized on vasopressor therapy, and immediate postoperative computed tomography revealed air bubbles in the left atrium along with tension pneumocephalus. He underwent urgent evacuation for the tension pneumocephalus followed by hyperbaric oxygen therapy to manage the hemodynamically significant air embolism. The patient was eventually extubated and went on to fully recover; a delayed angiogram revealed complete cure of the dural arteriovenous fistula.

LESSONS

Hyperbaric oxygen therapy should be considered for an intracardiac air embolism resulting in hemodynamic instability. In the postoperative neurosurgical setting, care should be taken to exclude pneumocephalus requiring operative intervention prior to hyperbaric therapy. A multidisciplinary management approach facilitated expeditious diagnosis and management for the patient.

A Young Woman With Dyspnea During Cardiac Catheterization

A woman in her mid-20s was evaluated for a history of dyspnea on exertion for 2 years. A 6F pigtail catheter was placed in the left ventricle via the right femoral artery, but the patient developed acute onset of dyspnea along with retrosternal chest pain; the catheter was pulled back into the right atrium, and chest fluoroscopy was performed. What would you do next?

Incidental Finding of Venous Air Embolism: A Case Report

Venous air embolism (VAE) is a rare but potentially lethal condition. It has numerous clinical and physiological causes. We present a case report of a 72-year-old Saudi male, known case of diabetes mellitus (DM), hypertension, and ischemic heart disease. The patient came to the emergency room (ER) complaining of the heaviness of the tongue that resolved spontaneously within a few hours. He underwent percutaneous coronary angiography three months ago. The patient with the previously mentioned neurological symptoms, who had been misdiagnosed as having transient cerebral ischemia, was, after a computerized tomography (CT) scan result, diagnosed with venous air embolism. Venous air embolism can occur in situations other than those in which patients are traditionally thought to be at risk, making diagnosis difficult. Any sudden change in mental status and hemodynamic alterations during minimally invasive procedures should raise the physician's suspicion of VAE. Because VAE is an uncommon complication, few cases have been recorded in Saudi Arabia.

Cerebral Air Embolism Following Transthoracic Lung Biopsy Successfully Treated With Hyperbaric Oxygen

Transthoracic lung biopsy is a frequently performed procedure performed worldwide. Although rare, air embolism is a potentially fatal complication. Rapid diagnosis and immediate treatment are essential to prevent patient clinical deterioration. Hyperbaric oxygen treatment is the standard of care in air embolism and time referral is critical for patient prognosis. We report a case of a man who underwent a percutaneous transthoracic lung biopsy which was complicated with arterial air embolism and severe neurologic symptoms; he was successfully treated with hyperbaric chamber treatment. Physicians performing such techniques should be aware of this severe complication as immediate support treatment and hyperbaric oxygen may prevent irreversible neurologic lesions.

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.

Iatrogenic stroke caused by cerebral air embolism and acute reperfusion therapy using hyperbaric oxygen

Objective:

Air embolisms are mostly iatrogenic and a rare yet dreaded complication following percutaneous procedures. Intravascular entrapment of air can result in occlusion of end arteries and subsequent tissue ischemia and infarction. Cerebrovascular occlusions caused by air embolisms are time-sensitive and an uncommon cause of ischemic stroke, warranting an alternative acute management and reperfusion strategy.

Methods:

During a CT-guided lung biopsy, the patient developed left-sided paresis and sensory deficits prior to loss of consciousness. CT revealed air in the aorta, both ophthalmic arteries and vessels in the right parietal region. The patient was swiftly air-lifted to the nearest hyperbaric oxygen chamber for an alternate emergency reperfusion therapy. The following eight days the patient received hyperbaric oxygen therapy and gradually improved. Nine days after symptom onset he was discharged with a minor left facial palsy.

Conclusions

Cerebrovascular occlusions are critical events regardless of etiology. Air embolism is rare but potentially catastrophic and can occur during both percutaneous procedures and surgeries. Vigilance and knowledge of this potential complication are needed to rapidly provide beneficial treatment. That is, high flow oxygen and correct positioning pending hyperbaric oxygen therapy.

Pineal region tumours in the sitting position: how I do it

Background

Pineal region tumours remain challenging neurosurgical pathologies.

Methods

Detailed anatomical knowledge of the posterior incisural space and its variations is critical. An opaque arachnoidal membrane seals the internal cerebral and basal veins, leading to thalamic, basal ganglia, mesencephalic/pontine infarctions if injured. Medium-size tumours can be removed en-bloc with all traction/manipulation applied on the tumour side, virtually without contact of ependymal surfaces of the pulvinars or third ventricle. Sacrifice of the cerebello-mesencephalic fissure vein may be required.

Conclusions

The sitting position offers superior anatomical orientation and remains safe with experienced teams. Meticulous microsurgical techniques and detailed anatomical knowledge are likely to secure safe outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-021-04821-3.

Multiple systemic venous air emboli after fatal basilar skull fracture

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This case is significant for extensive systemic vascular air emboli in the right ventricle (visually estimated at 30 ml), pulmonary artery, inferior vena cava, hepatic veins, and iliac vein, which is a rare and novel consequence of fatal basal skull fracture.

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Collections of air in the right ventricle and left external iliac vein were visible on imaging prior to contrast administration, making an iatrogenic etiology unlikely.

Massive cerebral air embolism following percutaneous transhepatic biliary drainage: A case report

RATIONALE

Cerebral air embolism from portal venous gas rarely occurs due to invasive procedures (e.g., endoscopic procedures, liver biopsy, or percutaneous transhepatic biliary drainage) that disrupt the gastrointestinal or hepatobiliary structures. Here, we report a rare case of fatal cerebral air embolism following a series of percutaneous transhepatic biliary drainage tube insertions.

PATIENT CONCERNS

A 50-year-old woman with a history of cholecystectomy, liver wedge resection, and hepaticojejunostomy for gallbladder cancer presented with altered mental status 1 week after percutaneous transhepatic biliary drainage tube placement.

DIAGNOSES

Extensive cerebral air embolism and acute cerebral infarction.

INTERVENTIONS

Brain computed tomography and magnetic resonance imaging, hyperbaric oxygen therapy, medical therapy.

OUTCOMES

Despite the use of hyperbaric oxygen therapy and medical treatment including vasopressors, the patient eventually died due to massive systemic air embolism.

LESSONS

To date, there have been no reports of cerebral air embolism due to percutaneous transhepatic biliary drainage with pronounced radiologic images. We reviewed previously reported fatal cases associated with endoscopic hepatobiliary procedures and assessed the possible mechanisms and potential causes of air embolism.

Transesophageal Echocardiography-Guided Aspiration of Venous Air Embolism During Liver Transplantation: A Case Report

Transesophageal echocardiography can be useful not only in diagnosing venous air embolism but also in guiding aspiration of air from the pulmonary artery. A 59-year-old man with a history of cirrhosis underwent combined kidney and liver transplantations. He developed acute hypotension after the native liver was removed due to a massive venous air embolism via a retained transjugular intrahepatic portosystemic shunt catheter. Transesophageal echocardiography revealed air in the pulmonary artery resulting in outflow obstruction. Under echocardiographic guidance, the pulmonary arterial catheter was withdrawn to the air pocket and aspirated, resulting in improved hemodynamics and successful completion of transplantations.

Venous Gas Embolism During Radical Robotic Prostatectomy: A Case Report and Evidence-Based Management Algorithm

Robotic-assisted radical prostatectomy (RARP) has gained rapid popularity in the last two decades after early reports of excellent survival rates, quick learning curves, and minimal invasion or tissue damage. Given the anatomical location of surgical prostatectomies and the utilization of intra-abdominal gas during laparoscopy, there is a risk of developing venous air embolism (VAE). We present a case of a 62-year-old male with hypothyroidism and benign prostatic hyperplasia who underwent robotic suprapubic prostatectomy under general anesthesia. One hour after incision the ETCO2 suddenly dropped (40 mmHg to 25 mmHg) as did the SpO2 (98% to 90%). There were no other vital sign changes, nor was there significant blood loss. The surgical team was notified, which prompted the surgeon to inform us that he had just been dissecting around the pelvic venous plexus. At this point, with the clinical suspicion of VAE, abdominal insufflation pressure was lowered, and inspired oxygen was increased to 100%. After 10 minutes, SpO2 and ETCO2 normalized. A debrief and literature review inspired us to develop a laparoscopic-specific VAE management algorithm, with attention to robotic-case management issues. To the best of our knowledge, this is a rare case report describing a clinical VAE during RARP.

Systemic vascular air embolus following CT-guided transthoracic needle biopsy: a potentially fatal complication

Following an uncomplicated CT-guided transthoracic biopsy, a patient becomes unconscious and subsequently dies despite immediate cardiac resuscitation. The patient felt well during the procedure but started complaining about dizziness and chest pain when he sat up. When he again was put in a supine position, cardiac arrest was noted. A CT scan performed when the symptoms initiated was afterwards rigorously reviewed by the team and revealed air located in the left ventricle, aorta and right coronary artery.We present a rare but potentially lethal complication following CT-guided transthoracic needle biopsy-systemic vascular air embolus. Knowledge and evidence about the complication are sparse because of low incidence and varying presentation. However, immediate initiation of treatment can save a life, and awareness of the complication is therefore crucial.

A rare appearance of the trigeminocardiac reflex during resection of posterior parasagittal meningioma

Background:

Although a well-recognized phenomenon of the tentorium and posterior fossa, the trigeminocardiac reflex (TCR) has been rarely reported during surgery involving the posterior falx cerebri.

Case Description:

We present the case of a 63-year-old woman who underwent repeat resection of an atypical parasagittal meningioma involving the posterior falx. During resection, TCR was repeatedly elicited during manipulation and coagulation of the falx. Air embolism and cardiac etiologies were initially considered while TCR was not suspected, given the location. Ultimately, TCR was recognized when asystole self-resolved upon cessation of stimulus and due to its reproducibility.

Conclusion:

Awareness by the anesthesiologist and neurosurgeon of the possibility of TCR during falcine procedures can help with rapid identification to avoid a potentially catastrophic outcome.

Massive venous air embolism with bleeding caused by femoral vein injury during total hip arthroplasty: A case report

INTRODUCTION

Venous air embolism (VAE) from vascular injuries, is of rare occurrence but can result in catastrophic complications during total hip arthroplasty (THA). Early recognition and prompt management of vascular injury are required to avoid severe complications. Especially, bleeding is generally associated with profound hypotension in venous injury. We report an unusual complication of venous air embolism induced by femoral vein rupture during THA.

PATIENT CONCERNS

A 54-year-old male patient with a history of old left acetabular fracture was scheduled for THA. We experienced massive bleeding and VAE induced by femoral vein rupture during total hip arthroplasty. The BP suddenly dropped from 100/70 mm Hg to 80/50 mm Hg with massive bleeding. ETCO2 and SaO2 decreased profoundly.

DIAGNOSIS

The VAE was diagnosed by the change in end- tidal CO2 (ETCO2) and change of vital signs, so we performed ABGA and inserted TEE for confirmination.

INTERVENTIONS

For treatment, patient was managed by oxygen therapy, inotropics, vasopressor, transfusion and surgical repair.

OUTCOMES

Upon consulting with a cardiologist, the patient was extubated the next day and was transferred to the general ward and recovered without serious complications. He stayed for 17 days until finally discharged without complications.

CONCLUSION

Preoperative vascular imaging may be recommended in the revisional case of THA or in patients with the history of hip trauma. The monitoring of ETCO2 and TEE might be helpful to recognize VAE earlier and therefore to avoid catastrophic complications through adequate treatment.

Acute pulmonary edema due to occult air embolism detected on an automated anesthesia record: illustrative case

BACKGROUND

The authors report a case of venous air embolism (VAE) during a pediatric posterior fossa craniotomy with resulting pulmonary edema requiring postoperative ventilation. Pulmonary edema is a known but rare complication of VAE, and diagnosis and treatment are discussed.

OBSERVATIONS

The embolism was undetected during the surgical procedure, and the first clinical sign of respiratory decompensation appeared an hour after the initial insult, with imaging suggesting acute pulmonary edema. A transient but significant end-tidal carbon dioxide decrease was detected on postoperative review of the anesthesiology record.

LESSONS

This report highlights an uncommon sequela of VAE and the importance of post hoc automated record review for intraoperative event analysis.

Air in the right ventricle and vein after basilar skull fracture: a case report

Background

Air in the venous system may cause vascular air embolism, which is a potentially life-threatening event. The presence of air in venous system after basilar skull fracture is very rare.

Case presentation

A 77-year-old man fell from a truck bed and suffered head and neck trauma. On hospital arrival, his consciousness was clear and his vital signs were stable. His chief complaint was pain in the back of his head and neck. Head CT showed traumatic subarachnoid hemorrhage in the right frontal area and basilar skull fracture of the occipital bone. Whole body CT showed pneumocephalus and air in the jugular vein and right ventricle. The patient was placed in the supine position in a state of absolute rest to prevent vascular air embolism and was treated conservatively. On hospital day 3, CT was reperformed, revealing disappearance of air in the right ventricle and decreased air in the veins of the head and neck. On hospital day 4, the air in the veins disappeared completely on CT. He did not experience vascular air embolism after increasing of his activity level (e.g., raising his head on hospital day 3 and standing and walking alone on day 5). He was discharged 34 days after admission without sequelae.

Conclusions

Head trauma patients with basilar skull fracture might develop vascular air embolism if physicians fail to detect air in the venous system on hospital arrival. A high degree of suspicion regarding air in venous system or heart is required when patients present with such injuries.

Systemic Air Embolism in a Patient With Lung Lesion Undergoing Neurosurgery in Sitting Position: A Case Report

Systemic air embolism secondary to venous air embolism is a known complication of sitting position surgery. However, the possibility of an isolated systemic air embolism must be considered, especially in patients with preexisting lung disease receiving positive pressure ventilation. These patients may benefit from a comprehensive preoperative evaluation and advanced intraoperative monitoring. We report a case of a 53-year-old woman with chronic obstructive airway disease and a preexisting fibrocavitary lung lesion, who developed isolated air entrainment into the left heart during sitting position surgery.

Arterial Gas Emboli Secondary to Portal Venous Gas Diagnosed With Point-of-Care Ultrasound: Case Report and Literature Review

BACKGROUND

Portal venous gas (PVG) is a rarely observed clinical finding generally associated with intestinal ischemia. The proper clinical response to the finding of PVG depends somewhat on the setting in which it is observed. Here we describe a case in which extensive arterial gas emboli (AGE) were encountered during point-of-care ultrasound (POCUS) and subsequent computed tomography (CT) identified PVG secondary to gastric wall ischemia as the likely source.

CASE REPORT

A 69-year-old woman with history of metastatic colon cancer presented to the emergency department (ED) with altered mental status. On arrival, she was hypotensive, hypothermic, cachectic, and with abdominal distension. POCUS was performed to evaluate the source of the patient's hypotension, revealing the presence of PVG, as well as gas bubbles in all four chambers of the heart and the aorta. CT scan revealed gastric wall ischemia and confirmed the presence of significant air emboli throughout the portal venous system. Given the overall poor prognosis, the decision was made to forego further chemotherapy or surgery and the patient died later that week while under hospice care. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: AGE can occur in the setting of PVG. This may cause multi-organ failure by disrupting blood flow to organs, especially in patients with circulatory dysfunction, such as shock. Depending on the setting in which it is diagnosed, early detection of PVG may expedite earlier assessments of a patient's negative prognosis or initiation of attempted life-saving treatment. In this case report, we show that POCUS can be used to obtain an expedited diagnosis in a critically ill patient.

Hyperbaric Oxygen Therapy for Vascular Air Embolism From Iatrogenic Intravenous Infusion of Air in a Patient With Atrial Septal Defect: A Case Report

Vascular air embolism (VAE) is an important complication of some routine medical procedures, particularly intravenous access for the administration of fluids or medications. The capillary bed of the pulmonary circulatory system is capable of compensating for small amounts of air entrained into a vein. However, large amounts of air can overwhelm that system and lead to complications ranging from cough, chest pain, or shortness of breath to cardiopulmonary collapse. Additionally, air entrained directly into the arterial system, or that which crosses from the venous system to the arterial system through a shunt can cause the acute coronary syndrome, loss of consciousness, arrhythmias, altered mental status, stroke, or limb ischemia. We present a case in which a patient with a known atrial septal defect had a moderate volume of air entrained through an intravenous catheter requiring hyperbaric oxygen therapy.

Stroke Following Successful PTMC in a Patient with Severe Mitral Stenosis: A Case Report and Presenting A Simple Stepwise Approach to PTMC-related Stroke

Stroke following percutaneous trans-septal mitral commissurotomy (PTMC) is an unusual complication that could significantly affect the quality of life of the patients, particularly the young and active ones. We present a middle-aged woman who experienced stroke following PTMC and successfully treated with thrombolytic therapy regarding the potential adverse effects of this type of therapy. Also, we present a simple novel stepwise clinical approach for PTMC-related stroke.

Acceptability of external jugular venepuncture for patients with liver disease and difficult venous access

BACKGROUND

Difficult venous access (DVA) is common in liver patients requiring blood collection using traditional peripheral approaches. This study aimed to understand the experience of DVA for liver patients and the acceptability of peripheral venepuncture versus external jugular venepuncture (EJV). A secondary aim was to explore the impact of EJV on local resource utilization.

METHODS

Semistructured interviews with liver outpatients with DVA (n = 10) requiring venepuncture were firstly themed inductively. We then deductively applied the acceptability framework of Sekhon et al. as a further analytic lens. Audit data from DVA encounters (n = 24) allowed analysis of issues from multiple perspectives. The Consolidated Criteria for Reporting Qualitative Research reporting checklist guides this report.

RESULTS

Peripheral venepuncture had poor prospective, concurrent, and retrospective acceptability, requiring significant mental and physical preparation. Fear, stigma, pain and distress, poor continuity of care, and poor effectiveness led to service disengagement. While EJV caused initial trepidation, it had high concurrent and retrospective acceptability. The significant improvement in patient experience was corroborated by audit data for both procedure duration (5 versus 15 minutes) and first attempt success (100 versus 28.5%) for EJV versus peripheral venepuncture, respectively. While EJV required a recumbent position, it required less staff.

CONCLUSIONS

EJV is highly acceptable to patients, using less time and staff resources. EJV protocols and staff training should be considered where DVA presentations are common. Individualized care plans and careful care coordination could divert DVA patients needing venepuncture to services that use EJV preferentially. HIGHLIGHTS Peripheral venepuncture results in fear, stigma, pain, & distress for those with DVA. This poor acceptability of traditional venepuncture leads to service disengagement. External jugular venepuncture is highly acceptable & improves resource utilization.

Endotracheal administration for intraoperative acute massive pulmonary embolism during laparoscopic hepatectomy: A case report

INTRODUCTION

Acute pulmonary embolism (APE) during an operation is a very urgent occurrence, especially when the patient with hemodynamic instability. Generally, drugs are administered intravenously; however, these drugs have little effects under most circumstances. We present a case of successful resuscitation in a patient with endotracheal administration.

PATIENT CONCERNS

A 67-year-old female presented for laparoscopic hepatectomy. Acute pulmonary gas embolism occurred during the operation with hemodynamic instability. The total amount of carbon dioxide and argon reached 300 mL. We used a novel way of administering drugs instead of intravenous administration for rescuing and the patient condition had improved greatly and was discharged from the hospital without any neurological deficits.

DIAGNOSES

A diagnosis of APE was made because of a lot of gas was extracted out from central venous catheter and sudden observable decrease in end-tidal CO2.

INTERVENTIONS

These measures included endotracheal administration, position adjustment, manual ventilation, and gas extraction.

OUTCOMES

The patient was discharged from the hospital and had no signs of neurological deficits.

CONCLUSION

Intravenous administration may not the best appropriate way of administration when patients occurred APE. Endotracheal administration as a unique method may work wonders and has the value of research and application.

Hyperbaric Oxygen Ameliorates Insulin Sensitivity by Increasing GLUT4 Expression in Skeletal Muscle and Stimulating UCP1 in Brown Adipose Tissue in T2DM Mice

Hyperbaric oxygen (HBO) therapy is a treatment modality useful for diseases. Hypoxia could stimulate the induction of insulin resistance. Therefore, we sought to determine whether hyperbaric oxygen would ameliorate insulin sensitivity by promoting glucose transporter type 4 (GLUT4) expression in muscle and by stimulating UCP1 in brown adipose tissue (BAT) in a streptozocin (STZ)-induced type 2 diabetes mellitus (T2DM) mouse model. Male C57BL/6J mice were treated three times with low-dose of streptozocin (60 mg/kg, i.p.) and were fed with high-fat diets (HFD) to establish the T2DM model. HBO was administered daily as 100% oxygen at 2.0 atmosphere absolute (ATA) for 1 h for a week. We found that HBO significantly reduced blood glucose levels and attenuated insulin resistance in T2DM mice. HBO modulated food intake by influencing the activity of neuropeptide Y (NPY)-positive neurons in the arcuate nucleus (Arc). HBO treatment increased GLUT4 amount and level of phosphorylated Akt (p-Akt) in muscles of T2DM mice whereas this treatment stimulated the phosphorylation of AMPK in muscles of both T2DM and HFD mice. The morphological staining of BAT and the increased expression of uncoupling of protein 1 (UCP1) demonstrated the promotion of metabolism after HBO treatment. These findings suggest that HBO ameliorates insulin sensitivity of T2DM mice by stimulating the Akt signaling pathway and by promoting GLUT4 expression in muscle, and by increasing UCP1 expression in BAT.

Clinical Presentation, Diagnosis, and Management of Air Embolism During Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive procedure that is widely used by endoscopists and has a robust therapeutic profile. It uses endoscopy and imaging for a variety of diagnostic as well as therapeutic purposes. It is used for the management of a lot of pancreaticobiliary diseases such as obstructive jaundice, obstruction related to bile ducts, pancreatic biliary tumors, and traumatic or iatrogenic damage to the bile ducts. Other therapeutic interventions that can be done via ERCP include sphincterotomy, dilation of strictures, removal of biliary stones and placement of stents. Air embolism presents with cardiovascular, pulmonary, and neurologic signs and symptoms. Treatment of air embolism should be started early in suspected cases, and it should be in the differential diagnoses of various complications secondary to high risk of ERCP, especially if a cardiopulmonary compromise is present. Air embolism is rare but a serious complication associated with ERCP. The physicians must keep this in mind while performing ERCP in patients with predisposing risk factors. This review highlights the mechanism, causes, risk factors, pathophysiology, clinical signs, diagnostic modalities, treatment, and preventive measures to deal with this catastrophic complication.

Doppler ultrasound dataset for the development of automatic emboli detection algorithms

The article describes a dataset of doppler ultrasound audio tracks taken on a sample of 30 divers according to the acquisition protocol defined by the Divers Alert Network. The audio tracks are accompanied by a medical evaluation for the decompression sickness risk according to the Spencer's scale levels.

During the acquisition campaign, each diver in the post-dive phase was subjected to a double doppler ultrasound examination of approximately 45 seconds each one in the precordial area using a Huntleigh FD1 Fetal doppler probe. The two measurements were separated by a time of 8–10 seconds necessary for carrying out specific physical exercises designed to free the bubbles trapped in the tissues. The audio tracks were stored without compression via the TASCAM DP-004 recorder and processed in order to eliminate the noise generated by the positioning of the probe and the time interval between the two measurements.

The audio tracks recorded during the acquisition campaign have been evaluated by experts belonging to three independent blind teams in order to provide an assessment of the decompression sickness risk according to Extended Spencer's scale. The specific typology of doppler ultrasound audio tracks and the associated medical evaluation according to the Spencer's scale levels make this dataset useful for the development, testing, and performance evaluation of new audio processing algorithms capable of automatically detecting bubbles in the blood vessels.

Air embolism through open hub of external jugular vein intravenous cannula

Introduction

Venous air embolism is a catastrophic complication that can result in sudden cardiac arrest and death. Massive air embolism has been reported with central venous catheter through the internal jugular and subclavian veins. Though external jugular vein is a potential site of an air embolism to cardiac chambers and subsequently to vital organs such as brain, heart and lungs but has not been reported yet in literature.

Case presentation

We are reporting a case of sudden pulmonary air embolism in a patient through the open hub of an intravenous cannula, vigilant monitoring and timely action saved the patient from a catastrophic outcome.

Conclusion

We recommend vigilant monitoring and adequate precaution in patients with external jugular venous cannulation in the operation theater, intensive care unit or wards to prevent iatrogenic complications.

Pneumodissection during Percutaneous Renal Ablation Resulting in Air Embolism: Percutaneous Management and a Review of the Literature

Percutaneous renal ablation is a nephron-sparing approach for selected patients with renal cell carcinoma. Common complications include hemorrhage, injury to the urinary collecting system, and abscess formation. The purpose of this article is to present a case of vascular air embolism as a complication of pneumodissection performed during percutaneous ablation of renal cell carcinoma, discuss its successful percutaneous management, review common complications of renal ablation, and outline steps physicians can take to lessen these complications.

Influx of air into the left atrium during lung resection

OBJECTIVES

In this study, we aimed to determine conditions associated with the development of air bubbles in the pulmonary veins during lung resection.

METHODS

A total of 28 patients who underwent lung resection at our institution between October 2016 and March 2018 were included in the study. An intraoperative transesophageal echocardiography was conducted, and the influx of air bubbles in the orifice of the pulmonary vein leading to the left atrium was observed during lung resection.

RESULTS

The median age of all patients was 75 years. The study included 13 men and 15 women. Moreover, seven, 14, and seven patients underwent wedge resection, segmentectomy, and lobectomy, respectively. The presence of air bubbles was observed in 15 patients and was detected when the lung parenchyma was cut (13 patients) or compressed (3 patients) using staplers and when an energy device was used (1 patient). No postoperative organ infarction occurred in any patients.

CONCLUSIONS

Although the presence of air bubbles was noted in the pulmonary vein during lung resection via transesophageal echocardiography, the clinical condition of the patients in our study did not deteriorate. The clinical significance of air bubbles is not clear. Therefore, more data about such events must be collected in future.

Oxygen Venous Embolism After Hydrogen Peroxide Use During Percutaneous Nephrolithotomy

Background: Hydrogen peroxide (H₂O₂) is a common antiseptic that is available without a prescription in the United States, and it is indicated for minor dermal abrasion; mouth, gum, or dental irritations; and removal of oral secretion. Several other medical uses have also been described, including clot dissolution during endoscopic gastrointestinal evaluation, cleansing of orthopedic surgical sites, and bladder irrigation. However, these uses of H₂O₂, as well as high-dose ingestion, have been associated with a wide variety of medical complications, including but not limited to air pulmonary embolism and stroke.

Case Presentation: Our patient is a 51-year-old female with a medical history of hypertension, familial, hypercholesterolemia, gallstones, depression, coronary artery disease (identified on calcium study because of familial hypercholesterolemia), nephrolithiasis, and recurrent cystitis. She required percutaneous nephrolithotomy and had H₂O₂ administered for clot dissolution. The clinical and temporal evidence would suggest a transient pulmonary air embolus after the intrarenal administration of or irrigation with H₂O₂, large amounts under high pressure.

Conclusion: This represents the first reported incidence of air embolus as a result of intrarenal administration of H₂O₂.

Venous carbon dioxide embolism during laparoscopic cholecystectomy a literature review

Laparoscopy has become the procedure of choice for routine gallbladder removal. A serious complication of this technique is the occurrence of gas emboli due to insufflation. It is associated with a high mortality rate of around 28%. The present systematic review intends to provide more insight into causes, symptoms and risk factors for this specific complication and to explore which measures should be taken to treat and prevent it. The Cochrane library and Pubmed were used as sources. Articles and their references were selected when they were related to the subject in sufficient detail. The course of this complication can vary from asymptomatic up to impairment of normal flow through the right ventricle (RV) or pulmonary artery, potentially leading to acute heart failure. The severity depends on the amount of gas, the rate of accumulation and the ability to remove the gas bubbles. It is difficult to estimate the true incidence of venous gas embolism during laparoscopic cholecystectomy as there are various diagnostic tools, each with different sensitivity. Precautions that need to be taken are: correct positioning of the needle, low insufflation pressure, low insufflation speed, screening for hypovolemia, Trendelenburg positioning, availability of intervention equipment at operation table, no placement of venous catheters during inspiration and catheter removing during expiration. Physicians need to be more aware of this harmful complication and the preventative measurements that need to be taken. As there are virtually no prospective data, future studies are needed to gain more knowledge on gas emboli during laparoscopic cholecystectomy.

Massive gas embolism in a child

A 16-month-old girl who was hospitalized with pneumonia and treated with antibiotics died after the nurse erroneously connected her intravenous left forearm catheter to the oxygen supply. Autopsy revealed an impressive gas embolism in the left subclavian and brachiocephalic veins, reduced crepitus and enlarged lung volume, and congestion of the meningeal vessels with some areas showing small air bubbles. Dilation of the right atrium and the right ventricle with efflux under pressure of large amounts of air bubbles were observed. The coronary arteries and veins were filled with air bubbles intercalated with segments containing blood. After exclusion of putrefactive artifacts as the source of such a large amount of gas in the body death was considered to be due to a massive air embolism. While embolisms are well recognized in adults, these cases are only infrequently encountered in forensic practice in younger decedents.

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.