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Neurocritical Care Feb 2023Arterial cerebral air embolism (CAE) is an uncommon but potentially catastrophic event. Patients can present with focal neurologic deficits, seizures, or coma. They may... (Review)
Review
BACKGROUND
Arterial cerebral air embolism (CAE) is an uncommon but potentially catastrophic event. Patients can present with focal neurologic deficits, seizures, or coma. They may be treated with hyperbaric oxygen therapy. We review the causes, radiographic and clinical characteristics, and outcomes of patients with CAE.
METHODS
We performed a retrospective chart review via an existing institutional database at Mayo Clinic to identify patients with arterial CAE. Demographic data, clinical characteristics, and diagnostic studies were extracted and classified on predefined criteria of diagnostic confidence, and descriptive and univariate analysis was completed.
RESULTS
Fifteen patients met criteria for inclusion in our study. Most presented with focal deficits (80%) and/or coma (53%). Seven patients (47%) had seizures, including status epilepticus in one (7%). Five presented with increased muscle tone at the time of the event (33%). Computed tomography (CT) imaging was insensitive for the detection of CAE, only identifying free air in 4 of 13 who underwent this study. When obtained, magnetic resonance imaging typically showed multifocal areas of restricted diffusion. Six patients (40%) were treated with hyperbaric oxygen therapy. Age, Glasgow Coma Scale score at nadir, and use of hyperbaric oxygen therapy were not associated with functional outcome at 1 year in our cohort. Twenty-six percent of patients had a modified Rankin scale score of 0 one year after the event, and functional improvement over time was common after discharge.
CONCLUSIONS
A high index of clinical suspicion is needed to identify patients with CAE because of low sensitivity of free air on CT imaging and nonspecific clinical presentation. Acute alteration of consciousness, seizures, and focal signs occur frequently. Because improvement over time is possible even among patients with severe presentation, early prognostication should be approached with caution.
Topics: Humans; Coma; Embolism, Air; Retrospective Studies; Tomography, X-Ray Computed; Seizures; Hyperbaric Oxygenation
PubMed: 36627433
DOI: 10.1007/s12028-022-01664-3 -
Current Opinion in Anaesthesiology Oct 2014Sitting position to surgically approach posterior fossa disorder continues to be the first choice for some neurosurgical teams. We underwent a literature research for... (Review)
Review
PURPOSE OF REVIEW
Sitting position to surgically approach posterior fossa disorder continues to be the first choice for some neurosurgical teams. We underwent a literature research for recent published studies involving neurosurgical patients operated on in this position. Preoperative evaluation, anesthetic technique, intraoperative monitoring, detection and treatment of venous or arterial air embolism episodes, and all the reported complications were recorded.
RECENT FINDINGS
A modified semisitting (lounging) position aiming to create a positive pressure in the transverse and sigmoid sinuses, with lower head and higher legs positioned above the top of the head, decreases the incidence and severity of venous air embolism. Hyperventilation, compromising cerebral blood flow, has to be avoided during a sitting position. Precordial Doppler or transesophageal echocardiography monitoring improves the detection of small venous air embolism enabling its early treatment and diminishing its consequences. Patients with known patent foramen ovale can be operated on in a sitting position, under strict protocol, with few reported clinical venous air embolism and no paradoxical air embolism.
SUMMARY
Sitting position for neurosurgical procedures may be a well tolerated approach for the patient if neurosurgeons and neuroanesthesiologists undergo a strict team protocol, including all necessary monitoring and meticulously followed.
Topics: Brain Diseases; Craniotomy; Embolism, Air; Humans; Monitoring, Intraoperative; Neurosurgical Procedures; Patient Positioning; Posture
PubMed: 25051265
DOI: 10.1097/ACO.0000000000000104 -
Kidney International Feb 2020
Topics: Catheters, Indwelling; Embolism, Air; Humans; Peritoneal Dialysis; Postoperative Complications
PubMed: 31980081
DOI: 10.1016/j.kint.2019.09.009 -
International Journal of Legal Medicine May 2020Venous air embolism (VAE) is a rare cause of death for which special procedures are needed for autopsy diagnosis. The current one of choice was devised by Richter in...
Venous air embolism (VAE) is a rare cause of death for which special procedures are needed for autopsy diagnosis. The current one of choice was devised by Richter in 1905 to prevent introduction of gas into the right heart while opening the thorax. We could find no published data demonstrating that that this occurs during standard autopsy technique. Two scenarios were investigated. In the first, the study group included cases using the traditional method to open the thoracic cage; in the control group, Richter's method was used. Gas was collected under water and measured in a calibrated tube. The second scenario involved cases in which an intracardiac catheter was present at autopsy. In these, 50 mL of air was injected prior to chest opening and the amount of intracardiac air was measured. The first (non-injected) study and control groups consisted of 28 and 26 cases, respectively. Gas was identified in 3 cases (10%) in the study group and 2 cases (7%) in the control group. In the ten injected cases, there was a significant difference in the amount of the gas recovered (10 mL in the standard cases and 30 mL in the Richter group). No significant artifactual gas entrapment occurs in the right heart using the standard autopsy technique. However, it is possible that this technique may cause loss of intracardiac gas and if there is a clinical suspicion of VAE, Richter's technique should be used.
Topics: Autopsy; Case-Control Studies; Embolism, Air; Gases; Humans
PubMed: 31595318
DOI: 10.1007/s00414-019-02158-2 -
Journal of Critical Care Dec 2017To narratively review published information on prevention, detection, pathophysiology, and appropriate treatment of vascular air embolism (VAE). (Review)
Review
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.
Topics: Anesthesia; Animals; Arteries; Catheterization, Central Venous; Disease Models, Animal; Early Diagnosis; Embolism, Air; Humans; Infusions, Intravenous; Patient Safety; Postoperative Complications; Veins
PubMed: 28802790
DOI: 10.1016/j.jcrc.2017.08.010 -
CJEM May 2023
Topics: Humans; Embolism, Air; Tomography, X-Ray Computed; Biopsy, Needle
PubMed: 37142857
DOI: 10.1007/s43678-023-00506-1 -
The New England Journal of Medicine Oct 2017
Topics: Adult; Decompression Sickness; Embolism, Air; Humans; Male; Portal Vein; Radiography, Abdominal; Skin; Tomography, X-Ray Computed; Vomiting
PubMed: 29045210
DOI: 10.1056/NEJMicm1615505 -
Digestive Endoscopy : Official Journal... Jul 2023
Topics: Humans; Embolism, Air; Stents
PubMed: 37218121
DOI: 10.1111/den.14601 -
Indian Pediatrics Dec 2018Vascular air embolism (VAE) is rare but potentially lethal condition, and survival is rarely reported in newborn.
BACKGROUND
Vascular air embolism (VAE) is rare but potentially lethal condition, and survival is rarely reported in newborn.
CHARACTERISTICS
A preterm (27+1 weeks) neonate on Continuous positive airway pressure developed sudden cardiac asystole on day 3 of life and required 30 minutes of cardiopulmonary resuscitation.
OBSERVATION
Infant had air embolism in liver and brain. He survived but developed cystic encephalomalcia requiring extensive neuro-rehabilitation.
MESSAGE
Air embolism should be considered as differential diagnosis of sudden unexplained cardiac deterioration in well neonate.
Topics: Embolism, Air; Humans; Infant, Newborn; Infant, Premature, Diseases; Male
PubMed: 30745484
DOI: No ID Found -
Inflammation Feb 2021Excessive amounts of air can enter the lungs and cause air embolism (AE)-induced acute lung injury (ALI). Pulmonary AE can occur during diving, aviation, and iatrogenic...
Excessive amounts of air can enter the lungs and cause air embolism (AE)-induced acute lung injury (ALI). Pulmonary AE can occur during diving, aviation, and iatrogenic invasive procedures. AE-induced lung injury presents with severe hypoxia, pulmonary hypertension, microvascular hyper-permeability, and severe inflammatory responses. Pulmonary AE-induced ALI is a serious complication resulting in significant morbidity and mortality. Surfactant is abundant in the lungs and its function is to lower surface tension. Earlier studies have explored the beneficial effects of surfactant in ALI; however, none have investigated the role of surfactant in pulmonary AE-induced ALI. Therefore, we conducted this study to determine the effects of surfactant in pulmonary AE-induced ALI. Isolated-perfused rat lungs were used as a model of pulmonary AE. The animals were divided into four groups (n = 6 per group): sham, air embolism (AE), AE + surfactant (0.5 mg/kg), and AE+ surfactant (1 mg/kg). Surfactant pretreatment was administered before the induction of pulmonary AE. Pulmonary AE was induced by the infusion of 0.7 cc air through a pulmonary artery catheter. After induction of air, pulmonary AE was presented with pulmonary edema, pulmonary microvascular hyper-permeability, and lung inflammation with neutrophilic sequestration. Activation of NF-κB was observed, along with increased expression of pro-inflammatory cytokines, and Na-K-Cl cotransporter isoform 1 (NKCC1). Surfactant suppressed the activation of NF-κB and decreased the expression of pro-inflammatory cytokines and NKCC1, thereby attenuating AE-induced lung injury. Therefore, AE-induced ALI presented with pulmonary edema, microvascular hyper-permeability, and lung inflammation. Surfactant suppressed the expressions of NF-κB, pro-inflammatory cytokines, and NKCC1, thereby attenuating AE-induced lung injury.
Topics: Acute Lung Injury; Animals; Embolism, Air; Gene Expression Regulation; Male; NF-kappa B; Rats; Rats, Sprague-Dawley; Solute Carrier Family 12, Member 2; Surface-Active Agents
PubMed: 33089374
DOI: 10.1007/s10753-020-01266-1