-
Cureus Sep 2023Compared to operative hysteroscopy, diagnostic hysteroscopy rarely leads to issues. However, one very uncommon yet potentially fatal complication is air embolism, with...
Compared to operative hysteroscopy, diagnostic hysteroscopy rarely leads to issues. However, one very uncommon yet potentially fatal complication is air embolism, with an incidence rate of three in 17,000 cases. This report describes an unexpected complication discovered during diagnostic hysteroscopy surgery. In the course of routine infertility testing, a 29-year-old woman underwent a diagnostic hysteroscopy under general anesthesia. Intraoperatively, her end-tidal carbon dioxide (EtCO2) levels decreased, oxygen saturation dropped, and heart rate increased, leading the anesthesiologists and critical care team to terminate the procedure and manage her further. Subsequent transesophageal echocardiography confirmed the diagnosis of air embolism. She was managed with 100% oxygen and inotropes and cardiopulmonary resuscitation but despite aggressive medical interventions, her condition did not improve, and she unfortunately passed away. To diagnose, prevent, and manage the potentially devastating consequences associated with diagnostic hysteroscopy, gynecologists and surgical teams must maintain vigilance. The focus should be on proper patient selection, optimal surgical techniques, and the use of high-quality equipment to mitigate the risk of air embolism.
PubMed: 37842363
DOI: 10.7759/cureus.45069 -
The Egyptian Heart Journal : (EHJ) :... Oct 2023Despite the fact that injectable filler usage in the gluteal region has not been recommended in formal medical institutions, illegal procedures are performed in many...
BACKGROUND
Despite the fact that injectable filler usage in the gluteal region has not been recommended in formal medical institutions, illegal procedures are performed in many clinics and beauty centers across Egypt. This case report illustrates the illegal practice culminating in a fatal complication.
CASE PRESENTATION
A 26-year-old female with no relevant medical history presented to the ER with acute onset shortness of breath. The complaint started 16 h before, with a rapidly progressive course, shortly after undergoing a gluteal filler injection at a center in Cairo. At ER, the patient was severely distressed, yet fully conscious and oriented. She was shocked (BP 70/40 mmHg), tachycardic (130 BPM), and tachypneic (30/min) with normal temperature. She had congested pulsating neck veins with positive Kussmaul sign. Chest auscultation revealed normal vesicular breathing with equal air entry and no adventitious sounds. Her O2 saturation was 60% on room air that improved to 85% on O2 mask. ECG showed sinus tachycardia. Echocardiography showed dilated right side, D-shaped septum with systolic flattening, dilated IVC, mild tricuspid regurgitation and estimated RV systolic pressure 53 mmHg. Her ABG showed compensated metabolic acidosis with elevated lactate level. At the ICU, CVP was 18 mmHg. Saline infusion was continued along with noradrenaline infusion initiation. A provisional diagnosis of high-risk pulmonary embolism was made, though CT pulmonary angiography was not available. Accordingly, thrombolytic therapy was initiated with alteplase (100 mg) over 2 h. Also, a dose of pulse steroids (methylprednisolone 200 mg) was given. Chest X-ray showed bilateral heterogenous opacity and ABG showed deteriorating hypoxia and combined metabolic and respiratory acidosis. The patient was intubated upon deterioration of conscious level and was put on mechanical ventilation. Her ET tube showed frequent blood-tinged secretions. Echocardiography showed more right-side dilatation that was consistent with deterioration of clinical status. Three hours after admission the patient developed cardiac arrest and died 2 h later.
CONCLUSIONS
This case report highlights the dangers associated with injectable filler usage in the gluteal region. Physicians and patients should be aware of the possible complications and how to avoid it.
PubMed: 37816906
DOI: 10.1186/s43044-023-00415-9 -
Chemosphere Dec 2023Climate change and pollution are increasingly important stress factors for life on Earth. Dispersal of poly- and perfluoroalkyl substances (PFAS) are causing worldwide...
Climate change and pollution are increasingly important stress factors for life on Earth. Dispersal of poly- and perfluoroalkyl substances (PFAS) are causing worldwide contamination of soils and water tables. PFAS are partially hydrophobic and can easily bioaccumulate in living organisms, causing metabolic alterations. Different plant species can uptake large amounts of PFAS, but little is known about its consequences for the plant water relation and other physiological processes, especially in woody plants. In this study, we investigated the fractionation of PFAS bioaccumulation from roots to leaves and its effects on the conductive elements of willow plants. Additionally, we focused on the stomal opening and the phytohormonal content. For this purpose, willow cuttings were exposed to a mixture of 11 PFAS compounds and the uptake was evaluated by LC-MS/MS. Stomatal conductance was measured and the xylem vulnerability to air embolism was tested and further, the abscisic acid and salicylic acid contents were quantified using LC-MS/MS. PFAS accumulated from roots to leaves based on their chemical structure. PFAS-exposed plants showed reduced stomatal conductance, while no differences were observed in abscisic acid and salicylic acid contents. Interestingly, PFAS exposure caused a higher vulnerability to drought-induced xylem embolism in treated plants. Our study provides novel information about the PFAS effects on the xylem hydraulics, suggesting that the plant water balance may be affected by PFAS exposure. In this perspective, drought events may be more stressful for PFAS-exposed plants, thus reducing their potential for phytoremediation.
Topics: Abscisic Acid; Salix; Chromatography, Liquid; Tandem Mass Spectrometry; Plant Leaves; Water; Plants; Xylem; Fluorocarbons; Salicylic Acid; Droughts
PubMed: 37813249
DOI: 10.1016/j.chemosphere.2023.140380 -
Frontiers in Immunology 2023Iatrogenic vascular air embolism is a relatively infrequent event but is associated with significant morbidity and mortality. These emboli can arise in many clinical... (Review)
Review
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 and 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.
Topics: Humans; Embolism, Air; Thromboinflammation; Inflammation; Thrombosis; Iatrogenic Disease
PubMed: 37795086
DOI: 10.3389/fimmu.2023.1230049 -
BMC Pulmonary Medicine Sep 2023Pulmonary vein perforation is an uncommon complication during cardiac intervention. We present a rare case of pulmonary vein perforation into the respiratory tract with...
BACKGROUND
Pulmonary vein perforation is an uncommon complication during cardiac intervention. We present a rare case of pulmonary vein perforation into the respiratory tract with systemic air embolism during left atrial appendage closure (LAAC).
CASE PRESENTATION
A 77-year-old man with persistent nonvalvular atrial fibrillation was referred for percutaneous LAAC under local anaesthesia (CHADS-VASc score of 4, HAS-BLED score of 3, and prior ischaemic stroke). During the procedure, after delivering a super-stiff guidewire into the left superior pulmonary vein (LSPV), the patient suddenly developed a severe cough with haemoptysis upon advancement of a delivery sheath along the guidewire. Fluoroscopy showed signs of blood entering the left main bronchus, and fast transthoracic echocardiography revealed bubbles in the left heart without pericardial effusion. The procedure was terminated because of a major complication indicated by the repeated haemoptysis and headache, and haemostatic drugs were immediately administered. Subsequent chest computed tomography angiography (CTA) revealed a filling defect in the LSPV branches and bubbles in the aorta. The patient was transferred to the critical care unit for haemostasis and antibacterial treatment. Transthoracic echocardiography later that day showed no bubbles in the heart. The headache and haemoptysis significantly abated the following day. The bubbles in the aorta disappeared on chest CTA 7 days later.
CONCLUSIONS
Interventional cardiologists should pay attention to anatomical variations of the pulmonary vein, which are associated with a high risk of complications of pulmonary vein perforation during LAAC. Preoperative CTA examination and intraoperative transoesophageal echocardiography might be helpful to avoid this complication.
Topics: Male; Humans; Aged; Stroke; Pulmonary Veins; Hemoptysis; Embolism, Air; Atrial Appendage; Brain Ischemia; Treatment Outcome; Atrial Fibrillation; Respiratory System; Headache
PubMed: 37770875
DOI: 10.1186/s12890-023-02634-x -
Research Square Sep 2023A human cadaveric model combining standard lung protective mechanical ventilation and modified cardiac bypass techniques was developed to allow investigation into...
PURPOSE
A human cadaveric model combining standard lung protective mechanical ventilation and modified cardiac bypass techniques was developed to allow investigation into automated modes of detection of venous air emboli (VAE) prior to in vivo human or animal investigations.
METHODS
In this study, in order to create an artificial cardiopulmonary circuit in a cadaver that could mimic VAE physiology, the direction of flow was reversed from conventional cardiac bypass. Saline was circulated in isolation through the heart and lungs as opposed to the peripheral organs by placing the venous cannula into the aorta and the arterial cannula into the inferior vena cava with selective ligation of other vessels.
RESULTS
Mechanical ventilation and this reversed cardiac bypass scheme allowed preliminary detection of VAE independently but not in concert in our current simulation scheme due to pulmonary edema in the cadaver. A limited dissection approach was used initially followed by a radical exposure of the great vessels, and both proved feasible in terms of air signal detection. We used electrical impendence as a preliminary tool to validate detection in this cadaveric model however we theorize that it would work for echocardiographic, intravenous ultrasound or other novel modalities as well.
CONCLUSION
A cadaveric model allows monitoring technology development with reduced use of animal and conventional human testing.
PubMed: 37720030
DOI: 10.21203/rs.3.rs-3320755/v1 -
Medicine Sep 2023One of the catastrophic complications of surgical hysteroscopy is venous gas embolism (VGE), and this event could cause morbidity and in serious cases may even lead to... (Review)
Review
RATIONALE
One of the catastrophic complications of surgical hysteroscopy is venous gas embolism (VGE), and this event could cause morbidity and in serious cases may even lead to death. However, in cases of VGE accompanied by refractory hypokalemia is rare and can significantly increase the difficulty of treatment and resuscitation. Here, we successfully treated a patient with fatal VGE during surgical hysteroscopy, accompanied by difficult resuscitation with refractory hypokalemia.
PATIENT CONCERNS
We report a rare case of sudden cardiac arrest due to VGE during surgical hysteroscopy, followed by difficult resuscitation with refractory hypokalemia.
DIAGNOSIS
VGE was diagnosed by a sudden decrease in EtCO2, a loud mill wheel murmur in the thoracic area, and a small number of air bubbles evacuated from the internal jugular catheter. And refractory hypokalemia was diagnosed by serum potassium levels dropping frequently to as low as 2.0 mmol/L within 36 hours of resuscitation after cardiac arrest.
INTERVENTIONS
Our vigilant anesthesiologist noticed the early sign of VGE with a sudden drop in EtCO2, and as the cardiac arrest occurred, interventional maneuvers were implemented quickly including termination of the surgical procedure, adjustment of the patient's position, cardiac resuscitation, continuous chest compression, and correction of electrolyte disturbances, particularly refractory hypokalemia during the early stage of resuscitation.
OUTCOMES
The patient regained consciousness 4 days after the cardiac arrest and was discharged 1 month later without any neurological deficits.
LESSONS
As a relatively simple procedure, surgical hysteroscopy may have catastrophic complications. This case demonstrates the full course of fatal gas embolism and difficult resuscitation during hysteroscopic surgery, and emphasizes the importance of early detection, prompt intervention, and timely correction of electrolyte disturbances, such as refractory hypokalemia.
Topics: Humans; Female; Pregnancy; Hypokalemia; Hysteroscopy; Embolism, Air; Heart Arrest; Water-Electrolyte Imbalance; Electrolytes
PubMed: 37713863
DOI: 10.1097/MD.0000000000035227 -
Surgical Neurology International 2023Cerebral air embolism is a rare cause of acute ischemic stroke that is becoming increasingly well-described in the literature. However, the mechanism and severity of...
BACKGROUND
Cerebral air embolism is a rare cause of acute ischemic stroke that is becoming increasingly well-described in the literature. However, the mechanism and severity of this type of injury can vary, with ischemia typically emerging early in the course of care. To the best of our knowledge, delayed ischemia in this setting has not yet been described.
CASE DESCRIPTION
A stroke code was called for an unresponsive, hospitalized, 75-year-old man. A computerized tomography (CT) scan of the head revealed air within the right greater than left hemispheric cortical veins with loss of sulcation, concerning for developing ischemia, and CT angiography revealed absent opacification of the distal cortical vessels in the right anterior cerebral artery and middle cerebral artery territories. Magnetic resonance imaging (MRI) of the brain was obtained 5.75 h after the patient's last known well-showed small areas of subtle cortical diffusion restriction. Follow-up CT head within 24 h showed near-complete resolution of the air emboli after treatment with 100% fraction of inspired oxygen on mechanical ventilation. Subsequent MRI, performed 4 days after the initial event, showed extensive cortical diffusion restriction and cerebral edema crossing vascular territories.
CONCLUSION
This case highlights that cerebral air emboli can cause delayed ischemia that may not be appreciated on initial imaging. As such, affected patients may require intensive neurocritical care management, close neurologic monitoring, and repeat imaging irrespective of initial radiographic findings.
PubMed: 37680929
DOI: 10.25259/SNI_382_2023 -
Frontiers in Psychiatry 2023The prevalence of patent foramen ovale (PFO) is 15-35% among adults. The role of right-to-left shunting through the PFO, anxiety, depression, and hypoxemia in the...
The prevalence of patent foramen ovale (PFO) is 15-35% among adults. The role of right-to-left shunting through the PFO, anxiety, depression, and hypoxemia in the systemic circulation remains poorly understood. Herein, we present the case of a 52-year-old woman with no heart or lung disease, who was admitted due to anxiety for 5 months and had symptom exacerbation with dizziness for 4 days and presented with cyanosis. She was noted to have acute hypoxemia, with an oxygen saturation of 94.48% on room air, and arterial blood gas showed an oxygen tension of 65.64 mmHg. Agitated saline contrast echocardiography showed right-to-left shunting due to PFO. Arteriovenous fistula, pneumonia, pulmonary embolism, pulmonary hypertension, congestion peripheral cyanosis, ischemic peripheral cyanosis, and methemoglobin were excluded. Additionally, the patient improved by taking Paroxetine, Oxazepam, and Olanzapine. Her oxygen tension returned to 90.42 mmHg, and her symptoms resolved. In the case of severe anxiety and depression, right-to-left shunting through the PFO may cause acute systemic hypoxemia a flow-driven mechanism, occasionally manifesting as cyanosis. When anxiety improved, hypoxia also improved. Thus, the treatment of anxiety and depression seems effective in improving hypoxemia. Notably, this is a rare report, and we hope to draw the attention of psychosomatic specialists, psychiatrists, and clinicians to seek the relationship between anxiety appearing as acute stress and PFO. This may be a new therapeutic method for treating severe anxiety disorder.
PubMed: 37674554
DOI: 10.3389/fpsyt.2023.1229995 -
Clinical Neuroradiology Mar 2024Cerebral infarctions caused by air embolisms (AE) are a feared risk in endovascular procedures; however, the relevance and pathophysiology of these AEs is still largely...
PURPOSE
Cerebral infarctions caused by air embolisms (AE) are a feared risk in endovascular procedures; however, the relevance and pathophysiology of these AEs is still largely unclear. The objective of this study was to investigate the impact of the origin (aorta, carotid artery or right atrium) and number of air bubbles on cerebral infarctions in an experimental in vivo model.
METHODS
In 20 rats 1200 or 2000 highly calibrated micro air bubbles (MAB) with a size of 85 µm were injected at the aortic valve (group Ao), into the common carotid artery (group CA) or into the right atrium (group RA) using a microcatheter via a transfemoral access, resembling endovascular interventions in humans. Magnetic resonance imaging (MRI) using a 9.4T system was performed 1 h after MAB injection followed by finalization.
RESULTS
The number (5.5 vs. 5.5 median) and embolic patterns of infarctions did not significantly differ between groups Ao and CA. The number of infarctions were significantly higher comparing 2000 and 1200 injected MABs (6 vs. 4.5; p < 0.001). The infarctions were significantly larger for group CA (median infarction volume: 0.41 mm vs. 0.19 mm; p < 0.001). In group RA and in the control group no infarctions were detected. Histopathological analyses showed early signs of ischemic stroke.
CONCLUSION
Iatrogenic AEs originating at the ascending aorta cause a similar number and pattern of cerebral infarctions compared to those with origin at the carotid artery. These findings underline the relevance and potential risk of AE occurring during endovascular interventions at the aortic valve and ascending aorta.
Topics: Humans; Rats; Animals; Embolism, Air; Cerebral Infarction; Magnetic Resonance Imaging; Endovascular Procedures; Iatrogenic Disease
PubMed: 37665351
DOI: 10.1007/s00062-023-01347-2