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General Thoracic and Cardiovascular... Jul 2024Intracardiac air remains an unsolved problem in the realm of cardiac surgery, leading to embolic events encompassing conduction disturbance, heart failure, and stroke.... (Review)
Review
Intracardiac air remains an unsolved problem in the realm of cardiac surgery, leading to embolic events encompassing conduction disturbance, heart failure, and stroke. Transesophageal echocardiography allows the visualization of three distinct types of retained intracardiac air: pooled air, coarse bubbles, and microbubbles. The former two predominantly manifest in the right upper pulmonary vein, left atrium, and left ventricle, exhibiting passive movement along the vessel walls by buoyancy. De-airing, involving "eradication" of air from circulation and "expulsion" of air from the heart into the systemic circulation assumes paramount importance in averting embolic events. Optimal de-airing strategies necessitate the thorough elimination of air during the static phase before the resumption of cardiac activity, achieved through aspiration or guided exit leveraging buoyancy. While the dynamic phase, characterized by active cardiac beating, presents challenges for air eradication, the majority of air expulsion occurs towards the aorta during this period. In this latter phase, collaborative efforts among the surgeon, anesthesiologist, and clinical engineer are pivotal to mitigate the risk of bolus air embolism. The efficacy of carbon dioxide insufflation is limited, as it is rapidly aspirated by wall suction or absorbed into the bloodstream. Consequently, the "air" identified by TEE is acknowledged as conventional air. Understanding the distinctive properties of air as well as timely and judicious collaboration for detection and removal, with the ultimate goal of eradication, emerges as an essential prerequisite for successful de-airing in the evolving era of cardiac surgery.
Topics: Humans; Embolism, Air; Echocardiography, Transesophageal; Cardiac Surgical Procedures
PubMed: 38750269
DOI: 10.1007/s11748-024-02041-x -
Current Sports Medicine Reports May 2024Breath-hold divers, also known as freedivers, are at risk of specific injuries that are unique from those of surface swimmers and compressed air divers. Using... (Review)
Review
Breath-hold divers, also known as freedivers, are at risk of specific injuries that are unique from those of surface swimmers and compressed air divers. Using peer-reviewed scientific research and expert opinion, we created a guide for medical providers managing breath-hold diving injuries in the field. Hypoxia induced by prolonged apnea and increased oxygen uptake can result in an impaired mental state that can manifest as involuntary movements or full loss of consciousness. Negative pressure barotrauma secondary to airspace collapse can lead to edema and/or hemorrhage. Positive pressure barotrauma secondary to overexpansion of airspaces can result in gas embolism or air entry into tissues and organs. Inert gas loading into tissues from prolonged deep dives or repetitive shallow dives with short surface intervals can lead to decompression sickness. Inert gas narcosis at depth is commonly described as an altered state similar to that experienced by compressed air divers. Asymptomatic cardiac arrhythmias are common during apnea, normally reversing shortly after normal ventilation resumes. The methods of glossopharyngeal breathing (insufflation and exsufflation) can add to the risk of pulmonary overinflation barotrauma or loss of consciousness from decreased cardiac preload. This guide also includes information for medical providers who are tasked with providing medical support at an organized breath-hold diving event with a list of suggested equipment to facilitate diagnosis and treatment outside of the hospital setting.
Topics: Humans; Diving; Breath Holding; Barotrauma; Decompression Sickness; Hypoxia; Inert Gas Narcosis
PubMed: 38709946
DOI: 10.1249/JSR.0000000000001168 -
British Journal of Hospital Medicine... Apr 2024
Topics: Humans; Embolism, Air; Lung Neoplasms; Intracranial Embolism; Stroke; Male; Tomography, X-Ray Computed; Middle Aged; Aged; Postoperative Complications; Catheter Ablation
PubMed: 38708979
DOI: 10.12968/hmed.2023.0379 -
American Journal of Perinatology Apr 2024To compare the risk of severe maternal morbidity (SMM) from the delivery admission to 42 days' postdischarge among persons with sickle cell disease (SCD) to those...
OBJECTIVE
To compare the risk of severe maternal morbidity (SMM) from the delivery admission to 42 days' postdischarge among persons with sickle cell disease (SCD) to those without SCD.
STUDY DESIGN
This retrospective cohort study included deliveries ≥20 weeks' gestation at an urban safety net hospital in Atlanta, GA from 2011 to 2019. The exposure was SCD diagnosis. The outcome was a composite of SMM from the delivery admission to 42 days' postdischarge. SMM indicators as defined by the Centers for Disease Control and Prevention were identified using the International Classification of Diseases, Ninth and Tenth Revisions (ICD-9/10) codes; transfusion of blood products and sickle cell crisis were excluded.
RESULTS
Of = 17,354 delivery admissions, = 92 (0.53%) had SCD. Persons with SCD versus without SCD had an increased risk of composite SMM (15.22 vs. 2.29%, < 0.001), acute renal failure (6.52 vs. 0.71%, < 0.001), acute respiratory distress syndrome (4.35 vs. 0.17%, < 0.001), puerperal cerebrovascular disorders (3.26 vs. 0.10%, < 0.001), sepsis (4.35 vs. 0.42%, < 0.01), air and thrombotic embolism (5.43 vs. 0.10%, < 0.001), and ventilation (2.17 vs. 0.09%, < 0.01). Ultimately, those with SCD had an approximately 6-fold higher incidence risk ratio of SMM, which remained after adjustment for confounders (adjusted incidence risk ratio [aIRR]: 5.96, 95% confidence interval [CI]: 3.4-9.19, < 0.001). Persons with SCD in active vaso-occlusive crisis at the delivery admission had an approximately 9-fold higher risk of SMM up to 42 days' postdischarge compared with those with SCD not in crisis at the delivery admission (incidence: 25.71 vs. 8.77%, < 0.05; aIRR: 8.92, 95% CI: 4.5-10.04, < 0.05). Among those with SCD, SMM at the delivery admission was primarily related to renal and cerebrovascular events, whereas most postpartum SMM was related to respiratory events or sepsis.
CONCLUSION
SCD is significantly associated with an increased risk of SMM during the delivery admission and through 42 days' postdischarge. Active crisis at delivery further increases the risk of SMM.
KEY POINTS
· Sickle cell disease was associated with an approximately 6-fold increased risk of SMM.. · Active vaso-occlusive crisis at delivery was associated with an approximately 9-fold increased risk of SMM.. · 48% of SMM events in persons with SCD occurred postpartum and were respiratory- or sepsis-related..
PubMed: 38653453
DOI: 10.1055/s-0044-1786174 -
Cureus Mar 2024Embolization of entrapped intracardiac air represents a significant risk to the patient undergoing open-heart surgery. Entrapment of as little as 0.5 mL of gas in the...
Embolization of entrapped intracardiac air represents a significant risk to the patient undergoing open-heart surgery. Entrapment of as little as 0.5 mL of gas in the heart can cause temporary myocardial dysfunction, cardiac arrhythmias, and systemic emboli. In contrast, larger emboli can disrupt the evaluation of heart function by limiting visualization during echocardiography. We present the case of a 67-year-old male who presented with dizziness, nausea, and chest pain. A left heart catheterization revealed multi-vessel disease. Undergoing general anesthesia, the patient received three-vessel coronary artery bypass grafting, mitral valve repair, ring annuloplasty, and left atrial appendage closure. Upon aortic unclamping, transgastric echocardiography showed significant gas almost wholly obscuring the left heart chambers despite de-airing maneuvers. Successful resolution relied upon higher mean blood pressure and time, demonstrating the importance of intraoperative imaging and interdisciplinary collaboration.
PubMed: 38646393
DOI: 10.7759/cureus.56525 -
Kyobu Geka. the Japanese Journal of... Apr 2024A man in his 50s was stabbed deeply in the back with a knife and brought to the emergency room. He was found to have a significant left hemopneumothorax. He was planned...
A man in his 50s was stabbed deeply in the back with a knife and brought to the emergency room. He was found to have a significant left hemopneumothorax. He was planned to undergo hemostatic surgery under general anesthesia. However, shortly after the change in a right lateral decubitus position, he experienced ventricular fibrillation. Hemostasis of the intercostal artery injury, the source of bleeding, and suture of the injured visceral pleura were performed under extracorporeal membrance oxgenation( ECMO). Although sinus rhythm was resumed, when positive pressure ventilation was applied to the left lung for an air leak test, ST elevation on the electrocardiogram and loss of arterial pressure occurred. A transesophageal echo revealed air accumulation in the left ventricle. It was determined that air had entered the damaged pulmonary vein from the injured bronchi due to the stab wound, leading to left ventricular puncture decompression and lower left lower lobectomy. Subsequently, his circulatory status stabilized, and ECMO was weaned off. He recovered without postoperative neurological deficits postoperatively. The mortality rate for chest trauma with systemic air embolism is very high. In cases of deep lung stab wounds, there is a possibility of systemic air embolism, so treatment should consider control of airway and vascular disruption during surgery.
Topics: Humans; Male; Wounds, Stab; Middle Aged; Heart Ventricles; Embolism, Air; Lung Injury
PubMed: 38644169
DOI: No ID Found -
Scandinavian Journal of Trauma,... Apr 2024The likelihood of return of spontaneous circulation with conventional advanced life support is known to have an exponential decline and therefore neurological outcome... (Clinical Trial)
Clinical Trial
BACKGROUND
The likelihood of return of spontaneous circulation with conventional advanced life support is known to have an exponential decline and therefore neurological outcome after 20 min in patients with a cardiac arrest is poor. Initiation of venoarterial ExtraCorporeal Membrane Oxygenation (ECMO) during resuscitation might improve outcomes if used in time and in a selected patient category. However, previous studies have failed to significantly reduce the time from cardiac arrest to ECMO flow to less than 60 min. We hypothesize that the initiation of Extracorporeal Cardiopulmonary Resuscitation (ECPR) by a Helicopter Emergency Medical Services System (HEMS) will reduce the low flow time and improve outcomes in refractory Out of Hospital Cardiac Arrest (OHCA) patients.
METHODS
The ON-SCENE study will use a non-randomised stepped wedge design to implement ECPR in patients with witnessed OHCA between the ages of 18-50 years old, with an initial presentation of shockable rhythm or pulseless electrical activity with a high suspicion of pulmonary embolism, lasting more than 20, but less than 45 min. Patients will be treated by the ambulance crew and HEMS with prehospital ECPR capabilities and will be compared with treatment by ambulance crew and HEMS without prehospital ECPR capabilities. The primary outcome measure will be survival at hospital discharge. The secondary outcome measure will be good neurological outcome defined as a cerebral performance categories scale score of 1 or 2 at 6 and 12 months.
DISCUSSION
The ON-SCENE study focuses on initiating ECPR at the scene of OHCA using HEMS. The current in-hospital ECPR for OHCA obstacles encompassing low survival rates in refractory arrests, extended low-flow durations during transportation, and the critical time sensitivity of initiating ECPR, which could potentially be addressed through the implementation of the HEMS system. When successful, implementing on-scene ECPR could significantly enhance survival rates and minimize neurological impairment.
TRIAL REGISTRATION
Clinicaltyrials.gov under NCT04620070, registration date 3 November 2020.
Topics: Adolescent; Adult; Humans; Middle Aged; Young Adult; Cardiopulmonary Resuscitation; Emergency Medical Services; Hospitals; Out-of-Hospital Cardiac Arrest; Retrospective Studies; Time Factors
PubMed: 38632661
DOI: 10.1186/s13049-024-01198-x -
American Journal of Respiratory and... Apr 2024
PubMed: 38631024
DOI: 10.1164/rccm.202308-1496IM -
The American Journal of Case Reports Apr 2024BACKGROUND A paradoxical air embolism (PAE) occurs when air entering the central venous circulation reaches the systemic circulation, occurring through an intracardiac...
BACKGROUND A paradoxical air embolism (PAE) occurs when air entering the central venous circulation reaches the systemic circulation, occurring through an intracardiac shunt or intrapulmonary shunting. Patients presenting for liver transplantation often have intrapulmonary shunting due to pulmonary arterial vasodilation, even in the absence of hepatopulmonary syndrome. Here, we present a case of hemodynamic collapse believed to be caused by a PAE, which was diagnosed intraoperatively with transesophageal echocardiography (TEE). CASE REPORT A 60-year-old man who was diagnosed with non-alcoholic steatohepatitis cirrhosis presented for deceased donor orthotopic liver transplantation with utilization of normothermic machine perfusion. Following reperfusion of the liver allograft, TEE detected intrapulmonary shunting resulting in air within the left atrium, left ventricle, and ascending aorta. The patient developed severe biventricular dysfunction with ST-segment changes on electrocardiography monitoring and became acutely hypotensive with significant hepatic congestion 5 min after liver reperfusion. High doses of inotropic and vasopressor support were used as well as inhaled nitric oxide. The patient recovered after 30 min of medical management. The liver transplantation operation was successfully completed and the patient was discharged home on postoperative day 7. CONCLUSIONS Intracardiac air at the time of reperfusion during liver transplantation can originate from the donor allograft and result in PAE in the setting of intrapulmonary shunting. PAE can result in intracoronary air and should be considered in cases of hemodynamic instability in liver transplantation, especially if air is seen within the left atrium, left ventricle, and ascending aorta.
Topics: Male; Humans; Middle Aged; Liver Transplantation; Embolism, Air; Liver Cirrhosis; Echocardiography, Transesophageal
PubMed: 38627956
DOI: 10.12659/AJCR.943042