A BREATHTAKING CENTRAL LINE

Abstract

SESSION TITLE: Medical Student/Resident Imaging Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Central venous catheters (CVC) are used commonly in critically ill patients. It is common practice done daily in the Intensive Care Units. Complications such as arrhythmias, arterial puncture, pneumothorax, thrombosis and rarely, but most lethal, air emboli can occur. We present a case of systemic air embolism after removal of CVC, where direct visualization of right atrium with point of care ultrasound (POCUS) showed presence of air bubbles. CASE PRESENTATION: 53-year-old female with history of IV drug abuse and COPD was admitted for sepsis, septic arthritis and skin abscesses, for which she required a prolonged course of IV antibiotics. Right internal jugular CVC was placed due to contraindication of peripheral IV access. CVC was no longer needed and removed, within a few seconds, patient became restless, tachycardic and tachypneic, with significant accessory muscles use. CXR was negative for pneumothorax or other abnormalities. Patient was placed on non-rebreather mask with 100% oxygen, only achieving 78% saturation. Initial ABG showed acute hypoxemic hypercarbic respiratory failure. It came to our knowledge that removal was done in upright position; air emboli was suspected and confirmed on POCUS (Figure 1). She was emergently intubated, mechanically ventilated on 100% FiO2 and placed in Trendelenburg position. Follow up echocardiogram showed no evidence of air emboli. No neurologic deficits were identified, patient was weaned off high FiO2 and extubated. DISCUSSION: Air emboli can occur during insertion, while within patient or during removal. Air embolism is managed mainly with supportive care. Incidence can be as low as 0.13%, despite using optimal positioning and placement techniques. True incidence is uncertain due to absorption of air prior to confirmation. The presence of air in vasculature results in acute hypoxemia and hypercapnia. If suspected, treatment includes stopping air entry into the system, aspiration of air from the right ventricle if possible, placing in Trendelenburg and left lateral decubitus position. This positioning allows for entrapped air in the heart to stabilize within the apex of the ventricle and relieve obstruction of pulmonary outflow tract. If severe, cardiac ischemia, arrhythmias, hypotension, and cardiac arrest can ensue. Rapid recognition and treatment can prevent this. CONCLUSIONS: Air embolism is a fatal complication during insertion/removal of CVC. Clinical manifestations range from none to cardiovascular collapse and death. Therefore education on proper care and technique is essential. These include explaining the procedure to the patient, laying them supine in Trendelenburg position and instructing to perform Valsalva maneuver on removal. Utilization of POCUS may facilitate early diagnosis and improve outcomes. Physicians and nursing staff should be aware of this iatrogenic complication and be able to identify it in a timely fashion. Reference #1: Marek A. Mirski, Abhijit Vijay Lele, Lunei Fitzsimmons, Thomas J. K. Toung; Diagnosis and Treatment of Vascular Air Embolism. Anesthesiology2007;106(1):164-177. doi: https://doi.org/. Reference #2: J Emerg Trauma Shock. 2009 Sep-Dec; 2(3): 180–185. doi: 10.4103/0974-2700.55330 Reference #3: Khan H, Zaidi A Paradoxical air embolism following central venous catheter removal Case Reports 2013;2013:bcr2013200630. DISCLOSURES: No relevant relationships by Lakshmi Alahari, source=Web Response No relevant relationships by Ammar Aliuddin, source=Web Response No relevant relationships by Gerardo Catalasan, source=Web Response No relevant relationships by Gabriela Orellana, source=Web Response