AIR IN THE BRAIN: AIR EMBOLISM ASSOCIATED WITH AN OUTPATIENT LINE

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cerebral air embolisms are a rare and potentially fatal phenomenon associated with central venous catheter (CVC) insertions, especially in patients with an underlying cardiac defect. We present a case of a 64 year old male with a patent foramen ovale who suffered severe complications from a massive air embolism while accessing a tunneled CVC. CASE PRESENTATION: 64-year-old male with a history of prostate adenocarcinoma, pulmonary embolism on anticoagulation, and multiple myeloma was originally admitted to the hospital to undergo a stem cell transplant. A tunneled right subclavian CVC which was placed 14 days prior was accessed for routine labwork before transplant. There was some difficulty reported while accessing the catheter this time similar to previous documentation. Immediately following this attempt to access the catheter, the patient was noted to develop acute loss of consciousness and was found unresponsive. On exam, he was noted to have asymmetric pupils, without any response to noxious stimuli. He was emergently intubated for airway protection. A CT Head showed multiple areas bilateral sulcal hypoattenuation concerning for air embolism along with areas of evolving infarct. (Figure 1) which was further confirmed by magnetic resonance imaging (MRI). Echocardiogram showed evidence of right to left shunting from a patent foramen ovale. Patient was transferred to a facility with a hyperbaric oxygen (HBO) chamber. During his initial HBO therapy which occurred about 12 hrs from the time of the event, the patient was noted to have persistent myoclonic seizures, deemed to be clinical myoclonic status. This warranted aborting the HBO therapy for appropriate medical management of his seizure activity. EEG performed noted severe cerebral dysfunction without any active epileptiform activity. A repeat MRI showed severe hypoxic injury and edema involving both cerebral hemispheres diffusely, the thalami and right caudate nucleus (Figure 2). Given the poor neurological status and irreversible neurological injury, the patient passed comfortably in the presence of family. DISCUSSION: We present a case of paradoxical embolism associated with a patent foramen ovale while accessing a CVC, that unfortunately resulted in cerebral air embolism and severe hypoxic brain injury. Supportive literature for such severe cases has shown benefit from HBO. However, the delay that results from transport to HBO treatment centers, as in our patient, remains a barrier for time sensitive efforts to prevent poor outcomes associated with cerebral air embolism CONCLUSIONS: Education and strong emphasis must be provided to health care providers to prevent air embolism while caring for or insertion of CVCs. If an air embolism occurred, high index of suspicion is essential for timely identification of cerebral air embolism which are associated with poor outcomes. REFERENCE #1: Gordy S, Rowell S. Vascular air embolism. Int J Crit Illn Inj Sci. 2013;3(1):73-76. doi:10.4103/2229-5151.109428 REFERENCE #2: Patel AR, Patel AR, Singh S, Singh S, Khawaja I. Central Line Catheters and Associated Complications: A Review. Cureus. 2019;11(5):e4717. Published 2019 May 22. doi:10.7759/cureus.4717 REFERENCE #3: Hinkle DA, Raizen DM, McGarvey ML, Liu GT. Cerebral air embolism complicating cardiac ablation procedures. Neurology. 2001 Mar 27;56(6):792-4. doi: 10.1212/wnl.56.6.792. PMID: 11274320. DISCLOSURES: No relevant relationships by Ashley Graziano, source=Web Response No relevant relationships by Aaron Haag, source=Web Response No relevant relationships by Swathi Sangli, source=Web Response