An explicitly multi-component arterial gas embolus dissolves much more slowly than its one-component approximation

Discussion of risk of scuba diving in individuals with allergic and respiratory diseases

Air embolism is a life threatening condition, which is commonly reported in sitting position surgery or when the venous sinuses are open. Symptoms may appear depending on volume of air entrained and rate of entrainment. Lung acts as a filter and if the area exposed is more than the critical volume, then ventilation – perfusion (V/Q) mismatch leads to hypoxia and ultimately death. In contrast, carbon dioxide in large volume, lead to right ventricular outflow tract (RVOT) obstruction and reduce cardiac output. In people with probe patent patent foramen ovale, this can reach left atrium and lead to systemic embolism. Laparoscopic surgery, in general is safe and in situations, where there is abnormal organ placement and arterio venous connection may lead to gas placement into circulation. Detection is by trans esophageal echocardiography, precordial doppler, end tidal carbon dioxide monitoring and pulse oximetry. We present one such case with altered anatomy leading to ptosis of liver and massive mixed air and carbon dioxide embolism, which was successfully re-suscitated. Keywords: Air embolism; Carbon dioxide embolism; Laparoscopy.

Article1 August 1957THE SAFETY OF INTRAVASCULAR CARBON DIOXIDE AND ITS USE FOR ROENTGENOLOGIC VISUALIZATION OF INTRACARDIAC STRUCTURESTHOMAS M. DURANT, M.D., F.A.C.P., H. M. STAUFFER, M.D., M. J. OPPENHEIMER, M.D., ROBERT E. PAUL JR., M.D.THOMAS M. DURANT, M.D., F.A.C.P.Search for more papers by this author, H. M. STAUFFER, M.D.Search for more papers by this author, M. J. OPPENHEIMER, M.D.Search for more papers by this author, ROBERT E. PAUL JR., M.D.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-47-2-191 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptThe injection of air into body cavities or tissues is a method that has been used for diagnostic purposes (e.g., perirenal insufflation, Rubin's test, etc.) and also for therapy (e.g., pneumoperitoneum, pneumothorax, etc.). Though these technics have been considered to have real value, each has been fraught with the risk of serious or even fatal accidents from air embolism.1, 2, 3Some accidents have been reported in the literature, but we have learned about a host of others only through personal communication. The frequency with which air embolism has been observed has varied with different procedures, but has been highest,...Bibliography1. DurantLongOppenheimer TMJMJ: Pulmonary (venous) air embolism, Am. Heart J. 33: 269, 1947. CrossrefMedlineGoogle Scholar2. DurantOppenheimerWesterLong TMMJMRJ: Arterial air embolism, Am. Heart J. 38: 481, 1949. CrossrefMedlineGoogle Scholar3. OppenheimerDurantLynch MJTMP: Body position in relation to venous air embolism and the associated cardiovascular-respiratory changes, Am. J. M. Sc. 225: 362, 1953. CrossrefMedlineGoogle Scholar4. RansomLandesMcLelland CLRRR: Air embolism following retroperitoneal pneumography: a nation-wide survey, J. Urol. 76: 664, 1956. CrossrefMedlineGoogle Scholar5. Teschendorf W: On the use of quickly absorbent gases in x-ray diagnosis, Acta radiol. 36: 297, 1951. CrossrefMedlineGoogle Scholar6. OppenheimerDurantStaufferStewartLynchBarrera MJTMHMGHPRF: In vivo visualization of intravascular structures with gaseous carbon dioxide: cardiovascular effects and associated changes in blood chemistry, Am. J. Physiol. 186: 325, 1956. CrossrefMedlineGoogle Scholar7. DurantOppenheimerLynchAscanioWebber TMMJPRGD: Body position in relation to venous air embolism: a roentgenologic study, Am. J. M. Sc. 227: 509, 1954. CrossrefMedlineGoogle Scholar8. StaufferDurantOppenheimer HMTMMJ: Gas embolism: roentgenologic considerations, including the experimental use of carbon dioxide as an intracardiac contrast material, Radiology 66: 686, 1956. CrossrefMedlineGoogle Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: Philadelphia, Pennsylvania*Presented at the Thirty-eighth Annual Session of The American College of Physicians, Boston, Massachusetts, April 9, 1957, together with a moving picture demonstration of the experimental material.From the Departments of Medicine, Radiology and Physiology, Temple University School of Medicine, Philadelphia, Pennsylvania.Aided by United States Public Health Service Grant No. H1883(C2).Requests for reprints should be addressed to Thomas M. Durant, M.D., Department of Medicine, Temple University School of Medicine and Hospital, Broad and Ontario Streets, Philadelphia 40, Pennsylvania. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byCarbon Dioxide Angiography Guided Endovascular Aortic Repair for Aortoiliac Aneurysm in Patients with Renal InsufficiencyIn vivo measurement of hemodynamic information in stenosed rat blood vessels using X-ray PIVMeasurement of real pulsatile blood flow using X-ray PIV technique with CO2 microbubblesUsage of CO 2 microbubbles as flow-tracing contrast media in X-ray dynamic imaging of blood flowsTotal bowel ischemia after carbon dioxide angiography in a patient with inferior mesenteric artery occlusionInterventional Techniques for Device ImplantationUtility and Safety of Axillo-subclavian Venous Imaging with Carbon Dioxide (CO2) Prior to Chronic Lead System RevisionsFoam sclerotherapy techniques: different gases and methods of preparation, catheter versus direct injectionLetale Kohlendioxid- (CO2-)Embolie?Radiofrequency Ablation Combined with CO 2 Injection for Treatment of Retroperitoneal Tumor: Protecting Surrounding Organs Against Thermal InjuryFirst experimental study of carbon dioxide digital subtraction lymphangiographyC0 2 -Angiographie: Blutflußmessung mit injizierten Gasblasen - Carbon Dioxide Angiography: Blood Flow Measurement with Injected Gas BubblesCO 2 -Angiographie: Untersuchungen zur Gasausfüllung der Gefäße und Erfassung von Einflußfaktoren auf den Injektionsvorgang am Kreislaufmodell - CO2-Angiography: Measurement of Vascular Gas-filling and Evaluation of Parameters Influencing Gas Injection using a Circulatory System ModelComparison of CO2- and N2O-Induced Discomfort During Peritoneoscopy Under Local AnesthesiaLaparoscopyCardiac arrhythmias during peritoneoscopy under local anesthesiaPrevention of air embolism with intravascular carbon dioxide washoutAnesthesia for Lap AroscopyDarstellung der Herzhöhlen, der Gefäßlumina und des BlutstromesInferior Vena Cava Obstruction Clinical Manifestations, Diagnostic Methods, and Related ProblemsMORRIS E. MISSAL, M.D., F.A.C.P., JAMES A. ROBINSON, M.D., RONALD W. TATUM, M.D.CARBODISSECTION OF PERIVASCULAR TISSUEPericarditisSINGLE AND DOUBLE CONTRAST CORONARY ARTERIOGRAPHYThe Contribution of Modern Hemodynamic Techniques to the Diagnosis of Acquired Heart DiseaseDiagnostic Carbon Dioxide Pneumomediastinography as an Extension of Scalene-Lymph-Node BiopsyAnte-Mortem Demonstration of Hepatic-Vein DistentionAdrenocortical adenoma with Cushing's syndrome and virilism in a 5-year-old childPheochromocytomaThe evolution and current concepts of the surgical treatment of constrictive pericarditisThe flat right atrial borderPericardial Effusion in Congestive Heart FailureNontraumatic hemopericardiumErkrankungen des PerikardChronic Idiopathic Pericardial Effusion without TamponadeSome uses for presacral oxygen insufflationCEREBRAL EMBOLISMINTRAVASCULAR CARBON DIOXIDE FOR ANGIOGRAPHY 1 August 1957Volume 47, Issue 2Page: 191-201KeywordsBlood plasmaCarbon dioxideDiagnostic radiologyMedical servicesRisk managementSafety ePublished: 1 December 2008 Issue Published: 1 August 1957 Copyright & PermissionsCopyright ©, 1957, by The American College of PhysiciansPDF downloadLoading ...

Divers, pneumatic construction workers, aviators, and astronauts sometimes suffer decompression illness (DCI). DCI includes decompression sickness (DCS) and arterial gas embolism (AGE) and is treated with recompression therapy. Etiology of DCS is highly related with micro bubbles formed in the body fluid. AGE is caused by pulmonary over inflation-induced rupture of the alveoli. Recompression therapy is a kind of hyperbaric oxygen therapy, for which U.S. Navy treatment tables are widely used. The purposes of recompression therapy are (1) to reduce volume of the bubbles in the body, (2) to increase absorption of the bubbles in the body fluid and exhalation of inert gases from the lung, and (3) to increase oxygen supply via plasma to the cells in peripheral tissues. Recompression therapy has other beneficial effects, such as anti-inflammatory, wound healing, and anti-infectious effects. During the evacuation of the DCI patient to an appropriate facility, to continue administration of 100% oxygen and not to decrease environmental pressure are both critical for stabilizing the patients’ condition. It is important for all physicians who have a chance to treat DCI patients to be versed in mechanisms of recompression therapy and handling the treatment tables.

Simulation studies of the combined effect of mass transport and impurities on step growth

Air embolism during an aircraft flight in a passenger with a pulmonary cyst: a favorable outcome with hyperbaric therapy.

Tissue and blood gas embolism (GE) associated with fisheries bycatch are likely a widespread, yet underestimated, cause of sea turtle mortality. Here, we evaluated risk factors associated with tissue and blood GE in loggerhead turtles caught incidentally by trawl and gillnet fisheries on the Valencian coastline of Spain. Of 413 turtles (303 caught by trawl, 110 by gillnet fisheries), 54% (n = 222) exhibited GE. For sea turtles caught in trawls, the probability and severity of GE increased with trawl depth and turtle body mass. In addition, trawl depth and the GE score together explained the probability of mortality (P[mortality]) following recompression therapy. Specifically, a turtle with a GE score of 3 caught in a trawl deployed at 110 m had a P[mortality] of ~50%. For turtles caught in gillnets, no risk variables were significantly correlated with either the P[GE] or GE score. However, gillnet depth or GE score, separately, explained P[mortality], and a turtle caught at 45 m or with a GE score between 3 and 4 had a P[mortality] of 50%. Differences in the fishery characteristics precluded direct comparison of GE risk and mortality between these gear types. Although P[mortality] is expected to be significantly higher in untreated turtles released at sea, our findings can improve estimates of sea turtle mortality associated with trawls and gillnets, and help guide associate conservation efforts.

L aparoscopic cholecystectomy has become the procedure of choice in the treatment of symptomatic cholecystolithiasis. Low morbidity and low incidence of serious complications have confirmed the advantages of laparoscopic surgery. The increasing popularity of minimal invasive techniques in gynecologic and general surgery is leading to a higher incidence of rare complications (1). The major problems during laparoscopic surgery are related to the cardiopulmonary effects of gas insufflation, venous gas embolism, pneumoperitoneum, systemic carbon dioxide resorption, extraperitoneal gas insufflation, and unintentional injury to intraabdominal structures (2). We describe a well documented case of venous embolism followed by cerebral arterial carbon dioxide embolism.

Cerebral Carbon Dioxide Embolism During Laparoscopic Cholecystectomy

Neurologic Complications of Percutaneus Nephrolithotomy

Bispectral index (BIS) and entropy measure electroencephalographic voltage between electrodes placed on the forehead. BIS is used to monitor and quantify depth of hypnosis1and to guide anesthetic drug administration during general anesthesia.2Entropy assesses loss of consciousness by the quantification of the degree of spatial and temporal integration of cerebral neuronal activity.3An entropy monitor has been introduced recently; it provides two indices, state entropy and response entropy, that decrease in healthy volunteers receiving propofol with a brief intervening period of wakefulness4and in surgical patients during propofol anesthetic induction.5We report two cases of perioperative gas embolism encountered during laparoscopic surgery while patients were being monitored simultaneously by BIS (Aspect A-2000 XP®, version 3.11; Aspect Medical Systems, Newton, MA) and entropy of electroencephalogram (S/5™ M-Entropy plug-in Module; Datex-Ohmeda Company, Limonest, France).In our first case, an 83-yr-old man was scheduled for a laparoscopic hemicolectomy under general anesthesia. Target-controlled infusion of propofol and remifentanil was achieved using a computer-assisted infusion device6while atracurium was administered continuously after a bolus. Standard monitoring was used as was BIS and entropy monitoring. Pneumoperitoneum was achieved with carbon dioxide. The first 90 min of anesthesia and surgery were uneventful. Suddenly, BIS and entropy indices dropped to zero as shown in figure 1. Partial pressure of end-tidal carbon dioxide decreased a few seconds later from 28 mmHg to 19 mmHg and arterial hypotension of 80/45 mmHg was noted (it was previously 149/85 mmHg). The surgeon reported no bleeding. Gas embolism was suspected, and the dramatic change in electroencephalographic-derived indices led to immediate exsufflation and conversion to laparotomy. BIS and entropy remained at low values for approximately 25 min with almost 100% burst suppression even after hemodynamic stability was restored. The colectomy was completed, the anesthetic was discontinued, and the patient awoke. Neurologic examination was performed and was normal. Transesophageal echocardiography performed the day after surgery confirmed a patent foramen ovale.In our second case, a 46-yr-old woman was scheduled for a laparoscopic cholecystectomy. Anesthesia and monitoring were similar to case 1. Shortly after the onset of carbon dioxide insufflation, partial pressure of end-tidal carbon dioxide suddenly decreased from 32 to 10 mmHg and arterial pressure decreased to less than 60 mmHg. BIS and entropy values decreased to approximately 20 and the burst suppression ratio was 80% within seconds. Laparoscopy showed a tear in the surface of the liver. The pneumoperitoneum was immediately exsufflated, and a laparotomy was performed. BIS and entropy values regained their former values within 5 min, but arterial pressure and partial pressure of end-tidal carbon dioxide remained low for 15 min. Cholecystectomy was performed. Transesophageal echocardiography performed during anesthesia revealed no septal defect. Anesthesia was discontinued at the end of the procedure and the patient awoke. Neurologic examination was normal.Sudden decreases in BIS have been reported at the onset of clinical deterioration. England was the first to describe the changes in BIS during a hypovolemic cardiac arrest.7An acute decrease in BIS can reflect cerebral hypoperfusion8–10or cerebral embolization.11An alternative explanation for an acute decrease in electroencephalographic-derived indices is an increase in plasma concentration of an anesthetic drug, especially propofol, as a result of rapid alteration of its elimination.12Our two cases showed simultaneous acute and profound decrease of BIS and entropy indices that forced the anesthesiologist to react quickly. After verification of good signal quality, the low level of electromyogram, the stability of anesthetic drug concentrations and the absence of acute bleeding, the diagnosis of gas embolism was made; this is a known complication of laparoscopic surgery. Using transesophageal echocardiography, a very sensitive method of detection, Derouin et al. reported gas embolism in 11 of 16 patients undergoing laparoscopic cholecystectomy.13The clinical impact of gas embolization can be as serious as cardiac arrest;14however, in most instances there are no lasting effects, probably because of the high solubility of carbon dioxide bubbles. Electroencephalographic monitoring modified the surgical and anesthetic management in our two cases. The chronology of events varied between the cases. In the first case, carbon dioxide bubbles reached the brain very rapidly through the patent foramen ovale; BIS and entropy values decreased before any significant changes in other parameters. Other methods of early detection of paradoxical gas embolism have been reported during laparoscopic cholecystectomy; by transesophageal echocardiography15and by transcranial Doppler.16In our second case, in which a patent foramen ovale was ruled out, the decrease of BIS and entropy was observed after hemodynamic and respiratory parameters changed and was transient, reflecting a decrease in cardiac output as a result of gas embolization.Finally, anesthesiologists should be aware of the potential for venous gas embolization during routine laparoscopic procedures; BIS or entropy monitoring may play a role in early detection and could complement routine monitoring.* Foch Hospital, Suresnes, France. m.fischler@hopital-foch.org.

The aim of this study was to evaluate the risk of an air embolization with the volume of the insufflation tube during induction of laparoscopy. A further objective was to determine the LD₅₀ of air in young piglets. End-tidal carbon dioxide pressure ([Formula: see text]), pulmonary arterial pressure (P pa), heart rate (f c), and mean arterial pressure (P a carot) were measured in 17 piglets divided into three groups: group 1 (n = 6), bolus application (CO₂ embolization, followed by air embolization, 2 mL/kg each), group 2 (n = 7), continuous air embolization (30 min, 0.2 mL/kg/min), and group 3 (n = 4), continuous CO₂ embolization (30 min, 0.4 mL/kg/min). All animals survived CO₂ embolism. Air embolization as a bolus (2 mL/kg) or with an accumulated volume of 3.1 mL/kg led to death. Decreases in [Formula: see text] indicated air or massive CO₂ embolization only. There was a good correlation between [Formula: see text] and P pa in case of air embolization (r = -0.80, p < 0.0001). In contrast, no dependency was recognized during CO₂ embolism (r = -0.17, p = 0.2). In order to minimize the lethal risk of gas embolization, the insufflation system has to be completely filled with CO₂ before connecting to the patient.

When Insufflation Goes Awry: Massive Gas Embolism During Laparoscopic Surgery

Sea turtles, like other air-breathing diving vertebrates, commonly experience significant gas embolism (GE) when incidentally caught at depth in fishing gear and brought to the surface. To better understand why sea turtles develop GE, we built a mathematical model to estimate partial pressures of N2 (PN2), O2 (PO2), and CO2 (PCO2) in the major body-compartments of diving loggerheads (Caretta caretta), leatherbacks (Dermochelys coriacea), and green turtles (Chelonia mydas). This model was adapted from a published model for estimating gas dynamics in marine mammals and penguins. To parameterize the sea turtle model, we used values gleaned from previously published literature and 22 necropsies. Next, we applied this model to data collected from free-roaming individuals of the three study species. Finally, we varied body-condition and cardiac output within the model to see how these factors affected the risk of GE. Our model suggests that cardiac output likely plays a significant role in the modulation of GE, especially in the deeper diving leatherback turtles. This baseline model also indicates that even during routine diving behavior, sea turtles are at high risk of GE. This likely means that turtles have additional behavioral, anatomical, and/or physiologic adaptions that serve to reduce the probability of GE but were not incorporated in this model. Identifying these adaptations and incorporating them into future iterations of this model will further reveal the factors driving GE in sea turtles.

VENOUS air embolism (VAE) has been reported in a wide variety of procedures. In most cases, signs of clinically significant VAE are present soon after the entry of air into the circulation. We present a case of urologic surgery in which no signs of VAE were recognized during surgery, but circulatory collapse occurred when the patient was transferred from the operating room bed to the transport stretcher. The presumptive diagnosis of VAE as the cause of circulatory collapse was made on aspiration of frothy blood from the central venous pressure (CVP) catheter and was confirmed with the immediate placement of a transesophageal echocardiography (TEE) probe.