Cerebral Air Embolism During Routine EGD: 2016 ACG Presidential Poster Award

Abstract

Introduction: Arterial air embolism may have devastating consequences and may lead to acute failure in any affected organ. Cerebral air embolisms are rare during endoscopy, but have been reported in virtually all endoscopic procedures, most frequently ERCP. Usually, prior surgery or other defect allowing introduction of air into systemic circulation is identifiable. Case: A 49 year old African American male was scheduled for a routine EGD for evaluation of dysphagia, and concurrently prepped for a screening colonoscopy to follow. Other than mild sleep apnea and childhood cleft lip repair, he had no other past medical or surgical history. Sedation was gradually achieved prior to procedure with a total of midazolam 5mg IV and meperidine 100mg IV. An obstructing Schatzki's ring in the distal esophagus was fractured with passage of the endoscope. The remainder of the exam was performed and unremarkable. Heme was noted at the GE junction prior to obtaining distal esophageal biopsies. While obtaining biopsies of the mid esophagus, the patient became unresponsive with decerebrate posturing and procedure was terminated. His oxygen saturation dropped into the 60's but rapidly responded to bagmask ventilation with 100% oxygen. Reversal with naloxone and flumazenil was attempted with no response. A second dose of naloxone was administered after 3 minutes and a code blue was initiated. He was breathing unassisted, but was intubated after remaining unresponsive. A CT of the head obtained in transit to the ICU suggested several small bubbles of air in the anterior right frontal lobe. Both transthoracic and transesophageal echocardiograms were performed and did not demonstrate any cardiopulmonary shunt. A MRI brain confirmed the CT findings. The patient was transferred to a local hospital and treated with hyperbaric therapy. After multiple treatments he regained consciousness, extubated, and ultimately transferred to a rehab facility with residual left sided weakness. Discussion: In our patient, it is plausible that air was introduced into the systemic circulation as a consequence of fracturing the Schatzki's ring, but this would require exposure to the arterial blood supply as no identifiable AV shunt was identified. This case highlights a rare complication of endoscopy. Prompt recognition is critical to preserve maximal neurologic function. Hyperbaric therapy is the treatment of choice for cerebral air embolism.Figure 1Figure 2Figure 3