In Response

Abstract

In Response We thank White et al1 for their constructive comments regarding our “Incidence of Venous Air Embolism During Endoscopic Retrograde Chol angiopancreatography” study.2 We also use Olympus endoscopes (Olympus, Tokyo, Japan) and Evis Exera lll CLV-190 (Olympus, Tokyo Japan) light source–/gas-regulating units (used only as a light source when CO2 used). We use a Bracco CO2MPACT Endoscopic Insufflator (US Endoscopy, Mentor, OH) for carbon dioxide (CO2) insufflation. The Bracco CO2 insufflator has low, medium, and high settings delivering 2.0, 2.9, and 3.4 L/min, respectively. The Bracco unit has a fixed mechanical pressure relief valve set at 375 mm Hg. We agree with the possibility that different endoscopes and gas-regulating units could deliver varying pressures and affect the incidence of gas embolism. We also concur that the gas pressure delivered through the endoscope using air or CO2 greatly exceeds central venous pressure. While insufflation pressure was not reported in our study, it stands to reason that higher pressures are associated with an increased likelihood of an embolic event. Like White et al1, we now exclusively use CO2 as an insufflation medium during endoscopic retrograde cholangiopancreatography, and to date we have not observed any incidents of a hemodynamically significant embolism. We appreciate the reminder of the steps to manage a significant gas embolism. Rapid recognition and treatment will hopefully prevent (or lessen) serious adverse consequences. Increasing the awareness of the risk of an embolism and having a protocol for prompt management by the entire clinical team involved in gastrointestinal procedures (eg, physicians, anesthesia staff, and nursing staff) will optimize the likelihood of a good outcome. Mark C. Phillips, MD, FASATimothy J. Ness, MD, PhDAyesha S. Bryant, MSPH, MDDepartment of Anesthesiology and Perioperative MedicineUniversity of Alabama at BirminghamBirmingham, Alabama[email protected]