MANAGEMENT OF ACUTE DECOMPENSATION FROM AIR EMBOLISM WITH BEDSIDE ULTRASONOGRAPHY AND MANUAL ASPIRATION

Abstract

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Vascular air embolism (VAE) is often iatrogenic and associated with high mortality and morbidity depending on the volume of air that has entered circulation. We describe a case of VAE occurring after removal of a central venous catheter (CVC) with rapid clinical improvement after aspiration of air from circulation. CASE PRESENTATION: A 75 year-old male patient with history of pancreatic cancer, coronary artery disease and atrial fibrillation was admitted to the intensive care unit (ICU) with septic shock, rapid ventricular rhythm and severe hypoxia due to multi-lobar pneumonia. He required vasopressor support with a CVC in the right internal jugular vein (RIJ). He received appropriate goal directed therapy. Although over the course of four days, he continued to require Hi-Flow 100% FiO2 and 55 liters per minute to maintain peripheral oxygen saturation (spO2) above 88%, pulmonary infiltrates on X-ray improved and shock resolved. Patient was weaned off of vasopressors and decision was made to remove the CVC. Within 15 minutes of CVC removal, he became unresponsive with agonal breathing and desaturation to spO2 55%. He developed right facial droop and right arm paralysis. A bedside ultrasound revealed a large amount of air in all four heart chambers. He was placed in Trendelenburg and left lateral position. A new CVC was inserted into the RIJ with the tip advanced into the right atrium. 150ml of blood was rapidly aspirated. After 15 minutes, the patient became responsive, his oxygenation improved, and he demonstrated neurological recovery. DISCUSSION: VAE is a rare and under-recognized complication of central venous access. As such, there may be a delay in detection as formal imaging is obtained and interpreted. We hypothesize that in this case, paradoxical transfer of bubbles to left heart chambers was possibly associated to undetected PFO. In mild cases, only supportive care may be necessary. In patients with hemodynamic instability, neurological changes, cardiopulmonary compromise, or end organ damage, hyperbaric oxygen therapy (HBOT) is the recommended definitive therapy to reduce air bubble size and vascular obstruction. However, HBOT is not available at every healthcare facility. In instances where it is available, even then, arrangement for HBOT takes time and transportation may be risky in unstable patients. Manual aspiration has been attempted previously but use of a multi-orifice catheter was recommended for that purpose. Unfortunately, multi-orifice catheters are not easily accessible. In this case, swift action using bedside cardiac ultrasound and intra-cardiac aspiration by a single orifice CVC lead to rapid clinical improvement. CONCLUSIONS: VAE is a serious iatrogenic complication that should be managed with appropriate acuity. Bedside ultrasonography and manual intra-cardiac aspiration has the potential to efficiently and effectively improve patient outcomes. Reference #1: Muth CM, Shank ES. Gas embolism. N Engl J Med. 2000 Feb 17;342(7):476-82. Reference #2: Palmon SC, Moore LE, Lundberg J, Toung T. Venous air embolism: a review. J Clin Anesth 1997;9:251-257 Reference #3: Hicks HC, Hummel JC. A new catheter for detection and treatment of venous air embolism. Technical note. J Neurosurg 1980;52:595-8. DISCLOSURES: no disclosure on file for Hector Cajigas; No relevant relationships by Kavitha Golpalratnam, source=Web Response No relevant relationships by Trinh Nguyen, source=Web Response