PORTAL VENOUS GAS CAUSING CEREBRAL VENOUS AND PULMONARY ARTERY AIR EMBOLISM

Abstract

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Venous air embolism can be caused by various mechanisms. Portal venous air as cause of venous air embolism has been reported very rarely in existing literature. CASE PRESENTATION: 67 y/o admitted to the hospital after episode of fall with hypoxia found to have right perinephric hematoma, multiple right rib fractures and bilateral transudative pleural effusion due to fluid overload. He also had MSSA bacteremia, getting treated with Cefazolin and HD catheter changed few weeks ago. Past medical history significant for ESRD on HD, DM II, CAD s/p CABG, A-fib on Coumadin, SSS s/p PPM, Bio prosthetic MVR, Infra-renal AAA, Chronic thrombocytopenia, HFpEF. Rapid response was called for acute change in neurological status and low BP of 84/58. He was noted to be alert but unresponsive even to pain, right gaze deviation, decorticate posturing. BP improved to 95/62 with 1L NS and was requiring 6LNC O2 supplementation to keep SpO2 > 90. Stroke Code was called, CTA Head and Neck showed air in multiple venous structures in neck, cavernous sinus, subarachnoid space and pulmonary artery. High flow oxygen was given and kept on Trendelenburg and left lateral position. CT Chest showed air in pulmonary artery and right atrium. CT Abdomen and Pelvis showed dilated small bowel with pneumatosis and extensive mesenteric venous and portal venous air. Surgery felt patient was poor surgical candidate. He went into sudden acute respiratory failure requiring intubation likely secondary to worsening air embolism. Due to poor prognosis and critical health family decided to transition to comfort care. DISCUSSION: Venous air embolism is usually caused by surgical procedure, trauma, central venous access and barotrauma. Pulmonary artery air embolism caused by portal venous air is rare with few case reported 1. Cerebral venous air embolism due to portal venous air has been reported only twice in literature 2,3. Based on literature review, there is no prior reported case of venous air embolism involving pulmonary artery and cerebral vein caused by portal venous air. CONCLUSIONS: Pulmonary artery air embolism and cerebral venous air embolism are rapidly fatal entity that could complicate patients with portal venous air, hence needs to be considered and recognized early. REFERENCE #1: Kamikado et al, Gas embolism caused by portal vein gas: case report and literature review. Case Rep Gastroenterology 2008;2:262-271 DOI: 10.1159/000146064 REFERENCE #2: Parikh et al, Gas embolic stroke secondary to bowel infarction. Journal of Stroke and Cerebrovascular Disease 2016;1;e1-e3 DOI: 10.1016 REFERENCE #3: Taydas et al, Retrograde cerebral air embolism in a patient with intestinal necrosis: a care report. Balkan Medical Journal 2017;34;371-373 DOI: 10.4274 DISCLOSURES: No relevant relationships by Woon Chong, source=Web Response No relevant relationships by Kiran Pokhrel, source=Web Response No relevant relationships by Gregory Wu, source=Web Response