VENOUS AIR EMBOLISM

BY
DR. EILIA MELIKA
ANESTHESIOLOGIST
TAYMA GENERAL HOSPITAL
 TYPES OF VAE
 Gas embolism(air,CO2,N2O)
a) CO2,N2O embolism → insufflation procedures(laparoscopy, hysteroscopy ,
arthroscopy)
b) air embolism→ head & neck , orthopedic , chest surgeries + intravascular cannulas +
epidural injection
• Fat embolism →orthopedic surgery
• Venous thrombo embolism → surgical manipulation in the pelvis
• Tumor embolism
• Amniotic fluid embolism


Brief notes on venous air embolism
Pathophysiology.

 Volume of entrained air

 Rate of accumulation.

 Position of the patient

 Height of the vein above the right heart

 Critical volume of air

 200-300 ml or 3-5 ml/kg

 The closer the vein of entrainment to the

right heart the lower the critical volume
 How big a hole ?
 A pressure decrease of 5 cm. H2O across
a 14G cannula(1.8 internal diameter) can
entrain 100ml of air/second.
 Clinical presentation in
anesthetized patients

 Tachyarrythmias

 Cardiovascular collapse
 High risk procedures
 Sitting position craniotomy
 Posterior fossa/neck surgery.
 Laparoscopic procedures
 Total hip arthroplasty.
 Cesarean section
 Central venous access
 Detection
 Trans-oesophageal echocardiography can
detect 0.02ml/kg
 Pre-cordial Doppler can detect
0.05ml/kg.Confirm position with “Bubble” test.
 End-tidal nitrogen-0.04% is significantly faster
than E-tidal C02 by 30-90 seconds
 End-tidal C02; decrease by 2mm Hg significant?
 Vigilance
 Management
 It is better to prevent VAE than to treat it
A. Prevention:
 Aim is to keep small +ve pressure in the
veins at the operative site by;
1) Proper positioning e.g park bench versus
sitting position for post.F. cran.
2) High index of suspicion wherever there is
a negative gradient between surgical
field and heart.
3) Reverse Trendelenberg 5deg. In c.s
 Prevention (contin.)
 Avoid N2O as possible as you can
 Expansion of the intravascular volume
 Controlled ventilation with peep
(controversial)
 Treatment
 When VAE is detected or suspected intra
operatively
1. Measures to prevent further air entry
2. Measures to ↑venous pressure at the
operative site
3. Measures to avoid expansion of air bubbles
4. Aspiration of air bubbles
5. Circulatory support
6. Finally rt. thoracotomy
 Treatment
 Prevent further air entrainment
 100% oxygen
 Trendelenberg position/Durant position
 CPR/ inotropes.
 Aspiration of air.
-Swan Ganz Catheter 6-16%
- Multi-orifice Cooke catheter 30-60%
  Chest radiograph after central venous cannulation showing a round opacity of
homogenous density but without airbronchogram in the right lower lung field.

Ku S et al. Thorax 2007;62:372-372

©2007 by BMJ Publishing Group Ltd and British Thoracic Society

  (A) Contrast-enhanced chest CT scan showing air bubble trapped around the central
venous catheter in the superior vena cava (arrow).
(B) Bilateral pleural-based, wedge-shaped ,mass-like consolidations with central necrosis
in both lower lobes

Ku S et al. Thorax 2007;62:372-372

©2007 by BMJ Publishing Group Ltd and British Thoracic Society

 Transoesophageal echocardiogram (bubble study), patent foramen ovale.

Eichhorn V et al. Br. J. Anaesth. 2009;102:717-718

© The Author [2009]. Published by Oxford University Press on behalf of The Board of Directors
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