Venous Air Embolism

Back

Background

Venous air embolism (VAE), a subset of gas embolism, is an entity with the potential for severe morbidity and mortality. It is a predominantly iatrogenic complication[1, 2] that occurs when atmospheric gas is introduced into the systemic venous system.[3]

In the past, VAE was mostly associated with neurosurgical procedures conducted in the sitting position.[4, 5] Subsequently, it has been associated with central venous catheterization,[3, 6, 7] scalp incision,[8] cervical spine fusion,[9] penetrating and blunt chest trauma,[10, 11, 12] high-pressure mechanical ventilation,[3] thoracocentesis,[1] hemodialysis,[3, 7, 13] and several other invasive vascular procedures.

VAE has also been observed during diagnostic studies, such as during radiocontrast injection for computed tomography (CT).[14, 15] The use of gases such as carbon dioxide and nitrous oxide during medical procedures and exposure to nitrogen during diving accidents can also result in VAE.[2] In addition, apparent cases of VAE resulting from pressurized, intravenous infusion of normal saline have been reported in professional football players.[16]

Many cases of VAE are subclinical with no adverse outcome and thus go unreported. Usually, when symptoms are present, they are nonspecific, and a high index of clinical suspicion for possible VAE is required to prompt investigations and initiate appropriate therapy.

Pathophysiology

The following two preconditions must exist for VAE to occur[4, 17] :

The key factors determining the degree of morbidity and mortality in venous air emboli are related to the volume of gas entrainment, the rate of accumulation, and the patient’s position at the time of the event.[1, 6, 15]

Generally, small amounts of air are broken up in the capillary bed and absorbed from the circulation without producing symptoms. Traditionally, it has been estimated that more than 5 mL/kg of air displaced into the intravenous space is required for significant injury (shock or cardiac arrest) to occur.[1] However, complications have been reported with as little as 20 mL of air[7] (the length of an unprimed IV infusion tubing) that was injected intravenously.

Injection of 2 or 3 mL of air into the cerebral circulation can be fatal.[18] Furthermore, as little as 0.5 mL of air in the left anterior descending coronary artery has been shown to cause ventricular fibrillation.[11, 18] Basically, the closer the vein of entrainment is to the right heart, the smaller the lethal volume is.[1]

Rapid entry or large volumes of air entering the systemic venous circulation puts a substantial strain on the right ventricle, especially if this results in a significant rise in pulmonary artery (PA) pressures. This increase in PA pressure can lead to right ventricular outflow obstruction and further compromise pulmonary venous return to the left heart. The diminished pulmonary venous return will lead to decreased left ventricular preload with resultant decreased cardiac output and eventual systemic cardiovascular collapse.[1, 4, 6]

With VAE, resultant tachyarrhythmias are frequent, but bradyarrhythmias can also occur.[2, 4]

The rapid ingress of large volumes of air (>0.30 mL/kg/min) into the venous circulatory system can overwhelm the air-filtering capacity of the pulmonary vessels, resulting in a myriad of cellular changes.[3] The air embolism effects on the pulmonary vasculature can lead to serious inflammatory changes in the pulmonary vessels; these include direct endothelial damage and accumulation of platelets, fibrin, neutrophils, and lipid droplets.[1]

Secondary injury as a result of the activation of complement and the release of mediators and free radicals can lead to capillary leakage and eventual noncardiogenic pulmonary edema.[1, 3, 7]

Alteration in the resistance of the lung vessels and ventilation-perfusion mismatching can lead to intra-pulmonary right-to-left shunting and increased alveolar dead space with subsequent arterial hypoxia and hypercapnia.[1, 4, 15]

Arterial embolism as a complication of VAE can occur through direct passage of air into the arterial system via anomalous structures such as an atrial or ventricular septal defect, a patent foramen ovale, or pulmonary arteriovenous malformations. This can cause paradoxic embolization into the arterial tree.[1, 2, 3, 4, 11] The risk for a paradoxical embolus seems to be increased during procedures performed in the sitting position.[1, 5]

Air embolism has also been described as a potential cause of the systemic inflammatory response syndrome (case report), triggered by the release of endothelium-derived cytokines.[17]

Etiology

In order for VAE to occur, the following two physical preconditions for the entry of gas into the venous system must be met[2, 4] :

Classically, VAE has been recognized as occurring in the context of decompression illness in divers, aviators, and astronauts. Barotrauma and air emboli complicate an estimated 7 of every 100,000 dives.[19, 20]  However, the most common cause of VAE is iatrogenic.

Surgical procedures

Surgical procedures are the primary cause of VAE. Neurosurgical procedures, especially those performed in the Fowler (sitting) position, and otolaryngologic interventions are the two most common surgeries complicated by VAE.[5]  Note the following:

Obstetric/gynecologic procedures, laparoscopy

Obstetric/gynecologic procedures (cesarean delivery) and laparoscopic surgeries each carry their own risk for VAE. Although this risk is commonly not considered, they each have a reported associated incidence risk of VAE greater than 50%.[1]  The risk of VAE during cesarean deliveries may be highest when the uterus is exteriorized. The risk of VAE in laparoscopic surgery may require an inadvertent opening of vascular channels through surgical manipulation rather than simply resulting from a complication of insufflation.

Both of these surgical procedures have been associated with intraoperative mortality as a direct sequelae of air emboli.[1, 26, 27, 28]  Despite this, the potential for venous air embolism is often ignored in laparoscopic surgery and cesarean delivery.

Iatrogenic creation of pressure gradient

VAE may also result from the iatrogenic creation of a pressure gradient for air entry. Procedures causing such a pressure gradient include lumbar puncture (case report),[1, 23]  peripheral intravenous lines,[1]  and central venous catheters.[2, 3, 22, 29]

Central venous catheterization

VAE is a potentially life-threatening and under-recognized complication of central venous catheterization (CVC), including central lines, pulmonary catheters, hemodialysis catheters[7, 13]  and Hickman (long-term) catheters. As mentioned earlier, the frequency of VAE associated with CVC use ranges from 1 in 47 to 1 in 3000. The emboli may occur at any point during line insertion, maintenance, and/or removal.[3]  A pressure gradient of 5 cm H2O between air and venous blood across a 14-gauge needle allows entry of air into the venous system at a rate of 100 mL/s.[1, 2, 11, 15, 21, 30]  Ingress of 300-500 mL of air at this rate can cause lethal effects.[15, 29]

A number of factors increase the risk of catheter-related VAE, including the following:

Mechanical insufflation or infusion

Mechanical insufflation or infusion is another cause of venous air emboli. Several different procedures involve the use of insufflation, including arthroscopic procedures, CO2 hysteroscopy, laparoscopy, urethral procedures, and orogenital sexual activity during pregnancy (by entering veins of the myometrium during pregnancy and/or after delivery).[1, 22]

Inadvertent infusion of air can also occur during the injection of IV contrast agents for CT,[14, 15, 31]  angiography,[2]  and cardiac catheterization, as well as during cardiac ablation procedures.[22, 32]  Little information exists on the incidence and the complication rate associated with iatrogenic air embolization caused by injections of contrast medium during CT examinations; however, this is a potentially serious complication, which could be catastrophic. Few case reports exist, and all agree that the actual number of such cases is probably higher than reported.

Positive-pressure ventilation

Positive-pressure ventilation during mechanical ventilation places patients at risk for barotrauma and, subsequently, arterial and/or venous air emboli.[1, 3]  Entry of gas into the circulation may result if violation of pulmonary vascular integrity occurs at the same time alveoli rupture from overdistention of the airspaces. This complication can occur in the setting of various diagnoses; however, it is most frequently reported in patients with acute respiratory distress syndrome and in premature neonates with hyaline membrane disease. For these same reasons, SCUBA divers can also have VAE from alveolar distention.

Other causes

VAE has also been described in the setting of blunt and penetrating chest and abdominal trauma, as well as in neck and craniofacial injuries.

Epidemiology

United States statistics

Because of the nonspecific nature of the signs and symptoms of VAE, as well as the difficulty of documenting the diagnosis, the true incidence of VAE is not known. Interventional radiology literature reports an incidence of 0.13% during the insertion and removal of central venous catheters despite optimal positioning and techniques.[33] The frequency of VAE with central venous catheters based on a reported case series has also ranged from 1 in 47 to 1 in 3000.[2, 30] The neurosurgical procedure-related complications of VAE have been estimated to be between 10-80%.[2, 21, 22] Reports of VAE in the setting of severe lung trauma have been estimated between 4-14%.[10, 11, 18, 22, 34]

Race-, sex-, and age-related demographics

No racial, sex, or specific age predilection exists for VAE.

Prognosis

The presence of gyriform air on CT scans of the brain appears to be a negative prognostic indicator in venous catheter-related cerebral air embolism.[35] Other potential predictors of unfavorable outcomes in patients with catheter-related VAE include older age of onset, an initial disturbance in consciousness, and the presence of hemparesis.

The potentially life-threatening and catastrophic consequences of VAE) are directly related to its effects on the affected organ system where the embolus lodges. VAE may be fatal and frequently carries high neurologic, respiratory, and cardiovascular morbidity. Catheter-associated VAE mortality is as high as 30%.[2]

In a case series of 61 patients with severe lung trauma, the mortality associated with concomitant VAE was 80% in the blunt trauma group and 48% in the penetrating trauma group.[10, 22, 34]  The morbidity and mortality associated with traumatic VAE, as with nontraumatic VAE, depends not only on associated injuries but also on the volume and rate of air entry, underlying cardiac condition, and the patient's position.

In a retrospective study of patients who were placed in a sitting position for neurosurgery, Ganslandt et al found a low rate of severe complications associated with VAE. In the study, 600 individuals underwent surgery for posterior fossa or cervical spinal disorders, with VAE occurring in 19% of these patients. However, only 3.3% of patients suffered severe VAE-associated complications, such as a drop in the partial pressure of oxygen or in blood pressure. Moreover, surgery had to be stopped in only three patients (0.5%) because the VAE could not be eliminated during surgery. No VAE-associated mortality occurred.[36]

History

Most cases of venous air embolism (VAE) go unrecognized because their presentations are protean and mimic other cardiac, pulmonary, and neurologic dysfunctions, such as the following (in awake patients)[16, 29] :

Because of the lack of specific signs and symptoms of VAE, a high index of suspicion is necessary to establish the diagnosis and institute the appropriate treatment. The number of procedures that place patients at risk for VAE has increased, and these procedures occur across almost all clinical specialties. This must be considered to aid in the confirmation or ruling out of VAE.

If VAE is suspected, obtain the following key historical elements:

Physical Examination

Many cases of VAE are subclinical and do not result in untoward outcomes. However, severe cases are characterized by cardiovascular collapse and/or acute vascular insufficiency of several specific organs, including, but not limited to, the brain, spinal cord, heart, and skin. As mentioned earlier, the spectrum of effects is largely dependent on the rate and volume of entrained VAE.[1, 6, 15]

Two additional contributing factors include whether or not the patient is spontaneously breathing (yielding negative thoracic pressure) or is under controlled positive-pressure ventilation.[1]  These two factors facilitate the entry of air down a pressure gradient.

The clinical presentation is also dependent on the patient's body position at the time of the event. Generally, if the patient is in a sitting position, gas will travel retrograde via the internal jugular vein to the cerebral circulation, leading to neurologic symptoms secondary to increased intracranial pressure. In a recumbent position, gas proceeds into the right ventricle and pulmonary circulation, subsequently causing pulmonary hypertension and systemic hypotension.[15]

An arterial air embolism can also form if passage of air occurred through a right-to-left shunt, as in the case of a patent foramen ovale.[2, 3]  The arterial air emboli can then lodge in the coronary or cerebral circulation, causing myocardial infarction or stroke.

The following hemodynamic, pulmonary, and neurologic complications primarily result from gas gaining entry into the systemic circulation, occluding the microcirculation and causing ischemic damage to these end organs. Animal studies have also suggested the presence of secondary tissue damage resulting from the release of inflammatory mediators and oxygen free radicals that occur in response to air embolism.

Cardiovascular signs include the following

Pulmonary features include the following:

Neurologic findings include the following:

Funduscopic examination may reveal ophthalmologic signs such as air bubbles in the retinal vessels.[18]

Dermatologic evaluation may reveal crepitus over superficial vessels (rarely seen in setting of massive air embolus) and/or livedo reticularis.

Laboratory Studies

Laboratory tests are neither sensitive nor specific for the diagnosis of venous air embolism (VAE). The only indication for obtaining routine laboratory tests is to evaluate the associated end-organ injury resulting from air embolism.

Extravasation of fluid into inflamed tissue may result in laboratory findings consistent with intravascular depletion.

Arterial blood gas samples often show hypoxemia, hypercapnia, and metabolic acidosis secondary to right-to-left pulmonary shunting.

Patients may develop a clinical picture similar to that of classic pulmonary embolism, with hypoxia, decreased PCO2 levels, and respiratory alkalosis.

Imaging Studies

Transesophageal echocardiography 

Transesophageal echocardiography (TEE) has the highest sensitivity for detecting the presence of air in the right ventricular outflow tract or major pulmonary veins. It can detect as little as 0.02 mL/kg of air administered by bolus injection.[1, 2, 5, 11, 15, 18, 22, 23, 38] It also has the added advantage of identifying paradoxical air embolism (PAE), and Doppler allows audible detection of venous air embolism (VAE).

Echocardiography, both TEE and transthoracic echocardiography (TTE), not only allows diagnosis of VAE but also aids in the diagnosis of cardiac anomalies, assessment of volume status, pulmonary hypertension, and cardiac contractility, thereby allowing exclusion of other causes of hypotension, dyspnea, and aiding in further patient management. The use of bedside TTE has become more common in emergency medicine. Its use in a case of VAE described by Maddukuri et al aided in the diagnosis and prompt initiation of appropriate therapy.[39]

Doppler ultrasonography

Precordial Doppler ultrasonography is the most sensitive noninvasive method for detecting venous air emboli. This modality is capable of detecting as little as 0.12 mL of embolized air (0.05 mL/kg).[1, 15, 22, 23, 38]

Transcranial Doppler ultrasonography is another imaging modality commonly used to detect cerebral microemboli.[1]

Radiography

Chest radiography may be normal or may show gas in the pulmonary arterial system, pulmonary arterial dilatation, focal oligemia (Westermark sign), and/or pulmonary edema.[11, 15, 22]

CT and MRI

Computed tomography (CT) can detect air emboli in the central venous system (especially the axillary and subclavian veins), right ventricle, and/or pulmonary artery. Small (< 1 mL) air defects, usually asymptomatic, occur during 10-25% of contrast-enhanced CT scans; thus, the specificity of this modality is best with large filling defects.[1, 11] CT of the head may show intracerebral air, cerebral edema, or infarction. Chest CT in lung trauma may show underlying conditions such as pneumothorax, hemothorax, or emphysematous blebs that may have led to air embolism but is not helpful for initial diagnosis.[40]

MRI of the brain may show increased water concentration in affected tissues, but this finding alone may not be reliable for the detection of gas emboli.

Other Tests

Electrocardiography

Electrocardiography (ECG) has a low sensitivity for VAE detection. The findings closely resemble those seen with venous thromboembolism and include tachycardia, right ventricular strain pattern, and ST depression. Transient myocardial ischemia may also occur (severe bradycardia, ST elevation in inferior leads and ST depression in L1 and avL, observed 3 minutes post CVC removal (case report).[1, 37]

End-tidal carbon dioxide (ETCO2)

VAE leads to ventilation/perfusion (V/Q) mismatching and increases in physiologic dead space. This produces a fall in end-tidal CO2 (normal value, < 5). A 2 mm Hg change in end-tidal carbon dioxide (ETCO2) can be an indicator of VAE. However, this finding is nonspecific and may also occur with other disease states, such as pulmonary embolism (PE), massive blood loss, hypotension, circulatory arrest, upper-airway obstruction, mouth breathing, and/or disconnection from monitor. The detector also has a slow response time.[1, 4, 15, 22, 23]

End-tidal nitrogen (ETN2)

End-tidal nitrogen (ETN2) is the most sensitive gas-sensing VAE detection modality; it measures increases in ETN2 as low as 0.04%. Response time is much faster than ETCO2 (30-90 s earlier). However, it does not detect subclinical VAE or decreases with hypotension and may falsely indicate resolution of VAE too prematurely.[1, 41]

Pulse oximetry

Changes in oxygen saturation are late findings with VAE. Measurement is often skewed secondary to exposure to high fraction of inspired oxygen. Like carbon dioxide measuring, it is on the lower end of sensitive measurements.[1]

Pulmonary artery catheter

A pulmonary artery catheter can detect increases in pulmonary artery pressures, which may be secondary to mechanical obstruction or vasoconstriction from the hypoxemia induced by the VAE. However, it is a relatively insensitive/nonspecific monitor of air entrainment (0.25 mL/kg).[1] The lumen catheter is also too small for air to be removed, thereby limiting its function.

Central venous catheter

If a central venous catheter is in place, aspiration of air may help to make the diagnosis. It is also helpful in monitoring central venous pressures, which may be increased in VAE.[1]

Procedures

Any procedure posing a risk for VAE, if in progress, should be aborted immediately once VAE is suspected.

During central venous catheter (CVC) insertion/removal, one attempt at aspirating air back from line may be useful. Prior to aspiration, the tip of the CVC should be optimally placed 2 cm below the junction of the superior vena cava and the right atrium; however, it may have to be advanced to optimize results.

The placement of a CVC (multiorifice) or PA catheter to attempt aspiration of air, if not already done, has been recommended by several authors.[1, 4, 18, 22, 41] When appropriately placed, it may be possible to aspirate approximately 50% of the entrained air with a right atrial catheter.

Catheter removal should be performed with the patient supine or in a Trendelenburg position while holding his/her breath at the end of inspiration or during a Valsalva maneuver.[2, 14, 22]

In the event of circulatory collapse, cardiopulmonary resuscitation (CPR) should be initiated in order to maintain cardiac output. CPR may also serve to break large air bubbles into smaller ones and force air out of the right ventricle into the pulmonary vessels, thus improving cardiac output.[18]

If an arrest is refractory to CPR, an immediate thoracotomy in the emergency department (ED) may be indicated. An emergency thoracotomy with clamping of the hilum of the injured lung is currently recommended for SAE-associated with unilateral lung injury. This prevents continued passage of air into the coronary, cerebral, and other systemic arteries.[11, 18]

Other measures include cross-clamping the aorta, cardiac massage, and aspirating air from the left ventricle, aortic roots, and pulmonary veins.[11]

Emergency Department Care

If venous air embolism (VAE) is known about before presentation to the emergency department (ED), affected patients should be transported in the left lateral decubitus position.[7]

Management of VAE, once it is suspected, includes identification of the source of air, prevention of further air entry (by clamping or disconnecting the circuit), reduction of the volume of air entrained, and hemodynamic support. 

Administer 100% O2 and perform endotracheal intubation for severe respiratory distress or refractory hypoxemia or in a somnolent or comatose patient in order to maintain adequate oxygenation and ventilation. Institution of high-flow (100%) O2 will help reduce the bubble's nitrogen content and therefore size.[1, 4, 7, 10, 11, 15, 23, 30]

Immediately place the patient in the left lateral decubitus (Durant maneuver) and Trendelenburg position. This helps to prevent air from traveling through the right side of the heart into the pulmonary arteries, leading to right ventricular outflow obstruction (air lock). If cardiopulmonary resuscitation (CPR) is required, place the patient in a supine and head-down position.[1, 7, 11, 15, 23]

Direct removal of air from the venous circulation by aspiration from a central venous catheter in the right atrium may be attempted. However, no current data support emergency catheter placement for air aspiration during an acute setting of VAE-induced hemodynamic instability.[1, 4, 11, 15]

If necessary, initiate CPR. Besides maintaining cardiac output, CPR may also serve to break large air bubbles into smaller ones and force air out of the right ventricle into the pulmonary vessels, thus improving cardiac output. Even without the need for CPR, this rationale holds for closed-chest massage. Animal studies have shown that the benefit of cardiac massage equals that of left lateral recumbency, as well as intracardiac aspiration of air.[1, 4, 11, 15]

Admit patients to the intensive care unit (ICU), as they may develop cardiopulmonary distress/failure following VAE.

Consider transfer to a hyperbaric oxygen therapy (HBOT) facility. Indications for HBOT include neurologic manifestations and cardiovascular instability. Potential benefits include compression of existing bubbles, establishing a high diffusion gradient to speed resolution of existing bubbles, improved oxygenation of ischemic tissues, and lowered intracranial pressure.

Immediate HBOT, once VAE is diagnosed, is recommended; however, prognosis may still be good if therapy is initiated beyond 6 hours of event. Prompt transfer to an HBOT center has been reported to decrease mortality in patients with cerebral air embolism. If transfer is necessary, ground transportation is preferred. If air transportation cannot be avoided, the lowest altitude should be sought.[1, 4, 7, 11, 14, 15, 18, 42]

Supportive therapy should include fluid resuscitation (to increase intravascular volume, increase venous pressure and venous return). There is also some evidence that gas emboli may cause a relative hemoconcentration, which increases viscosity and impairs the already compromised circulation. Hypovolemia is less tolerated than relative anemia. In animal studies, moderate hemodilution to a hematocrit of 30% reduces neurologic damage. Crystalloids may cause cerebral edema; therefore, colloids are preferred for hemodilution.[1, 4, 18]

The administration of vasopressors and mechanical ventilation are two other supportive measures that may be necessary.[1, 4, 41] In a case report of a patient undergoing a craniotomy who showed cardiopulmonary findings suggestive of acute VAE, inotropic treatment with ephedrine seemed to rapidly reverse the cardiopulmonary abnormalities. Early inotropic support of the right ventricle has been recommended if venous air embolism is suspected.[41]

In animal studies, the use of perfluorocarbons (FP-43) has been shown to enhance the reabsorption of bubbles and the solubility of gases, thereby decreasing both neurologic and cardiovascular complications of systemic and coronary VAE. These benefits, however, have not been validated in humans.[1]

Prevention

The optimal management of VAE is prevention. Minimizing the pressure gradient between the site of potential entry and the right atrium is essential in prevention of VAE.

Potential measures to reduce the risk and/or severity of VAE during neurosurgical interventions include the following[38] :

Measures to reduce the risk of air embolism during mechanical ventilation and central line insertion/removal/manipulation should be taken. With regard to these two procedures, the following interventions should be implemented:

What is venous air embolism (VAE)?What are the preconditions for venous air embolism (VAE) to occur?What is the pathophysiology of venous air embolism (VAE)?What causes venous air embolism (VAE)?What is the role of surgical procedures in the etiology of venous air embolism (VAE)?What the incidence of venous air embolism (VAE) due to cesarean delivery and laparoscopy surgery?Which procedures can cause venous air embolism (VAE) due a pressure gradient for airway entry?What is the role of central venous catheterization in the etiology of venous air embolism (VAE)?What are the risk factors for a catheter-related venous air embolism (VAE)?What is the role of mechanical insufflation or infusion in the etiology of venous air embolism (VAE)?What is the role of positive-pressure ventilation in the etiology of venous air embolism (VAE)?What is the role of trauma in the etiology of venous air embolism (VAE)?What is the prevalence of venous air embolism (VAE)?What is the prognosis of venous air embolism (VAE)?What are the signs and symptoms of venous air embolism (VAE)?Which clinical history findings suggest venous air embolism (VAE)?Which physical findings are characteristic of venous air embolism (VAE)?What are the cardiovascular signs of venous air embolism (VAE)?What are the pulmonary signs and symptoms of venous air embolism (VAE)?Which neurologic findings are characteristic of venous air embolism (VAE)?Which funduscopic findings are characteristic of venous air embolism (VAE)?What are the differential diagnoses for Venous Air Embolism?What is the role of lab tests in the workup of venous air embolism (VAE)?What is the role of TEE in the workup of venous air embolism (VAE)?What is the role of Doppler ultrasonography in the workup of venous air embolism (VAE)?What is the role of chest radiography in the workup of venous air embolism (VAE)?What is the role of CT and MRI in the workup of venous air embolism (VAE)?What is the role of end-tidal nitrogen (ETN2) testing in the workup of venous air embolism (VAE)?What is the role of ECG in the workup of venous air embolism (VAE)?What is the role of end-tidal carbon dioxide (ETCO2) testing in the workup of venous air embolism (VAE)?What is the role of pulse oximetry in the workup of venous air embolism (VAE)?What is the role of pulmonary artery catheter in the workup of venous air embolism (VAE)?What is the role of central venous catheter in the diagnosis of venous air embolism (VAE)?How is venous air embolism (VAE) treated in the presence of a catheter?How is venous air embolism (VAE) treated in the emergency department (ED)?What is included in supportive care for venous air embolism (VAE)?How is venous air embolism (VAE) prevented during neurosurgical interventions?How is venous air embolism (VAE) prevented during mechanical ventilation and central line insertion/removal/manipulation?

Author

Brenda L Natal, MD, MPH, Assistant Professor of Emergency Medicine, Simulation Director, Rutgers New Jersey Medical School; Attending Physician, Department of Emergency Medicine, University Hospital of Newark

Disclosure: Nothing to disclose.

Coauthor(s)

Christopher I Doty, MD, FAAEM, FACEP, Associate Professor of Emergency Medicine, Residency Program Director, Vice-Chair for Education, Department of Emergency Medicine, University of Kentucky-Chandler Medical Center

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David Eitel, MD, MBA, Associate Professor, Department of Emergency Medicine, York Hospital; Physician Advisor for Case Management, Wellspan Health System, York

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD, Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Additional Contributors

Daniel J Dire, MD, FACEP, FAAP, FAAEM, Clinical Professor, Department of Emergency Medicine, University of Texas Medical School at Houston; Clinical Professor, Department of Pediatrics, University of Texas Health Sciences Center San Antonio

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors, Andrew G Wittenberg, MD, MPH; Allison J Richard, MD; and Steven A Conrad, MD, PhD, to the development and writing of this article.

References

  1. Mirski MA, Lele AV, Fitzsimmons L, Toung TJ. Diagnosis and treatment of vascular air embolism. Anesthesiology. 2007 Jan. 106(1):164-77. [View Abstract]
  2. Sviri S, Woods WP, van Heerden PV. Air embolism--a case series and review. Crit Care Resusc. 2004 Dec. 6(4):271-6. [View Abstract]
  3. van Hulst RA, Klein J, Lachmann B. Gas embolism: pathophysiology and treatment. Clin Physiol Funct Imaging. 2003 Sep. 23(5):237-46. [View Abstract]
  4. Muth CM, Shank ES. Gas embolism. N Engl J Med. 2000 Feb 17. 342(7):476-82. [View Abstract]
  5. Wong AY, Irwin MG. Large venous air embolism in the sitting position despite monitoring with transoesophageal echocardiography. Anaesthesia. 2005 Aug. 60(8):811-3. [View Abstract]
  6. Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med. 2004 Jun 15. 140(12):1025-33. [View Abstract]
  7. Moon RE. Air or gas embolism. Feldmeier JJ. Hyperbaric Oxygen Therapy: Committee Report. Kensington, MD: Undersea and Hyperbaric Medical Society; 2003. 5-10.
  8. Spence NZ, Faloba K, Sonabend AM, Bruce JN, Anastasian ZH. Venous air embolus during scalp incision. J Clin Neurosci. 2016 Jun. 28:170-1. [View Abstract]
  9. Cruz AS, Moisi M, Page J, et al. Venous air embolus during prone cervical spine fusion: case report. J Neurosurg Spine. 2016 Dec. 25(6):681-4. [View Abstract]
  10. Ho AM, Ling E. Systemic air embolism after lung trauma. Anesthesiology. 1999 Feb. 90(2):564-75. [View Abstract]
  11. Platz E. Tangential gunshot wound to the chest causing venous air embolism: a case report and review. J Emerg Med. 2011 Aug. 41(2):e25-9. [View Abstract]
  12. Mercurio I, Capano D, Torre R, et al. A case of fatal cerebral air embolism after blunt lung trauma: postmortem computed tomography and autopsy findings. Am J Forensic Med Pathol. 2017 Dec 22. [View Abstract]
  13. Wong SS, Kwaan HC, Ing TS. Venous air embolism related to the use of central catheters revisited: with emphasis on dialysis catheters. Clin Kidney J. 2017 Dec. 10(6):797-803. [View Abstract]
  14. Imai S, Tamada T, Gyoten M, Yamashita T, Kajihara Y. Iatrogenic venous air embolism caused by CT injector--from a risk management point of view. Radiat Med. 2004 Jul-Aug. 22(4):269-71. [View Abstract]
  15. Sheasgreen J, Terry T, Mackey JR. Large-volume air embolism as a complication of augmented computed tomography: case report. Can Assoc Radiol J. 2002 Oct. 53(4):199-201. [View Abstract]
  16. Fibel KH, Barnes RP, Kinderknecht JJ. Pressurized intravenous fluid administration in the professional football player: a unique setting for venous air embolism. Clin J Sport Med. 2015 Jul. 25(4):e67-9. [View Abstract]
  17. Kapoor T, Gutierrez G. Air embolism as a cause of the systemic inflammatory response syndrome: a case report. Crit Care. 2003 Oct. 7(5):R98-R100. [View Abstract]
  18. Ho AM. Is emergency thoracotomy always the most appropriate immediate intervention for systemic air embolism after lung trauma?. Chest. 1999 Jul. 116(1):234-7. [View Abstract]
  19. Leitch DR, Green RD. Pulmonary barotrauma in divers and the treatment of cerebral arterial gas embolism. Aviat Space Environ Med. 1986 Oct. 57(10 Pt 1):931-8. [View Abstract]
  20. Schellart NA, Sterk W. Venous gas embolism after an open-water air dive and identical repetitive dive. Undersea Hyperb Med. 2012 Jan-Feb. 39(1):577-87. [View Abstract]
  21. Palmon SC, Moore LE, Lundberg J, Toung T. Venous air embolism: a review. J Clin Anesth. 1997 May. 9(3):251-7. [View Abstract]
  22. Zargaraff G, Zucker M. Radiology challenge: the sudden death. Israeli J of Emerg Med. Oct 2005. 5(4):49-51.
  23. Karaosmanoglu D, Oktar SO, Arac M, Erbas G. Case report: Portal and systemic venous gas in a patient after lumbar puncture. Br J Radiol. 2005 Aug. 78(932):767-9. [View Abstract]
  24. Schlundt J, Tzanova I, Werner C. A case of intrapulmonary transmission of air while transitioning a patient from a sitting to a supine position after venous air embolism during a craniotomy. Can J Anaesth. 2012 May. 59(5):478-82. [View Abstract]
  25. Longatti P, Marton E, Feletti A, Falzarano M, Canova G, Sorbara C. Carbon dioxide field flooding reduces the hemodynamic effects of venous air embolism occurring in the sitting position. Childs Nerv Syst. 2015 Aug. 31(8):1321-6. [View Abstract]
  26. Lew TW, Tay DH, Thomas E. Venous air embolism during cesarean section: more common than previously thought. Anesth Analg. 1993 Sep. 77(3):448-52. [View Abstract]
  27. Fong J, Gadalla F, Druzin M. Venous emboli occurring caesarean section: the effect of patient position. Can J Anaesth. 1991 Mar. 38(2):191-5. [View Abstract]
  28. Scoletta P, Morsiani E, Ferrocci G, et al. [Carbon dioxide embolization: is it a complication of laparoscopic cholecystectomy? ]. Minerva Chir. 2003 Jun. 58(3):313-20. [View Abstract]
  29. Yesilaras M, Atilla OD, Aksay E, Kilic TY. Retrograde cerebral air embolism. Am J Emerg Med. 2014 Dec. 32(12):1562.e1-2. [View Abstract]
  30. Orebaugh SL. Venous air embolism: clinical and experimental considerations. Crit Care Med. 1992 Aug. 20(8):1169-77. [View Abstract]
  31. Imai S, Tamada T, Gyoten M, Yamashita T, Kajihara Y. Iatrogenic venous air embolism caused by CT injector--from a risk management point of view. Radiat Med. 2004 Jul-Aug. 22(4):269-71. [View Abstract]
  32. Lou S, Ji B, Liu J, Yu K, Long C. Generation, detection and prevention of gaseous microemboli during cardiopulmonary bypass procedure. Int J Artif Organs. 2011 Nov. 34(11):1039-51. [View Abstract]
  33. Vesely TM. Air embolism during insertion of central venous catheters. J Vasc Interv Radiol. 2001 Nov. 12(11):1291-5. [View Abstract]
  34. Trunkey D. Initial treatment of patients with extensive trauma. N Engl J Med. 1991 May 2. 324(18):1259-63. [View Abstract]
  35. Cheng CK, Chang TY, Liu CH, et al. Presence of gyriform air predicts unfavorable outcome in venous catheter-related cerebral air embolism. J Stroke Cerebrovasc Dis. 2015 Oct. 24(10):2189-95. [View Abstract]
  36. Ganslandt O, Merkel A, Schmitt H, et al. The sitting position in neurosurgery: indications, complications and results. a single institution experience of 600 cases. Acta Neurochir (Wien). 2013 Oct. 155(10):1887-93. [View Abstract]
  37. Novack V, Shefer A, Almog Y. Images in cardiology. Coronary air embolism after removal of central venous catheter. Heart. 2006 Jan. 92(1):39. [View Abstract]
  38. Gracia I, Fabregas N. Craniotomy in sitting position: anesthesiology management. Curr Opin Anaesthesiol. 2014 Oct. 27(5):474-83. [View Abstract]
  39. Maddukuri P, Downey BC, Blander JA, Pandian NG, Patel AR. Echocardiographic diagnosis of air embolism associated with central venous catheter placement: case report and review of the literature. Echocardiography. 2006 Apr. 23(4):315-8. [View Abstract]
  40. Tins BJ, Cassar-Pullicino VN, Lalam R, Haddaway M. Venous air embolism in consecutive balloon kyphoplasties visualised on CT imaging. Skeletal Radiol. 2012 Sep. 41(9):1093-8. [View Abstract]
  41. Archer DP, Pash MP, MacRae ME. Successful management of venous air embolism with inotropic support. Can J Anaesth. 2001 Feb. 48(2):204-8. [View Abstract]
  42. Ohashi S, Endoh H, Honda T, Komura N, Satoh K. Cerebral air embolism complicating percutaneous thin-needle biopsy of the lung: complete neurological recovery after hyperbaric oxygen therapy. J Anesth. 2001. 15(4):233-6. [View Abstract]