An otherwise healthy male infant was brought to the hospital because the mother suspected superficial infection at the operative site 5 days after an inguinal hernia repair. He was admitted to the pediatric unit overnight to be evaluated by his surgeon the next morning. When a venous infusion of maintenance fluids was started, the patient immediately went into cardio-respiratory arrest and was pronounced dead after resuscitation efforts failed.
Cardiac air embolism should be suspected in any neonate with acute unexplained cardiovascular collapse or worsening oxygenation. We present here five cases that presented with the above symptoms.
Venous air embolism during identification of the epidural space in children.
Swartz N, Eisenkraft JB. Probable venous air embolism during epidural placement in an infant. Anesth Analg 1993;76:1136–8.
Chang AC, Wells W. Shunt lesions. In: Chung AC, Hanley FL, Wernovsky G, Wassell DL, editors. Pediatric cardiac intensive care. Philadelphia: Saunders, 2005:207–8.
Diagnosis & Treatment
Mirski MA, Lele AV, Fitzsimmons L, Toung TJ. Diagnosis and treatment of vascular air embolism. Anesthesiology. 2007 Jan;106(1):164-77. Review.
Vascular air embolism (VAE) is known since early nineteenth century. It is the entrainment of air or gas from operative field or other communications into the venous or arterial vasculature.
General Review Articles
Gas embolism, the entry of gas into vascular structures, is a largely iatrogenic clinical problem that can result in serious morbidity and even death.1 Since gas embolism can result from procedures performed in almost all clinical specialties (Table 1), it is important for all clinicians to be aware of this problem.
When air enters the circulatory system of the human body it can cause an air embolism. Air in the venous circulation will enter the right side of the heart where it may cause right ventricular outflow tract obstruction and acute pulmonary hypertension from pulmonary vasoconstriction.
Venous air embolism causes injury primarily by obstruction of blood flow from the right side of the heart to the left.
Venous air embolism (VAE) is a potential complication of surgical procedures as well as central venous access. There are several reports in the literature of VAE during the in-hospital use and placement of central venous access. However, we are unaware of previous cases of VAE in children who received home infusion therapy via central venous access.
To examine the existing literature concerning venous air embolism. Causes, pathophysiology, and management are emphasized.
Hartveit F, Lystad H, Minken A. The pathology of venous air embolism. Br J Exp Pathol. 1968 Feb;49(1):81-6.
Cardiopulmonary effects of intravenous gas embolism; with special reference to fate of intravascular gas bubbles
Oyama Y, Spencer MP. Cardiopulmonary effects of intravenous gas embolism; with special reference to fate of intravascular gas bubbles. Jpn Circ J. 1971 Dec;35(12):1541-9.
Procedure-related serious adverse events among home hemodialysis patients: a quality assurance perspective
There has been resurgent interest in home hemodialysis (HD) in recent years because of the reported benefits and its excellent safety record. However, the potential for adverse events, including potentially catastrophic ones, exists when patients are performing HD in their homes without supervision. There is a lack of literature on this important topic.
To establish the incidence and long-term prognosis of iatrogenic gas embolism.
Marchand P, Van Hasselt, Luntz CH. Massive venous air embolism. S Afr Med J. 1964 Mar 28;38:202-8.
Pulmonary (venous) air embolism is a catastrophe which may occur under a variety of circumstances in medical practice. It must be distinguished from arterial air embolism. Our studies in the experimental animal have shown that important factors in determining whether death or survival will occur are: (1) the amount of air which gains admission to the circulation, (2) the speed with which it enters, (3) the position of the body at the time of the embolic accident, and (4) the efficacy of the respiratory excretory mechanism.
Venous air embolism (VAE) can be a lethal complication of surgical procedures, during which (1) venous pressure at the site of surgery is subatmospheric or (2) gas is forced under-pressure into a body cavity.
Laidlow, Kate. Air Embolism ? : Don’t worry it was just a bubble…. IVNNZ Newsletter. 2011.
Serious complications after peripheral IV and arterial vascular cannulations have been reported. To assess liability associated with these peripheral vascular catheters for anesthesiologists, we reviewed claims in the American Society of Anesthesiologists Closed Claims database.
To assess changing patterns of injury and liability associated with central venous or pulmonary artery catheters, the authors analyzed closed malpractice claims for central catheter injuries in the American Society of Anesthesiologists Closed Claims database.
Gas embolism is a known complication of various invasive procedures, and its management is well established. The consequence of gas microemboli, microbubbles, is underrecognized and usually overlooked in daily practice. We present the current data regarding the pathophysiology of microemboli and their clinical consequences.
Microbubbles have been detected in the human circulation of end-stage renal disease patients who are treated by hemodialysis throughout the past decade as a result of advanced ultrasound and Doppler technology.
To narratively review published information on prevention, detection, pathophysiology, and appropriate treatment of vascular air embolism (VAE).
In-line filtration reduces severe complications and length of stay on pediatric intensive care unit: a prospective, randomized, controlled trial
In-line filtration is able to avert severe complications in critically ill patients. The overall complication rate during the PICU stay among the filter group was significantly reduced. In-line filtration was effective in reducing the occurrence of SIRS.
Warmers, Pumps & Filters
Amount of air infused to patient increases as fluid flow rates decrease when using the Hotline HL-90 fluid warmer.
The intraoperative use of fluid warming devices has been recommended to avoid perioperative hypothermia and related adverse outcomes. To evaluate whether these devices might introduce risks of their own, we measured the volume of air escaping from a warmed intravenous solution that might be delivered to a patient
Stevenson GW, Tobin M, Hall SC. Fluid warmer as a potential source of air bubble emboli. Anesth Analg. 1995 May; 80(5):1061.
In-line IV filters are commonly used in pediatric patients with congenital heart disease. The main purpose is the prevention of air from reaching the systemic circulation with resulting potential catastrophic effects in this patient population.
Wolin, J, Vasdev, G. Potential for air embolism using Hotline™ model HL90 fluid warmer. J Clin. Anesth. 1996; 8(1):81-82.
Air embolism can complicate peripheral IV fluid therapy (1) or central venous catheter monitoring, including problems with IV infusion pumps (2), improper flushing of IV sets (3), incorrect injection of drugs into the infusion system (3), and accidental disconnection of the hub or removal of central venous catheters (4).
Air injection is carefully avoided during IV solution administration; however, ambient air is dissolved in all liquids used for intravenous (IV) therapy. A portion of this gas will come out of solution in the form of bubbles as the solution is warmed to body temperature in a fluid warming system and/or within the body. We sought to quantify the proportion of the gas theoretically dissolved in room temperature crystalloid and 4°C blood products that comes out of solution in the IV tubing on warming to 37°C.
Volume of Air Generated from HotlineⓇ Warmer – Plenty to Cause Serious Injury/Morbidity in Pediatrics
To measure the volume of air released into patient IV lines during the process of fluid warming. The
intraoperative use of fluid warming devices has been recommended to avoid perioperative hypothermia and related adverse outcomes including infection. However, these devices may be introducing risks of their own in the form of air being introduced to the patient’s vasculature.
Haddad, I., Lobozzo, J. Limitations and Failures of In-Line IV Filters. ClearLine MD LLC. 2017.
Venous or arterial air embolism may be a life threatening event. The condition is seen in many fields of medicine, including intensive care.
There were 19 cases of air embolism (1%) among the first 2000 incidents reported to the Australian Incident Monitoring Study. No embolism-induced fatalities were reported. Serious acute systemic effects occurred in 14 incidents; one circulatory arrest required electrical counter-shock.
Cereda C, Staedler C, Moschovitis G, Caronni F, Bassetti CL, Azzola A. ‘Bubbles in the brain’: systemic air embolism syndrome from an atrial-oesophageal fistula. Emerg Med J. 2011 May;28(5):455. doi: 10.1136/emj.2010.093195.
Cerebral air embolism occurred in a patient undergoing posterior fossa surgery performed in the sitting position for acoustic neuroma removal. The patient experienced two episodes of venous air embolism, as evidenced by precordial Doppler, end-tidal carbon dioxide reduction, and oxygen desaturation.
Venous air embolism is a rare but recognized complication of posterior spinal fusion surgery and epidural placement using a loss of resistance to air technique. We report a case of a probable venous air embolism causing cardiac arrest in a 10-year-old girl undergoing posterior spinal fusion in the prone position.
Pressurized Intravenous Fluid Administration in the Professional Football Player: A Unique Setting for Venous Air Embolism.
Venous air embolism (VAE) is a potentially life-threatening event that is most commonly associated with certain surgical procedures, although this theoretical complication of pressurized rapid infusion of intravenous (IV) fluids has been described. This series of cases describes 4 athletes who presented with continuous coughing and other chest complaints after peripheral IV infusion of normal saline through manual pressurized infusion.
Air bubble contact with endothelial cells causes a calcium-independent loss in mitochondrial membrane potential.
Gas microembolism remains a serious risk associated with surgical procedures and decompression. Despite this, the signaling consequences of air bubbles in the vasculature are poorly understood and there is a lack of pharmacological therapies available. Here, we investigate the mitochondrial consequences of air bubble contact with endothelial cells.
Air bubble contact with endothelial cells in vitro induces calcium influx and IP3-dependent release of calcium stores.
Gas embolism is a serious complication of decompression events and clinical procedures, but the mechanism of resulting injury remains unclear. Previous work has demonstrated that contact between air microbubbles and endothelial cells causes a rapid intracellular calcium transient and can lead to cell death.
Vascular air embolism resulting from too rapid decompression is a well-known risk in deep-sea diving, aviation and space travel. It is also a common complication during surgery or other medical procedures when air or other endogenously administered gas is entrained in the circulation. Preventive and post-event treatment options are extremely limited for this dangerous condition, and none of them address the poorly understood pathophysiology of endothelial response to intravascular bubble presence.
Decompression sickness is a systemic pathophysiological process caused by bubbles and endothelial microparticles (EMPs) are established markers reflecting competency of endothelial function and vascular biology.
Arterial Limb Microemboli during Cardiopulmonary Bypass: Observations from a Congenital Cardiac Surgery Practice
Gaseous microemboli (GME) are known to be delivered to the arterial circulation of patients during cardiopulmonary bypass (CPB). An increased number of GME delivered during adult CPB has been associated with brain injury and postoperative cognitive dysfunction.