Venous air embolism: an under-recognized and potentially catastrophic complication in orthopaedic surgery

Successful management of a suspected air embolism during anaesthesia in a dog undergoing thoracic limb amputation

An 11-year-old, male, castrated, Springer Spaniel dog presented for right thoracic limb amputation due to chronic lameness. The dog was otherwise healthy. During brachial plexus dissection, end-tidal carbon dioxide dropped from 6.3 kPa to 1.3 kPa (47-10 mmHg) over 30 seconds, heart rate and spontaneous respiratory rate increased, and peripheral arterial haemoglobin oxygen saturation decreased from 98% to 78%. Initial patient assessment excluded equipment malfunction and cardiopulmonary arrest, prompting interdisciplinary conversation and targeted diagnostics. Arterial blood gas analysis, combined with the surgeons locating an entrainment point for air in the axillary vein, substantiated a diagnosis of vascular air embolism. Coordinated multidisciplinary interventions restored cardiorespiratory parameters within 40 minutes. The surgery was completed and the dog was successfully discharged. This report highlights the risk of venous air embolism during limb amputation and the importance of early recognition.

Structures Endangered During Minimally Invasive Plate Osteosynthesis of the Upper Extremity

Minimally invasive plate osteosynthesis is a surgical technique that is becoming increasingly common because radiographic images and implant technologies advance in capabilities. It is imperative for surgeons to enhance their understanding of the surgical anatomy related to new approaches for fracture fixation. While performing minimally invasive plate osteosynthesis, there is a danger of injuring structures in the common percutaneous and submuscular pathways. We describe the critical anatomical structures in these pathways and tips for injury avoidance when operating on the clavicle, scapula, humerus, and wrist.

Massive venous air embolism with bleeding caused by femoral vein injury during total hip arthroplasty: A case report

INTRODUCTION

Venous air embolism (VAE) from vascular injuries, is of rare occurrence but can result in catastrophic complications during total hip arthroplasty (THA). Early recognition and prompt management of vascular injury are required to avoid severe complications. Especially, bleeding is generally associated with profound hypotension in venous injury. We report an unusual complication of venous air embolism induced by femoral vein rupture during THA.

PATIENT CONCERNS

A 54-year-old male patient with a history of old left acetabular fracture was scheduled for THA. We experienced massive bleeding and VAE induced by femoral vein rupture during total hip arthroplasty. The BP suddenly dropped from 100/70 mm Hg to 80/50 mm Hg with massive bleeding. ETCO2 and SaO2 decreased profoundly.

DIAGNOSIS

The VAE was diagnosed by the change in end- tidal CO2 (ETCO2) and change of vital signs, so we performed ABGA and inserted TEE for confirmination.

INTERVENTIONS

For treatment, patient was managed by oxygen therapy, inotropics, vasopressor, transfusion and surgical repair.

OUTCOMES

Upon consulting with a cardiologist, the patient was extubated the next day and was transferred to the general ward and recovered without serious complications. He stayed for 17 days until finally discharged without complications.

CONCLUSION

Preoperative vascular imaging may be recommended in the revisional case of THA or in patients with the history of hip trauma. The monitoring of ETCO2 and TEE might be helpful to recognize VAE earlier and therefore to avoid catastrophic complications through adequate treatment.

Suicide by air embolism introduced by means of a bicycle pump

A 64-year-old man was found dead in bed in his flat. In his right hand he held a bicycle pump to which a small-gauge cannula was attached and two fresh puncture wounds were found on his left hand. During the autopsy an air embolism of ca. 50 ml air was detected in the right ventricle of the heart by means of an aspirometer. The air embolism could not be reliably detected in a thorax radiograph taken prior to autopsy. Blood in the right ventricle was foamy. Pathological changes to organs were not found. Aside from the puncture wounds, there were no signs of externally applied mechanical force. The results of the toxicological analyses were negative.

Gas Embolism During Hysteroscopic Surgery?: Three Cases and a Literature Review

During a period of 1 month, 3 episodes of probable or actual venous air embolism occurred during hysteroscopic surgery. All patients developed the same symptoms of ventilatory and hemodynamic decompensation, beginning with a reduction in end-tidal carbon dioxide, arterial desaturation, and cyanosis on the upper trunk, and rapidly progressed to hypotension and 2 cardiac arrests. While entrainment of some air is common during hysteroscopy, life-threatening embolism is a rare but serious complication for which an anesthetist needs to be vigilant and prepared. If even a small drop in end-tidal carbon dioxide occurs, venous air embolism should be suspected and the operation should be discontinued.

Fontan Fenestration Closure Prior to Posterior Spinal Fusion in Patients With Single-Ventricle Heart Disease

STUDY DESIGN

Case series.

OBJECTIVE

To describe transcatheter closure of the Fontan fenestration prior to posterior spinal fusion in two children to prevent paradoxical venous air embolism during the operation.

SUMMARY OF BACKGROUND DATA

Scoliosis is common among patients with single-ventricle congenital heart disease who have undergone Fontan operation and spinal surgery can offer physiologic benefits. Venous air embolism is a rare, but important reported complication during spinal surgery performed in the prone position. Patients with Fontan circulation can have significant right to left shunting via a patent Fontan fenestration that can increase the risk of paradoxical systemic embolization of any entrained venous air.

METHODS

We retrospectively reviewed the charts of two patients with single-ventricle congenital heart disease who had undergone fenestrated Fontan operation and underwent transcatheter fenestration closure prior to spinal fusion.

RESULTS

Two patients with Fontan circulation underwent successful transcatheter fenestration closure with Amplatzer Ductal Occluder II devices. Five to 6 months after closure, both underwent uncomplicated posterior spinal fusion.

CONCLUSION

Transcatheter closure of the Fontan fenestration prior to spinal fusion in two with Fontan circulation and scoliosis is a rare, but important indication for fenestration closure that warrants emphasis.

LEVEL OF EVIDENCE

N/A.

Unilateral postoperative visual loss in a patient undergoing hip arthroscopy in the supine position: a case report

Micro-emboli have been reported to occur commonly during arthroscopic surgery, which is frequently performed as an orthopedic surgical procedure. We here report a patient who experienced unilateral postoperative visual loss after a hip arthroscopy using irrigation fluid in the supine position without any evidence of external compression to either eye throughout the surgical procedure. Retinal fundoscopy suggested that the patient had central retinal artery occlusion, one of the causes of the postoperative visual loss. This case suggests that arthroscopic surgery may pose a substantial risk for paradoxical air embolism, such as central retinal artery occlusion, and suggests the need to prevent the entry of micro-air bubbles during such a type of surgery.

A prospective randomized study to compare systemic emboli using the computer-assisted and conventional techniques of total knee arthroplasty

BACKGROUND

Conventional total knee arthroplasty is performed with use of an intramedullary alignment guide, which produces elevated intramedullary pressure that can create fat emboli. Total knee arthroplasty performed via computer-assisted surgery does not require an intramedullary femoral rod, raising the question of whether computer-assisted surgery generates less embolic material than conventional total knee arthroplasty. The purpose of this study was to compare the emboli produced in the two techniques.

METHODS

Fifty-seven patients were randomized into two groups: the computer-assisted surgery group (n = 29) and the conventional total knee arthroplasty group (n = 28). An intramedullary femoral alignment jig was used in the conventional total knee arthroplasty group but not in the computer-assisted surgery group. Intraoperative invasive monitoring was performed with use of transesophageal echocardiography and a pulmonary artery catheter.

RESULTS

The mean embolic score was 6.21 points for the conventional technique group and 5.48 points for the computer-assisted surgery group (p = 0.0161). After tourniquet deflation, fat emboli were observed in the blood of five patients in the conventional surgery group and one patient in the computer-assisted surgery group.

CONCLUSIONS

The patients in the computer-assisted surgery group had lower embolic loads compared with the patients in the conventional total knee arthroplasty group. In patients with an uncompromised cardiopulmonary system, the embolic load difference between the techniques was not clinically relevant.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Major neurovascular complications of clavicle fracture surgery

Clavicle fracture fixation is becoming an increasingly common operation, with good clinical outcomes and a low rate of significant complications. However, there are several reports of rare but potentially life or limb threatening, neurovascular complications. Arterial injuries are usually pseudoaneurysms associated with prominent screws. These may be clinically silent for several years before presenting as subcritical upper limb ischaemia. Venous injuries are a result of tearing of the vessel wall by fracture manipulation, drills or implants. This produces intra-operative haemorrhage and potentially air embolism, which can be fatal if not rapidly recognized and managed. Brachial plexopathy is the result of traction on adherent plexus or impingement by fracture fragments or callus. It presents as severe arm pain and paralysis immediately postoperatively. Neurovascular injuries can be avoided by a combination of pre-operative planning, communication with anaesthetic staff and strategic surgical technique. The plane of the surgical exposure, release of the soft tissues, drill direction and depth and screw length are all important factors.