Fatal Cerebral Air Embolism Due to a Patent Foramen Ovale during Endoscopic Retrograde Cholangiopancreatography

Complications of Endoscopic Retrograde Cholangiopancreatography

Up to 1 in 6 patients will experience an unplanned hospitalization after endoscopic retrograde cholangiopancreatography (ERCP), largely for the evaluation and management of adverse events. Therefore, a commitment to the prevention, early recognition, and effective rescue of complications related to ERCP is critical toward improving outcomes. ERCP is most often complicated by acute pancreatitis, bleeding, infection, or perforation, although myriad other adverse events may occur. The prevention of post-ERCP pancreatitis has been the area of greatest interest and progress in the last decade, but the application of evidence-based prophylactic measures remains inconsistent. Innovations in stent, hemostasis, and perforation closure technology now allow effective and efficient endoscopic management of several important nonpancreatitis complications. Overall, our ability to prevent and treat ERCP-related adverse events has improved substantially, amplifying the importance of a high level of suspicion for and a thorough understanding of these events.

Carbon Dioxide Embolism Resulting From Liver Laceration During Peritoneal Optical Trocar Entry

Venous air emboli have been reported to occur in numerous settings, including trauma, various surgical procedures, both laparoscopic and radiologically, and even idiopathically. In this case study, a liver laceration was made during a robot-assisted left colectomy and colostomy in a 69-year-old female resulting in air embolism during insufflation. A drop in end-tidal CO₂ was noted and the patient went into immediate cardiac arrest. Adequate pressure was applied and over-suturing of the liver laceration was made with reverse Trendelenburg positioning during the administration of cardiopulmonary resuscitation (CPR) for approximately one minute. The patient completed an open hemicolectomy the following day and made a complete recovery. Preventative and intraoperative measures to prevent further recurrences of venous air emboli are discussed.

Massive cerebral air embolism following percutaneous transhepatic biliary drainage: A case report

RATIONALE

Cerebral air embolism from portal venous gas rarely occurs due to invasive procedures (e.g., endoscopic procedures, liver biopsy, or percutaneous transhepatic biliary drainage) that disrupt the gastrointestinal or hepatobiliary structures. Here, we report a rare case of fatal cerebral air embolism following a series of percutaneous transhepatic biliary drainage tube insertions.

PATIENT CONCERNS

A 50-year-old woman with a history of cholecystectomy, liver wedge resection, and hepaticojejunostomy for gallbladder cancer presented with altered mental status 1 week after percutaneous transhepatic biliary drainage tube placement.

DIAGNOSES

Extensive cerebral air embolism and acute cerebral infarction.

INTERVENTIONS

Brain computed tomography and magnetic resonance imaging, hyperbaric oxygen therapy, medical therapy.

OUTCOMES

Despite the use of hyperbaric oxygen therapy and medical treatment including vasopressors, the patient eventually died due to massive systemic air embolism.

LESSONS

To date, there have been no reports of cerebral air embolism due to percutaneous transhepatic biliary drainage with pronounced radiologic images. We reviewed previously reported fatal cases associated with endoscopic hepatobiliary procedures and assessed the possible mechanisms and potential causes of air embolism.

When in Trouble Think of the Bubble: Paradoxical Cerebral Arterial Gas Embolism after Endoscopic Retrograde Cholangiopancreatography

Air embolism (a result of direct communication with the vasculature and an external pressure gradient from the gastrointestinal or the biliary tract), although rare, is a potentially devastating adverse event seen in endoscopic retrograde cholangiopancreatography (ERCP) procedures. Whether venous, arterial, or paradoxical, the clinical presentation ranges from asymptomatic patients to cardiorespiratory arrest. This is of particular importance because it makes the diagnosis of air embolism even more difficult in an already sedated patient. Since early recognition increases the chances of patients' survival, endoscopists should be highly motivated and trained to recognize this complication as early as possible. With only 60 cases of air embolism reported (and even fewer related to paradoxical air embolism), we aimed to report a case of paradoxical cerebral air embolism in a patient undergoing ERCP due to a common bile duct stricture and to provide a mini-review of this clinical entity that can serve as a bedside quick reference guide for endoscopists worldwide.

Clinical Presentation, Diagnosis, and Management of Air Embolism During Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive procedure that is widely used by endoscopists and has a robust therapeutic profile. It uses endoscopy and imaging for a variety of diagnostic as well as therapeutic purposes. It is used for the management of a lot of pancreaticobiliary diseases such as obstructive jaundice, obstruction related to bile ducts, pancreatic biliary tumors, and traumatic or iatrogenic damage to the bile ducts. Other therapeutic interventions that can be done via ERCP include sphincterotomy, dilation of strictures, removal of biliary stones and placement of stents. Air embolism presents with cardiovascular, pulmonary, and neurologic signs and symptoms. Treatment of air embolism should be started early in suspected cases, and it should be in the differential diagnoses of various complications secondary to high risk of ERCP, especially if a cardiopulmonary compromise is present. Air embolism is rare but a serious complication associated with ERCP. The physicians must keep this in mind while performing ERCP in patients with predisposing risk factors. This review highlights the mechanism, causes, risk factors, pathophysiology, clinical signs, diagnostic modalities, treatment, and preventive measures to deal with this catastrophic complication.

Gas embolism during endoscopic retrograde cholangiopancreatography: diagnosis and management

Air embolism is rarely diagnosed and is often fatal. The diagnosis is often not made in a timely manner given the rapid and severe clinical deterioration that often develops, frequently leading to cardiac arrest. Many patients are only diagnosed post-mortem. With the increasing use of endoscopic retrograde cholangiopancreatography, air embolism should be considered in the differential diagnosis in patients who experience sudden clinical deterioration during or immediately after the procedure. Clinical suspicion is key in the diagnosis and management of air embolism. Use of precordial Doppler ultrasound and transesophageal echocardiogram can aid in the diagnosis of air embolism. Once the diagnosis is made, supportive management of airway, breathing and circulation is pivotal. Advanced cardiac life support should be initiated when necessary. Fluid resuscitation and vasopressors can improve cardiac output. Hyperbaric oxygen therapy should be considered when possible in cases of suspected cerebral air embolism cases to improve neurological outcome. A multidisciplinary team approach and effective communication with experts, potentially including an anesthesiologist, cardiologist, intensivist, radiologist and surgeon, can improve the outcome in air embolism.

Multiple small hemorrhagic infarcts in cerebral air embolism: a case report

Background

Cerebral air embolism is a rare cause of cerebral infarction. In cerebral air embolism, T2 star-weighted imaging shows numerous spotty hypointense signals. Previous reports have suggested that these signals represent air in the brain and are gradually diminished and absorbed. We experienced two cases of cerebral air embolism, and in one of them, we conducted an autopsy.

Case presentation

Case 1 was a 76-year-old Japanese man with lung cancer and emphysema. A spasmodic cough induced massive cerebral and cardiac air embolisms and the patient died because of cerebral herniation. T2 star-weighted imaging of brain magnetic resonance imaging showed multiple spotty low signals. Brain autopsy showed numerous spotty hemorrhagic infarcts in the area of T2 star-weighted imaging signals. Case 2 was an 85-year-old Japanese man with emphysema who suffered from acute stroke. Similar spotty T2 star-weighted imaging signals were observed and remained unchanged 2 months after the onset.

Conclusions

These findings indicate that T2 star-weighted imaging in cerebral air embolism partially represents micro-hemorrhagic infarction caused by air bubbles that have migrated into the brain.