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Malhotra AK, Chang AP, Lawton JP, Alves AC, Jerath A, Tillmann BW, Foster H, Mashari A, da Costa L, Kumar A. Intraoperative air embolism diagnosis and treatment using hyperbaric oxygen therapy after craniotomy: illustrative case. J Neurosurg Case Lessons 2023; 5:CASE2342. [PMID: 36941197 PMCID: PMC10550683 DOI: 10.3171/case2342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 02/24/2023] [Indexed: 03/22/2023]
Abstract
BACKGROUND This report describes the use of hyperbaric oxygen therapy for the acute management of an intraoperative air embolism encountered during a neurosurgical procedure. Furthermore, the authors highlight the concomitant diagnosis of tension pneumocephalus requiring evacuation prior to hyperbaric therapy. OBSERVATIONS A 68-year-old male developed acute ST-segment elevation and hypotension during elective disconnection of a posterior fossa dural arteriovenous fistula. The semi-sitting position had been used to minimize cerebellar retraction, raising the concern for acute air embolism. Intraoperative transesophageal echocardiography was utilized to establish the diagnosis of air embolism. The patient was stabilized on vasopressor therapy, and immediate postoperative computed tomography revealed air bubbles in the left atrium along with tension pneumocephalus. He underwent urgent evacuation for the tension pneumocephalus followed by hyperbaric oxygen therapy to manage the hemodynamically significant air embolism. The patient was eventually extubated and went on to fully recover; a delayed angiogram revealed complete cure of the dural arteriovenous fistula. LESSONS Hyperbaric oxygen therapy should be considered for an intracardiac air embolism resulting in hemodynamic instability. In the postoperative neurosurgical setting, care should be taken to exclude pneumocephalus requiring operative intervention prior to hyperbaric therapy. A multidisciplinary management approach facilitated expeditious diagnosis and management for the patient.
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Affiliation(s)
- Armaan K. Malhotra
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ashton P. Chang
- Department of Anesthesiology, Sunnybrook Health Sciences, Toronto, Ontario, Canada
| | - Joseph P. Lawton
- Department of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Aderaldo Costa Alves
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health SciencesCentre, Toronto, Ontario, Canada
| | - Angela Jerath
- Department of Anesthesiology, Sunnybrook Health Sciences, Toronto, Ontario, Canada
- Department of Anesthesiology, Schulich Heart Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Bourke W. Tillmann
- Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdeparmtental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada; and
| | - Harry Foster
- Department of Anesthesiology, Sunnybrook Health Sciences, Toronto, Ontario, Canada
- Department of Anesthesiology, Schulich Heart Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Azad Mashari
- Division of Anesthesiology, University Health Network, Toronto, Ontario, Canada
| | - Leodante da Costa
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health SciencesCentre, Toronto, Ontario, Canada
| | - Ashish Kumar
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health SciencesCentre, Toronto, Ontario, Canada
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