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Zhang W, Xing W, Zhu M, He J. Using stent thrombectomy to cure middle cerebral artery air embolism. Neurol Sci 2024; 45:2907-2911. [PMID: 38319479 DOI: 10.1007/s10072-024-07381-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/28/2024] [Indexed: 02/07/2024]
Affiliation(s)
- Wensheng Zhang
- Department of Neurology, Heyuan People's Hospital, Guangdong Provincial People's Hospital Heyuan Hospital, No. 733 Wenxiang Road, Yuancheng District, Heyuan, 517000, Guangdong Province, China
| | - Weifang Xing
- Department of Neurology, Heyuan People's Hospital, Guangdong Provincial People's Hospital Heyuan Hospital, No. 733 Wenxiang Road, Yuancheng District, Heyuan, 517000, Guangdong Province, China
| | - Minzhen Zhu
- Department of Neurology, Heyuan People's Hospital, Guangdong Provincial People's Hospital Heyuan Hospital, No. 733 Wenxiang Road, Yuancheng District, Heyuan, 517000, Guangdong Province, China
| | - Jinzhao He
- Department of Neurology, Heyuan People's Hospital, Guangdong Provincial People's Hospital Heyuan Hospital, No. 733 Wenxiang Road, Yuancheng District, Heyuan, 517000, Guangdong Province, China.
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2
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Zhou X, Zhong X, Dong L. Air embolism caused by peripheral superficial vein catheterization: A case report. Medicine (Baltimore) 2024; 103:e37640. [PMID: 38579042 PMCID: PMC10994460 DOI: 10.1097/md.0000000000037640] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/27/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Air embolization is usually an iatrogenic complication that can occur in both veins and arteries. Intravenous air embolization is mainly associated with large central vein catheters and mechanical ventilation. A 59-year-old woman was sent to our hospital with spontaneous cerebral hemorrhage and treated conservatively with a left forearm peripheral venous catheter infusion drug. After 48 hours, the patient's oxygen saturation decreased to 92 % with snoring breathing. Computer tomography of the head and chest revealed scattered gas in the right subclavian, the right edge of the sternum, the superior vena cava, and the leading edge of the heart shadow. METHODS She was sent to the intensive care unit for high-flow oxygen inhalation and left-side reclining instantly. As the patient was at an acute stage of cerebral hemorrhage and did not take the Trendelenburg position. RESULTS The computed tomography (CT) scan after 24 hours shows that the air embolism subsides. CONCLUSION SUBSECTIONS Air embolism can occur in any clinical scenario, suggesting that medical staff should enhance the ability to identify and deal with air embolism. For similar cases in clinical practice, air embolism can be considered.
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Affiliation(s)
- Xiaoxiao Zhou
- The Department of Neurosurgery, The First People’s Hospital of Huzhou, Zhejiang, China
| | - XingMing Zhong
- The Department of Neurosurgery, The First People’s Hospital of Huzhou, Zhejiang, China
| | - Liying Dong
- The Department of Nursing, The First People’s Hospital of Huzhou, Zhejiang, China
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3
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Tantisarasart T, Tantichamnankul T, Kitsiripant C, Choochuen P. Venous air emboli during esophagoscopy confirmed by computed tomographic pulmonary angiography -a case report. Korean J Anesthesiol 2024; 77:278-281. [PMID: 38029795 PMCID: PMC10982525 DOI: 10.4097/kja.23722] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Esophagogastroduodenoscopy (EGD) is vital for the diagnosis and treatment of various gastrointestinal conditions but carries a low risk of venous air embolism (VAE). We report a case of VAE during EGD, confirmed by computed tomographic pulmonary angiography (CTPA). CASE A 56-year-old male with a history of hypopharyngeal cancer underwent EGD for dysphagia-related esophageal dilation. Signs of VAE were noted, prompting swift interventions, including oxygen therapy, positional changes, and CTPA. CTPA revealed the Mercedes-Benz sign, pneumomediastinum, and a minimal pneumothorax. The patient's oxygen saturation improved within 30 min before undergoing CTPA, and he was discharged on postoperative day 4. CONCLUSIONS Timely recognition of VAE, resulting in appropriate interventions supported by CTPA, resulted in favorable patient outcomes.
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Affiliation(s)
| | | | | | - Panjai Choochuen
- Department of Radiology, Prince of Songkla University, Songkhla, Thailand
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4
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Platogiannis N, Karelas D, Platogiannis D, Papanikolaou J. Aspiring use of a thrombectomy catheter for coronary air embolism aspiration. J Invasive Cardiol 2024; 36. [PMID: 38412441 DOI: 10.25270/jic/23.00259] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
A 52-year-old man with a history of percutaneous coronary intervention (PCI) in the left anterior descending (LAD) coronary artery was admitted for a facilitated PCI following an anterior ST-elevation myocardial infarction treated with thrombolysis at a nearby clinic.
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Affiliation(s)
| | - Dimitrios Karelas
- The Cardiology Department, Trikala Hospital, Trikala, Thessaly, Greece.
| | | | - John Papanikolaou
- The Cardiology Department, Trikala Hospital, Trikala, Thessaly, Greece
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5
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Tsushima R, Mori K, Imaki S. Secondary deterioration in a patient with cerebral and coronary arterial gas embolism after brief symptom resolution: a case report. Diving Hyperb Med 2024; 54:61-64. [PMID: 38507911 DOI: 10.28920/dhm54.1.61-64] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/12/2023] [Indexed: 03/22/2024]
Abstract
Introduction Hyperbaric oxygen treatment (HBOT) is recommended for arterial gas embolism (AGE) with severe symptoms. However, once symptoms subside, there may be a dilemma to treat or not. Case presentation A 71-year-old man was noted to have a mass shadow in his left lung, and a transbronchial biopsy was performed with sedation. Flumazenil was intravenously administered at the end of the procedure. However, the patient remained comatose and developed bradycardia, hypotension, and ST-segment elevation in lead II. Although the ST changes spontaneously resolved, the patient had prolonged disorientation. Whole- body computed tomography revealed several black rounded lucencies in the left ventricle and brain, confirming AGE. The patient received oxygen and remained supine. His neurological symptoms gradually improved but worsened again, necessitating HBOT. HBOT was performed seven times, after which neurological symptoms resolved almost completely. Conclusions AGE can secondarily deteriorate after symptoms have subsided. We recommend that HBOT be performed promptly once severe symptoms appear, even if they resolve spontaneously.
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Affiliation(s)
- Ryota Tsushima
- Yokohama Municipal Citizen's Hospital 1-1, Mitsuzawanishi-chou, Kanagawa-ku, Yokohama-city, Kanagawa-ken 221-0855, Japan
- Corresponding author: Dr Ryota Tsushima, Yokohama Municipal Citizen's Hospital 1-1, Mitsuzawanishi-chou, Kanagawa-ku, Yokohama-city, Kanagawa-ken 221-0855, Japan,
| | - Kosuke Mori
- Yokohama Minami Kyosai Hospital 1-21-1, Mutsurahigashi, Kanazawa-ku, Yokohama- city, Kanagawa-ken 236-0037, Japan
| | - Shohei Imaki
- Yokohama Municipal Citizen's Hospital 1-1, Mitsuzawanishi-chou, Kanagawa-ku, Yokohama-city, Kanagawa-ken 221-0855, Japan
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Mitchell SJ. Decompression illness: a comprehensive overview. Diving Hyperb Med 2024; 54:1-53. [PMID: 38537300 PMCID: PMC11098596 DOI: 10.28920/dhm54.1.suppl.1-53] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/31/2024] [Indexed: 05/20/2024]
Abstract
Decompression illness is a collective term for two maladies (decompression sickness [DCS] and arterial gas embolism [AGE]) that may arise during or after surfacing from compressed gas diving. Bubbles are the presumed primary vector of injury in both disorders, but the respective sources of bubbles are distinct. In DCS bubbles form primarily from inert gas that becomes dissolved in tissues over the course of a compressed gas dive. During and after ascent ('decompression'), if the pressure of this dissolved gas exceeds ambient pressure small bubbles may form in the extravascular space or in tissue blood vessels, thereafter passing into the venous circulation. In AGE, if compressed gas is trapped in the lungs during ascent, pulmonary barotrauma may introduce bubbles directly into the pulmonary veins and thence to the systemic arterial circulation. In both settings, bubbles may provoke ischaemic, inflammatory, and mechanical injury to tissues and their associated microcirculation. While AGE typically presents with stroke-like manifestations referrable to cerebral involvement, DCS can affect many organs including the brain, spinal cord, inner ear, musculoskeletal tissue, cardiopulmonary system and skin, and potential symptoms are protean in both nature and severity. This comprehensive overview addresses the pathophysiology, manifestations, prevention and treatment of both disorders.
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Affiliation(s)
- Simon J Mitchell
- Department of Anaesthesiology, School of Medicine, University of Auckland, Auckland, New Zealand
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
- Slark Hyperbaric Medicine Unit, North Shore Hospital, Auckland, New Zealand
- Corresponding address: Department of Anaesthesiology, School of Medicine, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand, ORCiD: 0000-0002-5149-6371,
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7
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Popat A, Yadav S. Air Embolism-Induced Ischemic Stroke Following Orthognathic Surgery in a Patient With Goldenhar Syndrome. Clin Med Res 2024; 22:44-48. [PMID: 38609140 DOI: 10.3121/cmr.2024.1882] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 03/02/2024] [Accepted: 03/03/2024] [Indexed: 04/14/2024]
Abstract
Goldenhar syndrome, a rare congenital anomaly, manifests as craniofacial malformations often necessitating intricate surgical interventions. These procedures, though crucial, can expose patients to diverse postoperative complications, including hemorrhage or infection. A noteworthy complication is stroke, potentially linked to air embolism or local surgical trauma. We highlight a case of a male patient, aged 20 years, who experienced a significant postoperative complication of an ischemic stroke, theorized to be due to an air embolism, after undergoing orthognathic procedures for Goldenhar syndrome. The patient was subjected to LeFort I maxillary osteotomy, bilateral sagittal split ramus osteotomy of the mandible, and anterior iliac crest bone grafting to the right maxilla. He suffered an acute ischemic stroke in the left thalamus post-surgery, theorized to stem from an air embolism. Advanced imaging demonstrated air pockets within the cavernous sinus, a rare and concerning finding suggestive of potential air embolism. This case underscores the intricate challenges in treating Goldenhar syndrome patients and the rare but significant risk of stroke due to air embolism or surgical trauma. Limited literature on managing air embolism complications specific to Goldenhar syndrome surgeries exists. Generally, management includes immediate recognition, positional adjustments, air aspiration via central venous catheters, hyperbaric oxygen therapy, hemodynamic support, and high-flow oxygen administration to expedite air resorption. Our patient was conservatively managed post-surgery, and at a 3-month neurology follow-up, he showed significant improvement with only residual right arm weakness. It emphasizes the imperative of a comprehensive, multidisciplinary approach.
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Affiliation(s)
- Apurva Popat
- Marshfield Clinic Health System, Internal Medicine, Marshfield, Wisconsin, USA
| | - Sweta Yadav
- GMERS Medical College, Internal Medicine, Ahmedabad, Ahmedabad, India
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8
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Sinclair De Frías J, Olivero L, Fleissner Z, Burns J, Chadha R, Moreno Franco P. Intraoperative vascular air embolism and intracardiac thrombosis complicating liver transplantation: a case report. J Med Case Rep 2024; 18:59. [PMID: 38368412 PMCID: PMC10874554 DOI: 10.1186/s13256-024-04376-8] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 01/11/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Intracardiac thrombus and vascular air embolism represent rare complications in the context of orthotopic liver transplantation. While isolated reports exist for intracardiac thrombus and vascular air embolism during orthotopic liver transplantation, this report presents the first documentation of their simultaneous occurrence in this surgical setting. CASE PRESENTATION This case report outlines the clinical course of a 60-year-old white female patient with end-stage liver disease complicated by portal hypertension, ascites, and hepatocellular carcinoma. The patient underwent orthotopic liver transplantation and encountered concurrent intraoperative complications involving intracardiac thrombus and vascular air embolism. Transesophageal echocardiography revealed the presence of air in the left ventricle and a thrombus in the right atrium and ventricle. Successful management ensued, incorporating hemodynamic support, anticoagulation, and thrombolytic therapy, culminating in the patient's discharge after a week. CONCLUSIONS This report highlights the potential for simultaneous intraoperative complications during orthotopic liver transplantation, manifesting at any phase of the surgery. It underscores the critical importance of vigilant monitoring throughout orthotopic liver transplantation to promptly identify and effectively address these rare yet potentially catastrophic complications.
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Affiliation(s)
| | - Lorenzo Olivero
- Department of Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, USA
| | | | - Justin Burns
- Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Ryan Chadha
- Department of Anesthesiology, Mayo Clinic, Jacksonville, FL, USA
| | - Pablo Moreno Franco
- Department of Critical Care, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, USA.
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9
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Franco MA, Ng P, Tuft MJ, Keuski BM. The Influence of Advanced Hyperbaric Medical Training on Arterial Gas Embolism Treatment. Mil Med 2024; 189:e401-e404. [PMID: 37436921 DOI: 10.1093/milmed/usad260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/18/2023] [Accepted: 06/29/2023] [Indexed: 07/14/2023] Open
Abstract
3d Reconnaissance Battalion, a forward-deployed Marine Corps unit in Okinawa, Japan, frequently performs diving operations. Often throughout the year, several reconnaissance teams are diving simultaneously in different locations for training. We present a case of an otherwise healthy 30-year-old-male Reconnaissance Marine who surfaced from a dive with abnormal symptoms and received prompt care from exercise participants who were nonmedical personnel. Studies have demonstrated improved morbidity outcomes in decompression illness patients with shorter times to hyperbaric treatment following the onset of symptoms. High-risk military exercises with diving components have a mandatory safety structure that includes recompression chamber support. All United States Marine Corps Reconnaissance, Marine Corps Special Operations Command, and U.S. Navy dive operations are required to have at least one diving supervisor. To expand the diving capabilities of the unit, Marines are encouraged to attend training and qualify as diving supervisors. This case study demonstrates the efficacy and importance of training Recon Marines to recognize decompression illness as diving supervisors.
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Affiliation(s)
- Michael A Franco
- 3d Reconnaissance Battalion, United States Marine Corps, Unit 36180 FPO, AP 96389, USA
| | - Peter Ng
- 3d Marine Division, United States Marine Corps, Unit 35801 FPO, AP 96382, USA
| | - Michael J Tuft
- United States Naval Hospital Okinawa, United States Navy, Camp Foster FPO, AP 96362, USA
| | - Brian M Keuski
- Naval Special Operations Medical Institute, Navy Medicine Operational Training Command, Fort Bragg, North Carolina 28310, USA
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10
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Takahashi K, Ozawa E, Tajima K, Fukushima M, Imamura I, Matsushima H, Adachi T, Hayashi Y, Eguchi S, Nakao K. [Air embolism after biliary stent removal during endoscopic retrograde cholangiopancreatography for cholangitis after biliary reconstruction: a case report]. Nihon Shokakibyo Gakkai Zasshi 2024; 121:144-153. [PMID: 38346762 DOI: 10.11405/nisshoshi.121.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
A 62-year-old male patient underwent pancreaticoduodenectomy with modified Child reconstruction for distal cholangiocarcinoma. After eight years, a contrast-enhanced computed tomography (CT) revealed a recurrent lesion at the biliojejunal anastomosis, and a biliary stent was placed for obstructive cholangitis in the right posterior segment of the liver. A right hepatectomy was planned for a local recurrent lesion;thus, percutaneous transhepatic portal embolization was performed on the portal vein's right branch to enlarge the left liver. However, he was referred to our department for endoscopic retrograde biliary drainage for the subsequent cholangitis and liver abscess appearance. A double-balloon enteroscope under CO2 insufflation was used to reach the bile duct-jejunal anastomosis. After removing the bile duct stent with grasping forceps, his general condition suddenly deteriorated, causing cardiopulmonary arrest. He was diagnosed with air embolism based on the findings of air in the heart, aorta, and brain on CT after the return of spontaneous circulation. Treatment for the air embolism and subsequent complications continued in the intensive care unit, but he eventually died 114 days after the onset of the air embolism due to his deteriorating general condition. Pathological autopsy revealed cholangiocarcinoma that extends from the porta hepatis to the posterior segment. Additionally, the proximity between the bile duct and vein extended by the adenocarcinoma and the fibrous obstruction of the vein were revealed, indicating the possibility of a bile duct-vein shunt.
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Affiliation(s)
- Kosuke Takahashi
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences
| | - Eisuke Ozawa
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences
| | - Kazuaki Tajima
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences
| | - Masanori Fukushima
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences
| | - Ippo Imamura
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Hajime Matsushima
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Tomohiko Adachi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Yoko Hayashi
- Department of Pathology, Nagasaki University School of Medicine and Graduate School of Biomedical Sciences
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences
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11
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Banham N, da Silva E, Lippmann J. Cerebral arterial gas embolism (CAGE) during open water scuba certification training whilst practising a controlled emergency swimming ascent. Diving Hyperb Med 2023; 53:345-350. [PMID: 38091595 PMCID: PMC10944668 DOI: 10.28920/dhm53.4.345-350] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/06/2023] [Indexed: 12/18/2023]
Abstract
We report the case of a 23-year-old male novice diver who sustained cerebral arterial gas embolism (CAGE) during his open water certification training whilst practising a free ascent as part of the course. He developed immediate but transient neurological symptoms that had resolved on arrival to hospital. Radiological imaging of his chest showed small bilateral pneumothoraces, pneumopericardium and pneumomediastinum. In view of this he was treated with high flow normobaric oxygen rather than recompression, because of the risk of development of tension pneumothorax upon chamber decompression. There was no relapse of his neurological symptoms with this regimen. The utility and safety of free ascent training for recreational divers is discussed, as is whether a pneumothorax should be vented prior to recompression, as well as return to diving following pulmonary barotrauma.
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Affiliation(s)
- Neil Banham
- Department of Hyperbaric Medicine, Fiona Stanley Hospital, Murdoch, Australia
- Corresponding author: Dr Neil Banham, Department of Hyperbaric Medicine, Fiona Stanley Hospital, 11 Warren Drive, Murdoch WA 6150, Australia,
| | - Elisabete da Silva
- Department of Hyperbaric Medicine, Fiona Stanley Hospital, Murdoch, Australia
| | - John Lippmann
- Australasian Diving Safety Foundation, Melbourne, Australia
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12
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White EG, Hayes HA, Clark P, Cloran FJ. Subclinical to catastrophic: a range of outcomes in cerebral air embolism. Emerg Radiol 2023; 30:823-827. [PMID: 37953444 DOI: 10.1007/s10140-023-02181-2] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/26/2023] [Indexed: 11/14/2023]
Abstract
Cerebral air embolism (CAE) is a rare, yet potentially devastating condition characterized by entrance of air into cerebral vasculature, that is nearly always iatrogenic. While many findings of CAE are subclinical and incidental at computed tomography (CT), there remain cases of catastrophic and fatal embolisms. Increasing physician awareness of prevention, presentation, and treatment for CAE is crucial for reducing morbidity and mortality. In this case series, we highlight this preventable entity by comparing three cases of CAE that showcase a diverse array of presentations, radiologic findings, and clinical outcomes. We will also explore predisposing factors, prognostic predictors, diagnostic considerations, and available treatments.
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Affiliation(s)
- E G White
- Uniformed Services University of Health Sciences, Bethesda, USA.
| | - H A Hayes
- Department of Radiology, San Antonio Uniformed Services Health Education Consortium, San Antonio, TX, USA
| | - P Clark
- Department of Radiology, San Antonio Uniformed Services Health Education Consortium, San Antonio, TX, USA
| | - F J Cloran
- Department of Radiology, San Antonio Uniformed Services Health Education Consortium, San Antonio, TX, USA
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13
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Geers MS, van der Sar-van der Brugge S, van Norden AGW, van Hulst RA, De Backer ICF. [Cerebral arterial air embolism: the effect of hyperbaric oxygen therapy]. Ned Tijdschr Geneeskd 2023; 167:D7480. [PMID: 37994739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
BACKGROUND Iatrogenic gas embolism is the presence of gas in vascular structures. Feared are those in coronary or cerebral arteries. These can result in cerebral or myocardial infarction. CASE DESCRIPTION A 79-year-old female underwent CT-guided biopsy of the lung. Minutes later she developed neurological symptoms. After administration of oxygen her symptoms initially improved, but later worsened. Based on her symptoms air embolism was suspected. She recovered fully after treatment with hyperbaric oxygen. CONCLUSION Air embolism is a potentially life-threatening complication of surgical, radiological or vascular interventions. Early recognition can lead to prompt treatment and better prognosis. If air embolism is suspected the patient should be treated according to ABCDE principles and oxygen should be administered. In case of neurological or circulatory symptoms a hospital that could provide hyperbaric oxygen therapy should be contacted as soon as possible.
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Affiliation(s)
- Marloes S Geers
- Erasmus MC, afd. Longgeneeskunde, Rotterdam
- Contact: Marloes S. Geers
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14
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Marsh PL, Moore EE, Moore HB, Bunch CM, Aboukhaled M, Condon SM, Al-Fadhl MD, Thomas SJ, Larson JR, Bower CW, Miller CB, Pearson ML, Twilling CL, Reser DW, Kim GS, Troyer BM, Yeager D, Thomas SG, Srikureja DP, Patel SS, Añón SL, Thomas AV, Miller JB, Van Ryn DE, Pamulapati SV, Zimmerman D, Wells B, Martin PL, Seder CW, Aversa JG, Greene RB, March RJ, Kwaan HC, Fulkerson DH, Vande Lune SA, Mollnes TE, Nielsen EW, Storm BS, Walsh MM. Iatrogenic air embolism: pathoanatomy, thromboinflammation, endotheliopathy, and therapies. Front Immunol 2023; 14:1230049. [PMID: 37795086 PMCID: PMC10546929 DOI: 10.3389/fimmu.2023.1230049] [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] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 07/12/2023] [Indexed: 10/06/2023] Open
Abstract
Iatrogenic vascular air embolism is a relatively infrequent event but is associated with significant morbidity and mortality. These emboli can arise in many clinical settings such as neurosurgery, cardiac surgery, and liver transplantation, but more recently, endoscopy, hemodialysis, thoracentesis, tissue biopsy, angiography, and central and peripheral venous access and removal have overtaken surgery and trauma as significant causes of vascular air embolism. The true incidence may be greater since many of these air emboli are asymptomatic and frequently go undiagnosed or unreported. Due to the rarity of vascular air embolism and because of the many manifestations, diagnoses can be difficult and require immediate therapeutic intervention. An iatrogenic air embolism can result in both venous and arterial emboli whose anatomic locations dictate the clinical course. Most clinically significant iatrogenic air emboli are caused by arterial obstruction of small vessels because the pulmonary gas exchange filters the more frequent, smaller volume bubbles that gain access to the venous circulation. However, there is a subset of patients with venous air emboli caused by larger volumes of air who present with more protean manifestations. There have been significant gains in the understanding of the interactions of fluid dynamics, hemostasis, and inflammation caused by air emboli due to in vitro and in vivo studies on flow dynamics of bubbles in small vessels. Intensive research regarding the thromboinflammatory changes at the level of the endothelium has been described recently. The obstruction of vessels by air emboli causes immediate pathoanatomic and immunologic and thromboinflammatory responses at the level of the endothelium. In this review, we describe those immunologic and thromboinflammatory responses at the level of the endothelium as well as evaluate traditional and novel forms of therapy for this rare and often unrecognized clinical condition.
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Affiliation(s)
- Phillip L. Marsh
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Ernest E. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health and University of Colorado Health Sciences Center, Denver, CO, United States
| | - Hunter B. Moore
- University of Colorado Health Transplant Surgery - Anschutz Medical Campus, Aurora, CO, United States
| | - Connor M. Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Michael Aboukhaled
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Shaun M. Condon
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | | | - Samuel J. Thomas
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - John R. Larson
- Department of Emergency Medicine, Goshen Health, Goshen, IN, United States
| | - Charles W. Bower
- Department of Emergency Medicine, Goshen Health, Goshen, IN, United States
| | - Craig B. Miller
- Department of Family Medicine, Saint Joseph Health System, Mishawaka, IN, United States
| | - Michelle L. Pearson
- Department of Family Medicine, Saint Joseph Health System, Mishawaka, IN, United States
| | | | - David W. Reser
- Department of Emergency Medicine, Goshen Health, Goshen, IN, United States
| | - George S. Kim
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
- Department of Emergency Medicine, Goshen Health, Goshen, IN, United States
| | - Brittany M. Troyer
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
- Department of Emergency Medicine, Goshen Health, Goshen, IN, United States
| | - Doyle Yeager
- Department of Emergency Medicine, Goshen Health, Goshen, IN, United States
| | - Scott G. Thomas
- Department of Trauma & Surgical Research Services, South Bend, IN, United States
| | - Daniel P. Srikureja
- Department of Trauma & Surgical Research Services, South Bend, IN, United States
| | - Shivani S. Patel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Sofía L. Añón
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Anthony V. Thomas
- Indiana University School of Medicine, South Bend, IN, United States
| | - Joseph B. Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - David E. Van Ryn
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
- Department of Emergency Medicine, Goshen Health, Goshen, IN, United States
- Department of Emergency Medicine, Beacon Health System, Elkhart, IN, United States
| | - Saagar V. Pamulapati
- Department of Internal Medicine, Mercy Health Internal Medicine Residency Program, Rockford, IL, United States
| | - Devin Zimmerman
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Byars Wells
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Peter L. Martin
- Department of Emergency Medicine, Goshen Health, Goshen, IN, United States
| | - Christopher W. Seder
- Department of Cardiovascular and Thoracic Surgery, RUSH Medical College, Chicago, IL, United States
| | - John G. Aversa
- Department of Cardiovascular and Thoracic Surgery, RUSH Medical College, Chicago, IL, United States
| | - Ryan B. Greene
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Robert J. March
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Hau C. Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, IL, United States
| | - Daniel H. Fulkerson
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
- Department of Trauma & Surgical Research Services, South Bend, IN, United States
| | - Stefani A. Vande Lune
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, VA, United States
| | - Tom E. Mollnes
- Research Laboratory, Nordland Hospital, Bodø, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Immunology, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Erik W. Nielsen
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Anesthesia and Intensive Care Medicine, Surgical Clinic, Nordland Hospital, Bodø, Norway
- Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | - Benjamin S. Storm
- Department of Anesthesia and Intensive Care Medicine, Surgical Clinic, Nordland Hospital, Bodø, Norway
- Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | - Mark M. Walsh
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
- Indiana University School of Medicine, South Bend, IN, United States
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15
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Xu R, Zhou X, Wang L, Cao Y. Gas embolism during surgical hysteroscopy leading to cardiac arrest and refractory hypokalemia: A case report and review of literature. Medicine (Baltimore) 2023; 102:e35227. [PMID: 37713863 PMCID: PMC10508465 DOI: 10.1097/md.0000000000035227] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 08/24/2023] [Indexed: 09/17/2023] Open
Abstract
RATIONALE One of the catastrophic complications of surgical hysteroscopy is venous gas embolism (VGE), and this event could cause morbidity and in serious cases may even lead to death. However, in cases of VGE accompanied by refractory hypokalemia is rare and can significantly increase the difficulty of treatment and resuscitation. Here, we successfully treated a patient with fatal VGE during surgical hysteroscopy, accompanied by difficult resuscitation with refractory hypokalemia. PATIENT CONCERNS We report a rare case of sudden cardiac arrest due to VGE during surgical hysteroscopy, followed by difficult resuscitation with refractory hypokalemia. DIAGNOSIS VGE was diagnosed by a sudden decrease in EtCO2, a loud mill wheel murmur in the thoracic area, and a small number of air bubbles evacuated from the internal jugular catheter. And refractory hypokalemia was diagnosed by serum potassium levels dropping frequently to as low as 2.0 mmol/L within 36 hours of resuscitation after cardiac arrest. INTERVENTIONS Our vigilant anesthesiologist noticed the early sign of VGE with a sudden drop in EtCO2, and as the cardiac arrest occurred, interventional maneuvers were implemented quickly including termination of the surgical procedure, adjustment of the patient's position, cardiac resuscitation, continuous chest compression, and correction of electrolyte disturbances, particularly refractory hypokalemia during the early stage of resuscitation. OUTCOMES The patient regained consciousness 4 days after the cardiac arrest and was discharged 1 month later without any neurological deficits. LESSONS As a relatively simple procedure, surgical hysteroscopy may have catastrophic complications. This case demonstrates the full course of fatal gas embolism and difficult resuscitation during hysteroscopic surgery, and emphasizes the importance of early detection, prompt intervention, and timely correction of electrolyte disturbances, such as refractory hypokalemia.
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Affiliation(s)
- Rong Xu
- Health Science Center, Ningbo University, Ningbo, China
| | - Xuefei Zhou
- Department of Anesthesiology, Beilun District People’s Hospital of Ningbo, Ningbo, China
| | - Longfei Wang
- Department of Anesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Yunfei Cao
- Department of Anesthesiology, Beilun District People’s Hospital of Ningbo, Ningbo, China
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16
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Hall M. Resuscitation of a preterm infant with massive air embolism. Arch Dis Child Fetal Neonatal Ed 2023; 108:549-550. [PMID: 37277170 DOI: 10.1136/archdischild-2023-325758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 06/07/2023]
Affiliation(s)
- Michael Hall
- Health Sciences, University of Southampton, Southampton, UK
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17
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Tunc EM, Utarnachitt RB, Latimer A, Calhoun A, Gamache D, Wall J. Air Medical Transport of a 12-Year-Old Girl With Cerebral Gas Embolism Due to Helium Inhalation. Air Med J 2023; 42:377-379. [PMID: 37716812 DOI: 10.1016/j.amj.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/04/2023] [Indexed: 09/18/2023]
Abstract
This case report describes the initial care and transport considerations of a pediatric patient who suffered from cerebral gas embolism sustained after inhalation of helium from a pressurized tank. The patient demonstrated neurologic symptoms necessitating hyperbaric oxygen therapy and required fixed wing air transport across a mountain range from a rural community hospital to a tertiary center for the treatment. We review the pathophysiology of cerebral gas embolism and strategies for transporting patients with cerebral gas embolism and other trapped gas.
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Affiliation(s)
- Emine M Tunc
- Seattle Children's Hospital, Seattle, WA; Pediatrics, University of Washington School of Medicine, Seattle, WA.
| | - Richard B Utarnachitt
- Emergency Medicine, University of Washington School of Medicine, Seattle, WA; Airlift Northwest Critical Care Transport Team, Seattle, WA
| | - Andrew Latimer
- Emergency Medicine, University of Washington School of Medicine, Seattle, WA; Airlift Northwest Critical Care Transport Team, Seattle, WA
| | - Ashley Calhoun
- Airlift Northwest Critical Care Transport Team, Seattle, WA
| | | | - Jessica Wall
- Seattle Children's Hospital, Seattle, WA; Pediatrics, University of Washington School of Medicine, Seattle, WA; Emergency Medicine, University of Washington School of Medicine, Seattle, WA; Airlift Northwest Critical Care Transport Team, Seattle, WA
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18
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Asorey I, Corletto F. Suspected systemic gas embolism associated with lung tissue perforation caused by a previously inserted chest drain in a dog. J Vet Emerg Crit Care (San Antonio) 2023; 33:613-618. [PMID: 37573257 DOI: 10.1111/vec.13318] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/11/2022] [Accepted: 05/28/2022] [Indexed: 08/14/2023]
Abstract
OBJECTIVE To report a case of systemic gas embolism associated with removal of a chest drain perforating a lung lobe in a dog undergoing sternotomy under general anesthesia and intermittent positive pressure ventilation. CASE SUMMARY An 8-year-old Cocker Spaniel underwent an exploratory thoracotomy via median sternotomy for surgical management of pyothorax that was treated conservatively for 7 days prior to referral following bilateral chest drain placement. The surgical procedure consisted of a subphrenic mediastinectomy and pericardiectomy. During surgery, it became apparent that the right drain was perforating the right middle lung lobe. Sudden desaturation and rapid hemodynamic deterioration occurred after the drain was removed. A systemic gas embolism was suspected on the basis of clinical signs and results of an arterial blood gas analysis, and immediate supportive treatment was started with an adequate response. Once the surgical procedure was completed, a clear "mill wheel" sound was audible on cardiac auscultation and point-of-care cardiac ultrasound confirmed the presence of gas bubbles in the cardiac chambers. The dog recovered from anesthesia and was managed in the intensive care unit where arterial blood gas analyses were nearly normal and the dog made a full recovery. NEW OR UNIQUE INFORMATION PROVIDED In people, there are reports of fatal air embolism related to the use of chest drains. To our knowledge, this is the first case report in dogs of a systemic gas embolism during open-chest surgery caused by a chest drain perforating a lung lobe. Immediate recognition and aggressive treatment of this life-threatening condition should be provided in order to achieve a favorable outcome.
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19
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Jevnikar WR, Almassi N, Wright A, Sreedharan R. Urology Clinical Challenge: Venous Air Embolism. Urology 2023; 178:e195-e196. [PMID: 37302760 DOI: 10.1016/j.urology.2023.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/15/2023] [Accepted: 05/30/2023] [Indexed: 06/13/2023]
Affiliation(s)
- William R Jevnikar
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Nima Almassi
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
| | - Alexandra Wright
- Department of Intensive Care & Resuscitation, Anesthesiology & Pain Management Institute, Cleveland Clinic, Cleveland, OH
| | - Roshni Sreedharan
- Department of Intensive Care & Resuscitation, Anesthesiology & Pain Management Institute, Cleveland Clinic, Cleveland, OH
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20
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Hentschel R, Müller C, Hock S, Uhl M. Resuscitation of a preterm infant with massive air embolism. Arch Dis Child Fetal Neonatal Ed 2023; 108:319. [PMID: 34413094 DOI: 10.1136/archdischild-2020-320532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/06/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Roland Hentschel
- Neonatology/Pediatric Intensive Care, Medical Center and Faculty of Medicine, University of Freiburg, Universitaetsklinikum Freiburg, Zentrum fuer Kinder-und Jugendmedizin, Freiburg, Germany
| | - Christoph Müller
- Neonatology/Pediatric Intensive Care, Medical Center and Faculty of Medicine, University of Freiburg, Universitaetsklinikum Freiburg, Zentrum fuer Kinder-und Jugendmedizin, Freiburg, Germany
| | - Simone Hock
- Neonatology/Pediatric Intensive Care, Medical Center and Faculty of Medicine, University of Freiburg, Universitaetsklinikum Freiburg, Zentrum fuer Kinder-und Jugendmedizin, Freiburg, Germany
| | - Markus Uhl
- Radiology, Medical Center and Faculty of Medicine, University of Freiburg, Universitaetsklinikum Freiburg, Zentrum fuer Kinder-und Jugendmedizin, Freiburg, Germany
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21
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Todd MM, McGovern R, Johnson A. Venous Air Embolism During Awake Deep Brain Stimulator Placement. J Neurosurg Anesthesiol 2023; 35:254-255. [PMID: 35389934 DOI: 10.1097/ana.0000000000000844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Ma Y, Miao J, Ge S. Intraoperative Cerebral Arterial Air Embolism: A Rare and Shocking Imaging Record. J Neurosurg Anesthesiol 2023; 35:255-256. [PMID: 35650683 DOI: 10.1097/ana.0000000000000858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- YuanYuan Ma
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, China
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23
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Parekh A, McCormick J, Hussain-Amin A, Barnosky B, Edwards M. A Case of Cardiac Arrest Caused by Air Embolism from Routine Root Canal Procedure. Methodist Debakey Cardiovasc J 2022; 18:68-72. [PMID: 36212678 PMCID: PMC9503891 DOI: 10.14797/mdcvj.1067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 07/19/2022] [Indexed: 11/08/2022] Open
Abstract
Venous air embolism (VAE) occurs when air is introduced into the venous system and subsequently travels into the right heart and pulmonary circulation. VAE mainly occurs from air that is forced by positive pressure or drawn in by negative pressure. We present a rare case of fatal VAE that occurred during a routine dental root canal procedure. A 69-year-old male was undergoing a root canal procedure at an outpatient dental office under local anesthesia. During the procedure, he went into cardiopulmonary arrest. He was resuscitated, and return of spontaneous circulation was achieved. Thoracic computed tomography was performed and revealed large amounts of air within the right ventricle and portal venous system. VAE should be recognized as a potentially fatal complication resulting from routine dental procedures.
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Affiliation(s)
- Akarsh Parekh
- Department of Cardiovascular Medicine, McLaren Macomb Medical Center, Mount Clemens, Michigan, US
- Michigan State University, East Lansing, Michigan, US
| | - Joel McCormick
- Department of Cardiovascular Medicine, McLaren Macomb Medical Center, Mount Clemens, Michigan, US
- Department of Internal Medicine, McLaren Macomb Medical Center, Mount Clemens, Michigan, US
| | - Atheer Hussain-Amin
- Department of Cardiovascular Medicine, McLaren Macomb Medical Center, Mount Clemens, Michigan, US
- Department of Internal Medicine, McLaren Macomb Medical Center, Mount Clemens, Michigan, US
| | - Bryan Barnosky
- Department of Cardiovascular Medicine, McLaren Macomb Medical Center, Mount Clemens, Michigan, US
- Department of Critical Care Medicine, McLaren Macomb Medical Center, Mount Clemens, Michigan, US
| | - Matthew Edwards
- Department of Cardiovascular Medicine, McLaren Macomb Medical Center, Mount Clemens, Michigan, US
- Michigan State University, East Lansing, Michigan, US
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24
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Chang J, Casal R. Anesthetic Management of Gas Embolism During Rigid Bronchoscopy with Argon Plasma Coagulation: A Case Report. AANA J 2022; 90:293-295. [PMID: 35943756] [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] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Gas embolism is a procedure-related complication and has been reported during endoscopy, surgical procedures, intravenous catheterization, positive pressure ventilation, and a multitude of scenarios. Recognizing the potential for gas embolus and a high level of suspicion are paramount to timely intervention to prevent significant morbidity and mortality. There is such rapid decompensation that only clinical suspicion can guide timely intervention; it is not uncommon for gas embolus to be diagnosed postmortem. It then must be determined whether the gas embolus has a venous or systemic entry point. Overall management is similar for both forms of gas emboli with focus on hemodynamic support and preservation of organ function. This case report discusses an occurrence of presumed systemic gas embolus from argon plasma coagulation and management of a patient under general anesthesia during rigid bronchoscopy.
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Affiliation(s)
- Jen Chang
- is a staff nurse anesthetist for the Department of Anesthesiology and Perioperative Medicine at The University of Texas MD Anderson Cancer Center in Houston, Texas.
| | - Roberto Casal
- is an Associate Professor for the Department of Pulmonary Medicine and Division of Internal Medicine at The University of Texas MD Anderson Cancer Center in Houston, Texas.
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25
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Ishihara T, Sato S, Manabe S, Ozawa H. Complications of cerebral air embolism associated with pleural lavage for empyema. BMJ Case Rep 2022; 15:e249618. [PMID: 35760513 PMCID: PMC9237889 DOI: 10.1136/bcr-2022-249618] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Standard initial treatment for acute empyema involves antibiotic administration and chest tube drainage; however, pleural lavage with saline is another treatment that mitigates the need for surgical drainage. Although this treatment is recognised as non-invasive and safe, the complications of cerebral air embolism are less recognised.In this case, a man in his late 40s was diagnosed with acute empyema and treated with chest tube (28 Fr) drainage and antibiotics. Empyema remained on follow-up chest imaging; thus intrapleural fibrinolytic therapy (urokinase 120 000 units/day for a total of 3 days) and pleural lavage (0.9% saline 1000 mL/day daily) were administered. During the 10th pleural lavage, the patient suddenly became unconscious. Head imaging revealed a cerebral air embolism. Consequently, he received urgent hyperbaric oxygen therapy and improved without any neurological sequelae.Clinicians should be aware of the complications of sudden cerebral air embolism due to pleural lavage for empyema.
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Affiliation(s)
- Toru Ishihara
- Division of General Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Shota Sato
- Division of General Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Saki Manabe
- Division of General Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Hideki Ozawa
- Division of General Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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26
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Ganesan V, Chirammal Valappil U, Sebastian P, Mannambeth Karikkan A. Pulmonary artery air embolism after permanent pacemaker implantation. BMJ Case Rep 2022; 15:e249673. [PMID: 35613835 PMCID: PMC9134167 DOI: 10.1136/bcr-2022-249673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Vijayan Ganesan
- Cardiology, Aster MIMS Hospital Kannur, Kannur, Kerala, India
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27
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Savioli G, Alfano C, Zanza C, Bavestrello Piccini G, Varesi A, Esposito C, Ricevuti G, Ceresa IF. Dysbarism: An Overview of an Unusual Medical Emergency. Medicina (Kaunas) 2022; 58:104. [PMID: 35056412 PMCID: PMC8778177 DOI: 10.3390/medicina58010104] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/27/2021] [Accepted: 12/29/2021] [Indexed: 02/03/2023]
Abstract
Dysbarism is a general term which includes the signs and symptoms that can manifest when the body is subject to an increase or a decrease in the atmospheric pressure which occurs either at a rate or duration exceeding the capacity of the body to adapt safely. In the following review, we take dysbarisms into account for our analysis. Starting from the underlying physical laws, we will deal with the pathologies that can develop in the most frequently affected areas of the body, as the atmospheric pressure varies when acclimatization fails. Manifestations of dysbarism range from itching and minor pain to neurological symptoms, cardiac collapse, and death. Overall, four clinical pictures can occur: decompression illness, barotrauma, inert gas narcosis, and oxygen toxicity. We will then review the clinical manifestations and illustrate some hints of therapy. We will first introduce the two forms of decompression sickness. In the next part, we will review the barotrauma, compression, and decompression. The last three parts will be dedicated to gas embolism, inert gas narcosis, and oxygen toxicity. Such an approach is critical for the effective treatment of patients in a hostile environment, or treatment in the emergency room after exposure to extreme physical or environmental factors.
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Affiliation(s)
- Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
- PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Claudia Alfano
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
| | - Christian Zanza
- “Ospedale Alba-Bra Onlus”—Department of Emergency Medicine, Anesthesia and Critical Care Medicine, Michele and Pietro Ferrero Hospital, 12060 Verduno, Italy;
- Research Training Innovation Infrastructure, Research and Innovation Department, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy;
| | | | - Angelica Varesi
- Department of Biology and Biotechnology, University of Pavia, 27100 Pavia, Italy;
| | - Ciro Esposito
- Unit of Nephrology and Dialysis, ICS Maugeri, University of Pavia, 27100 Pavia, Italy;
| | - Giovanni Ricevuti
- School of Pharmacy, Department of Drug Sciences, University of Pavia, 27100 Pavia, Italy;
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28
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Biggs AT, Littlejohn LF, Dainer HM. Department of Defense positions on alternative uses of hyperbaric oxygen therapy. Undersea Hyperb Med 2022; 49:57-63. [PMID: 35226976] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Hyperbaric oxygen therapy is an existing and approved treatment to address multiple medical conditions, including decompression sickness, air or gas embolism, carbon monoxide poisoning, and profound blood loss when transfusion cannot be accomplished. However, recent efforts have emerged to promote hyperbaric oxygen therapy for other purposes. The most controversial applications have been utilizing this therapy as a treatment for mild traumatic brain injury and post-traumatic stress disorder. As evidence accumulates and the debate continues about whether published studies have satisfied the threshold of clinical significance, a common issue is raised regarding current clinical practices and health insurance coverage as allowed or recommended by the Department of Defense and other federal agencies. This review describes the current federal policies regarding medical insurance issues for providers and clinical practice guidelines as they pertain to alternative uses of hyperbaric oxygen therapy. First, the current policies are explored for what is reimbursable under federal insurance as approved clinical or research usages. Second, these policies are compared to the clinical practice guidelines to determine what might be clinical best practice versus exploratory research. Third, the evidence from government reports is reviewed as supporting documentation for these positions. As such, the current discussion addresses what can and cannot be covered under health insurance and where various federal health care organizations stand currently on using hyperbaric oxygen therapy as an alternative therapeutic technique. The primary goal is informing military healthcare practitioners and prospective patients about the treatment options available to them under current federal guidelines.
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29
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Lee JH, Lee HY, Lim MK, Kang YH. Massive cerebral air embolism following percutaneous transhepatic biliary drainage: A case report. Medicine (Baltimore) 2021; 100:e28389. [PMID: 34967372 PMCID: PMC8718232 DOI: 10.1097/md.0000000000028389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 12/02/2021] [Indexed: 01/05/2023] Open
Abstract
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.
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30
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Abstract
We report the case of a 87-year-old woman admitted to our Emergency Department for mild abdominal pain associated with vomiting. An abdominal X-ray showed gas present in the portal venules of the left hepatic lobe, a finding associated with numerous surgical and medical conditions. The patient was successfully managed with conservative treatment. Isolated intrahepatic gas is a rare radiologic finding; emergency surgery should be performed only when there are signs of associated acute intestinal infarction.
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Affiliation(s)
- N Zorzetti
- Department of General Surgery, "Ospedale Civile Umberto I", Lugo, Ravenna, Italy.
| | - A Lauro
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - A Ruffato
- Department of General Surgery, "Ospedale Civile Umberto I", Lugo, Ravenna, Italy
| | - V D'Andrea
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - L Ferruzzi
- Department of General Surgery, "Ospedale Civile Umberto I", Lugo, Ravenna, Italy
| | - N Antonacci
- Department of General Surgery, "Ospedale Civile Umberto I", Lugo, Ravenna, Italy
| | - R M Tranchino
- Department of General Surgery, "Ospedale Civile Umberto I", Lugo, Ravenna, Italy
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Guo JL, Wang HB, Wang H, Le Y, He J, Zheng XQ, Zhang ZH, Duan GR. Transesophageal echocardiography detection of air embolism during endoscopic surgery and validity of hyperbaric oxygen therapy: Case report. Medicine (Baltimore) 2021; 100:e26304. [PMID: 34115039 PMCID: PMC8202586 DOI: 10.1097/md.0000000000026304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/25/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Air embolism has the potential to be serious and fatal. In this paper, we report 3 cases of air embolism associated with endoscopic medical procedures in which the patients were treated with hyperbaric oxygen immediately after diagnosis by transesophageal echocardiography. In addition, we systematically review the risk factors for air embolism, clinical presentation, treatment, and the importance of early hyperbaric oxygen therapy efficacy after recognition of air embolism. PATIENT CONCERNS We present 3 patients with varying degrees of air embolism during endoscopic procedures, one of which was fatal, with large amounts of gas visible in the right and left heart chambers and pulmonary artery, 1 showing right heart enlargement with increased pulmonary artery pressure and tricuspid regurgitation, and 1 showing only a small amount of gas images in the heart chambers. DIAGNOSES Based on ETCO2 and transesophageal echocardiography (TEE), diagnoses of air embolism were made. INTERVENTIONS The patients received symptomatic supportive therapy including CPR, 100% O2 ventilation, cerebral protection, hyperbaric oxygen therapy and rehabilitation. OUTCOMES Air embolism can causes respiratory, circulatory and neurological dysfunction. After aggressive treatment, one of the 3 patients died, 1 had permanent visual impairment, and 1 recovered completely without comorbidities. CONCLUSIONS While it is common for small amounts of air/air bubbles to enter the circulatory system during endoscopic procedures, life-threatening air embolism is rare. Air embolism can lead to serious consequences, including respiratory, circulatory, and neurological impairment. Therefore, early recognition of severe air embolism and prompt hyperbaric oxygen therapy are essential to avoid its serious complications.
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Affiliation(s)
- Ji-ling Guo
- Guangdong Medical University. Wenming East Road No.2, Zhanjiang
- Department of Anesthesiology
| | | | | | - Yue Le
- Department of Anesthesiology
| | - Jian He
- Department of Anesthesiology
| | | | | | - Guang-rong Duan
- Department of Information, The First People's Hospital of Foshan, North of Ling Nan Road No. 81, Foshan, Guangdong, China
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Zatloukal A. Gas embolism after periproctal abscess incision and lavage with hydrogen peroxide a case report Should the use of hydrogen peroxide in surgery be continued? Rozhl Chir 2021; 100:37-39. [PMID: 33691422 DOI: 10.33699/pis.2021.100.1.37-39] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Hydrogen peroxide is an antiseptic solution still often used in surgical departments for lavage of wounds. Its use is nevertheless linked to an important risk of gas embolism. Such a case report has not yet been published in the Czech literature and awareness of this danger is low among surgeons. CASE REPORT The author describes the case of gas embolism in a 40 years old patient after lavage of a periproctal abscess incision with 3% hydrogen peroxide. The lavage resulted in a cardiopulmonary arrest with the need of cardiopulmonary resuscitation. Fortunately, the patient recovered without any health consequences. CONCLUSION In the view of important risks and questionable and insufficiently proven benefits it may be the time to possibly reconsider the use of hydrogen peroxide in surgery and replace it with a different antiseptic agent.
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Midtgard A, Sand KØ. Cerebral venous air embolism. Tidsskr Nor Laegeforen 2021; 141:20-0727. [PMID: 33624980 DOI: 10.4045/tidsskr.20.0727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Lee JS, Cha YS. Application of a new hyperbaric oxygen therapy protocol in patients with arterial and venous gas embolism due to hydrogen peroxide poisoning. Undersea Hyperb Med 2021; 48:187-193. [PMID: 33975410 DOI: 10.22462/03.04.2021.10] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Hydrogen peroxide (H2O2) ingestion can cause vascular gas embolism (GE). Hyperbaric oxygen therapy (HBO2) is known to improve neurological abnormalities in patients with arterial gas embolism (AGE). Previously, HBO2 based on the U.S. Navy Table 6 diving protocol has been adopted for treating AGE and preventing the progression of portal venous GE, caused by H2O2 ingestion, to AGE. However, the indication and protocol for HBO2 have not been established for GE related to H2O2 ingestion. Herein, we describe a case in which GE caused by H2O2 ingestion was treated using HBO2 with a short protocol. A 69-year-old female patient presented with abdominal pain, vomiting, and transient loss of consciousness after ingesting 35% H2O2. Computed tomography revealed gastric wall and portal venous gas. She was administered an HBO2 protocol with 2.8-atmosphere absolute (ATA) compression for 45 minutes. This was followed by a 2.0-ATA treatment for 60 minutes with a five-minute air break, after which all gas bubbles disappeared. After HBO2 treatment, brain magnetic resonance imaging revealed focal cytotoxic edema lesions; however, the patient was discharged without additional symptoms.
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Affiliation(s)
- Je-Seop Lee
- Department of Emergency Medicine and Research Institute of Hyperbaric Medicine and Science, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Yong Sung Cha
- Department of Emergency Medicine and Research Institute of Hyperbaric Medicine and Science, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
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Pak S, Valencia D, Lee C, Lach J, Ortiz G. Ingestion of food grade hydrogen peroxide with resultant gastrointestinal and neurologic symptoms treated with hyperbaric oxygen therapy: case report and review with emphasis on the therapeutic value of HBO2 in vascular gas embolism. Undersea Hyperb Med 2021; 48:177-186. [PMID: 33975409 DOI: 10.22462/03.04.2021.9] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
A 52-year-old male accidentally ingested approximately 100 mL of 35% hydrogen peroxide (H2O2), resulting in the sudden onset of gastrointestinal and neurologic symptoms. Non-contrast abdominal CT revealed extensive portal venous gas and gastric pneumatosis. The patient was treated with hyperbaric oxygen therapy which resulted in complete resolution of symptoms. The case highlights the therapeutic value of hyperbaric oxygen therapy in the treatment of vascular gas embolism and mitigation of concentrated H2O2 ingestion toxicity.
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Affiliation(s)
- Stella Pak
- Department of Internal Medicine, Orange Regional Medical Center Middletown, New York U.S
| | - Damian Valencia
- Department of Internal Medicine, Kettering Medical Center, Kettering, Ohio U.S
| | - Christopher Lee
- Department of Internal Medicine, Kettering Medical Center, Kettering, Ohio U.S
| | - Joseph Lach
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio U.S
| | - George Ortiz
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio U.S
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Lee CH, Choi JG, Lee JS, Lee Y, Kim H, Kim YS, Cha YS. Seizure during hyperbaric oxygen therapy: experience at a single academic hospital in Korea. Undersea Hyperb Med 2021; 48:43-51. [PMID: 33648032 DOI: 10.22462/01.03.2021.5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Hyperbaric oxygen (HBO2) therapy is a safe and well-tolerated treatment modality. Seizures, one of the most severe central nervous system side effects of HBO2 therapy, can occur. Episodes of seizures during HBO2 therapy have not yet been reported in countries such as Korea, where hyperbaric medicine is still in the developmental stage. METHODS The registry data of all patients treated with HBO2 therapy in a tertiary academic hospital in Korea were prospectively collected, and patients who developed seizures during HBO2 therapy between October 2016 and December 2019 were evaluated. In addition, we reviewed previous studies on occurrence of seizures during HBO2 therapy. RESULTS During the study period, a total of 10,425 treatments were provided to 1,308 patients. The most frequently treated indication was carbon monoxide (CO) poisoning ABSTRACT (n=547, 41.8%). During the HBO2 therapy sessions (total: 10,425), five seizure episodes occurred (patients with CO poisoning: n=4; patients with arterial gas embolism [AGE]: n=1). The frequency of seizures in patients with CO poisoning (0.148%) and AGE (3.448%) was significantly higher than that in patients with all indications (0.048%) (p=0.001). None of the patients had lasting effects due to the seizures. CONCLUSION Our study revealed a similar frequency rate in terms of all indications and CO poisoning, and a slightly higher rate in AGE. Seizures were observed in patients with CO poisoning and AGE. Therefore, if clinicians plan to operate a hyperbaric center in a country like Korea, where there are several patients with acute CO poisoning, they should be prepared to handle seizures that may occur during HBO2 therapy.
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Affiliation(s)
- Chan Hee Lee
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jin Guel Choi
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Research Institute of Hyperbaric Medicine and Science, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Je Seop Lee
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Research Institute of Hyperbaric Medicine and Science Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yoonsuk Lee
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Research Institute of Hyperbaric Medicine and Science Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Research Institute of Hyperbaric Medicine and Science, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yoon-Seop Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Research Institute of Hyperbaric Medicine and Science, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yong Sung Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Research Institute of Hyperbaric Medicine and Science, Yonsei University Wonju College of Medicine, Wonju, Korea
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Nilès C, Mathieu D, Parmentier-Decrucq E. Treating ARDS-associated air embolism: a question of priorities. Undersea Hyperb Med 2021; 48:169-172. [PMID: 33975407 DOI: 10.22462/03.04.2021.7] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Gas embolism is a potential and often life-threatening complication of central venous catheters. We report a case of air embolism after tearing of the central catheter associated with severe acute respiratory distress syndrome. The severity of the clinical situation meant choices had to be made regarding the order of treatments. This clinical case provided useful eye-openers for patient management regarding the prioritization of treatments as well as the possibilities offered by hyperbaric oxygen therapy.
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Affiliation(s)
- Christopher Nilès
- Intensive Care Unit and Hyperbaric Center, Lille University Hospital, Lille, France
| | - Daniel Mathieu
- Intensive Care Unit and Hyperbaric Center, Lille University Hospital, Lille, France
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Zhao SL, Zhang XY, Xiao Y, Mo XY, Chen ZP, Lin W, Huang ZF, Chen BL. Gas Embolism After Hydrogen Peroxide Use During Spine Surgery: Case Report and Literature Review. World Neurosurg 2020; 143:228-231. [PMID: 32758653 DOI: 10.1016/j.wneu.2020.07.210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/25/2020] [Accepted: 07/28/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND As an irrigant, an antiseptic, and a hemostatic agent, hydrogen peroxide (H2O2) is widely used in surgical treatment, but it has been surrounded by persistent controversy. Fatal or near-fatal embolic events caused by H2O2 have been reported sporadically in spine surgery. CASE DESCRIPTION In this report, we present an 87-year-old man who underwent lumbar instrumentation removal and debridement consequent to surgical site infection in a prone position. H2O2 was used to irrigate the infected screw tracks and surrounding tissues during the procedures. Soon after irrigation, the patient suddenly developed tachycardia, hypotension, and rapid oxygen desaturation, followed by bradycardia. Transesophageal echocardiography indicated gas embolism. After prompt first aid treatment, the patient's condition improved and the gas embolus disappeared within a few minutes without any evidence of organ embolism. CONCLUSIONS Spine surgeons should reconsider the pending results of using H2O2 during surgery. Prolonged prone positioning and semiclosed cavities may increase the risk of gas embolism. An early diagnosis and timely intervention may be the key measures to prevent the occurrence of fatal consequences caused by gas embolism.
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Affiliation(s)
- Sheng-Li Zhao
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao-Yan Zhang
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ying Xiao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao-Yi Mo
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhi-Peng Chen
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Lin
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zi-Fang Huang
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bai-Ling Chen
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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Gonda M, Osuga T, Ikura Y, Hasegawa K, Kawasaki K, Nakashima T. Optimal treatment strategies for hepatic portal venous gas: A retrospective assessment. World J Gastroenterol 2020; 26:1628-1637. [PMID: 32327911 PMCID: PMC7167419 DOI: 10.3748/wjg.v26.i14.1628] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 03/25/2020] [Accepted: 03/31/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatic portal venous gas (HPVG) generally indicates poor prognoses in patients with serious intestinal damage. Although surgical removal of the damaged portion is effective, some patients can recover with conservative treatments.
AIM To establish an optimal treatment strategy for HPVG, we attempted to generate computed tomography (CT)-based criteria for determining surgical indication, and explored reliable prognostic factors in non-surgical cases.
METHODS Thirty-four cases of HPVG (patients aged 34-99 years) were included. Necessity for surgery had been determined mainly by CT findings (i.e. free-air, embolism, lack of contrast enhancement of the intestinal wall, and intestinal pneumatosis). The clinical data, including treatment outcomes, were analyzed separately for the surgical cases and non-surgical cases.
RESULTS Laparotomy was performed in eight cases (surgical cases). Seven patients (87.5%) survived but one (12.5%) died. In each case, severe intestinal damage was confirmed during surgery, and the necrotic portion, if present, was removed. Non-occlusive mesenteric ischemia was the most common cause (n = 4). Twenty-six cases were treated conservatively (non-surgical cases). Surgical treatments had been required for twelve but were abandoned because of the patients’ poor general conditions. Surprisingly, however, three (25%) of the twelve inoperable patients survived. The remaining 14 of the 26 cases were diagnosed originally as being sufficiently cured by conservative treatments, and only one patient (7%) died. Comparative analyses of the fatal (n = 10) and recovery (n = 16) cases revealed that ascites, peritoneal irritation signs, and shock were significantly more frequent in the fatal cases. The mortality was 90% if two or all of these three clinical findings were detected.
CONCLUSION HPVG related to intestinal necrosis requires surgery, and our CT-based criteria are probably useful to determine the surgical indication. In non-surgical cases, ascites, peritoneal irritation signs and shock were closely associated with poor prognoses, and are applicable as predictors of patients’ prognoses.
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Affiliation(s)
- Masanori Gonda
- Department of Gastroenterology, Takatsuki General Hospital, Takatsuki 5691192, Japan
| | - Tatsuya Osuga
- Department of Gastroenterology, Takatsuki General Hospital, Takatsuki 5691192, Japan
| | - Yoshihiro Ikura
- Department of Pathology, Takatsuki General Hospital, Takatsuki 5691192, Japan
| | - Kazunori Hasegawa
- Department of Gastroenterology, Takatsuki General Hospital, Takatsuki 5691192, Japan
| | - Kentaro Kawasaki
- Department of Surgery, Takatsuki General Hospital, Takatsuki 5691192, Japan
| | - Takatoshi Nakashima
- Department of Gastroenterology, Takatsuki General Hospital, Takatsuki 5691192, Japan
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Vieira J, Frakes M, Cohen J, Wilcox S. Extracorporeal Membrane Oxygenation in Transport Part 2: Complications and Troubleshooting. Air Med J 2020; 39:124-132. [PMID: 32197690 DOI: 10.1016/j.amj.2019.09.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/03/2019] [Indexed: 06/10/2023]
Abstract
Factors taken for granted while the extracorporeal membrane oxygenation (ECMO) patient is maintained in a hospital setting can become critical when planning for transport. These issues include but are not limited to positioning of patients on a small transport stretcher, positioning of cannulas and equipment, ensuring adequate power sources and supply, inefficient temperature control, and a much higher risk of decannulation. It is paramount to be comfortable with the management strategies required to handle common complications of ECMO with limited resources in a relatively austere environment. Coagulopathy and bleeding are the most common complications occurring in up to 50% of ECMO patients. Loss of flow and hypotension from loss of volume or profound vasodilation after ECMO initiation need to be managed accordingly. Oxygenator malfunction can occur, and clinicians must be able to recognize the indicators of this complication promptly. Loss of pulsatility, low end-tidal carbon dioxide (ETCO2), and differential hypoxia are common complications in venoarterial ECMO. In addition, an air embolism is life-threatening on venoarterial ECMO but may be better tolerated in the setting of venovenous ECMO. Recirculation in venovenous ECMO leads to circulation of poorly oxygenated blood and must be recognized and addressed. Lastly, pump failure, circuit rupture, and decannulation are devastating complications. Over the last decade, the use of extracorporeal membrane oxygenation (ECMO) has accelerated rapidly,1-3 providing support for patients in severe respiratory or cardiac failure. With ongoing clinical experience and improvements in technology, the indications for ECMO are increasing.4 Many areas are developing centralized ECMO centers to serve their surrounding communities.5-7 To use a centralized ECMO referral model, patients need access to effective, safe critical care transport, but transporting a patient on ECMO carries a significant risk of adverse events.8-13 The purpose of this review is to highlight some of the most common adverse events in ECMO transports and provide management suggestions. Note that these recommendations are not a substitution for close collaboration with medical control, and all adverse events should be promptly reported per organizational protocols.
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Affiliation(s)
| | | | - Jason Cohen
- Boston MedFlight, Bedford, MA; Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Susan Wilcox
- Boston MedFlight, Bedford, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
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Binkley M, Kelly M, Hardy K. Cerebral arterial gas embolism in a patient with hypoplastic left heart syndrome treated with emergent hyperbaric oxygen: case report. Undersea Hyperb Med 2020; 47:431-434. [PMID: 32931669] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
A 30-year-old female with a history of seizure disorder and hypoplastic left heart syndrome treated with a Norwood procedure in 1986 followed by a modified non-fenestrated Fontan (Left SVC to IVC to pulmonary arteries) with a known baffle leak presented to the emergency department. On day of presentation, the patient became unresponsive, with perioral cyanosis, rightward gaze and a left facial droop near the end of a platelet transfusion. An emergent non-contrast head CT revealed intracranial air in the right MCA distribution. She was taken to the hyperbaric chamber and was treated with a U.S. Navy Table 6 in a multiplace chamber with no extensions. Ten minutes into the treatment patient became more alert and spontaneously asked questions. The following day she was treated with a U.S. Navy Table 5. Patient had repeat CT of the head, which showed resolution of intracerebral gas and small areas of ischemia in right frontal lobe and right caudate. On hospital day five neurologic exam was normal, with 5/5 strength and no residual deficits. Treating the patient was a concern because patient has a single ventricle, in which the pulmonary artery is connected directly to the vena cava. There is very little data regarding the effects of hyperbaric oxygen (HBO2)therapy on single-ventricle physiology. Only two case reports of three pediatric patients treated with HBO2 for CAGE in a similar setting are known. In these cases the patients had improvements in their symptoms following HBO2. These cases and ours indicate HBO2 is feasible and indicated for CAGE in patients with cyanotic congenital heart disease.
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Affiliation(s)
- Mark Binkley
- Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania U.S
| | - Matthew Kelly
- Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania U.S
| | - Kevin Hardy
- Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania U.S
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Liu Y, Zhao L, Wang S, Wu Q, Jin F, Liu G, Qi F. Endotracheal administration for intraoperative acute massive pulmonary embolism during laparoscopic hepatectomy: A case report. Medicine (Baltimore) 2020; 99:e18595. [PMID: 32011438 PMCID: PMC7220129 DOI: 10.1097/md.0000000000018595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 11/06/2019] [Accepted: 12/04/2019] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Acute pulmonary embolism (APE) during an operation is a very urgent occurrence, especially when the patient with hemodynamic instability. Generally, drugs are administered intravenously; however, these drugs have little effects under most circumstances. We present a case of successful resuscitation in a patient with endotracheal administration. PATIENT CONCERNS A 67-year-old female presented for laparoscopic hepatectomy. Acute pulmonary gas embolism occurred during the operation with hemodynamic instability. The total amount of carbon dioxide and argon reached 300 mL. We used a novel way of administering drugs instead of intravenous administration for rescuing and the patient condition had improved greatly and was discharged from the hospital without any neurological deficits. DIAGNOSES A diagnosis of APE was made because of a lot of gas was extracted out from central venous catheter and sudden observable decrease in end-tidal CO2. INTERVENTIONS These measures included endotracheal administration, position adjustment, manual ventilation, and gas extraction. OUTCOMES The patient was discharged from the hospital and had no signs of neurological deficits. CONCLUSION Intravenous administration may not the best appropriate way of administration when patients occurred APE. Endotracheal administration as a unique method may work wonders and has the value of research and application.
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Gambrell J, Bhatt NA, Kitchen L. A case of a critically injured diver with multiorgan failure and severe pulmonary overinflation syndrome in a resource-limited setting. Undersea Hyperb Med 2020; 47:555-560. [PMID: 33227831 DOI: 10.22462/10.12.2020.4] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
A diver practicing controlled emergency ascent training on the island of Guam suffered bilateral pneumothorax, pneumomediastinum, coronary arterial gas embolism, and developed multiple organ dysfunction syndrome. Due to limitations of available resources he was medically managed in the intensive care unit until he could be transferred to University of California San Diego for definitive management. We provide an account of our management of the patient, the pathophysiology of injury as well as a review of the safety of recreational diving skills training, current standards of practice and potential pitfalls when considering proper management of a critically injured diver.
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Hughes SM, Hodgson J, Richards MF. Diving medical officers as hospitalists: a case of arterial gas embolism following a routine GI procedure. Undersea Hyperb Med 2020; 47:621-624. [PMID: 33227838 DOI: 10.22462/10.12.2020.11] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Arterial gas embolism is a well-described and frequently seen injury encountered in both civilian and military diving operations. It is becoming increasingly reported and potentially increasingly more common in the hospital environment as a complication of more frequent gastroenterology procedures. We present a case of a 49-year-old, active-duty female who developed significant left-sided neurological deficits manifesting as diffuse left-sided weakness, subjective confusion, and severe headache following esophagogastroduodenoscopy. With increased clinical suspicion for arterial gas embolism, the patient was evaluated by the hyperbaric medicine team at our facility and subsequently treated to near-resolution of symptoms by multiple hyperbaric oxygen treatments. This case highlights the importance of considering this rare complication during or following common invasive procedures. Furthermore, the unique training and experience of physicians with expertise in diving medicine and their ability to recognize these types of injury in the hospital setting highlights the importance of continued training in these fields within Military Medicine in addition to civilian Undersea and Hyperbaric Medicine fellowships.
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Affiliation(s)
- Stephen M Hughes
- Internal Medicine Service, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas U.S
| | - Joni Hodgson
- Undersea and Hyperbaric Medicine Service, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas U.S
| | - Michael F Richards
- Undersea and Hyperbaric Medicine Service, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas U.S
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46
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Moon RE. Hyperbaric treatment of air or gas embolism: current recommendations. Undersea Hyperb Med 2019; 46:673-683. [PMID: 31683367] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Gas can enter arteries (arterial gas embolism, AGE) due to alveolar-capillary disruption (caused by pulmonary over-pressurization, e.g. breath-hold ascent by divers) or veins (venous gas embolism, VGE) as a result of tissue bubble formation due to decompression (diving, altitude exposure) or during certain surgical procedures where capillary hydrostatic pressure at the incision site is subatmospheric. Both AGE and VGE can be caused by iatrogenic gas injection. AGE usually produces stroke-like manifestations, such as impaired consciousness, confusion, seizures and focal neurological deficits. Small amounts of VGE are often tolerated due to filtration by pulmonary capillaries; however VGE can cause pulmonary edema, cardiac "vapor lock" and AGE due to transpulmonary passage or right-to-left shunt through a patient foramen ovale. Intravascular gas can cause arterial obstruction or endothelial damage and secondary vasospasm and capillary leak. Vascular gas is frequently not visible with radiographic imaging, which should not be used to exclude the diagnosis of AGE. Isolated VGE usually requires no treatment; AGE treatment is similar to decompression sickness (DCS), with first aid oxygen then hyperbaric oxygen. Although cerebral AGE (CAGE) often causes intracranial hypertension, animal studies have failed to demonstrate a benefit of induced hypocapnia. An evidence based review of adjunctive therapies is presented.
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Affiliation(s)
- Richard E Moon
- Depts. of Anesthesiology and Medicine, Center for Hyperbaric Medicine and Environmental Physiology, Duke University Medical Center, Durham, North Carolina U.S
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Sadler C, Latham E, Hollidge M, Boni B, Brett K. Delayed hyperbaric oxygen therapy for severe arterial gas embolism following scuba diving: a case report. Undersea Hyperb Med 2019; 46:197-202. [PMID: 31051065] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
We present the case of a 42-year-old female who was critically ill due to an arterial gas embolism (AGE) she experienced while diving in Maui, Hawaii. She presented with shortness of breath and dizziness shortly after surfacing from a scuba dive and then rapidly lost consciousness. The diver then had a complicated hospital course: persistent hypoxemia (likely secondary to aspiration) requiring intubation; markedly elevated creatine kinase; atrial fibrillation requiring cardioversion; and slow neurologic improvement. She had encountered significant delay in treatment due to lack of availability of local hyperbaric oxygen (HBO2) therapy. Our case illustrates many of the complications that can occur when a patient suffers a severe AGE. These cases may occur even without a history of rapid ascent or risk factors for pulmonary barotrauma, and it is imperative that they be recognized and treated as quickly as possible with HBO2. Unfortunately, our case also highlights the challenges in treating critically ill divers, particularly with the growing shortage of 24/7 hyperbaric chambers able to treat these ICU-level patients.
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Affiliation(s)
| | - Emi Latham
- University of California, San Diego (UCSD)
| | - Melanie Hollidge
- Maui Memorial Hospital
- Anesthesiology / Critical Care Medicine, Duke University School of Medicine
| | | | - Kaighley Brett
- University of California, San Diego (UCSD)
- Canadian Armed Forces
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Kirby JP. Hyperbaric Oxygen Therapy Emergencies. Mo Med 2019; 116:180-183. [PMID: 31527936 PMCID: PMC6690296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Emergent indications for HBO2 are not only for some of the most serious conditions, but also may be the only modality to directly target the patient's pathophysiology. They are to begin emergently or urgently, but may be limited by either the instability of the patient's condition or transfer logistics. Often these emergent treatments involve several treatments in the first 24 hours for best outcomes. If one considers the effects of HBO2 upon the body while breathing 100% oxygen at pressure many benefits become evident. This article will concisely review hyperbaric oxygen's emergent indications.
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Affiliation(s)
- John P Kirby
- John P. Kirby MD, FACS, is the Director of Wound Healing Programs, Associate Professor of Surgery, Section of Acute and Critical Care Surgery, at Washington University School of Medicine, Barnes-Jewish Hospital, in St. Louis, Missouri
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Wang MY, Liu YS, An XB, Li K, Liu YJ, Wang F. Cerebral arterial air embolism after computed tomography-guided hook-wire localization of a pulmonary nodule: A case report. Medicine (Baltimore) 2019; 98:e15437. [PMID: 31045810 PMCID: PMC6504259 DOI: 10.1097/md.0000000000015437] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Cranial arterial air embolism is a rare but potentially fatal complication after computed tomography (CT)-guided pulmonary interventions. PATIENT CONCERNS A 64-year-old man was diagnosed with a pulmonary nodule (diameter: approximately 1 cm) in the right lower lobe. The patient developed convulsions after CT-guided hook-wire localization. DIAGNOSIS Cranial CT revealed arborizing/linearly distributed gas in the territory of the right middle cerebral artery. INTERVENTIONS The patient was administered hyperbaric oxygen, antiplatelet aggregation therapy, and dehydration treatment. OUTCOMES Clinical death occurred 55 hours after air embolism. LESSONS Systemic air embolism is a serious complication of lung puncture. Clinicians should improve their understanding of this complication and remain vigilant against air embolism.
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Brede JR. Venous air embolism. Tidsskr Nor Laegeforen 2019; 139:18-0017. [PMID: 30644669 DOI: 10.4045/tidsskr.18.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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