Venous or arterial air embolism may be a life threatening event. The condition is seen in many fields of medicine, including intensive care and operating room. The circumstances under which physicians and nurses may encounter air embolism are no longer limited to neurosurgical procedures conducted in the “sitting position” and occur in such diverse areas as the interventional radiology suite or laparoscopic surgical center. Radiological procedures such as angiography and during the injection of air as a contrast agent have also been implicated in venous and arterial air embolism, as have cardiac catheterizations and cardiac ablation procedures. The causes of air embolism include entry of air through intravascular catheters such as peripheral and central venous cannula, pulmonary artery catheters, hemodialysis catheters, pressurized infusion systems and long term central catheters such as Hickman catheters. Vascular air embolism is the entrainment (appearance) of air (or exogenously delivered gas) from the operative field or other communication with the environment into the venous or arterial vasculature, producing systemic effects. Most episodes of VAE (Vascular Air Embolism) are likely preventable. Venous or arterial emboli may produce sudden cardiovascular decompensation with rapidly developing falls in end tidal carbon dioxide, haemoglobin saturation, and blood pressure associated with heart rate and rhythm changes. This is a life threatening situation in which prompt diagnosis and immediate intervention is critical. The two fundamental factors determining the morbidity and mortality of VAE are directly related to the amount of air entering the blood-stream, the speed with which it enters and the body position at the time of embolism. Rapid entry of air into the circulation may cause severe hemodynamic instability. A fatal dose is considered to be 300 - 500 mL of air at a rate of 100 mL/sec; a rate which is possible with a 14 gauge needle and a pressure gradient of only 5 cm H2O between air and venous blood. In the critically ill, unstable patient, smaller volumes of air may also be fatal. When a large bolus of air rapidly enters into the venous system, it causes an air lock in the right atrium and ventricle causing right ventricular outflow obstruction and death. With slow entry of air into the right ventricle, obstruction occurs at the level of the pulmonary vasculature, causing vasoconstriction and pulmonary hypertension. This may cause severe morbidity and mortality, and can be due to direct entry of air into the arterial circulation or paradoxical venous embolism. The term “paradoxical embolism” is used to describe situations in which gas crosses into the left atrium through a patent foramen ovale or atrial septal defect, thus causing air embolism within the systemic circulation. This may cause cardiac and neurological manifestations, although neurological deficits may develop as a result of prolonged hypoxemia and shock as well as direct air embolism While a large share of VAE occurs at the commencement of surgery - 78.7%, still 18% of embolic phenomena are reported at the end of surgery, probably associated with reopening of injured vein when retractors are removed.
Surgical Procedures at Risk for Air Embolism • Neurosurgical sitting position craniotomies. Posterior fossa procedures • Cervical laminectomy • Spinal fusion • Radical neck dissection • Thyroidectomy • Ophthalmologic procedures • Cardiac surgery, Coronary air embolism • Orthopedic procedures such as total hip arthroplasty, arthroscopy, • Thoracic procedures such as thoracocentesis • Obstetric–gynecologic procedures such as cesarean delivery • Laparoscopic procedures, Rubin insufflation procedures, vacuum abortion • Urology–prostatectomy • Gastrointestinal surgery such as laparoscopic cholecystectomy, gastrointestinal endoscopy and liver transplantation
Risk of Air Embolism in Direct Vascular Access Procedures • Central venous access related • Radial artery catheterization • Parenteral nutrition therapy • Interventional radiology • Pain management procedures • Epidural catheter placement (loss of resistance to air technique) • Diagnostic procedures • Contrast-enhanced CT • Contrast-enhanced CT chest • Lumbar puncture • Thoracentesis • Hemoperfusion • Intraaortic balloon rupture • Rapid blood cell infusion systems • Blood storage container
Air embolism that cause injury may give rise to a medical malpractice cause of action. If as a result of a physician's or nurse's error your condition worsened or you have been unexpectedly injured, you deserve legal representation. If you are suffering from complications due to an air embolism, let Dr. Borten and the Boston area medical malpractice attorneys at Gorovitz & Borten review the specifics of your case. We can help you assert your rights and get the compensation you deserve.
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