Air embolism overview: Difference between revisions

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==Overview==
==Overview==
An ''air embolism'', or more generally ''gas embolism'', is a medical condition caused by [[gas]] bubbles in the bloodstream (''[[embolism]]'' in a medical context refers to any large moving mass or defect in the blood stream). Small amounts of air may enter the blood [[circulation]] during [[surgery]], other invasive medical procedures, or deep sea diving. [[venous]] air [[embolism|embolisms]] rarely present with [[symptom]]s. Symptoms or death may occur if a large bubble of gas becomes lodged in the heart, stopping blood from flowing from the right [[Ventricle (heart)|ventricle]] to the [[lungs]] (this is similar to vapor lock in engine fuel systems). However, the amount of gas necessary for this to happen is quite variable, and also depends on a number of other factors, such as body position.
An ''air embolism'', or more generally ''gas embolism'', is a medical condition caused by [[gas]] bubbles in the bloodstream (''[[embolism]]'' in a medical context refers to any large moving mass or defect in the blood stream). Small amounts of air may enter the blood [[circulation]] during [[surgery]], other invasive medical procedures, or deep sea diving. There are two types of air embolisms: [[venous]] or [[arterial]].  [[venous]] air [[embolism|embolisms]] rarely present with [[symptom]]s. Symptoms or death mainly occur in the arterial system.  Symptoms may occur in the venous system, if a large bubble of gas becomes lodged in the heart, stopping blood from flowing from the right [[Ventricle (heart)|ventricle]] to the [[lungs]] (this is similar to vapor lock in engine fuel systems). However, the amount of gas necessary for this to happen is quite variable, and also depends on a number of other factors, such as body position.


Gas embolism into an [[artery]], termed [[artery|arterial]] gas [[embolism]], or AGE, is a more severe diagnosis than [[venous]] air [[embolism]], since a gas bubble in an [[artery]] may directly cause [[ischemia]] to an area fed by the [[artery]]. The [[symptom]]s of AGE depend on the [[artery]] and the organs that it supplies. For example,a [[stroke]] or a [[myocardial infarction|heart attack]] may occur if the brain or heart (respectively) are affected.
Gas embolism into an [[artery]], termed [[artery|arterial]] gas [[embolism]], or AGE, is a more severe diagnosis than [[venous]] air [[embolism]], since a gas bubble in an [[artery]] may directly cause [[ischemia]] to an area fed by the [[artery]]. The [[symptom]]s of AGE depend on the [[artery]] and the organs that it supplies. For example,a [[stroke]] or a [[myocardial infarction|heart attack]] may occur if the brain or heart (respectively) are affected.


[[Decompression sickness]] (DCS) is one of the [[diving disorders]] SCUBA divers sometimes suffer when they have [[barotrauma|pressure damage]] to their lungs following a rapid ascent where the breath is inappropriately held against a closed [[glottis]], allowing pressure to build up inside the lungs, relative to the blood. It is termed "gas" because the diver may be using a diving [[breathing gas]] other than [[air]]. The gas bubbles can impede the flow of oxygen-rich blood to the brain and other vital organs. They can also cause [[clot]]s to form in [[blood]] [[vessel]]s.
[[Decompression sickness]] (DCS) is a [[diving disorders|diving disorder]] that SCUBA divers sometimes suffer when they have [[barotrauma|pressure damage]] to their lungs following a rapid ascent where the breath is inappropriately held against a closed [[glottis]], allowing pressure to build up inside the lungs, relative to the blood. It is termed "gas" because the diver may be using a diving [[breathing gas]] other than [[air]]. The gas bubbles can impede the flow of oxygen-rich blood to the brain and other vital organs. They can also cause [[clot]]s to form in [[blood]] [[vessel]]s.
 
Gas [[embolism]] and [[decompression sickness]] (DCS) may be difficult to distinguish, as they may have similar [[symptom]]s, especially in the [[central nervous system]]. The treatment for both is the same, because they are both the result of gas bubbles in the body.  


Gas [[embolism]] and [[decompression sickness]] (DCS) have similar [[symptom]]s, especially in the [[central nervous system]]. The treatment for both is the same, because they are both the result of gas bubbles in the body.


==Historical Perspective==
==Historical Perspective==
: Not much is known about the history of air [[embolim|embolism]], but it has been diagnosed as early as the 19th century.<ref>{{Cite journal
| author = [[Nissar Shaikh]] & [[Firdous Ummunisa]]
| title = Acute management of vascular air embolism
| journal = [[Journal of emergencies, trauma, and shock]]
| volume = 2
| issue = 3
| pages = 180–185
| year = 2009
| month = September
| doi = 10.4103/0974-2700.55330
| pmid = 20009308
}}</ref>


==Classification==
==Classification==
Line 21: Line 32:


==Pathophysiology==
==Pathophysiology==
Air embolism can occur whenever a blood [[vessel]] is open and a pressure gradient exists favoring entry of gas. Because the pressure in most [[artery|arteries]] and [[vein]]s is greater than [[atmospheric pressure]], an air [[embolus]] does not always happen when a blood [[vessel]] is injured. In the [[vein]]s above the heart, such as in the head and neck, the pressure is less than atmospheric and an injury may let air in. This is one reason why [[surgery|surgeon]]s must be particularly careful when operating on the [[brain]], and why the head of the bed is tilted down when inserting or removing a [[central venous catheter]] from the [[jugular vein|jugular]] or [[subclavian vein]]s.
Air embolism can occur whenever there is access to an open blood [[vessel]] and a pressure gradient exists favoring entry of gas. Because the pressure in most [[artery|arteries]] and [[vein]]s is greater than [[atmospheric pressure]], an air [[embolus]] does not always happen when a blood [[vessel]] is injured. In the [[vein]]s above the heart, such as in the head and neck, the pressure is less than atmospheric and an injury may let air in. This is one reason why [[surgery|surgeon]]s must be particularly careful when operating on the [[brain]], and why the head of the bed is tilted down when inserting or removing a [[central venous catheter]] from the [[jugular vein|jugular]] or [[subclavian vein]]s.


When air enters the [[vein]]s, it travels to the right side of the heart, and then to the lungs. This can cause the [[vessel]]s of the lung to constrict, raising the pressure in the right side of the heart. If the pressure rises high enough in a patient who is one of the 20% to 30% of the population with a [[patent foramen ovale]], the gas bubble can then travel to the left side of the heart, and on to the brain or [[coronary circulation|coronary arteries]]. Such bubbles are responsible for the most serious of gas [[embolus|embolic]] [[symptom]]s.
When air enters the [[vein]]s, it travels to the right side of the heart, and then to the lungs. This can cause the [[vessel]]s of the lung to constrict, raising the pressure in the right side of the heart. If the pressure rises high enough in a patient who is one of the 20% to 30% of the population with a [[patent foramen ovale]], the gas bubble can then travel to the left side of the heart, and on to the brain or [[coronary circulation|coronary arteries]]. Such bubbles are responsible for the most serious of gas [[embolus|embolic]] [[symptom]]s.


[[physical trauma|Trauma]] to the lung can also cause an air [[embolism]]. This may happen after a patient is placed on a [[ventilator]] and air is forced into an injured vein or [[artery]], causing sudden death. Breath-holding while ascending from scuba diving may also force lung air into [[pulmonary artery|pulmonary arteries]] or [[vein]]s in a similar manner, due to the pressure difference.  
[[physical trauma|Trauma]] to the lung can also cause an air [[embolism]]. This may happen after a patient is placed on a [[ventilator]] and air is forced into an injured vein or [[artery]], causing sudden death. Breath-holding and rapid ascent from scuba diving may also force nitrogen air into [[pulmonary artery|pulmonary arteries]] or [[vein]]s causing [[Decompression Sickness]] During a deep sea dive nitrogen accumulates in the tissues of the body, as the diver ascends, the nitrogen leaves the body through the lungs, if the ascent occurs too rapidly nitrogen bubble can form and diffuse into the circulation causing an air embolism.<ref>{{Cite journal
| author = [[Asadullah Naqvi]] & [[Derrick Clarence]]
| title = A case of decompression illness not responding to hyperbaric oxygen
| journal = [[Journal of intensive care]]
| volume = 6
| pages = 29
| year = 2018
| month =
| doi = 10.1186/s40560-018-0299-3
| pmid = 29796283
}}</ref>


Air can be injected directly into the [[vein]]s either accidentally or as a deliberate act. Examples include misuse of a [[syringe]], and [[industrial injury]] resulting from use of compressed air. However, despite being employed by writers of fiction as a clandestine method of murder, amounts of air such as would be administered by a single small syringe are not likely to suddenly stop the heart, nor cause instant death. Single air bubbles in a [[vein]] do not stop the heart, due to being too small. However, such bubbles may occasionally reach the arterial system through a [[patent foramen ovale]], as noted above, and cause random [[ischemic]] damage, depending on their route of [[artery|arterial]] travel.
Air can be injected directly into the [[vein]]s either accidentally or as a deliberate act. Examples include misuse of a [[syringe]], and [[industrial injury]] resulting from use of compressed air. However, despite being employed by writers of fiction as a clandestine method of murder, amounts of air such as would be administered by a single small syringe are not likely to suddenly stop the heart, nor cause instant death. Single air bubbles in a [[vein]] do not stop the heart, due to being too small. However, such bubbles may occasionally reach the arterial system through a [[patent foramen ovale]], as noted above, and cause random [[ischemic]] damage, depending on their route of [[artery|arterial]] travel.


==Causes==
==Causes==
* Air embolism may be cause by invasive vascular procedures (iatrogenic), lung trauma, or by rapid ascent during deep sea diving( [[Decompression Sickness]] / [[Caisson's Disease]]).
* Iatrogenic Causes:
* Iatrogenic Causes:
** [[Central Venous Catheter]]
** [[Central Venous Catheter/IV catheters]]<ref>{{Cite journal
** [[Hemodialysis]]
| author = [[Nicholas J. Parkinson]], [[Harold C. McKenzie]], [[Michelle H. Barton]], [[Jennifer L. Davis]], [[Bettina Dunkel]], [[Amy L. Johnson]] & [[Elizabeth S. MacDonald]]
** [[Laparoscopic surgery]]
| title = Catheter-associated venous air embolism in hospitalized horses: 32 cases
** [[Contrast Studies]]
| journal = [[Journal of veterinary internal medicine]]
** [[Endoscopic retrograde cholangiopancreatography|ERCP]]
| volume = 32
   
| issue = 2
| pages = 805–814
| year = 2018
| month = March
| doi = 10.1111/jvim.15057
| pmid = 29460300
}}</ref> <ref>{{Cite journal
| author = [[T. M. Vesely]]
| title = Air embolism during insertion of central venous catheters
| journal = [[Journal of vascular and interventional radiology : JVIR]]
| volume = 12
| issue = 11
| pages = 1291–1295
| year = 2001
| month = November
| pmid = 11698628
}}</ref>
** [[Hemodialysis]]<ref>{{Cite journal
| author = [[Lawrence Lau]] & [[Kory London]]
| title = Cortical Blindness and Altered Mental Status following Routine Hemodialysis, a Case of Iatrogenic Cerebral Air Embolism
| journal = [[Case reports in emergency medicine]]
| volume = 2018
| pages = 9496818
| year = 2018
| month =
| doi = 10.1155/2018/9496818
| pmid = 29732225
}}</ref>
** [[Laparoscopic surgery/Abdominal surgery]]<ref>{{Cite journal
| author = [[J. M. Bao]], [[J. P. Lin]], [[X. Yu]] & [[H. Yu]]
| title = &#91;Effects of pneumoperitoneal pressure on air embolism duringlaparoscopic hepatectomy and degree of postoperative inflammation&#93;
| journal = [[Zhonghua yi xue za zhi]]
| volume = 98
| issue = 26
| pages = 2088–2091
| year = 2018
| month = July
| pmid = 30032506
}}</ref>
** [[Contrast Studies]]<ref>{{Cite journal
| author = [[Kalpana Yeddula]], [[Iftikhar Ahmad]], [[Shafaath Husain Syed Mohammed]], [[Sandeep Hedgire]], [[Vikram Venkatesh]], [[Suhny Abbara]] & [[Sanjeeva P. Kalva]]
| title = Paradoxical air embolism following contrast material injection through power injectors in patients with a patent foramen ovale
| journal = [[The international journal of cardiovascular imaging]]
| volume = 28
| issue = 8
| pages = 2085–2090
| year = 2012
| month = December
| doi = 10.1007/s10554-012-0017-5
| pmid = 22302647
}}</ref>
** [[Endoscopic retrograde cholangiopancreatography|ERCP]]<ref>{{Cite journal
| author = [[Jonathan P. Wanderer]] & [[Naveen Nathan]]
| title = Bubble Trouble: Venous Air Embolism in Endoscopic Retrograde Cholangiopancreatography
| journal = [[Anesthesia and analgesia]]
| volume = 127
| issue = 2
| pages = 324
| year = 2018
| month = August
| doi = 10.1213/ANE.0000000000003599
| pmid = 30028380
}}</ref>
** [[Lung Biopsy]]<ref>{{Cite journal
  | author = [[Rika Yoshida]], [[Takeshi Yoshizako]], [[Megumi Nakamura]], [[Shinji Ando]], [[Mitsunari Maruyama]], [[Minako Maruyama]], [[Yoshikazu Takinami]], [[Yukihisa Tamaki]], [[Tomonori Nakamura]] & [[Hajime Kitagaki]]
| title = Nonfatal air embolism complicating percutaneous CT-guided lung biopsy and VATS marking: Four cases from a single institution
| journal = [[Clinical imaging]]
| volume = 48
| pages = 127–130
| year = 2018
| month = March
| doi = 10.1016/j.clinimag.2017.10.010
| pmid = 29100079
}}</ref>
** High pressure mechanical ventilation<ref>{{Cite journal
| author = [[Se-Min Ryu]] & [[Sung-Min Park]]
| title = Unexpected complication during extracorporeal membrane oxygenation support: Ventilator associated systemic air embolism
| journal = [[World journal of clinical cases]]
| volume = 6
| issue = 9
| pages = 274–278
| year = 2018
| month = September
| doi = 10.12998/wjcc.v6.i9.274
| pmid = 30211207
}}</ref>
** Endoscopy<ref>{{Cite journal
| author = [[Richard C. Prielipp]] & [[Sorin J. Brull]]
| title = Vascular Air Embolism and Endoscopy: Every Bubble Matters
| journal = [[Anesthesia and analgesia]]
| volume = 127
| issue = 2
| pages = 333–335
| year = 2018
| month = August
| doi = 10.1213/ANE.0000000000003329
| pmid = 30028384
}}</ref>
** Intracranial Surgery<ref>{{Cite journal
| author = [[Arnoley S. Abcejo]], [[Jeffrey J. Pasternak]] & [[William J. Perkins]]
| title = Urgent Repositioning After Venous Air Embolism During Intracranial Surgery in the Seated Position: A Case Series
| journal = [[Journal of neurosurgical anesthesiology]]
| year = 2018
| month = August
| doi = 10.1097/ANA.0000000000000534
| pmid = 30148744
}}</ref>
** Gynecological Surgery<ref>{{Cite journal
| author = [[John K. Chan]], [[Austin B. Gardner]], [[Amandeep K. Mann]] & [[Daniel S. Kapp]]
| title = Hospital-acquired conditions after surgery for gynecologic cancer - An analysis of 82,304 patients
| journal = [[Gynecologic oncology]]
| volume = 150
| issue = 3
| pages = 515–520
| year = 2018
| month = September
| doi = 10.1016/j.ygyno.2018.07.009
| pmid = 30037490
}}</ref>
 
* Deep sea diving (Decompression Sickness/ Caisson's Disease/ "the bends")<ref>{{Cite journal
| author = [[Josep M. Casadesus]], [[Fernando Aguirre]], [[Ana Carrera]], [[Pere Boadas-Vaello]], [[Maria T. Serrando]] & [[Francisco Reina]]
| title = Diagnosis of arterial gas embolism in SCUBA diving: modification suggestion of autopsy techniques and experience in eight cases
| journal = [[Forensic science, medicine, and pathology]]
| volume = 14
| issue = 1
| pages = 18–25
| year = 2018
| month = March
| doi = 10.1007/s12024-018-9951-4
| pmid = 29460254
}}</ref>
* Blunt chest trauma <ref>{{Cite journal
| author = [[Isabella Mercurio]], [[Daniele Capano]], [[Riccardo Torre]], [[Aldo Taddei]], [[Gianmarco Troiano]], [[Michele Scialpi]] & [[Mario Gabbrielli]]
| title = A Case of Fatal Cerebral Air Embolism After Blunt Lung Trauma: Postmortem Computed Tomography and Autopsy Findings
| journal = [[The American journal of forensic medicine and pathology]]
| volume = 39
| issue = 1
| pages = 61–68
| year = 2018
| month = March
| doi = 10.1097/PAF.0000000000000375
| pmid = 29278540
}}</ref>
 
==Differentiating Air Embolism from other Diseases==
==Differentiating Air Embolism from other Diseases==
*Air embolism must be differentiated from other diseases that cause dyspnea, joint and muscle pain, and mental status changes , such as:
*Air embolism must be differentiated from other diseases that cause dyspnea, joint and muscle pain, and mental status changes, such as<ref>{{Cite journal
:*Thrombotic pulmonary emboli
| author = [[Nissar Shaikh]] & [[Firdous Ummunisa]]
:*Myocardial Infarction
| title = Acute management of vascular air embolism
| journal = [[Journal of emergencies, trauma, and shock]]
| volume = 2
| issue = 3
| pages = 180–185
| year = 2009
| month = September
| doi = 10.4103/0974-2700.55330
| pmid = 20009308
}}</ref>
:*Pulmonary emboli
:*Myocardial Infarction/Acute coronary syndrome <ref>{{Cite journal
| author = [[C.-M. Chao]], [[W.-L. Liu]], [[C.-F. Hsieh]] & [[C.-C. Lai]]
| title = Pulmonary air embolism
| journal = [[QJM : monthly journal of the Association of Physicians]]
| volume = 109
| issue = 4
| pages = 283–284
| year = 2016
| month = April
| doi = 10.1093/qjmed/hcv226
| pmid = 26742568
}}</ref>
:*Stroke
:*Stroke
:*Cardiogenic shock
 
==Epidemiology and Demographics==
==Epidemiology and Demographics==
* The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
* The prevalence of air [[embolism]] is approximately 2.65 per 100,000 hospitalizations.<ref>{{Cite journal
* In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].
| author = [[Jacques Bessereau]], [[Nicolas Genotelle]], [[Cendrine Chabbaut]], [[Anne Huon]], [[Alexis Tabah]], [[Jerome Aboab]], [[Sylvie Chevret]] & [[Djillali Annane]]
| title = Long-term outcome of iatrogenic gas embolism
| journal = [[Intensive care medicine]]
| volume = 36
| issue = 7
| pages = 1180–1187
| year = 2010
| month = July
| doi = 10.1007/s00134-010-1821-9
| pmid = 20221749
}}</ref>
* The prevalence of air embolism is approximately 7 per 100,000 divers.<ref>{{Cite journal
| author = [[D. R. Leitch]] & [[R. D. Green]]
| title = Pulmonary barotrauma in divers and the treatment of cerebral arterial gas embolism
| journal = [[Aviation, space, and environmental medicine]]
| volume = 57
| issue = 10 Pt 1
| pages = 931–938
| year = 1986
| month = October
| pmid = 3778391
}}</ref>
   
   
===Age===
===Age===
Line 56: Line 264:
===Race===
===Race===
*There is no racial predilection for Air [[embolism]].
*There is no racial predilection for Air [[embolism]].
 
==Risk Factors==
==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
*Common risk factors in the development of air [[embolism]] are:
   
*Operative site more that 5cm above the right atrium<ref>{{Cite journal
| author = [[Nissar Shaikh]] & [[Firdous Ummunisa]]
| title = Acute management of vascular air embolism
| journal = [[Journal of emergencies, trauma, and shock]]
| volume = 2
| issue = 3
| pages = 180–185
| year = 2009
| month = September
| doi = 10.4103/0974-2700.55330
| pmid = 20009308
}}</ref>
*Numerous uncompressed venous channels in surgical site<ref>{{Cite journal
| author = [[Nissar Shaikh]] & [[Firdous Ummunisa]]
| title = Acute management of vascular air embolism
| journal = [[Journal of emergencies, trauma, and shock]]
| volume = 2
| issue = 3
| pages = 180–185
| year = 2009
| month = September
| doi = 10.4103/0974-2700.55330
| pmid = 20009308
}}</ref>
*Pressure gradient during surgery<ref>{{Cite journal
| author = [[J. P. Flanagan]], [[I. A. Gradisar]], [[R. J. Gross]] & [[T. R. Kelly]]
| title = Air embolus--a lethal complication of subclavian venipuncture
| journal = [[The New England journal of medicine]]
| volume = 281
| issue = 9
| pages = 488–489
| year = 1969
| month = August
| doi = 10.1056/NEJM196908282810907
| pmid = 5796967
}}</ref>
*Insertion or removal of catheter<ref>{{Cite journal
| author = [[Nissar Shaikh]] & [[Firdous Ummunisa]]
| title = Acute management of vascular air embolism
| journal = [[Journal of emergencies, trauma, and shock]]
| volume = 2
| issue = 3
| pages = 180–185
| year = 2009
| month = September
| doi = 10.4103/0974-2700.55330
| pmid = 20009308
}}</ref>
**Fracture/de attachment of catheter
**Failure to occlude needle hub
**Deep inspiration
**Hypovolemia
**Up right position
*Scuba diving<ref>{{Cite journal
| author = [[J. Aharon-Peretz]], [[Y. Adir]], [[C. R. Gordon]], [[S. Kol]], [[N. Gal]] & [[Y. Melamed]]
| title = Spinal cord decompression sickness in sport diving
| journal = [[Archives of neurology]]
| volume = 50
| issue = 7
| pages = 753–756
| year = 1993
| month = July
  | pmid = 8323480
}}</ref>
**Rapid ascent rate
**Diving too long
**Diving at great depth
 
== Natural History, Complications and Prognosis==
== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*Early clinical features include chest pain dyspnea, and altered mental status.
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of air [[embolism]] include, stroke, seizures, and infarction of various organs.
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Prognosis is generally variable,it depends on the size and location of the embolism , and the mortality rate of patients with air [[embolism]] is approximately 48-80%.<ref>{{Cite journal
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
| author = [[A. M. Ho]] & [[E. Ling]]
*Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].
| title = Systemic air embolism after lung trauma
   
| journal = [[Anesthesiology]]
| volume = 90
| issue = 2
| pages = 564–575
| year = 1999
| month = February
| pmid = 9952165
}}</ref>
*A 200-300ml bolus or 3-5 ml/kg of air in a human is fatal<ref>{{Cite journal
| author = [[T. J. Toung]], [[M. I. Rossberg]] & [[G. M. Hutchins]]
| title = Volume of air in a lethal venous air embolism
| journal = [[Anesthesiology]]
  | volume = 94
| issue = 2
| pages = 360–361
| year = 2001
| month = February
| pmid = 11176104
}}</ref>
 
== Diagnosis ==
== Diagnosis ==
===Diagnostic Criteria===
===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
*There is no established diagnostic criteria for air [[embolism]].
:*[criterion 1]
*The diagnosis of air [[embolism]] is clinical and should be suspected in patients with history of:
:*[criterion 2]
:*High risk procedures
:*[criterion 3]
:*Scuba diving
:*[criterion 4]
:*Trauma to head, neck, thorax or abdomen
:*Hemodialysis catheters
:*Positive pressure ventilation
 
=== Symptoms ===
=== Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of air [[embolism]] depend on:<ref>{{Cite journal
*Symptoms of [disease name] may include the following:
| author = [[Marek A. Mirski]], [[Abhijit Vijay Lele]], [[Lunei Fitzsimmons]] & [[Thomas J. K. Toung]]
:*[symptom 1]
| title = Diagnosis and treatment of vascular air embolism
:*[symptom 2]
| journal = [[Anesthesiology]]
:*[symptom 3]
| volume = 106
:*[symptom 4]
| issue = 1
:*[symptom 5]
| pages = 164–177
:*[symptom 6]
| year = 2007
| month = January
| pmid = 17197859
}}</ref>
**the location
**size of the emboli
**rate of emboli formation
** patient spontaneously breathing
** patient under controlled positive pressure ventilation
*Symptoms include the following:
:*Dyspnea
:*Cough
:*Chest pain
:*Mental status changes
:*Dizziness/ Vertigo
:*Nausea
:*Syncope
:*Headache
:*Anxiety
 
=== Physical Examination ===
=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Patients with air [[embolism]] usually appear distressed.
*Physical examination may be remarkable for:
*Physical examination may be remarkable for:
:*[finding 1]
:*Cardiovascular Findings:<ref>{{Cite journal
:*[finding 2]
| author = [[Marek A. Mirski]], [[Abhijit Vijay Lele]], [[Lunei Fitzsimmons]] & [[Thomas J. K. Toung]]
:*[finding 3]
| title = Diagnosis and treatment of vascular air embolism
:*[finding 4]
| journal = [[Anesthesiology]]
:*[finding 5]
| volume = 106
:*[finding 6]
| issue = 1
   
| pages = 164–177
| year = 2007
| month = January
| pmid = 17197859
}}</ref> <ref>{{Cite journal
| author = [[S. L. Orebaugh]]
| title = Venous air embolism: clinical and experimental considerations
| journal = [[Critical care medicine]]
| volume = 20
| issue = 8
| pages = 1169–1177
| year = 1992
| month = August
| pmid = 1643897
}}</ref>
:**Arrythmias
:**Murmmurs
:**Jugular venous distension
:**Hypotension
:**ST and T wave changes
:**Pulmonary arterial hypertension
:**Increased central venous pressure
:**Shock and cardiovascular collapse
:*Respiratory Findings:<ref>{{Cite journal
| author = [[Marek A. Mirski]], [[Abhijit Vijay Lele]], [[Lunei Fitzsimmons]] & [[Thomas J. K. Toung]]
| title = Diagnosis and treatment of vascular air embolism
| journal = [[Anesthesiology]]
| volume = 106
| issue = 1
| pages = 164–177
| year = 2007
| month = January
| pmid = 17197859
}}</ref><ref>{{Cite journal
| author = [[S. L. Orebaugh]]
| title = Venous air embolism: clinical and experimental considerations
| journal = [[Critical care medicine]]
| volume = 20
| issue = 8
| pages = 1169–1177
| year = 1992
| month = August
| pmid = 1643897
}}</ref>
:**Rales/ wheezing
:**Tachypnea
:**Hemoptysis
:**Cyanosis
:**Decreased End Tidal Co2
:**Hypercapnia
:**Pulmonary edema
:**Apnea
:*Central Nervous System Findings:<ref>{{Cite journal
| author = [[Marek A. Mirski]], [[Abhijit Vijay Lele]], [[Lunei Fitzsimmons]] & [[Thomas J. K. Toung]]
| title = Diagnosis and treatment of vascular air embolism
| journal = [[Anesthesiology]]
| volume = 106
| issue = 1
| pages = 164–177
| year = 2007
| month = January
| pmid = 17197859
}}</ref><ref>{{Cite journal
| author = [[S. L. Orebaugh]]
| title = Venous air embolism: clinical and experimental considerations
| journal = [[Critical care medicine]]
  | volume = 20
| issue = 8
| pages = 1169–1177
| year = 1992
| month = August
| pmid = 1643897
}}</ref>
:**Altered mental status
:**Seizures
:**Focal neurological deficits
:**Loss of consciousness
:**Coma
 
=== Laboratory Findings ===
=== Laboratory Findings ===
*There are no specific laboratory findings associated with [disease name].
*There is no one test that is diagnostic for air [[embolism]].
 
*The diagnosis is clinical but some lab findings can help lead to the diagnosis, and can indicate which organs and systems are affected.
*Laboratory findings consistent with the diagnosis of air [[embolism]] include:<ref>{{Cite journal
| author = [[Marek A. Mirski]], [[Abhijit Vijay Lele]], [[Lunei Fitzsimmons]] & [[Thomas J. K. Toung]]
| title = Diagnosis and treatment of vascular air embolism
| journal = [[Anesthesiology]]
| volume = 106
| issue = 1
| pages = 164–177
| year = 2007
| month = January
| pmid = 17197859
}}</ref>
**Decreased End tidal CO2<ref>{{Cite journal
| author = [[T. M. Brechner]] & [[V. L. Brechner]]
| title = An audible alarm for monitoring air embolism during neurosurgery
| journal = [[Journal of neurosurgery]]
| volume = 47
| issue = 2
| pages = 201–204
| year = 1977
| month = August
| doi = 10.3171/jns.1977.47.2.0201
| pmid = 874544
}}</ref>
**Increased End tidal Nitrogen<ref>{{Cite journal
| author = [[J. E. Souders]]
| title = Pulmonary air embolism
| journal = [[Journal of clinical monitoring and computing]]
| volume = 16
| issue = 5-6
| pages = 375–383
| year = 2000
| month =
| pmid = 12580220
}}</ref>
**Increased pulmonary artery pressure<ref>{{Cite journal
| author = [[Nissar Shaikh]] & [[Firdous Ummunisa]]
| title = Acute management of vascular air embolism
| journal = [[Journal of emergencies, trauma, and shock]]
| volume = 2
| issue = 3
| pages = 180–185
| year = 2009
| month = September
| doi = 10.4103/0974-2700.55330
| pmid = 20009308
}}</ref>


*A  [positive/negative] [test name] is diagnostic of [disease name].
*An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
*Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
===Imaging Findings===
===Imaging Findings===
*There are no [imaging study] findings associated with [disease name].
*Transesophageal Echocardiography (TEE) is the most sensitive imaging modality for air [[embolism]].<ref>{{Cite journal
   
| author = [[R. A. Jaffe]], [[L. C. Siegel]], [[I. Schnittger]], [[J. W. Propst]] & [[J. G. Brock-Utne]]
*[Imaging study 1] is the imaging modality of choice for [disease name].
| title = Epidural air injection assessed by transesophageal echocardiography
*On [imaging study 1], [disease name] is characterized by [finding 1], [finding 2], and [finding 3].
| journal = [[Regional anesthesia]]
*[Imaging study 2] may demonstrate [finding 1], [finding 2], and [finding 3].
| volume = 20
   
| issue = 2
=== Other Diagnostic Studies ===
| pages = 152–155
*[Disease name] may also be diagnosed using [diagnostic study name].
| year = 1995
*Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].
| month = March-April
| pmid = 7605763
}}</ref><ref>{{Cite journal
| author = [[H. Furuya]], [[T. Suzuki]], [[F. Okumura]], [[Y. Kishi]] & [[T. Uefuji]]
  | title = Detection of air embolism by transesophageal echocardiography
| journal = [[Anesthesiology]]
| volume = 58
| issue = 2
| pages = 124–129
| year = 1983
| month = February
| pmid = 6401948
}}</ref>
**On TEE, air embolism is characterized by detection of air in circulation.
*Precordial Doppler Ultrasound is the most sensitive noninvasive imaging modality for air [[embolism]].<ref>{{Cite journal
| author = [[S. G. Soriano]], [[M. L. McManus]], [[L. J. Sullivan]], [[R. M. Scott]] & [[M. A. Rockoff]]
| title = Doppler sensor placement during neurosurgical procedures for children in the prone position
| journal = [[Journal of neurosurgical anesthesiology]]
| volume = 6
| issue = 3
| pages = 153–155
| year = 1994
| month = July
| pmid = 8081094
}}</ref><ref>{{Cite journal
| author = [[J. L. Chang]], [[M. S. Albin]], [[L. Bunegin]] & [[T. K. Hung]]
| title = Analysis and comparison of venous air embolism detection methods
| journal = [[Neurosurgery]]
| volume = 7
| issue = 2
| pages = 135–141
| year = 1980
| month = August
| pmid = 7422108
}}</ref>
**Precordial Doppler Ultrasound may demonstrate air in circulation.
*Transcranial Doppler Ultrasound is also used to detect air [[Embolism|embolism.]]
**Transcranial Doppler Ultrasound may demonstrate cerebral emboli.
*Contrast enhanced CT scan of the chest may be used to help diagnose air embolism.
**CT chest may show intra-cardial air<ref>{{Cite journal
| author = [[Julio Lanfranco]], [[Ivan Romero Legro]], [[Amado X. Freire]], [[Katherine Nearing]] & [[Sanjay Ratnakant]]
| title = Pulmonary Air Embolism: An Infrequent Complication in the Radiology Suite
| journal = [[The American journal of case reports]]
| volume = 18
| pages = 80–84
| year = 2017
| month = January
| pmid = 28115731
}}</ref><ref>{{Cite journal
| author = [[Kyong Shil Im]], [[Joon Suk Woo]] & [[Jae Myeong Lee]]
| title = Recurrence of fatal venous air embolism
| journal = [[Korean journal of anesthesiology]]
  | volume = 67
| issue = Suppl
| pages = S111–S112
| year = 2014
| month = December
| doi = 10.4097/kjae.2014.67.S.S111
| pmid = 25598879
}}</ref>
** CT chest may show a filling defect in the lungs<ref>{{Cite journal
| author = [[Julio Lanfranco]], [[Ivan Romero Legro]], [[Amado X. Freire]], [[Katherine Nearing]] & [[Sanjay Ratnakant]]
| title = Pulmonary Air Embolism: An Infrequent Complication in the Radiology Suite
| journal = [[The American journal of case reports]]
| volume = 18
| pages = 80–84
| year = 2017
| month = January
| pmid = 28115731
}}</ref>
*CT or MRI of the head may be used to diagnose air embolism<ref>{{Cite journal
| author = [[Jochen Bauerle]], [[Andreas Fischer]], [[Tobias Hornig]], [[Karl Egger]], [[Tobias Wengenmayer]] & [[Jurgen Bardutzky]]
| title = Therapeutic hypothermia in cerebral air embolism: a case report
| journal = [[SpringerPlus]]
| volume = 2
| pages = 411
| year = 2013
| month =
| doi = 10.1186/2193-1801-2-411
| pmid = 24024097
}}</ref>
**Contrast enhanced CT may show areas of ischemia or entrapment of air
**MRI may show areas of ischemia


=== Other Diagnostic Studies. ===
*EKG may also be used to help diagnose air embolism.
**Findings on EKG include ST segment changes, peaked P waves, and tachyarrthmia.<ref>{{Cite journal
| author = [[P. L. Gildenberg]], [[R. P. O'Brien]], [[W. J. Britt]] & [[E. A. Frost]]
| title = The efficacy of Doppler monitoring for the detection of venous air embolism
| journal = [[Journal of neurosurgery]]
| volume = 54
| issue = 1
| pages = 75–78
| year = 1981
| month = January
| doi = 10.3171/jns.1981.54.1.0075
| pmid = 7463123
}}</ref>
*Pulse Oximetry showing saturation changes is a late finding.<ref>{{Cite journal
| author = [[Marek A. Mirski]], [[Abhijit Vijay Lele]], [[Lunei Fitzsimmons]] & [[Thomas J. K. Toung]]
| title = Diagnosis and treatment of vascular air embolism
| journal = [[Anesthesiology]]
| volume = 106
| issue = 1
| pages = 164–177
| year = 2007
| month = January
| pmid = 17197859
}}</ref>
*Chest X-ray may be used to rule out other causes of dyspnea and chest pain.
**Chest X-ray may show intra-cardiac air.<ref>{{Cite journal
| author = [[Kyong Shil Im]], [[Joon Suk Woo]] & [[Jae Myeong Lee]]
| title = Recurrence of fatal venous air embolism
| journal = [[Korean journal of anesthesiology]]
| volume = 67
| issue = Suppl
| pages = S111–S112
| year = 2014
| month = December
| doi = 10.4097/kjae.2014.67.S.S111
| pmid = 25598879
}}</ref>


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
Recompression is the most effective treatment of an air [[embolism]]. Normally this is carried out in a recompression chamber. This is because as pressure increases, the solubility of a gas increases.
Air embolism is a medical emergency.The mainstay of therapy for air embolism is high flow oxygen therapy with 100% oxygen.
 
During surgery:
 
*Cover surgical site
**This prevents further air trapping<ref>{{Cite journal
| author = [[Marek A. Mirski]], [[Abhijit Vijay Lele]], [[Lunei Fitzsimmons]] & [[Thomas J. K. Toung]]
| title = Diagnosis and treatment of vascular air embolism
| journal = [[Anesthesiology]]
| volume = 106
| issue = 1
| pages = 164–177
| year = 2007
| month = January
| pmid = 17197859
}}</ref>
*Tilt operating table
**This lowers the source of air entry and eliminates negative air pressure gradient<ref>{{Cite journal
| author = [[Marek A. Mirski]], [[Abhijit Vijay Lele]], [[Lunei Fitzsimmons]] & [[Thomas J. K. Toung]]
| title = Diagnosis and treatment of vascular air embolism
| journal = [[Anesthesiology]]
| volume = 106
| issue = 1
| pages = 164–177
| year = 2007
| month = January
| pmid = 17197859
}}</ref>
*Reverse Trendelenburg in procedures that are lower than the heart<ref>{{Cite journal
| author = [[Marek A. Mirski]], [[Abhijit Vijay Lele]], [[Lunei Fitzsimmons]] & [[Thomas J. K. Toung]]
| title = Diagnosis and treatment of vascular air embolism
| journal = [[Anesthesiology]]
| volume = 106
| issue = 1
| pages = 164–177
| year = 2007
| month = January
| pmid = 17197859
}}</ref>
*Jugular venous compression during cranial or facial surgery
**This decreases distal venous pressure and eliminates further air entry from face and head<ref>{{Cite journal
| author = [[T. Takahashi]], [[K. Yano]], [[T. Kimura]], [[T. Komatsu]] & [[Y. Shimada]]
| title = Prevention of venous air embolism by jugular venous compression under superior sagittal sinus pressure monitoring in a brachycephalic patient during craniofacial reconstruction
| journal = [[Paediatric anaesthesia]]
| volume = 7
| issue = 3
| pages = 259–260
| year = 1997
| month =
| pmid = 9189976
}}</ref>
Post Surgery:


[[Oxygen first aid]] treatment is useful for suspected gas [[embolism]] casualties or divers who have made fast ascents or missed decompression stops. Most fully closed-circuit [[rebreather]]s can deliver sustained high concentrations of oxygen-rich [[breathing gas]] and could be used as an alternative to pure open-circuit oxygen [[resuscitator]]s.
*High flow oxygen therapy/Hyperbaric oxygen therapy
**This increases partial pressure of nitrogen and oxygen in blood leading to decrease in size of bubble and acceleration of bubble resorption<ref>{{Cite journal
| author = [[Marek A. Mirski]], [[Abhijit Vijay Lele]], [[Lunei Fitzsimmons]] & [[Thomas J. K. Toung]]
| title = Diagnosis and treatment of vascular air embolism
| journal = [[Anesthesiology]]
| volume = 106
| issue = 1
| pages = 164–177
| year = 2007
| month = January
| pmid = 17197859
}}</ref>
*Aspiration of air from right atrium
**Using the Bunegin Albin catheter<ref>{{Cite journal
| author = [[P. S. Colley]] & [[A. A. Artru]]
| title = Bunegin-Albin catheter improves air retrieval and resuscitation from lethal venous air embolism in upright dogs
| journal = [[Anesthesia and analgesia]]
| volume = 68
| issue = 3
| pages = 298–301
| year = 1989
| month = March
| pmid = 2919770
}}</ref>
**Swan Ganz catheter is shown to be ineffective<ref>{{Cite journal
| author = [[R. F. Bedford]], [[W. K. Marshall]], [[A. Butler]] & [[J. E. Welsh]]
| title = Cardiac catheters for diagnosis and treatment of venous air embolism: a prospective study in man
| journal = [[Journal of neurosurgery]]
| volume = 55
| issue = 4
| pages = 610–614
| year = 1981
| month = October
| doi = 10.3171/jns.1981.55.4.0610
| pmid = 6792326
}}</ref>
*Hemodynamic  and Cardiopulmonary resuscitation if necessary
**Some studies have shown cardiac massage may be beneficial
***This forces air out of pulmonary outflow tract leading to improved lateral blood flow<ref>{{Cite journal
| author = [[J. A. ERICSSON]], [[J. D. GOTTLIEB]] & [[R. B. SWEET]]
| title = CLOSED-CHEST CARDIAC MASSAGE IN THE TREATMENT OF VENOUS AIR EMBOLISM
| journal = [[The New England journal of medicine]]
| volume = 270
| pages = 1353–1354
| year = 1964
| month = June
| doi = 10.1056/NEJM196406182702507
| pmid = 14140269
}}</ref>


==Surgery==
==Surgery==


===Primary Prevention===
===Primary Prevention===
During Venous catheter placement:<ref>{{Cite journal
| author = [[Colin J. McCarthy]], [[Sasan Behravesh]], [[Sailendra G. Naidu]] & [[Rahmi Oklu]]
| title = Air Embolism: Practical Tips for Prevention and Treatment
| journal = [[Journal of clinical medicine]]
| volume = 5
| issue = 11
| year = 2016
| month = October
| doi = 10.3390/jcm5110093
| pmid = 27809224
}}</ref>
*Place patient in Trendelenburg position
**this increases the CVP
*Adequate hydration <ref>{{Cite journal
| author = [[C. M. Domaingue]]
| title = Neurosurgery in the sitting position: a case series
| journal = [[Anaesthesia and intensive care]]
| volume = 33
| issue = 3
| pages = 332–335
| year = 2005
| month = June
| pmid = 15973915
}}</ref>
*Avoid placement during inspiration
*Flush catheter lumens
During Venous catheter removal:<ref>{{Cite journal
| author = [[Colin J. McCarthy]], [[Sasan Behravesh]], [[Sailendra G. Naidu]] & [[Rahmi Oklu]]
| title = Air Embolism: Practical Tips for Prevention and Treatment
| journal = [[Journal of clinical medicine]]
| volume = 5
| issue = 11
| year = 2016
| month = October
| doi = 10.3390/jcm5110093
| pmid = 27809224
}}</ref> <ref>{{Cite journal
| author = [[P. Ingram]], [[Linda Sinclair]] & [[Toby Edwards]]
| title = The safe removal of central venous catheters
| journal = [[Nursing standard (Royal College of Nursing (Great Britain) : 1987)]]
| volume = 20
| issue = 49
| pages = 42–46
| year = 2006
| month = August
| doi = 10.7748/ns2006.08.20.49.42.c4483
| pmid = 16939143
}}</ref>
*Place patient in Trendelenburg position
*Remove Catheter during valsalva or expiration
*Cover site and apply pressure for 5-10 minutes
*Patient should remain supine for 30 minutes post procedure
During other Invasive procedures:<ref>{{Cite journal
| author = [[Colin J. McCarthy]], [[Sasan Behravesh]], [[Sailendra G. Naidu]] & [[Rahmi Oklu]]
| title = Air Embolism: Practical Tips for Prevention and Treatment
| journal = [[Journal of clinical medicine]]
| volume = 5
| issue = 11
| year = 2016
| month = October
| doi = 10.3390/jcm5110093
| pmid = 27809224
}}</ref>
*Use of a flush in a closed system
*Prime tubing with saline
*No air should be present in syringes
*Intra operative use of precordial doppler
*Avoid use of Nitrous oxide during abdominal procedures
*"park bench position" should be used for surgeries performed in the sitting position<ref>{{Cite journal
| author = [[T. Mammoto]], [[Y. Hayashi]], [[Y. Ohnishi]] & [[M. Kuro]]
| title = Incidence of venous and paradoxical air embolism in neurosurgical patients in the sitting position: detection by transesophageal echocardiography
| journal = [[Acta anaesthesiologica Scandinavica]]
| volume = 42
| issue = 6
| pages = 643–647
| year = 1998
| month = July
| pmid = 9689268
}}</ref>
*Use of Reverse Trendelenburg position during Cesarian section<ref>{{Cite journal
| author = [[J. Fong]], [[F. Gadalla]] & [[M. Druzin]]
| title = Venous emboli occurring caesarean section: the effect of patient position
| journal = [[Canadian journal of anaesthesia = Journal canadien d'anesthesie]]
| volume = 38
| issue = 2
| pages = 191–195
| year = 1991
| month = March
| pmid = 2021988
}}</ref>
If an [[artery|arterial]] gas [[embolism]] resulting from [[patent foramen ovale]] is suspected, an exam by [[echocardiography]] may be performed to [[diagnosis|diagnose]] the defect. In this test, very fine (microscopic) bubbles are introduced into a patient's vein by agitating saline in a [[syringe]] to produce the bubbles, then injecting them into an arm [[vein]]. A few seconds later, these bubbles may be clearly seen in the [[ultrasound]] image, as they travel through the patient's [[right atrium]] and [[ventricle]]. At this time, bubbles may be observed directly crossing a septal defect, or else a [[patent foramen ovale]] may be opened temporarily by asking the patient to perform the [[Valsalva maneuver]] while the bubbles are crossing through the right heart-- an action which will open the [[foramen ovale|foramen]] flap and show bubbles passing into the left heart. Such bubbles are too small to cause harm in the test, but such a [[diagnosis]] may alert the patient to possible problems which may occur from larger bubbles, formed during activities like scuba diving.
If an [[artery|arterial]] gas [[embolism]] resulting from [[patent foramen ovale]] is suspected, an exam by [[echocardiography]] may be performed to [[diagnosis|diagnose]] the defect. In this test, very fine (microscopic) bubbles are introduced into a patient's vein by agitating saline in a [[syringe]] to produce the bubbles, then injecting them into an arm [[vein]]. A few seconds later, these bubbles may be clearly seen in the [[ultrasound]] image, as they travel through the patient's [[right atrium]] and [[ventricle]]. At this time, bubbles may be observed directly crossing a septal defect, or else a [[patent foramen ovale]] may be opened temporarily by asking the patient to perform the [[Valsalva maneuver]] while the bubbles are crossing through the right heart-- an action which will open the [[foramen ovale|foramen]] flap and show bubbles passing into the left heart. Such bubbles are too small to cause harm in the test, but such a [[diagnosis]] may alert the patient to possible problems which may occur from larger bubbles, formed during activities like scuba diving.


==Secondary Prevention==
==Secondary Prevention==
If air embolism is suspected during a procedure:<ref>{{Cite journal
| author = [[Colin J. McCarthy]], [[Sasan Behravesh]], [[Sailendra G. Naidu]] & [[Rahmi Oklu]]
| title = Air Embolism: Practical Tips for Prevention and Treatment
| journal = [[Journal of clinical medicine]]
| volume = 5
| issue = 11
| year = 2016
| month = October
| doi = 10.3390/jcm5110093
| pmid = 27809224
}}</ref>
*Flush should be stopped
*Rotating hemostatic valve should be opened


==References==
==References==

Latest revision as of 17:38, 23 October 2018

Air Embolism Microchapters

Home

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Overview

Historical Perspective

Classification

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Causes

Differentiating Air embolism from Other Diseases

Epidemiology and Demographics

Risk Factors

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Natural History, Complications, and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

CT

MRI

Echocardiography or Ultrasound

Other Imaging Findings

Other Diagnostic Studies

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

An air embolism, or more generally gas embolism, is a medical condition caused by gas bubbles in the bloodstream (embolism in a medical context refers to any large moving mass or defect in the blood stream). Small amounts of air may enter the blood circulation during surgery, other invasive medical procedures, or deep sea diving. There are two types of air embolisms: venous or arterial. venous air embolisms rarely present with symptoms. Symptoms or death mainly occur in the arterial system. Symptoms may occur in the venous system, if a large bubble of gas becomes lodged in the heart, stopping blood from flowing from the right ventricle to the lungs (this is similar to vapor lock in engine fuel systems). However, the amount of gas necessary for this to happen is quite variable, and also depends on a number of other factors, such as body position.

Gas embolism into an artery, termed arterial gas embolism, or AGE, is a more severe diagnosis than venous air embolism, since a gas bubble in an artery may directly cause ischemia to an area fed by the artery. The symptoms of AGE depend on the artery and the organs that it supplies. For example,a stroke or a heart attack may occur if the brain or heart (respectively) are affected.

Decompression sickness (DCS) is a diving disorder that SCUBA divers sometimes suffer when they have pressure damage to their lungs following a rapid ascent where the breath is inappropriately held against a closed glottis, allowing pressure to build up inside the lungs, relative to the blood. It is termed "gas" because the diver may be using a diving breathing gas other than air. The gas bubbles can impede the flow of oxygen-rich blood to the brain and other vital organs. They can also cause clots to form in blood vessels.

Gas embolism and decompression sickness (DCS) have similar symptoms, especially in the central nervous system. The treatment for both is the same, because they are both the result of gas bubbles in the body.

Historical Perspective

Not much is known about the history of air embolism, but it has been diagnosed as early as the 19th century.[1]

Classification

  • Air embolism may be classified according to location into 2 subtypes:

Pathophysiology

Air embolism can occur whenever there is access to an open blood vessel and a pressure gradient exists favoring entry of gas. Because the pressure in most arteries and veins is greater than atmospheric pressure, an air embolus does not always happen when a blood vessel is injured. In the veins above the heart, such as in the head and neck, the pressure is less than atmospheric and an injury may let air in. This is one reason why surgeons must be particularly careful when operating on the brain, and why the head of the bed is tilted down when inserting or removing a central venous catheter from the jugular or subclavian veins.

When air enters the veins, it travels to the right side of the heart, and then to the lungs. This can cause the vessels of the lung to constrict, raising the pressure in the right side of the heart. If the pressure rises high enough in a patient who is one of the 20% to 30% of the population with a patent foramen ovale, the gas bubble can then travel to the left side of the heart, and on to the brain or coronary arteries. Such bubbles are responsible for the most serious of gas embolic symptoms.

Trauma to the lung can also cause an air embolism. This may happen after a patient is placed on a ventilator and air is forced into an injured vein or artery, causing sudden death. Breath-holding and rapid ascent from scuba diving may also force nitrogen air into pulmonary arteries or veins causing Decompression Sickness During a deep sea dive nitrogen accumulates in the tissues of the body, as the diver ascends, the nitrogen leaves the body through the lungs, if the ascent occurs too rapidly nitrogen bubble can form and diffuse into the circulation causing an air embolism.[2]

Air can be injected directly into the veins either accidentally or as a deliberate act. Examples include misuse of a syringe, and industrial injury resulting from use of compressed air. However, despite being employed by writers of fiction as a clandestine method of murder, amounts of air such as would be administered by a single small syringe are not likely to suddenly stop the heart, nor cause instant death. Single air bubbles in a vein do not stop the heart, due to being too small. However, such bubbles may occasionally reach the arterial system through a patent foramen ovale, as noted above, and cause random ischemic damage, depending on their route of arterial travel.

Causes

  • Deep sea diving (Decompression Sickness/ Caisson's Disease/ "the bends")[14]
  • Blunt chest trauma [15]

Differentiating Air Embolism from other Diseases

  • Air embolism must be differentiated from other diseases that cause dyspnea, joint and muscle pain, and mental status changes, such as[16]
  • Pulmonary emboli
  • Myocardial Infarction/Acute coronary syndrome [17]
  • Stroke
  • Cardiogenic shock

Epidemiology and Demographics

  • The prevalence of air embolism is approximately 2.65 per 100,000 hospitalizations.[18]
  • The prevalence of air embolism is approximately 7 per 100,000 divers.[19]

Age

  • Patients of all age groups may develop Air embolism.

Gender

  • Air embolism affects men and women equally.

Race

  • There is no racial predilection for Air embolism.

Risk Factors

  • Common risk factors in the development of air embolism are:
  • Operative site more that 5cm above the right atrium[20]
  • Numerous uncompressed venous channels in surgical site[21]
  • Pressure gradient during surgery[22]
  • Insertion or removal of catheter[23]
    • Fracture/de attachment of catheter
    • Failure to occlude needle hub
    • Deep inspiration
    • Hypovolemia
    • Up right position
  • Scuba diving[24]
    • Rapid ascent rate
    • Diving too long
    • Diving at great depth

Natural History, Complications and Prognosis

  • Early clinical features include chest pain dyspnea, and altered mental status.
  • Common complications of air embolism include, stroke, seizures, and infarction of various organs.
  • Prognosis is generally variable,it depends on the size and location of the embolism , and the mortality rate of patients with air embolism is approximately 48-80%.[25]
  • A 200-300ml bolus or 3-5 ml/kg of air in a human is fatal[26]

Diagnosis

Diagnostic Criteria

  • There is no established diagnostic criteria for air embolism.
  • The diagnosis of air embolism is clinical and should be suspected in patients with history of:
  • High risk procedures
  • Scuba diving
  • Trauma to head, neck, thorax or abdomen
  • Hemodialysis catheters
  • Positive pressure ventilation

Symptoms

  • Symptoms of air embolism depend on:[27]
    • the location
    • size of the emboli
    • rate of emboli formation
    • patient spontaneously breathing
    • patient under controlled positive pressure ventilation
  • Symptoms include the following:
  • Dyspnea
  • Cough
  • Chest pain
  • Mental status changes
  • Dizziness/ Vertigo
  • Nausea
  • Syncope
  • Headache
  • Anxiety

Physical Examination

  • Patients with air embolism usually appear distressed.
  • Physical examination may be remarkable for:
  • Cardiovascular Findings:[28] [29]
    • Arrythmias
    • Murmmurs
    • Jugular venous distension
    • Hypotension
    • ST and T wave changes
    • Pulmonary arterial hypertension
    • Increased central venous pressure
    • Shock and cardiovascular collapse
  • Respiratory Findings:[30][31]
    • Rales/ wheezing
    • Tachypnea
    • Hemoptysis
    • Cyanosis
    • Decreased End Tidal Co2
    • Hypercapnia
    • Pulmonary edema
    • Apnea
  • Central Nervous System Findings:[32][33]
    • Altered mental status
    • Seizures
    • Focal neurological deficits
    • Loss of consciousness
    • Coma

Laboratory Findings

  • There is no one test that is diagnostic for air embolism.
  • The diagnosis is clinical but some lab findings can help lead to the diagnosis, and can indicate which organs and systems are affected.
  • Laboratory findings consistent with the diagnosis of air embolism include:[34]
    • Decreased End tidal CO2[35]
    • Increased End tidal Nitrogen[36]
    • Increased pulmonary artery pressure[37]

Imaging Findings

  • Transesophageal Echocardiography (TEE) is the most sensitive imaging modality for air embolism.[38][39]
    • On TEE, air embolism is characterized by detection of air in circulation.
  • Precordial Doppler Ultrasound is the most sensitive noninvasive imaging modality for air embolism.[40][41]
    • Precordial Doppler Ultrasound may demonstrate air in circulation.
  • Transcranial Doppler Ultrasound is also used to detect air embolism.
    • Transcranial Doppler Ultrasound may demonstrate cerebral emboli.
  • Contrast enhanced CT scan of the chest may be used to help diagnose air embolism.
    • CT chest may show intra-cardial air[42][43]
    • CT chest may show a filling defect in the lungs[44]
  • CT or MRI of the head may be used to diagnose air embolism[45]
    • Contrast enhanced CT may show areas of ischemia or entrapment of air
    • MRI may show areas of ischemia

Other Diagnostic Studies.

  • EKG may also be used to help diagnose air embolism.
    • Findings on EKG include ST segment changes, peaked P waves, and tachyarrthmia.[46]
  • Pulse Oximetry showing saturation changes is a late finding.[47]
  • Chest X-ray may be used to rule out other causes of dyspnea and chest pain.
    • Chest X-ray may show intra-cardiac air.[48]

Treatment

Medical Therapy

Air embolism is a medical emergency.The mainstay of therapy for air embolism is high flow oxygen therapy with 100% oxygen.

During surgery:

  • Cover surgical site
    • This prevents further air trapping[49]
  • Tilt operating table
    • This lowers the source of air entry and eliminates negative air pressure gradient[50]
  • Reverse Trendelenburg in procedures that are lower than the heart[51]
  • Jugular venous compression during cranial or facial surgery
    • This decreases distal venous pressure and eliminates further air entry from face and head[52]

Post Surgery:

  • High flow oxygen therapy/Hyperbaric oxygen therapy
    • This increases partial pressure of nitrogen and oxygen in blood leading to decrease in size of bubble and acceleration of bubble resorption[53]
  • Aspiration of air from right atrium
    • Using the Bunegin Albin catheter[54]
    • Swan Ganz catheter is shown to be ineffective[55]
  • Hemodynamic and Cardiopulmonary resuscitation if necessary
    • Some studies have shown cardiac massage may be beneficial
      • This forces air out of pulmonary outflow tract leading to improved lateral blood flow[56]

Surgery

Primary Prevention

During Venous catheter placement:[57]

  • Place patient in Trendelenburg position
    • this increases the CVP
  • Adequate hydration [58]
  • Avoid placement during inspiration
  • Flush catheter lumens

During Venous catheter removal:[59] [60]

  • Place patient in Trendelenburg position
  • Remove Catheter during valsalva or expiration
  • Cover site and apply pressure for 5-10 minutes
  • Patient should remain supine for 30 minutes post procedure

During other Invasive procedures:[61]

  • Use of a flush in a closed system
  • Prime tubing with saline
  • No air should be present in syringes
  • Intra operative use of precordial doppler
  • Avoid use of Nitrous oxide during abdominal procedures
  • "park bench position" should be used for surgeries performed in the sitting position[62]
  • Use of Reverse Trendelenburg position during Cesarian section[63]

If an arterial gas embolism resulting from patent foramen ovale is suspected, an exam by echocardiography may be performed to diagnose the defect. In this test, very fine (microscopic) bubbles are introduced into a patient's vein by agitating saline in a syringe to produce the bubbles, then injecting them into an arm vein. A few seconds later, these bubbles may be clearly seen in the ultrasound image, as they travel through the patient's right atrium and ventricle. At this time, bubbles may be observed directly crossing a septal defect, or else a patent foramen ovale may be opened temporarily by asking the patient to perform the Valsalva maneuver while the bubbles are crossing through the right heart-- an action which will open the foramen flap and show bubbles passing into the left heart. Such bubbles are too small to cause harm in the test, but such a diagnosis may alert the patient to possible problems which may occur from larger bubbles, formed during activities like scuba diving.

Secondary Prevention

If air embolism is suspected during a procedure:[64]

  • Flush should be stopped
  • Rotating hemostatic valve should be opened

References

  1. ↑ Nissar Shaikh & Firdous Ummunisa (2009). "Acute management of vascular air embolism". Journal of emergencies, trauma, and shock. 2 (3): 180–185. doi:10.4103/0974-2700.55330. PMID 20009308. Unknown parameter |month= ignored (help)
  2. ↑ Asadullah Naqvi & Derrick Clarence (2018). "A case of decompression illness not responding to hyperbaric oxygen". Journal of intensive care. 6: 29. doi:10.1186/s40560-018-0299-3. PMID 29796283.
  3. ↑ Nicholas J. Parkinson, Harold C. McKenzie, Michelle H. Barton, Jennifer L. Davis, Bettina Dunkel, Amy L. Johnson & Elizabeth S. MacDonald (2018). "Catheter-associated venous air embolism in hospitalized horses: 32 cases". Journal of veterinary internal medicine. 32 (2): 805–814. doi:10.1111/jvim.15057. PMID 29460300. Unknown parameter |month= ignored (help)
  4. ↑ T. M. Vesely (2001). "Air embolism during insertion of central venous catheters". Journal of vascular and interventional radiology : JVIR. 12 (11): 1291–1295. PMID 11698628. Unknown parameter |month= ignored (help)
  5. ↑ Lawrence Lau & Kory London (2018). "Cortical Blindness and Altered Mental Status following Routine Hemodialysis, a Case of Iatrogenic Cerebral Air Embolism". Case reports in emergency medicine. 2018: 9496818. doi:10.1155/2018/9496818. PMID 29732225.
  6. ↑ J. M. Bao, J. P. Lin, X. Yu & H. Yu (2018). "[Effects of pneumoperitoneal pressure on air embolism duringlaparoscopic hepatectomy and degree of postoperative inflammation]". Zhonghua yi xue za zhi. 98 (26): 2088–2091. PMID 30032506. Unknown parameter |month= ignored (help)
  7. ↑ Kalpana Yeddula, Iftikhar Ahmad, Shafaath Husain Syed Mohammed, Sandeep Hedgire, Vikram Venkatesh, Suhny Abbara & Sanjeeva P. Kalva (2012). "Paradoxical air embolism following contrast material injection through power injectors in patients with a patent foramen ovale". The international journal of cardiovascular imaging. 28 (8): 2085–2090. doi:10.1007/s10554-012-0017-5. PMID 22302647. Unknown parameter |month= ignored (help)
  8. ↑ Jonathan P. Wanderer & Naveen Nathan (2018). "Bubble Trouble: Venous Air Embolism in Endoscopic Retrograde Cholangiopancreatography". Anesthesia and analgesia. 127 (2): 324. doi:10.1213/ANE.0000000000003599. PMID 30028380. Unknown parameter |month= ignored (help)
  9. ↑ Rika Yoshida, Takeshi Yoshizako, Megumi Nakamura, Shinji Ando, Mitsunari Maruyama, Minako Maruyama, Yoshikazu Takinami, Yukihisa Tamaki, Tomonori Nakamura & Hajime Kitagaki (2018). "Nonfatal air embolism complicating percutaneous CT-guided lung biopsy and VATS marking: Four cases from a single institution". Clinical imaging. 48: 127–130. doi:10.1016/j.clinimag.2017.10.010. PMID 29100079. Unknown parameter |month= ignored (help)
  10. ↑ Se-Min Ryu & Sung-Min Park (2018). "Unexpected complication during extracorporeal membrane oxygenation support: Ventilator associated systemic air embolism". World journal of clinical cases. 6 (9): 274–278. doi:10.12998/wjcc.v6.i9.274. PMID 30211207. Unknown parameter |month= ignored (help)
  11. ↑ Richard C. Prielipp & Sorin J. Brull (2018). "Vascular Air Embolism and Endoscopy: Every Bubble Matters". Anesthesia and analgesia. 127 (2): 333–335. doi:10.1213/ANE.0000000000003329. PMID 30028384. Unknown parameter |month= ignored (help)
  12. ↑ Arnoley S. Abcejo, Jeffrey J. Pasternak & William J. Perkins (2018). "Urgent Repositioning After Venous Air Embolism During Intracranial Surgery in the Seated Position: A Case Series". Journal of neurosurgical anesthesiology. doi:10.1097/ANA.0000000000000534. PMID 30148744. Unknown parameter |month= ignored (help)
  13. ↑ John K. Chan, Austin B. Gardner, Amandeep K. Mann & Daniel S. Kapp (2018). "Hospital-acquired conditions after surgery for gynecologic cancer - An analysis of 82,304 patients". Gynecologic oncology. 150 (3): 515–520. doi:10.1016/j.ygyno.2018.07.009. PMID 30037490. Unknown parameter |month= ignored (help)
  14. ↑ Josep M. Casadesus, Fernando Aguirre, Ana Carrera, Pere Boadas-Vaello, Maria T. Serrando & Francisco Reina (2018). "Diagnosis of arterial gas embolism in SCUBA diving: modification suggestion of autopsy techniques and experience in eight cases". Forensic science, medicine, and pathology. 14 (1): 18–25. doi:10.1007/s12024-018-9951-4. PMID 29460254. Unknown parameter |month= ignored (help)
  15. ↑ Isabella Mercurio, Daniele Capano, Riccardo Torre, Aldo Taddei, Gianmarco Troiano, Michele Scialpi & Mario Gabbrielli (2018). "A Case of Fatal Cerebral Air Embolism After Blunt Lung Trauma: Postmortem Computed Tomography and Autopsy Findings". The American journal of forensic medicine and pathology. 39 (1): 61–68. doi:10.1097/PAF.0000000000000375. PMID 29278540. Unknown parameter |month= ignored (help)
  16. ↑ Nissar Shaikh & Firdous Ummunisa (2009). "Acute management of vascular air embolism". Journal of emergencies, trauma, and shock. 2 (3): 180–185. doi:10.4103/0974-2700.55330. PMID 20009308. Unknown parameter |month= ignored (help)
  17. ↑ C.-M. Chao, W.-L. Liu, C.-F. Hsieh & C.-C. Lai (2016). "Pulmonary air embolism". QJM : monthly journal of the Association of Physicians. 109 (4): 283–284. doi:10.1093/qjmed/hcv226. PMID 26742568. Unknown parameter |month= ignored (help)
  18. ↑ Jacques Bessereau, Nicolas Genotelle, Cendrine Chabbaut, Anne Huon, Alexis Tabah, Jerome Aboab, Sylvie Chevret & Djillali Annane (2010). "Long-term outcome of iatrogenic gas embolism". Intensive care medicine. 36 (7): 1180–1187. doi:10.1007/s00134-010-1821-9. PMID 20221749. Unknown parameter |month= ignored (help)
  19. ↑ D. R. Leitch & R. D. Green (1986). "Pulmonary barotrauma in divers and the treatment of cerebral arterial gas embolism". Aviation, space, and environmental medicine. 57 (10 Pt 1): 931–938. PMID 3778391. Unknown parameter |month= ignored (help)
  20. ↑ Nissar Shaikh & Firdous Ummunisa (2009). "Acute management of vascular air embolism". Journal of emergencies, trauma, and shock. 2 (3): 180–185. doi:10.4103/0974-2700.55330. PMID 20009308. Unknown parameter |month= ignored (help)
  21. ↑ Nissar Shaikh & Firdous Ummunisa (2009). "Acute management of vascular air embolism". Journal of emergencies, trauma, and shock. 2 (3): 180–185. doi:10.4103/0974-2700.55330. PMID 20009308. Unknown parameter |month= ignored (help)
  22. ↑ J. P. Flanagan, I. A. Gradisar, R. J. Gross & T. R. Kelly (1969). "Air embolus--a lethal complication of subclavian venipuncture". The New England journal of medicine. 281 (9): 488–489. doi:10.1056/NEJM196908282810907. PMID 5796967. Unknown parameter |month= ignored (help)
  23. ↑ Nissar Shaikh & Firdous Ummunisa (2009). "Acute management of vascular air embolism". Journal of emergencies, trauma, and shock. 2 (3): 180–185. doi:10.4103/0974-2700.55330. PMID 20009308. Unknown parameter |month= ignored (help)
  24. ↑ J. Aharon-Peretz, Y. Adir, C. R. Gordon, S. Kol, N. Gal & Y. Melamed (1993). "Spinal cord decompression sickness in sport diving". Archives of neurology. 50 (7): 753–756. PMID 8323480. Unknown parameter |month= ignored (help)
  25. ↑ A. M. Ho & E. Ling (1999). "Systemic air embolism after lung trauma". Anesthesiology. 90 (2): 564–575. PMID 9952165. Unknown parameter |month= ignored (help)
  26. ↑ T. J. Toung, M. I. Rossberg & G. M. Hutchins (2001). "Volume of air in a lethal venous air embolism". Anesthesiology. 94 (2): 360–361. PMID 11176104. Unknown parameter |month= ignored (help)
  27. ↑ Marek A. Mirski, Abhijit Vijay Lele, Lunei Fitzsimmons & Thomas J. K. Toung (2007). "Diagnosis and treatment of vascular air embolism". Anesthesiology. 106 (1): 164–177. PMID 17197859. Unknown parameter |month= ignored (help)
  28. ↑ Marek A. Mirski, Abhijit Vijay Lele, Lunei Fitzsimmons & Thomas J. K. Toung (2007). "Diagnosis and treatment of vascular air embolism". Anesthesiology. 106 (1): 164–177. PMID 17197859. Unknown parameter |month= ignored (help)
  29. ↑ S. L. Orebaugh (1992). "Venous air embolism: clinical and experimental considerations". Critical care medicine. 20 (8): 1169–1177. PMID 1643897. Unknown parameter |month= ignored (help)
  30. ↑ Marek A. Mirski, Abhijit Vijay Lele, Lunei Fitzsimmons & Thomas J. K. Toung (2007). "Diagnosis and treatment of vascular air embolism". Anesthesiology. 106 (1): 164–177. PMID 17197859. Unknown parameter |month= ignored (help)
  31. ↑ S. L. Orebaugh (1992). "Venous air embolism: clinical and experimental considerations". Critical care medicine. 20 (8): 1169–1177. PMID 1643897. Unknown parameter |month= ignored (help)
  32. ↑ Marek A. Mirski, Abhijit Vijay Lele, Lunei Fitzsimmons & Thomas J. K. Toung (2007). "Diagnosis and treatment of vascular air embolism". Anesthesiology. 106 (1): 164–177. PMID 17197859. Unknown parameter |month= ignored (help)
  33. ↑ S. L. Orebaugh (1992). "Venous air embolism: clinical and experimental considerations". Critical care medicine. 20 (8): 1169–1177. PMID 1643897. Unknown parameter |month= ignored (help)
  34. ↑ Marek A. Mirski, Abhijit Vijay Lele, Lunei Fitzsimmons & Thomas J. K. Toung (2007). "Diagnosis and treatment of vascular air embolism". Anesthesiology. 106 (1): 164–177. PMID 17197859. Unknown parameter |month= ignored (help)
  35. ↑ T. M. Brechner & V. L. Brechner (1977). "An audible alarm for monitoring air embolism during neurosurgery". Journal of neurosurgery. 47 (2): 201–204. doi:10.3171/jns.1977.47.2.0201. PMID 874544. Unknown parameter |month= ignored (help)
  36. ↑ J. E. Souders (2000). "Pulmonary air embolism". Journal of clinical monitoring and computing. 16 (5–6): 375–383. PMID 12580220.
  37. ↑ Nissar Shaikh & Firdous Ummunisa (2009). "Acute management of vascular air embolism". Journal of emergencies, trauma, and shock. 2 (3): 180–185. doi:10.4103/0974-2700.55330. PMID 20009308. Unknown parameter |month= ignored (help)
  38. ↑ R. A. Jaffe, L. C. Siegel, I. Schnittger, J. W. Propst & J. G. Brock-Utne (1995). "Epidural air injection assessed by transesophageal echocardiography". Regional anesthesia. 20 (2): 152–155. PMID 7605763. Unknown parameter |month= ignored (help)
  39. ↑ H. Furuya, T. Suzuki, F. Okumura, Y. Kishi & T. Uefuji (1983). "Detection of air embolism by transesophageal echocardiography". Anesthesiology. 58 (2): 124–129. PMID 6401948. Unknown parameter |month= ignored (help)
  40. ↑ S. G. Soriano, M. L. McManus, L. J. Sullivan, R. M. Scott & M. A. Rockoff (1994). "Doppler sensor placement during neurosurgical procedures for children in the prone position". Journal of neurosurgical anesthesiology. 6 (3): 153–155. PMID 8081094. Unknown parameter |month= ignored (help)
  41. ↑ J. L. Chang, M. S. Albin, L. Bunegin & T. K. Hung (1980). "Analysis and comparison of venous air embolism detection methods". Neurosurgery. 7 (2): 135–141. PMID 7422108. Unknown parameter |month= ignored (help)
  42. ↑ Julio Lanfranco, Ivan Romero Legro, Amado X. Freire, Katherine Nearing & Sanjay Ratnakant (2017). "Pulmonary Air Embolism: An Infrequent Complication in the Radiology Suite". The American journal of case reports. 18: 80–84. PMID 28115731. Unknown parameter |month= ignored (help)
  43. ↑ Kyong Shil Im, Joon Suk Woo & Jae Myeong Lee (2014). "Recurrence of fatal venous air embolism". Korean journal of anesthesiology. 67 (Suppl): S111–S112. doi:10.4097/kjae.2014.67.S.S111. PMID 25598879. Unknown parameter |month= ignored (help)
  44. ↑ Julio Lanfranco, Ivan Romero Legro, Amado X. Freire, Katherine Nearing & Sanjay Ratnakant (2017). "Pulmonary Air Embolism: An Infrequent Complication in the Radiology Suite". The American journal of case reports. 18: 80–84. PMID 28115731. Unknown parameter |month= ignored (help)
  45. ↑ Jochen Bauerle, Andreas Fischer, Tobias Hornig, Karl Egger, Tobias Wengenmayer & Jurgen Bardutzky (2013). "Therapeutic hypothermia in cerebral air embolism: a case report". SpringerPlus. 2: 411. doi:10.1186/2193-1801-2-411. PMID 24024097.
  46. ↑ P. L. Gildenberg, R. P. O'Brien, W. J. Britt & E. A. Frost (1981). "The efficacy of Doppler monitoring for the detection of venous air embolism". Journal of neurosurgery. 54 (1): 75–78. doi:10.3171/jns.1981.54.1.0075. PMID 7463123. Unknown parameter |month= ignored (help)
  47. ↑ Marek A. Mirski, Abhijit Vijay Lele, Lunei Fitzsimmons & Thomas J. K. Toung (2007). "Diagnosis and treatment of vascular air embolism". Anesthesiology. 106 (1): 164–177. PMID 17197859. Unknown parameter |month= ignored (help)
  48. ↑ Kyong Shil Im, Joon Suk Woo & Jae Myeong Lee (2014). "Recurrence of fatal venous air embolism". Korean journal of anesthesiology. 67 (Suppl): S111–S112. doi:10.4097/kjae.2014.67.S.S111. PMID 25598879. Unknown parameter |month= ignored (help)
  49. ↑ Marek A. Mirski, Abhijit Vijay Lele, Lunei Fitzsimmons & Thomas J. K. Toung (2007). "Diagnosis and treatment of vascular air embolism". Anesthesiology. 106 (1): 164–177. PMID 17197859. Unknown parameter |month= ignored (help)
  50. ↑ Marek A. Mirski, Abhijit Vijay Lele, Lunei Fitzsimmons & Thomas J. K. Toung (2007). "Diagnosis and treatment of vascular air embolism". Anesthesiology. 106 (1): 164–177. PMID 17197859. Unknown parameter |month= ignored (help)
  51. ↑ Marek A. Mirski, Abhijit Vijay Lele, Lunei Fitzsimmons & Thomas J. K. Toung (2007). "Diagnosis and treatment of vascular air embolism". Anesthesiology. 106 (1): 164–177. PMID 17197859. Unknown parameter |month= ignored (help)
  52. ↑ T. Takahashi, K. Yano, T. Kimura, T. Komatsu & Y. Shimada (1997). "Prevention of venous air embolism by jugular venous compression under superior sagittal sinus pressure monitoring in a brachycephalic patient during craniofacial reconstruction". Paediatric anaesthesia. 7 (3): 259–260. PMID 9189976.
  53. ↑ Marek A. Mirski, Abhijit Vijay Lele, Lunei Fitzsimmons & Thomas J. K. Toung (2007). "Diagnosis and treatment of vascular air embolism". Anesthesiology. 106 (1): 164–177. PMID 17197859. Unknown parameter |month= ignored (help)
  54. ↑ P. S. Colley & A. A. Artru (1989). "Bunegin-Albin catheter improves air retrieval and resuscitation from lethal venous air embolism in upright dogs". Anesthesia and analgesia. 68 (3): 298–301. PMID 2919770. Unknown parameter |month= ignored (help)
  55. ↑ R. F. Bedford, W. K. Marshall, A. Butler & J. E. Welsh (1981). "Cardiac catheters for diagnosis and treatment of venous air embolism: a prospective study in man". Journal of neurosurgery. 55 (4): 610–614. doi:10.3171/jns.1981.55.4.0610. PMID 6792326. Unknown parameter |month= ignored (help)
  56. ↑ J. A. ERICSSON, J. D. GOTTLIEB & R. B. SWEET (1964). "CLOSED-CHEST CARDIAC MASSAGE IN THE TREATMENT OF VENOUS AIR EMBOLISM". The New England journal of medicine. 270: 1353–1354. doi:10.1056/NEJM196406182702507. PMID 14140269. Unknown parameter |month= ignored (help)
  57. ↑ Colin J. McCarthy, Sasan Behravesh, Sailendra G. Naidu & Rahmi Oklu (2016). "Air Embolism: Practical Tips for Prevention and Treatment". Journal of clinical medicine. 5 (11). doi:10.3390/jcm5110093. PMID 27809224. Unknown parameter |month= ignored (help)
  58. ↑ C. M. Domaingue (2005). "Neurosurgery in the sitting position: a case series". Anaesthesia and intensive care. 33 (3): 332–335. PMID 15973915. Unknown parameter |month= ignored (help)
  59. ↑ Colin J. McCarthy, Sasan Behravesh, Sailendra G. Naidu & Rahmi Oklu (2016). "Air Embolism: Practical Tips for Prevention and Treatment". Journal of clinical medicine. 5 (11). doi:10.3390/jcm5110093. PMID 27809224. Unknown parameter |month= ignored (help)
  60. ↑ P. Ingram, Linda Sinclair & Toby Edwards (2006). "The safe removal of central venous catheters". Nursing standard (Royal College of Nursing (Great Britain) : 1987). 20 (49): 42–46. doi:10.7748/ns2006.08.20.49.42.c4483. PMID 16939143. Unknown parameter |month= ignored (help)
  61. ↑ Colin J. McCarthy, Sasan Behravesh, Sailendra G. Naidu & Rahmi Oklu (2016). "Air Embolism: Practical Tips for Prevention and Treatment". Journal of clinical medicine. 5 (11). doi:10.3390/jcm5110093. PMID 27809224. Unknown parameter |month= ignored (help)
  62. ↑ T. Mammoto, Y. Hayashi, Y. Ohnishi & M. Kuro (1998). "Incidence of venous and paradoxical air embolism in neurosurgical patients in the sitting position: detection by transesophageal echocardiography". Acta anaesthesiologica Scandinavica. 42 (6): 643–647. PMID 9689268. Unknown parameter |month= ignored (help)
  63. ↑ J. Fong, F. Gadalla & M. Druzin (1991). "Venous emboli occurring caesarean section: the effect of patient position". Canadian journal of anaesthesia = Journal canadien d'anesthesie. 38 (2): 191–195. PMID 2021988. Unknown parameter |month= ignored (help)
  64. ↑ Colin J. McCarthy, Sasan Behravesh, Sailendra G. Naidu & Rahmi Oklu (2016). "Air Embolism: Practical Tips for Prevention and Treatment". Journal of clinical medicine. 5 (11). doi:10.3390/jcm5110093. PMID 27809224. Unknown parameter |month= ignored (help)

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