Multidisciplinary Approach to Obstructive Shock From Air Embolism

Document Type

Conference Proceeding

Publication Date

10-2024

Publication Title

Chest

Abstract

INTRODUCTION: Air embolism is a rare complication of CT guided lung biopsy with a high morbidity and mortality. We present a case of massive venous air emboli observed in the right atrium during the procedure leading to cardiac arrest and subsequent death despite aggressive medical and surgical therapy. CASE PRESENTATION: An 86-year-old gentleman with multiple myeloma presented to radiology for CT-guided biopsy of a left upper lobe spiculated nodule. The procedure was complicated by an air embolism moving to the right heart. He was placed in left lateral decubitus (LLD) position and subsequently had a pulseless electrical activity arrest with multiple cycles of cardiopulmonary resuscitation. He was transferred to the ICU after return of spontaneous circulation. He had severe obstructive shock requiring maximal doses of 3 vasopressors. Bilateral chest tubes were placed by surgery without massive evacuation of air for concern of pneumothorax. He was placed in Trendelenburg position and hyper oxygenated with 100% FiO2. The pulmonary embolism response team was activated, with recommendation for aspiration of air and bedside transesophageal echocardiogram (TEE). 30 cc of air was aspirated via a left internal jugular central venous catheter (CVC). Cardiac windows obtained via ultrasound showed air bubbles in the right atrium, right ventricle, and inferior vena cava. DISCUSSION: Air emboli are largely an iatrogenic complication of CT guided needle biopsies due to air entering the pulmonary vasculature affecting gas exchange and leading to cardiac arrythmias. The air emboli cause right ventricular strain, increased pulmonary arterial pressures, decrease in pulmonary venous return, and decreased left ventricular preload leading to cardiac failure. Our patient developed ventricular tachycardia; TEE showed severely decreased right ventricle (RV) systolic function, RV volume overload and enlargement. Other findings include mill-wheel murmur on cardiac auscultation and decreased end tidal carbon dioxide on capnometry. Our patient was evaluated by cardiology at bedside and was not stable for TEE or transport for hyperbaric oxygenation. Hyperbaric oxygen is shown to decrease the size of the air emboli and is second line management. Patients with patent foramen ovale can have paradoxical emboli with neurological complications from emboli to the cerebral circulation. An estimate of 200-300 cc of air is thought to be fatal secondary to obstructive shock. CONCLUSIONS: Venous or arterial air embolism can be fatal hence prompt identification, further prevention of air entry into the vessels, and multidisciplinary management is required. It can manifest as rapid hemodynamic deterioration with cardiorespiratory collapse and/or neurologic symptoms. Patients should be managed supportively with resuscitation, oxygenation with 100% Fio2, Trendelenburg/LLD positioning for venous emboli, supine/right lateral decubitus/Trendelenburg for arterial emboli, and hyperbaric chamber treatment. Aspiration of air from the right ventricle, lidocaine, steroids and anticoagulation do not have sufficient evidence of benefit currently. Collaboration between medical ICU, surgery, and cardiology is essential for decreasing morbidity and mortality in patients with obstructive shock from air emboli.

Volume

166

Issue

4 Suppl

First Page

A2824

Last Page

A2825

Comments

Chest 2024 Annual Meeting, October 6-9, 2024, Boston, MA

DOI

10.1016/j.chest.2024.06.1710

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