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Anesthesiology:

January 2007 - Volume 106 - Issue 1 - pp 164-177

Review Article

Diagnosis and Treatment of Vascular Air Embolism

Mirski, Marek A. M.D., Ph.D.*; Lele, Abhijit Vijay M.D.†; Fitzsimmons, Lunei M.D.†; Toung, Thomas J. K. M.D.‡

Section Editor(s): Warltier, David C. M.D., Ph.D., Editor

Free Access

Continued Medical Education

Article Outline

AbstractVascular air embolism is a potentially life-threatening event that is now encountered routinely in the operating room and other patient care areas. 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 surgicalcenter. Advances in monitoring devices coupled with an understanding of the pathophysiology of vascular air embolism will enable the physician to successfully manage these potentially challenging clinical scenarios. A comprehensive review of the etiology and diagnosis of vascular air embolism, including approaches to prevention and management based on experimental and clinical data, is presented.This compendium of information will permit the healthcare professional to rapidly assess the relative risk of vascular air embolism and implement monitoring and treatment strategies appropriate for the planned invasive procedure.

INTRAOPERATIVE vascular air embolism (VAE) was reported as early as the 19th century, in both pediatric and adult practice. Well over 4,000 articles have beenpublished during the past 30 yr alone, providing ample resonance to the ubiquity and seriousness of this vascular event. Perhaps the most striking feature accumulated during this period is the myriad of clinical circumstances in which VAE may present itself, a result primarily of the increased technological complexity and invasiveness of modern therapeutics. Most episodes of VAE are likely preventable.This article provides a systematic review of the pathophysiology and clinical presentation of this acute phenomenon, as well as an in-depth analysis and algorithms for favorable methods of detection, prevention, and treatment.

Vascular air embolism is the entrainment of air (or exogenously delivered gas) from the operative field or other communication with the environment into the venous orarterial vasculature, producing systemic effects. The true incidence of VAE may be never known, much depending on the sensitivity of detection methods used during the procedure. In addition, many cases of VAE are subclinical, resulting in no untoward outcome, and thus go unreported. Historically, VAE is most often associated with sitting position craniotomies (posterior fossa). Although this surgicaltechnique is a high-risk procedure for air embolism, other recently described circumstances during both medical and surgical therapeutics have further increased concern about this adverse event. Conditions during which air embolism has been documented have substantively broadened, and much of the credit is owed to Albin et al.1–4 for their description of the pathophysiology during a variety ofsurgical procedures. Not only does the historic modus operandi of a gravitational gradient remain a concern, but we must now as well be suspicious of VAE during modern procedures where gas may be entrained under pressure, both within the peritoneal cavity or via vascular access. Hence, it is imperative for anesthesiologists to be aware of the causes of VAE, its morbidity, diagnostic considerations,treatment options, and adoption of practice patterns that best lead to the prevention of this potentially fatal condition.

Pathophysiology

The two fundamental factors determining the morbidity and mortality of VAE are directly related to the volume of air entrainment and rate of accumulation. When dealing simply with air being suctioned by a gravitational gradient, these variables are...