Air emboli in surgery. benefits of co2

Comparison of air, oxygen and carbon dioxide embolization. Arnold Kunkler, M.D., Harold King, M.D.

From the Department of Surgery, Indiana University School of Medicine , Indianaolis, Indiana. Annals of Surgery 1959.

"When compared with air, carbon dioxide is about 34 times as soluble in water at 30 degrees centigrade. It is only slightly less soluble in serum at 38 degrees. This probably explains why the carbon dioxide embolus is so unstable."

"This study gives support to the simple clinical procedure of bathing the field of operation in an atmosphere of carbon dioxide gas. Since it is 1.53 times as dense as air, it should largely displace air in the operative field."

THE SIGNIFICANCE OF AIR EMBOLISM DURING CARDIOPULMONARY BYPASS. 

F.C.Spencer, M.D., N.P. Rossi, M.D., Shao-Chi Yu, M.D., and J.A.Koepke, M.D., Lexington, Ky.

"It was repeatedly noted, however, that the disappearance of visible air did not always indicate restoration of normal myocardial capillary blood flow. The areas of cyanosis remained much longer than did the visible air bubbles."

"In some experiments with repeated air emboli, areas of cyanosis persisted and were associated with progressive heart failure."

"With visible air bubbles in a failing heart, the injury was obvious. By contrast, though, was the occasional persistence of a feebly contracting cyanotic heart after all visible air had disappeared. This was probably due to widespread capillary occlusion from microscopic emboli. It was clear, though, that if the earlier air emboli had not been seen, the origin of the cardiac injury would have been obscure and could have been erroneously attributed to a number of causes - metabolic acidosis, rate of perfusion, gas or silicone emboli from pump oxygenator, et cetera"   

Venous emobolization during sternotomy in children undergoing corrective heart surgery.

Ilan Keidan, MD, Yael Mardor, PhD, Sergei Preisman, MD, and David Mishaly, Tel Aviv, Israel.

The Journal of Thoracic and Cardiovascular Surgery. 2004.

"VAEs were detected in 14 (70%) patients."

"The peak number of emboli appeared approximately 5 seconds after sternotomy and returned to baseline at the end of the procedure."

"The fact that embolus incidence was higher with the saw compared with the scissors is not straightforward."

"In summary, our results suggest that VAE during sternotomy is a frequent occurrence and that the number of emboli is related to the method of sternotomy."

Carbon dioxide in the prevention of air embolism during open-heart surgery.

W.SHANG NG AND MICHAEL ROSEN.

From the Department of Anaesthetics, the Royal Infirmary, Cardiff.

Thorax (1968),23,194

"It seems that there would be a reasonable case for the use of carbon dioxide displacement during open-heart surgery if 'high' levels of carbon dioxide were reached in the operating field."  

Embolic Activity During In Vivo Cardiopulmonary Bypass.

Gordon R. DeFoe, CCP, Norman A.Dame, CCP, Mark S.Farrell, CCP, Cathy S.Ross, MS; Craig W.Langner, MS, MBA; Donald S. Likosky, PhD

The Journal of ExtraCorporeal Technology 2014;46:150-156

"Neurologic injury after cardiac surgery is principally associated with emboli"

"Neurologic injury us a leading cause of morbidity subsequent to cardiac surgery and is thought to be principally the result of embolization"

"In conclusion, we have demonstrated that even with the advances in circuit design, emboli may still be detected in large numbers on CPB and may be associated with discrete processes of the perfusionist's care."

Vascular air embolism: A silent hazard to patient safety.

Brull SJ, Prielipp RC. Journal of Critical Care 2017. 

"VAE may be introduced through disruption in the integrity of the venous circulation that occurs during insertion, maintenance, or removal of intravenous or central venous catheters. VAE impacts pulmonary circulation, respiratory and cardiac function, systemic inflammation and coagulation, often with serious or fatal consequences. When VAE enters arterial circulation, air emboli affect cerebral blood flow and the central nervous system. New medical devices remove air from intravenous infusions. Early recognition and treatment reduce the clinical sequelae of VAE. An organized team approach to treatment including clinical simulation can facilitate preparedness for VAE. The MAUDE database included 416 injuries and 95 fatalities from VAE. Data from the American Society of Anesthesiologists Closed Claims Project showed 100% of claims for VAE resulted in a median payment of $325,000."

AIR EMBOLISM DURING SPINAL SURGERY.

Veronica Mortera1 DVM MRCVS, Hugo van Oostrom1 DVM PhD MRCVS, Carmen Yeamans2 DVM, Rodrigo Gutierrez-Quintana2 MVZ MVM DipECVN MRCVS, Jacques Penderis3 BVSc MVM PhD CVR DECVN MRCVS3, Nicolas Granger1* DVM PhD DECVN FHEA MRCVS.

"Spontaneous intraoperative VAE is a life-threatening event, and a fatal outcome was reported for 10 out of 22 humans undergoing spinal surgery (Wills et al., 2005). It is also recognised during other surgeries in human patients (Mirski et al., 2007).

Venous air embolism has been associated with neurosurgery performed in the sitting position,"

The sitting position in neurosurgery-not yet obsolete!

British Journal Of Anaesthesia. January 2002.

"Duke and colleagues reported a 28% incidence of VAE in the sitting position"

Percutaneous cardiopulmonary support to treat suspected

venous air embolism with cardiac arrest during open eye

surgery.

Seokyung Shin, Bokyung Nam, Sarah Soh, and Bon-Nyeo Koo.

Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine,

Yonsei University Health System, Seoul, Korea.

"Prompt termination of air infusion

is needed when VAE is suspected during air-fluid exchange, and extracorporeal life support should be considered in

fatal cases"

A case of cardiac arrest due to air

embolism during scoliosis surgery.

Mohamad Zaki Haji Mohd Amin, James Tan Boon Beng,

Brian Teo Yian Young, Nur Aida Faruk Seman,

Teo Shu Ching and Wong Chung Chek.

"This report serves as a reminder of a potentially fatal complication in

scoliosis surgery. Early detection and prompt resuscitation will help to save lives and ensure a favourable outcome."

A Case of Massive Cerebral Arterial

Air Embolism Induced by Artificial

Pneumothorax and Its Analysis.

Xiao-Hua Gou, Wei Yang, Yan-Li Zhang, Ya Li, Xin Wu

Med Princ Pract 2019;28:297–300.

"Artificial pneumothorax may induce cerebral arterial air embolism, and the application of carbon dioxide to

establish artificial pneumothorax can effectively reduce the risk of air embolism"

The Harmful Effects and Treatment of Coronary Air Embolism During Open-Heart Surgery. 

Claire Justice, M.D., John Leach, M.D., and W. Sterling Edwards, M.D.

THE ANNALS OF THORACIC SURGERY.

"Larger quantities of air, or repeated small quantities, however, can cause enough coronary obstruction to significantly depress myocardial contractility even on bypass." 

The impact of transesophageal echocardiography based protocol for management of adults in the sitting position on the incidence of clinically significant venous air embolism.

Dmitry A. Averyanov, Roman S. Lakotko, Aleksey V. Shchyogolev, Dmitry V. Svistov, Aleksey I. Gayvoronsky.

Russian Open Medical Journal. January 2020.

"High sensitivity, apparently, allows early detection of VAE, without bringing the episode of air embolism to the development of clinical signs. This is evidenced by the large difference between the overall frequency of VAE and clinically significant VAE, which according to the results of the study was 52% and 7.1%, respectively."

Volume of Air in a Lethal Venous Air Embolism.

Thomas J. K. Toung, M.D., Mark I. Rossberg, M.D., Grover M. Hutchins, M.D.

Anesthesiology 2001; 94:360–1

"This is the first report in an adult

human to document an exact lethal volume of air, 200 ml (albeit in a patient with congestive heart failure), rather than to estimate retrospectively the lethal

volume after the incident of fatal venous air embolism. It is still unclear whether this amount, 200 ml, represents the minimum volume of air considered to be

lethal to healthy adult humans."

Gas embolism in anaesthesia.

S Webber FRCA., J Andrzejowski FRCA., G Francis FRCA.

British Journal of Anaesthesia | CEPD Reviews | Volume 2 Number 2 2002

"Venous, arterial and paradoxical air emboli are potential complications

in many of the clinical scenarios encountered by anaesthetists"

"In high risk situations, prevention is better than cure and it is essential

that the appropriate preventative measures, monitoring tools and treatment modalities are in place"

Air embolism during anaesthesia for shoulder arthroscopy.

R. T. Hegde* and R. N. Avatgere

British Journal of Anaesthesia 85 (6): 926-7 (2000)

"Intravenous air is five times more dangerous than carbon dioxide. Therefore, carbon dioxide or normal saline are safer agents for distension of joints during arthroscopy."

Air embolism in hip surgery

ROSALIND MICHEL

Anaesthesia, 1980, Volume 35

"The hearts of 49 patients undergoing hip-replacement surgery were auscultated and the characteristic

sounds of air emboli were heard in 15 of them - 30% of the total"

"In two of these patients marked falls in blood pressure coincided with pronounced heart sound changes"

Paradoxical air embolism during hepatic resection.

S.Y.Lee et al

British Journal of Anaethesia. 2002;88: 136-8

"Although the incidence of venous air embolism and paradoxical air embolism during hepatic resection is unknown, VAE is a potentially hazardous complication during hepatectomy. Many patients who undergo hepatectomy have liver cirrhosis, and VAE is particularly dangerous in such patients because 15-45% have pulmonary abnormalities including intrapulmonary shunting caused by pulmonary vascular dilation and arteriovenous communication. In these patients, paradoxical emboli can occur during air embolism even if intracardiac abnormalities are not present."

Intraoperative Embolic Events During Total Knee Arthroplasty with Use of

Pulsatile Saline versus Carbon Dioxide Lavage

Lassiter, T E; Schroeder, R A; McDonagh, D L; Bolognesi, M P; Sarin, V K; Monk, T G

Duke University Medical Center, Durham, NC

"The results of this study suggest that CO2 gas lavage, as compared to

pulsatile saline lavage, reduces the number of intraoperative cardiac emboli

during total knee arthroplasty. Additional studies with larger sample sizes are

planned"

Venous Air Embolism during Surgery, Especially Cesarean Delivery

Chang Seok Kim, Jia Liu, Ja-Young Kwon, Seo Kyung Shin and Ki Jun Kim

J Korean Med Sci 2008; 23: 753-61

"The incidence of VAE during cesarean delivery ranges from 10 to 97% depending on surgical position or diagnostic tools"

"it is reported that VAE is responsible for about 1 percent of all maternal deaths"