Peripheral Venous Air Embolism in a Pregnancy (Case Report)
Lütfiye Pirbudak1*, Neslihan Bayramoğlu Tepe2, Yusuf Emeli1, Ergün Mendeş1
1Department of Anaesthesiology and Reanimation, University of Gaziantep, Turkey,
2Department of Obstetrics and Gynaecology, University of Gaziantep, Turkey,
Submission: April 5, 2018;Published: May 25, 2018
*Corresponding author: Lütfiye pirbudak, Department of Anaesthesiology, Division of Algology, Medical School, University of Gaziantep, Gaziantep, Turkey; Email: firstname.lastname@example.org
How to cite this article: Lütfiye Pirbudak, Neslihan Bayramoğlu Tepe, Yusuf Emeli, Ergün Mendeş. Peripheral Venous Air Embolism in a Pregnancy (Case Report). Glob J Reprod Med. 2018; 4(4): 555645. DOI:10.19080/GJORM.2018.04.555645.
Air embolism can occur in many medical surgical situations. Venous air embolism is often lethal when it enters to the venous circulation rapidly. Massive air embolism is usually diagnosed clinically with sudden hemodynamic deterioration. In this case report, the importance of ETCO2 monitoring in the treatment of pregnant patients with peripheral venous embolism (PVE) has been discussed.
Air embolism can occur in many medical surgical situations. Venous air embolism is often lethal when it enters to the venous circulation rapidly. It can cause significant morbidity when it is passed to systemic arterial circulation. Massive air embolism is usually diagnosed clinically with sudden hemodynamic deterioration . In this case report, the importance of ETCO2 monitoring in the treatment of pregnant patients with pulmoner venous embolism (PVE) has been discussed.
The patient was a 30-years-old, 17 week first pregnancy woman with no known additional disease and no active problems in follow-up. While the patient was using sefazolin (İespor®) 500 mg due to infectious influenza, she applied to another emergency service on the 4th day of treatment. A venous vascular access was opened to receive antibiotic treatment in 100cc 0.9% NaCl. Approximately 1 minute after the solution begins to be given to the patient; dizziness, dyspnea and loss of consciousness presented in the patient. On the controls, it was noticed that there was air in the settee. Promptly, the patient was given a supine position and the patient’s blood pressure was 70/30mmHg with spontaneous breathing, which was a positive light reflex. Electrocardiography detected sinus bradycardia. A new venous vascular access was opened to the patient for fluid replacement and 100% O2 therapy was given. Approximately 5 minutes later, she regained consciousness and the patient’s blood pressure was measured 90/50mmHg. The patient described blurred vision and dyspnea. The systolic function of the patient was normal, valve movements were natural, and EF is 60% on ECHO. Fetal heart rate was positive under USG control and no additional distress was observed. In case of consultation with cardiovascular surgeon, he was not considered a massive embolism since no heat change, swelling, diameter difference was detected in both legs. Since the patient was pregnant, no radiation-containing examinations were performed. Eco was normal but clinic was significant.
At the end of the third day, the patient was admitted to our polyclinic with ongoing dyspnea and tachypnea. The patient underwent end-tidal CO2 measurement with an nasal capnography device and found to be 26mm/Hg; SPO2, measured at 96mm/Hg. After three days of follow-up, 100% O2 therapy and fluid replacement were performed at regular intervals. At the end of the third day ET-CO2 was measured 32mm/Hg, SPO2 was measured at 98mm/Hg. Dyspnea decreased significantly at the end of 3 days. Blurred vision was completely improved.
Peripheral venous air embolism is rare but can result in
serious complications. Possible sources for air embolism are
perfusator systems, serum sets, air in the injector which is not
evacuated during intravenous drug injection.It is reported that
the caesarean case which depends on in anesthesia, the usage of
closed loop/circuit/cycle within in a short period high-power air
interference is resulted death . In computerized tomography
(CT), a case was reported in which carelessly antecubital
injection of 150 ml air was performed during contrast medium
injection . Generally, in the venous system a small amount of
air can be absorbed spontaneously, but when a large amount of
air crosses over the systemic circulation rapidly, this can cause
significant morbidity and mortality. Fatal air volume is defined
as 200-300mL or 3-5mL/kg for adults in case reports, while air
collection rate is also important [3,4]. In this case, in the case
of pulmonary venous air embolism which may be encountered
during routine peripheral venous interventions, the symptoms
and end-tidal CO2 pressure were guided by the fact that patient
was a pregnant.
Clinical indicators are late findings of pulmoner venous
air embolism and these are not specific. Monitors are more
sensitive but can give false positives. End-tidal capnography
and precordial doppler are the most sensitive combination. But
none of these are specific to Venous air embolisation (VAE).
Transesophageal echocardiography (TOE), is the most sensitive
and specific monitor . Nasal ETCO2 level was considered in the
diagnosis and treatment of our patient. On the 3rd day of 100%
oxygen treatment, it was determined that O2 treatment was
sufficient when ETCO2 level was reached normal limit. ETCO2 is a
useful tool for detecting VAE because of its widespread use in the
operating room. A change in ETCO2 is considered significant and
can be determined if it reduces 0.2% of baseline (53) or 2mm/Hg
(57) . Critical care doctors need to be aware of the symptoms
of air embolism and be ready to implement possible therapeutic
maneuvers . Peripheral air embolism should be treated with
100% O2, fluid infusion and vasopressor should be given to
correct hypotension. Durant’s maneuver (Left-lateral decubitus,
up-down positioning) can also be applied . Although VAE is
uncommon complication, it is potentially life-threatening and
requires prevention and early detection. It should be keep in
mind that medical personnel should be trained better, especially
to improve the training of injector technicians is crucial because
of to prevent this preventable complication.
Air embolism is a rare complication. It is potentially lifethreatening
and should be prevented and detected early. Patients
should be suspected if they have a sudden onset of respiratory
distress and / or are experiencing a neurological event in a
known risk factor setting. We believe that ETCO2 measurement
is a simple and effective method in the diagnosis and treatment
of pregnant patients. We recommend that 100% O2 treatment
should be continued until ETCO2 normalizes.