The Journal of Emergency Medicine, Vol. 49, No. 1, pp. e27–e28, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.12.071
Visual Diagnosis in Emergency Medicine
CEREBRAL AIR EMBOLISM AFTER HEMODIALYSIS Matthew K. Hysell, MD Lakeland HealthCare, St. Joseph, Michigan Reprint Address: Matthew K. Hysell, MD, Lakeland HealthCare, 1234 Napier Avenue, St. Joseph, MI 49085
and the techniques used to hook him up via his right internal jugular tunneled access to the machine reviewed by the treating nephrologist, though the cause of the air embolization remained unclear.
INTRODUCTION Cerebral air embolism is a rare complication of hemodialysis. Despite increased safeguards with modern dialysis equipment, this entity remains possible as demonstrated here. Treatment is reviewed.
DISCUSSION Air embolism is an uncommon condition most frequently seen after dive injuries (1). However, it is also an iatrogenic complication, including, most commonly, with central venous catheter placement, removal, or
CASE REPORT An 88-year-old man presented after collapse about 10 min into his scheduled hemodialysis. At dialysis he slumped over, became unresponsive, and was laid flat and disconnected from the circuit. Chest compressions were required briefly. At presentation to the Emergency Department (ED), he was poorly responsive, with a Glasgow Coma Scale score of 9, a blood pressure of 85/60 mm Hg, and a heart rate of 95 beats/min. A 250-mL 0.9% normal saline bolus and Trendelenburg positioning improved his blood pressure to 105/70 mm Hg, allowing him to be emergently taken for computed tomography (CT). Review of the CT scan (Figure 1) revealed venous air embolism, primarily on the right. The patient was placed on 100% nonrebreather oxygen, and transfer for hyperbaric oxygen considered. Family discussions ensued after he developed seizures; ultimately, they elected comfort care. The hemodialysis machine the patient was running on was taken out of use until it could be fully inspected
Figure 1. Prominent air in the bridging veins of the right cerebral hemisphere (white arrows) and small amount in the dural sinus (black arrow).
RECEIVED: 4 June 2014; FINAL SUBMISSION RECEIVED: 16 December 2014; ACCEPTED: 22 December 2014 e27
e28
dislodgement, or neurosurgical procedures (2). In the ED, it may be encountered after a burgeoning number of varied outpatient procedures such as hysteroscopy, laparoscopic surgery, and even pacemaker placement, in addition to hemodialysis (3–6). Although modern hemodialysis machines make air embolism very rare, this disease process persists, as demonstrated by this case. Iatrogenic air embolism that occurs with the patient upright is more likely to cause neurological symptoms, whereas those that occur with the patient recumbent are more likely to cause cardiac symptoms such as chest discomfort and dyspnea (7). Diagnosis can be difficult, as only 75% of cerebral air embolism patients will manifest visible air on CT (8). Once cerebral air embolism has occurred, maintaining normal blood pressure will help maximize cerebral perfusion (1). Prolonged use of Trendelenburg positioning can induce cerebral edema and is not enough to cause bubbles to flow out of the cerebral vasculature. Hyperbaric oxygen treatment is recommended for patients with significant symptoms (9).
M. K. Hysell
REFERENCES 1. Van Hulst RA, Klein J, Lachmann B. Gas embolism: pathophysiology and treatment. Clin Physiol Funct Imaging 2003;23:237–46. 2. Sviri S, Woods WPD, Van Heerden PV. Air embolism—a case series and review. Crit Care Resusc 2004;6:271–6. 3. Groenman FA, Peters LW, Rademaker BM, et al. Embolism of air and gas in hysteroscopic procedures: pathophysiology and implication for daily practice. J Minim Invasive Gynecol 2008;15:241–7. 4. Azevedo JL, Azevedo OC, Miyahira SA, et al. Injuries caused by Veress needle insertion for creation of pneumoperitoneum: a systematic literature review. Surg Endosc 2009;23:1428–32. 5. Bongiorni MG, De Cori A, Soldati E, et al. Iatrogenic risk of permanent pacemaker and defibrillator implantation : [Italian]. G Ital Cardiol (Rome) 2009;10:395–406. 6. Yu AS, Levy E. Paradoxical cerebral air embolism from a hemodialysis catheter. Am J Kidney Dis 1997;29:453–5. 7. Bregman H, Daugirdas JT, Ing TS. Complications during hemodialysis. In: Daugirdas JT, Ing TS, eds. Handbook of dialysis. New York: Little, Brown; 1994:148–68. 8. Heckmann JG, Lang CJG, Kindler K, et al. Neurologic manifestations of cerebral air embolism as a complication of central venous catheterization. Crit Care Med 2000;28:1621–5. 9. Muth CM, Shank ES. Gas embolism. N Engl J Med 2000;342: 476–82.
http://dx.doi.org/10.1016/j.jemermed.2014.12.071
Visual Diagnosis in Emergency Medicine
CEREBRAL AIR EMBOLISM AFTER HEMODIALYSIS Matthew K. Hysell, MD Lakeland HealthCare, St. Joseph, Michigan Reprint Address: Matthew K. Hysell, MD, Lakeland HealthCare, 1234 Napier Avenue, St. Joseph, MI 49085
and the techniques used to hook him up via his right internal jugular tunneled access to the machine reviewed by the treating nephrologist, though the cause of the air embolization remained unclear.
INTRODUCTION Cerebral air embolism is a rare complication of hemodialysis. Despite increased safeguards with modern dialysis equipment, this entity remains possible as demonstrated here. Treatment is reviewed.
DISCUSSION Air embolism is an uncommon condition most frequently seen after dive injuries (1). However, it is also an iatrogenic complication, including, most commonly, with central venous catheter placement, removal, or
CASE REPORT An 88-year-old man presented after collapse about 10 min into his scheduled hemodialysis. At dialysis he slumped over, became unresponsive, and was laid flat and disconnected from the circuit. Chest compressions were required briefly. At presentation to the Emergency Department (ED), he was poorly responsive, with a Glasgow Coma Scale score of 9, a blood pressure of 85/60 mm Hg, and a heart rate of 95 beats/min. A 250-mL 0.9% normal saline bolus and Trendelenburg positioning improved his blood pressure to 105/70 mm Hg, allowing him to be emergently taken for computed tomography (CT). Review of the CT scan (Figure 1) revealed venous air embolism, primarily on the right. The patient was placed on 100% nonrebreather oxygen, and transfer for hyperbaric oxygen considered. Family discussions ensued after he developed seizures; ultimately, they elected comfort care. The hemodialysis machine the patient was running on was taken out of use until it could be fully inspected
Figure 1. Prominent air in the bridging veins of the right cerebral hemisphere (white arrows) and small amount in the dural sinus (black arrow).
RECEIVED: 4 June 2014; FINAL SUBMISSION RECEIVED: 16 December 2014; ACCEPTED: 22 December 2014 e27
e28
dislodgement, or neurosurgical procedures (2). In the ED, it may be encountered after a burgeoning number of varied outpatient procedures such as hysteroscopy, laparoscopic surgery, and even pacemaker placement, in addition to hemodialysis (3–6). Although modern hemodialysis machines make air embolism very rare, this disease process persists, as demonstrated by this case. Iatrogenic air embolism that occurs with the patient upright is more likely to cause neurological symptoms, whereas those that occur with the patient recumbent are more likely to cause cardiac symptoms such as chest discomfort and dyspnea (7). Diagnosis can be difficult, as only 75% of cerebral air embolism patients will manifest visible air on CT (8). Once cerebral air embolism has occurred, maintaining normal blood pressure will help maximize cerebral perfusion (1). Prolonged use of Trendelenburg positioning can induce cerebral edema and is not enough to cause bubbles to flow out of the cerebral vasculature. Hyperbaric oxygen treatment is recommended for patients with significant symptoms (9).
M. K. Hysell
REFERENCES 1. Van Hulst RA, Klein J, Lachmann B. Gas embolism: pathophysiology and treatment. Clin Physiol Funct Imaging 2003;23:237–46. 2. Sviri S, Woods WPD, Van Heerden PV. Air embolism—a case series and review. Crit Care Resusc 2004;6:271–6. 3. Groenman FA, Peters LW, Rademaker BM, et al. Embolism of air and gas in hysteroscopic procedures: pathophysiology and implication for daily practice. J Minim Invasive Gynecol 2008;15:241–7. 4. Azevedo JL, Azevedo OC, Miyahira SA, et al. Injuries caused by Veress needle insertion for creation of pneumoperitoneum: a systematic literature review. Surg Endosc 2009;23:1428–32. 5. Bongiorni MG, De Cori A, Soldati E, et al. Iatrogenic risk of permanent pacemaker and defibrillator implantation : [Italian]. G Ital Cardiol (Rome) 2009;10:395–406. 6. Yu AS, Levy E. Paradoxical cerebral air embolism from a hemodialysis catheter. Am J Kidney Dis 1997;29:453–5. 7. Bregman H, Daugirdas JT, Ing TS. Complications during hemodialysis. In: Daugirdas JT, Ing TS, eds. Handbook of dialysis. New York: Little, Brown; 1994:148–68. 8. Heckmann JG, Lang CJG, Kindler K, et al. Neurologic manifestations of cerebral air embolism as a complication of central venous catheterization. Crit Care Med 2000;28:1621–5. 9. Muth CM, Shank ES. Gas embolism. N Engl J Med 2000;342: 476–82.
