air embolism- related cerebral ischemic event€¦ · air embolism-related cerebral ischemic event...

Air Embolism-Related Cerebral Ischemic Event

Presented byDr. Ann Plohal, PhD, APRN, ACNS-BC, CRNI

Phoenix, AZ

Objectives

• Identify portals of entry for air embolism in the use of vascular access devices and related preventive measures.• Describe emergent interventions in suspected cerebral ischemia related to air embolism.

Outline• 1. Causes of embolism to cerebral area

• Central venous access device manipulation, insertion, exchange, removal, hemodynamic monitoring, medication administration.

• Arterial catheter access• Diagnostic procedures

• 2. Diagnosis of air embolism-‐related cerebral ischemia• Sudden onset of neurological decline related to catheter manipulation

• Hemodynamic instability• Imaging

• 3. Prevention measures during insertion, maintenance, removal• 4. Treatment strategies

Definition

• Embolism:• Occlusion/obstruction of vessel by abnormal air or mass

• Embolis:• Detached intravascular solid, liquid, or gas

• Etiology?• 90-‐99% of all emboli are dislodged thrombus

Air Embolism

• Underreported• Unrecognized• Reported as differentCondition?

History

• 1769-‐Morgagni reported arterial air embolism

• 1821-‐Megendie consequences of pulmonary overinflation-‐arterial gas embolism.

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Etiology

• 20,000 cases of air embolism a year in US.• Not all reported

• Arterial or Venous• Venous-‐negative pressure in thoracic vessels-‐

• Respiration• Arterial-‐air travels until trapped• Venous potential arterial emboli?

• Patent foramen ovale

Causes

• Sudden decompression• Trauma• Iatrogenic• Miscellaneous

Sudden Decompression

• Pulmonary barotrauma• Divers• Burst lung

• Rapid decompression• Altitude chamber• Loss chamber pressure

Trauma

• Head and Neck Injuries• High-‐Altitude accidents• CPR in patients with undetected neck injury

Fatal & Nonfatal Fall Injuries

12,800

388,0001,230,000? Millions

1% Died

24% Treated in ED and hospitalized

76% Treated in ED and released

Fall related injuries

People 65+

Iatrogenic

• Most common cause• Greek-‐brought forth by the healer• Resulting from healthcare professionals that does not support the goal of the person affected. • Medical error?

Iatrogenic

• Diagnostic Procedures• Intraoperative Complications

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Intraoperative Complications

• Neurosurgical operations sitting position• Cardiac surgery-‐open heart with extracorporeal circulation• Vascular surgery-‐carotid endarterectomy with shunt• Thoracic surgery-‐pulmonary veins• Endobronchial resection of lung• Pelvic surgery in Trendelenburg position• Cesarean section

Diagnostic Procedures• IV fluids• CVP lines• Arterial lines• Angiography• Mechanical Positive Pressure Ventilation• Air contrast salpingogram• Air insufflation with pneumatic otoscope• Needle biopsy of the lung• Hemodialysis• Gastrointestinal Endoscopy

Risk During Catheter Insertion

• 0.13-‐0.5%• Tunneled and peelaway

• Mortality• 23-‐50%

• Subclavian, IJ, Femoral

Risk During Catheter Removal

• Most common events documented. • Failure to place supine or Trendelenburg• Failure to provide occlusive dressing

• Causes• Fibrinous tract not formed• Sitting, deep breathing, coughing• Occlusive properties of dressings• Location and availability of supplies• Competency of staff removing central lines

Risk During PIV or IO

Van Rijn, Knoester, Maes, van der Wal, Kubat 20087 month old, ED, food aspirationIOAutopsy: Fatal cerebral air embolism

Levy. Peripheral IV fluids-‐another cause of air embolism. Acta Paediatr. 1996.

Priming of catheterRate of air entry with 14 gauge needle?

Therapeutic Phlebotomy

• Evacuator bottlePhlebotomy 75-‐100Open and close handPatient repositioned self, tourniquet loosened

Reverse flow from bottleConfusion, deterioration, coded, expired

Autopsy: 40ml air in brain

Chwirut, 1982.

Case Study #1

• 73 year old woman • Dialysis treatment for one year• AV Shunt placed• Short term dialysis catheter• Shunt healed and catheter removed

Capozzoli, Schenk, Vezzai 2012

Case Study Continued

• Day one: CVC Removed• Hypertension, headache, perspiration, loss of conscious• Regained conscious after 10 min-‐motor deficit all limbs• Suspected embolic event• Hours later-‐seizures, left hemi-‐paresis• CT: no ischemia, mod brain atrophy• CT angio: no occlusions • MRI: normal representation• Started on Diazepam and Diphenylidantoin• Continue dialysis


Case Study Day 2

• New seizures• Creatinine 8mg/dL (continue dialysis)• Moved to ICU for monitoring and resistance of seizures


Clinical Course

• Day 3: new seizure. Added Midazolam 5mg. Continue HD• Day 4: Awake and alert. No seizures. Transferred to nephology unit.• Day 5: cerebral angio/MRI repeated. No change• Day 15: Discharged home. Complete resolution of left hemi-‐syndrome and seizures.


Review of the Case

• Review of the films: air bubbles in cavernous sinus• 2nd CT: air at neck level at point of CVC removal.• Fibrin sheath formation to anonymous vein to cavernous sinus• Retrograde cerebral air embolism


Pathophysiology

• Air emboli lodge in smaller vessels and obstruct flow of blood.• Ischemia, hypoxia, cerebral edema

• Vessel wall damage• Platelets-‐prostaglandin• Activation of leukocytes

• Secondary ischemia

• Fibrin prevent bubble from dissolving

Case Study #2

• 42 year old man respiratory failure after retinoic acid for acute promyelocytic leukemia.• CT chest: nodular lesions.• Biopsy: invasive aspergillus species. Treated with antifungals, mechanical ventilation. • Improving, then sudden hemoptysis, and cardiac arrest.• CT brain: cerebral air embolism, anterior arterial circulation, cerebral edema.

Dutra and Massumoto, 2012, New England Journal of Medicine

Causes?

1. CPR2. Lung Biopsy3. Central lines in place-‐manipulated4. Unknown

Clinical Presentation

• Neurological or Cardiovascular• Dependent on patient • Posture• Route of entry• Volume of air• Size of bubbles• Rate of air entry

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Positioning

• Reclining-‐coronary arteries

• Upright-‐cerebral arteries

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Signs & Symptoms

• Sudden change in sensorium (most common)• Disorientation to coma

• Focal neurological deficits• Hemiplegia or monoplegia (location dependent)

• Hypotension, Tachycardia• Respiratory arrest• Seizures• Shock like state (late)• Myocardial ischemia• Leibermeister’s sign-‐Pallor of the tongue

Diagnosis

• Patient history• Neurological findings• Transcranial doppler studies• Two-‐dimensional echocardiogram• EEG monitoring• CT Scan• Arterial blood sampling

Case Study #3

• 54 year male admitted to ICU after triple bypass• Mechanical ventilation, Inotroic support, central lines, PA catheter.• Day 5-‐PA catheter removed, but introducer was left in place.• Day 6-‐introducer removed while patient semi recumbent in a chair.

Bowles, Lear, Maccario, & Kong, (2014).

Case Study #3

• Insertion site dry • Occlusive dressing NOT applied• 2-‐3 min later:• Agitation, confusion, unresponsive• Rapid radial pulse• BP unobtainable• Arterial line inserted-‐BP 108/60• EKG: Sinus tachycardia 120/min• Unresponsive• Patient re-‐intubated


Case Study #3

• Bedside Transthoracic Echocardiogram (TEE)• Within 10 min• Multiple air emboli in all cardiac chambers

• CT brain• 2 hours later• No significant abmormality


Case Study #3

• Moved to bed, laid supine.• Oral airway, bag, mask, oxygen.• Sedation, Propofol infusion, intubation, mechanically ventilated. • Following day:• Extubated

• Day 9-‐transered toward and discharged home with no neurological deficit• Follow-‐up at 3,6,12 months normal neurological function. Bowles, Lear, Maccario, & Kong, (2014).

Treatment Options• Preparedness & Anticipation• Time is the MOST important element• Shorter the delay, better the outcome

• Emergency measures• Initiate code or rapid response• Position patient left lateral decub, Trendelenburg• 100% oxygen• Identify and stop the passage of air• Fluid resuscitation• Document• Complete Unusual Occurrence

Treatment

• Dexamethasone 10mg IV-‐prevent cerebral edema• Consider transport to facility with hyperbaric facility• Air transport-‐pressurized cabin and low altitude

Treatment

• Compression of bubbles • Delivery of high levels of oxygen• Ischemia and hypoxia

• Fick’s law-‐Nitrogen diffusion• Decrease cerebral edema• Vasoconstriction

Adjunct Treatments

• Antiplatelet Medications• Heparin versus Aspirin

• Steroids • Caution with HB

• Hemodilution• Dextran 40

• Control of Seizures• Lidocaine

• Measures to Improve Cerebral Metabolism• Glucose Control

Case Study #4• 65 year female with hypertension and rheumatoid arthritis• Total hip replacement with spinal and epidural anesthesia• Spinal anesthesia with 3mL 0.5 Bupivacaine & Fentanyl 25mcg given at L3-‐4. • 20 g epidural catheter introduced and fixed at 12cm.• Test dose and Bupivacaine 0.125% and Fentanyl (2mcg/ml) 2ml/hr.

Sinha & Ray, 2015

Case Study #4

• Surgery lasted 8 hours• Epidural infusion stopped at 6 hours-‐hypotention, bleeding (1100ml).• Fluids through PIV.• ICU-‐severe pain, epidural bolus 10ml, Tramadol 50mg IV and Promethazine 12.5mg IV• Only 8ml bolus given-‐sudden bradycardia and hypotension.• Jerking, gasping decreased LOC

Sinha & Ray, 2015

Case Study #4

• Blood glucose 242• Left pupil dilated and fixed• CPR, fluids, low dose noradrenaline, intubated

Differential Diagnosis• Stroke• Total spinal anesthesia toxicity• Cerebral emboli• Cerebral hematoma

Sinha & Ray, 2015

Case Study #4

• Stat CT• Air around brain stem, no bleeding• Within one hour, awake, left pupil remained fixed and dilated.• Extubated following day• Altered sensorium lasted two days.

Prevention

• Luer-‐lock design• Air is ALWAYS purged

• Don’t leave unprimed sets attached to solution

• Patients/caregivers instructed in prevention and critical actions for air embolism

Infusion Therapy Standards of Practice 2016

Prevention

• Never use scissors or razors near catheter• Clamp VAD before changing sets/caps• Patient positioning

Infusion Therapy Standards of Practice 2016

Prevention During Line Placement or Removal• Patient positioning• Insertion site below the heart

• Valsalva• Contraindications?• Other options

• Sterile petroleum-‐based ointment/sterile dressing• Flat or reclining 30 minutes

Case Study #5

• 57 year old revision of ileostomy• On discharge-‐remove IJ• Flat for removal, placed sterile gauze• Sitting position after 5 minutes• Dizzy, slumped in chair

• CT-‐neg. MRI-‐air embolism• CVA and minor cerebral edema• Discharged 10 days later• Weak in LLE, ambulated with cane/walker

Brockmeyer, Simon, Seery, Johnson, Armstrong, 2009

Summary

• Prime• Position• Equipment• Attention and Preparedness• Competency• Education

References

• Bowles, P.F., Lear, C., Maccario, M., & Kong, R. (2014). Paradoxical air embolism and neurological insult during removal of a pulmonary artery catheter introducer. BMJ, 1-‐3,

• Broadhurst, D. (2013). Death by Air: How much is too much? Vascular Access, 16-‐25.

• Brockmeyer, J., Simon, T., Seery, J., Johnson, E., & Armstrong. (2009). Cerebral air embolism following removal of central venous catheter. Military Medicine, 174, 8, 878-‐880.

• Capozzoli, C., Schenk, C., & Vezzali, N. (2012). Cerebral air embolism after central dialysis line removal: The role of the fibrinsheath as portal of air entry. J Vasc Access, 13(4), 516-‐519.

• Dultra, M. & Masssumoto, C. (2012). Cerebral Air Embolism. N Engl J Med, 367; 850.

• Infusion Therapy Standards of Practice (2016). Journal of Infusion Nursing, 39, 1S, S108.

• Levy, I. (1996). Peripheral intravenous fluids-‐another cause of air embolism. Acta Paediatr, 85(3), 385-‐386.

• Sinha, S. & Ray, B. (2015). Indian Journal of Critical Care Medicine, 19(2), 116-‐118.

• Van Rijn, RR, Knoester, H. Maes, A, van der Wal AC, Kubat, B. (2008). Cerebral arterial air emblism in a child after intraosseous infusion. Emergency Radiology, 15(4), 259-‐262.

air embolism- related cerebral ischemic event€¦ · air embolism-related cerebral ischemic event...

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