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Interesting case from my MICU month. Pt is a middle aged WM with hx of HIV, CVA presented to the ED with hypoxic respiratory failure and sepsis. Intubated in the ED and admitted to the unit. Pt self extubated few hours later in the MICU. Responded well to fluids, antibiotics and O2 nasal cannula. Few days later, nurse d/c’ed his RIJ central line.
Within minutes, pt became severely altered, O2 sats plummeted to the 60s and bedside ultrasound showed significant air bubbles in the cardiac chambers.
What happened? When central line was removed, the wound site was not immediately occluded (with fingers, dressing with tape, etc). As pt inhaled, air traveled through the communicating conduit into the central blood vessel.
What to do now? Intubate for severe respiratory distress. Place pt in left lateral decubitus position and Trendelenburg position–prevents air from traveling to the pulmonary arteries causing airflow obstruction. Hyperbaric oxygen therapy, if you suspect cerebral embolism, as it decreases mortality.
The pt was intubated, placed on his side with bed tilted down. Did fine and transferred to floor the next day.
What a great case. I heard about this from the MICU fellow that took the video. This could easily be published I believe. I did a very brief search and saw a couple still images, CT chest with air embolus, but did not see anything with a video. Let me know if you need help, give it a shot.
Thanks. I thought about it and I’m glad you brought it up.I’m out of town, but will send you an email some ideas shortly.
This same concept goes into effect when you are placing an IJ/subclavian as well and you don’t occlude the ports when placing caps and it allows air to track in during inhalation. Either occlude it with your thumb or lock it someway. An anesthesiologist taught me a long time ago that the body can withstand up to 1 cc/kg of air, which is why those small amount in IV tubing and etc usually don’t cause any problems. I’ve never seen that figure anywhere else so don’t quote me on it. Anyways great case!
I think that’s probably about right Neagum. I was told by a trauma surgeon it takes about 15-20cc before you get any sort of change, more than that to cause hemodynamic compromise. Of course, this is for adults. Be even more cautious with the wee ones.
Yes one of those rare but life threatening and seconds counting diagnoses. It was great of the MICU team to think to Echo the patient immediately.
Another use for bedside Echo in central line placement is to infuse a saline flush while looking with Echo. Should see bubbles of flow (not air) to let you know you’re in the SVC / atrium. Worked for Obrien and me once when we were trying to verify that we had moved an IJ catheter back into the SVC after it threaded into the subclavian vein.