Air Embolism during Anesthesia for Shoulder Arthroscopy

Faure, Eveline A. M.; Cook, Richard I.; Miles, David

doi:10.1097/00000542-199809000-00055

Cited by 26 publications

(14 citation statements)

References 3 publications

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“…[11] First and primary etiology of VAE is surgical procedure where the operative site is above the level of heart, such as sitting neurosurgical procedure, posterior fossa surgery,[12] obstetric procedure,[13] and orthopedic surgeries. [14] Second etiological reason is iatrogenic creation of pressure gradient which facilitate air entry into the circulation such as during insertion of central venous catheter. [15] Third etiological cause is mechanical insufflations or pressure infusion such as laparoscopic surgeries[16] and gastrointestinal endoscopies.…”

Section: Etiologymentioning

confidence: 99%

Acute management of vascular air embolism

Shaikh

Ummunisa

2009

J Emerg Trauma Shock

123

108

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Vascular air embolism (VAE) is known since early nineteenth century. It is the entrainment of air or gas from operative field or other communications into the venous or arterial vasculature. Exact incidence of VAE is difficult to estimate. High risk surgeries for VAE are sitting position and posterior fossa neurosurgeries, cesarean section, laparoscopic, orthopedic, surgeries invasive procedures, pulmonary overpressure syndrome, and decompression syndrome. Risk factors for VAE are operative site 5 cm above the heart, creation of pressure gradient which will facilitate entry of air into the circulation, orogenital sex during pregnancy, rapid ascent in scuba (self contained underwater breathing apparatus) divers and barotrauma or chest trauma. Large bolus of air can lead to right ventricular air lock and immediate fatality. In up to 35% patient, the foramen ovale is patent which can cause paradoxical arterial air embolism. VAE affects cardiovascular, pulmonary and central nervous system. High index of clinical suspicion is must to diagnose VAE. The transesophgeal echocardiography is the most sensitive device which will detect smallest amount of air in the circulation. Treatment of VAE is to prevent further entrainment of air, reduce the volume of air entrained and haemodynamic support. Mortality of VAE ranges from 48 to 80%. VAE can be prevented significantly by proper positioning during surgery, optimal hydration, avoiding use of nitrous oxide, meticulous care during insertion, removal of central venous catheter, proper guidance, and training of scuba divers.

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Section: Etiologymentioning

confidence: 99%

Acute management of vascular air embolism

Shaikh

Ummunisa

2009

J Emerg Trauma Shock

123

108

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“…A BRIEF REVIEW OF RECENT LITERATURE demonstrates that gas embolism is known to occur in cardiac surgery, both on-pump from bypass circuit sources (8) and offpump (2). It happens in endoscopy (1), laparoscopic surgery (16), tissue biopsy (21), neurosurgery (30), liver transplantation (29), during central venous line insertion and removal (12), in orthopedic surgery (7), with laser surgery (20), during neuroangiography and cardiac catheterization procedures (26,34), in cardiac ablation procedures (17), and in arthroscopy (14). It has been reported during cardiopulmonary resuscitation (15), with positive-pressure ventilation (19), during intravenous antibiotic delivery at home (24), with the use of ultrasound bubble contrast media (18), and as a result of iatragenic embolization (31).…”

mentioning

confidence: 99%

Microvascular gas embolization clearance following perfluorocarbon administration

Eckmann

Ломиворотов

2003

Journal of Applied Physiology

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Effective treatment of vascular gas embolism may be possible with emulsified fluorocarbon compounds. We tested the hypothesis that a fluorocarbon emulsion delivered before gas embolization would enhance bubble motion through the vasculature, favoring more rapid clearance. Air microbubbles were injected into the rat cremaster microcirculation in six groups of rats receiving Perftoran, an emulsified fluorocarbon, or saline immediately before, 2 h before, or after bubble injection. Embolism dimensions and dynamics were observed by using intravital microscopy. Surface area at lodging was equal between groups. Bubbles having smaller volume embolized smaller diameter vessels in the Perftoran pretreatment groups. A higher incidence of bubble dislodgement and larger distal displacement occurred in these two groups, with a 36% decrease in the time to bubble clearance and restoration of blood flow. Intravascular emulsified fluorocarbon administration before gas embolization affected initial bubble conformation, increased bubble dislodgement, and resulted in bubble displacement further into the periphery of the microcirculation. These dynamic events did not occur if embolization preceded fluorocarbon administration.

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“…The latter have included reports of stroke from paradoxical air embolism in the presence of a patent foramen ovale. 29,30 In a retrospective analysis from a single institution there were no strokes in 5177 patients undergoing either orthopedic or neurological surgery in the BCP. 31 Researchers have speculated that hemodynamic changes associated with head elevation and anesthesia may result in inadvertent cerebral hypotension when anesthesiologists fail to consider the gravitational effects of head elevation on cerebral perfusion.…”

Section: Discussionmentioning

confidence: 99%

Shoulder Surgery in the Beach Chair Position Is Associated with Diminished Cerebral Autoregulation but No Differences in Postoperative Cognition or Brain Injury Biomarker Levels Compared with Supine Positioning

Laflam¹,

Joshi

Brady

et al. 2015

Anesthesia &Amp; Analgesia

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Background Although controversial, failing to consider the gravitational effects of head elevation on cerebral perfusion is speculated to increase susceptibility to rare, but devastating, neurologic complications after shoulder surgery in the beach chair position (BCP). We hypothesized that patients in the BCP have diminished cerebral blood flow autoregulation than those who undergo surgery in the lateral decubitus position (LDP). A secondary aim was to examine whether there is a relationship between patient positioning during surgery and postoperative cognition or serum brain injury biomarker levels. Methods Patients undergoing shoulder surgery in the BCP (n=109) or LDP (n=109) had mean arterial blood pressure (MAP) and regional cerebral oxygen saturation (rScO2) monitored with near-infrared spectroscopy. A continuous, moving Pearson’s correlation coefficient was calculated between MAP and rScO2, generating the variable cerebral oximetry index (COx). When MAP is in the autoregulated range, COx approaches zero because there is no correlation between cerebral blood flow and arterial blood pressure. In contrast, when MAP is below the limit of autoregulation, COx is higher because there is a direct relationship between lower arterial blood pressure and lower cerebral blood flow. Thus, diminished autoregulation would be manifest as higher COx. Psychometric testing was performed before surgery and then 7–10 days and 4–6 weeks after surgery. A composite cognitive outcome was determined as the Z-score. Serum S100β, neuron-specific enolase, and glial fibrillary acidic protein were measured at baseline, after surgery, and on postoperative day 1. Results After adjusting for age and history of hypertension, COx (p=0.035) was higher and rScO2 lower (p<0.0001) in the BCP group than in the LDP group. After adjusting for baseline composite cognitive outcome, there was no difference in Z-score 7 to 10 day (p=0.530) or 4 to 6 weeks (p=0.202) after surgery between the BCP and the LDP groups. There was no difference in serum biomarker levels between the 2 position groups Conclusions Compared with patients in the LDP, patients undergoing shoulder surgery in the BCP are more likely to have higher COx indicating diminished cerebral autoregulation and lower rScO2. There were no differences in the composite cognitive outcome between the BCP and LDP groups after surgery after accounting for baseline Z-score.

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Air Embolism during Anesthesia for Shoulder Arthroscopy

Cited by 26 publications

References 3 publications

Acute management of vascular air embolism

Acute management of vascular air embolism

Microvascular gas embolization clearance following perfluorocarbon administration

Shoulder Surgery in the Beach Chair Position Is Associated with Diminished Cerebral Autoregulation but No Differences in Postoperative Cognition or Brain Injury Biomarker Levels Compared with Supine Positioning

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