Disseminated intravascular coagulation following air embolism during orthotropic liver transplantation: is this just a coincidence?

Abstract

Background During orthotopic liver transplantation, venous air embolism may occur due to iatrogenic injury of the inferior vena cava. However, venous air embolism followed by coagulopathy is a rare event. In this case report, we discuss a possible connection between venous air embolism and disseminated intravascular coagulation. Case presentation A 37-year-old male patient with chronic hepatitis B- and C-induced liver cirrhosis was admitted for orthotopic liver transplantation. During the dissection phase of the surgery, arterial blood pressure, heart rate, saturation and end-tidal carbon dioxide levels suddenly decreased, indicating the occurrence of venous air embolism. After stabilizing the patient’s condition, various coagulation issues started developing. Venous air embolism-induced coagulopathy was handled by administering transfusions of various blood products. However, the patient’s condition continued to deteriorate leading to a complete asystole. Conclusions This is a rare case of venous air embolism-induced disseminated intravascular coagulation. The real connection remains unclear as disseminated intravascular coagulation for end-stage liver disease patients can be induced by various causes during different stages of liver transplantation. Certainly, both venous air embolism and coagulopathy were significant and led to an unfavorable outcome. Further studies are needed to better understand the possible mechanisms and correlation between these two life-threatening complications.

Individualized Management of Coagulopathy in Patients with End-Stage Liver Disease

“…Finally, important issues during bleeding in the operating room are adequate communication skills and safe, confident, and patient-orientated teamwork [ 98 , 99 ].…”

Venous Air Embolism Activates Complement C3 Without Corresponding C5 Activation and Trigger Thromboinflammation in Pigs

“…Air may also transverse the pulmonary circulation, enter the arterial circulation, disrupt blood circulation, and cause organ ischemia and damage, such as acute myocardial infarction or stroke (6,8,9). Patient case reports have described prolonged severe inflammation after air embolism (6,10), and one case report described a suspected link between perioperative air embolism and disseminated intravascular coagulation, albeit with an unknown pathophysiological mechanism (11). In vitro experiments in human serum and heparinized blood have shown that air activates C3 to C3(H 2 0), also termed iC3 (12)(13)(14), and in vitro studies in lepirudin anticoagulated human whole blood have shown that air emboli trigger a complement C3-driven thromboinflammation (15), which is attenuated by C3 inhibition (15).…”