Gas embolism during endoscopic retrograde cholangiopancreatography: diagnosis and managementn

Abstract

Air embolism is rarely diagnosed and is often fatal. The diagnosis is often not made in a timely manner given the rapid and severe clinical deterioration that often develops, frequently leading to cardiac arrest. Many patients are only diagnosed post-mortem. With the increasing use of endoscopic retrograde cholangiopancreatography, air embolism should be considered in the differential diagnosis in patients who experience sudden clinical deterioration during or immediately after the procedure. Clinical suspicion is key in the diagnosis and management of air embolism. Use of precordial Doppler ultrasound and transesophageal echocardiogram can aid in the diagnosis of air embolism. Once the diagnosis is made, supportive management of airway, breathing and circulation is pivotal. Advanced cardiac life support should be initiated when necessary. Fluid resuscitation and vasopressors can improve cardiac output. Hyperbaric oxygen therapy should be considered when possible in cases of suspected cerebral air embolism cases to improve neurological outcome. A multidisciplinary team approach and effective communication with experts, potentially including an anesthesiologist, cardiologist, intensivist, radiologist and surgeon, can improve the outcome in air embolism.

A Dreaded Procedural Complication During Endoscopic Retrograde Cholangiopancreatography

“…Lanke and Adler identified 51 cases of air embolism following ERCP, which includes systemic air embolism, venous air embolism, and cerebral air embolism. According to this data out of 51 patients, 25 patients succumbed to the complication, which are 49.02% mortality [2]. A systemic review done by Donepudi et al shows the data of 26 patients who underwent ERCP developed air embolism and 15 patients died, which accounts for 57.7% [3].…”

“…A lthough a commonly performed intervention, endoscopic retrograde cholangiopancreatography (ERCP) poses a greater challenge to the surgeon as well as the anesthesiologist, and it is associated with a substantially increased risk of morbidity and mortality [1]. Incidence of air embolism is very rare, only 51 cases of air embolism reported following the ERCP, according to the literature search [2]. It can present as cardiopulmonary instability and neurological symptoms [3].…”

Clinical Presentation, Diagnosis, and Management of Air Embolism During Endoscopic Retrograde Cholangiopancreatography

“…A computed tomography scan can be done if systemic air embolism is suspected to identify air in the affected organs only after initial stabilization and resuscitation of the patient [44]. Moreover, pulmonary embolism should always be in the differentials of hemodynamic instability [11].…”

“…If echocardiography confirms air in the right heart, the central catheter is inserted. High-flow 100% oxygen, Trendelenburg, and left lateral decubitus positions are used to prevent air migrating to the brain and to force the air into the outflow tract of the right ventricle [11]. Hyperbaric oxygen therapy is considered first-line treatment as it reduces the size of the air bubbles, increases nitrogen absorption, and increases blood oxygen concentration, which helps reduce cerebral ischemic injury [25].…”

“…The amount of air that causes a circulatory air embolism ranges from 10 to 480 mL, depending on the speed of air entering into circulation and the organ vasculature into which the embolus extends [10]. Air embolism is a serious complication that can occur during an endoscopic procedure, and it can cause significant morbidity and mortality if not diagnosed early [11]. Therefore, it is imperative to keep the possibility of air embolism in mind whenever a patient experiences sudden deterioration of vitals or neurologic compromise, apart from other significant causes.…”