1/6. Venous air embolism from central venous catheterization: a need for increased physician awareness.OBJECTIVES: To report a series of patients with clinically diagnosed venous air embolism (VAE) and major sequelae as a complication of the use of central venous catheters (CVCs), to survey health care professionals' practices regarding CVCs, and to implement an educational intervention for optimizing approaches to CVC insertion and removal. SETTING: Tertiary care, university-based 806-bed medical center. INTERVENTIONS: We surveyed 140 physicians and 53 critical care nurses to appraise their awareness of the proper management and complications of CVCs. We then designed, delivered, and measured the effects of a multidisciplinary educational intervention given to 106 incoming house officers. MEASUREMENTS AND MAIN RESULTS: Although most physicians (127, 91%) chose the Trendelenburg position for CVC insertion, only 42 physicians (30%) reported concern for VAE. On CVC removal, only 36 physicians (26%) cited concern for VAE. Some physicians (13, 9%) reported elevating the head of the bed during CVC removal, possibly increasing the risk of VAE. awareness of VAE or its prevention did not correlate with the level of physician training, experience, or specialty. After the educational intervention, concern for and awareness of proper methods of prevention of VAE improved (p < .001). At 6-month follow-up, reported use of the Trendelenburg position continued, but concern cited for VAE had returned to baseline. CONCLUSIONS: There is inadequate awareness of VAE as a complication of CVC use. Focused instruction can improve appreciation of this potentially fatal complication and knowledge of its prevention, but the effect declines rapidly. To achieve a more sustained improvement, a more intensive, hands-on, periodic educational program will likely be necessary, as well as reinforcement through enhanced supervision of CVC insertion and removal practices.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/6. neurologic manifestations of cerebral air embolism as a complication of central venous catheterization.OBJECTIVE, patients, AND methods: A severe case of cerebral air embolism after unintentional central venous catheter disconnection was the impetus for a systematic literature review (1975-1998) of the clinical features of 26 patients (including our patient) with cerebral air embolism resulting from central venous catheter complications. RESULTS: The jugular vein had been punctured in eight patients and the subclavian vein, in 12 patients. embolism occurred in four patients during insertion, in 14 patients during unintentional disconnection, and in eight patients after removal and other procedures. The total mortality rate was 23%. Two types of neurologic manifestations may be distinguished: group A (n = 14) presented with encephalopathic features leading to a high mortality rate (36%); and group B (n = 12) presented with focal cerebral lesions resulting in hemiparesis or hemianopia affecting mostly the right hemisphere, with a mortality rate as high as 8%. In 75% of patients, an early computed tomography indicated air bubbles, proving cerebral air embolism. Hyperbaric oxygen therapy was performed in only three patients (12%). A cardiac defect, such as a patent foramen ovale was considered the route of right to left shunting in 6 of 15 patients (40%). More often, a pulmonary shunt was assumed (9 of 15 patients; 60%). For the remainder, data were not available. CONCLUSION: When caring for critically ill patients needing central venous catheterization, nursing staff and physicians should be aware of this potentially lethal complication.- - - - - - - - - - ranking = 0.1keywords = physician (Clic here for more details about this article) |
3/6. Documented arterial gas embolism after spinal epidural injection.We report the case of a 90-year-old man with syncope, arrhythmia, cardiac ischemia, and neurologic deficit after undergoing spinal epidural injection for control of pain related to post-herpetic neuralgia. The diagnosis of arterial gas embolus was made after air was identified in the left ventricle of the heart on an abdominal computed tomographic scan. Emergency physicians should consider and rapidly diagnose this rare but potentially fatal complication of spinal epidural puncture.- - - - - - - - - - ranking = 0.1keywords = physician (Clic here for more details about this article) |
4/6. Air embolism in central venous catheterization: diagnosis, treatment, and prevention.Air embolism associated with central venous catheterization carries with it a significant morbidity and mortality. The diagnosis should be suggested by sudden alterations in cardiovascular, respiratory, or central nervous system function in a patient with a central venous catheter. A "mill wheel" cardiac murmur is characteristic. Placing the patient in the left lateral decubitus with the head down allows displacement of the air from the pulmonary outflow tract. Prevention of the complication involves thorough patient and physician preparation before subclavian catheterization, use of a Luer lock between catheter and tubing, meticulous catheter care, and employment of a pump with an in-line air detector.- - - - - - - - - - ranking = 0.1keywords = physician (Clic here for more details about this article) |
5/6. Air embolism death of a pregnant woman secondary to orogenital sex.Air embolism produced by vaginal insufflation is an unusual but potentially lethal consequence of sexual activity, especially in the pregnant patient. Reported here is the case of a young pregnant woman who presented to the ED in full cardiac arrest, with little history to explain her condition. Despite aggressive resuscitative measures, the patient died, but her infant son was delivered via perimortem cesarean section and survived. A high level of suspicion for air embolism should be maintained for young women who unexpectedly develop cardiac arrest, particularly during sexual activity. Air embolism patients may require vigorous medical resuscitation, hyperbaric oxygen therapy, or surgical intervention to survive. The emergency physician should be familiar with the indications for perimortem cesarean delivery in the third-trimester patient presenting to the ED with cardiac arrest.- - - - - - - - - - ranking = 0.1keywords = physician (Clic here for more details about this article) |
6/6. Delayed onset arterial gas embolism.Numerous civilian and military personnel are involved in SCUBA diving activities. In this day of rapid air travel it is important that all physicians, not just those living near the coast or dive centers, be familiar with the basics of diagnosing and treating diving-related injuries. One of the more serious complications of dysbarism is Arterial Gas embolism (AGE). This case history involves an atypical presentation of delayed onset AGE in a military diver trainee, and its treatment. This article then reviews the incidence, etiology, pathophysiology, "classic" presentation and current treatment of this disease. Systemic pathophysiology secondary to the effects of intravascular air of AGE is also discussed.- - - - - - - - - - ranking = 0.1keywords = physician (Clic here for more details about this article) |