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Critical Care |

Iatrogenic Air Embolism Complicating a Case of Severe Septic Shock

Frederick Clayton, MD
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East Tennessee State University, Mountain Home, TN


Chest. 2013;144(4_MeetingAbstracts):300A. doi:10.1378/chest.1703959
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Abstract

SESSION TITLE: ICU Complications

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 27, 2013 at 07:30 AM - 08:30 AM

INTRODUCTION: Sepsis affects millions of patients yearly and has been touted as a leading cause of death in the ICU. Septic shock is associated with a mortality of 36-47%. Venous air embolism is a preventable complication of intravenous access. Discovered during the initial imaging, we present the unfortunate consequences of introducing venous air into a hypotensive, septic patient.

CASE PRESENTATION: A 74-year-old confused man, with a one day history of constipation and chills, was brought into the Emergency Department by his wife. During triage he became diaphoretic, dizzy, and ashen in color. Initial exam revealed a pulse of 115 beats/min, a blood pressure of 108/80 mmHg, and respirations of 24/min. Two size #20 IV access catheters were placed. The patient was sent to the CT scanner with NS now under pressure and 100% O2 by non-rebreather mask. CT’s were completed without contrast. Laboratory panels were notable for leucocytes of 8400/mcL with 14% bands. He required intubation with mechanical ventilation. Despite starting vasopressors, he briefly lost a pulse and was given CPR with epinephrine. Although he regained a pulse after only about 5 minutes of chest compressions, he remained hypotensive. The scan of the chest showed 60-70ml of air in the right ventricle, right atrium and the main pulmonary arterial trunk. After the results of the scan, he was placed in left lateral decubitus position (Durant's maneuver). Bedside echocardiogram showed a nearly akinetic right ventricle. Further cardiovascular collapse ensued causing the patient's death. The patient’s blood cultures later proved positive for Escherichia Coli.

DISCUSSION: Without any suspicion, a large air embolism was found. Although the source of intravenous air was never positively identified, the most likely culprit was the peripheral IV’s under pressure bag augmentation. Research shows that at a diameter of #20 gauge, there is a negligible difference in the flow of fluids under pressures of 200-300mmHg. This patient’s triad of severe right heart failure, pulmonary hypertension, and shock are all well documented consequences of a venous air embolism.

CONCLUSIONS: There is little to no benefit of pressure bag augmentation during fluid resuscitation through small IV's. Ultimately this patient’s gram negative bacteremia has a high mortality coupled with extreme administration of fluids may have led to the unintentional and often deadly complication of an iatrogenic venous air embolism.

Reference #1: Dellinger , et. al., Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Crit Care Med. 2013 Feb;41(2):580-637.

Reference #2: Hall MJ, Williams SN, DeFrances CJ, Golosinskiy A. Inpatient care for septicemia or sepsis: A challenge for patients and hospitals. NCHS data brief, no 62. Hyattsville, MD: National Center for Health Statistics. 2011.

Reference #3: Stoneham MD. An evaluation of methods of increasing the flow rate of i.v. fluid administration. Br J Anaesth 1995; 75: 361-5.

DISCLOSURE: The following authors have nothing to disclose: Frederick Clayton

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