Pulmonary Vascular Disease |

It's Not All Air! FREE TO VIEW

Hammad Arshad, MD; Mohammad Bilal, MD; Marvin Balaan, MD
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Allegheny General Hospital, Pittsburgh, PA

Chest. 2014;146(4_MeetingAbstracts):866A. doi:10.1378/chest.1991294
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SESSION TITLE: Pulmonary Vascular Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Venous air embolism(VAE) is a potentially life threatening condition that may be seen in situations other than high risk procedures.We present an interesting case initially diagnosed as VAE but subsequently also found to have saddle pulmonary embolism.

CASE PRESENTATION: A 68 year old female presented with one day history of chest pain and diaphoresis two weeks after laparoscopic hernia repair.She was hypotensive but had an otherwise normal physical examination.Her BP improved with fluids.EKG and troponin levels were normal.Non contrasted CT chest showed air throughout the venous system in the upper chest extending into right ventricle .Patient was admitted to the ICU for hemodynamic monitoring and was treated with hyperbaric oxygen.Her echocardiogram showed right heart strain and McConnell sign. Chest CT pulmonary angiogram(CTPA) revealed a saddle pulmonary embolism extending into all pulmonary vessels.Patient was started on IV heparin with resolution of symptoms.She was discharged on oral warfarin.CTPA after 6 months showed complete resolution of the pulmonary and air emboli.

DISCUSSION: Venous air embolism(VAE) is the entrainment of air from the operative field into the venous or arterial vasculature,producing systemic effects.Mortality is related directly to volume of air entrained and rate of accumulation.Though most cases manifest acutely with cardiopulmonary symptoms many remain subclinical and get diagnosed during routine radiological assessment.VAE has been reported in procedures as benign as lumbar puncture,contrast CT chest and laproscopic surgery.The positive pressure inflation of gas used during laparoscopy is a significant embolism hazard.Air embolism may result not only in a catastrophic event like cardiogenic arrest but also pulmonary hypertension,edema and platelet aggregation.This case presented with delayed recognition of venous air embolism two weeks after laparoscopic hernia repair and concomitant pulmonary thromboembolism.

CONCLUSIONS: Clinicians should be aware of this silent but dangerous entity that can occur during many seemingly routine operative procedures.Air embolism should be considered in the differential diagnosis of respiratory symptoms in patients who had a recent laparoscopic surgery.Acute pulmonary embolism may present concomitantly.

Reference #1: Diagnosis and Treatment of Vascular air embolism; A Mirski et al; Anesthesiology 2007;106;164-77

Reference #2: Richter et al.Air in the insufflation tube may cause fatal embolizations in laparoscopic surgery:Surg Endosc2013 May;27(5):1791-7.

DISCLOSURE: The following authors have nothing to disclose: Hammad Arshad, Mohammad Bilal, Marvin Balaan

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