Critical Care: Student/Resident Case Report Poster - Critical Care I |

Airy Marrow: A Case Report FREE TO VIEW

Abdullah Al Twal, MD; Ayodeji Olarewaju, MBChB; Ioana Amzuta, MD
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SUNY Upstate University Hospital, Syracuse, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):386A. doi:10.1016/j.chest.2016.08.399
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Acute gas embolism (AGE) is an extremely rare but potentially catastrophic procedural complication related to inadvertent introduction of air into vasculature. Most cases are iatrogenic and may occur during surgery, fluid infusion, central venous catheter insertion, pacemaker or defibrillator placement, needle biopsy, colonoscopy, positive pressure ventilation and chest trauma. We describe a case of AGE presumably secondary to bone marrow biopsy.

CASE PRESENTATION: A 63-year-old man presented to a peripheral hospital after a mechanical fall. He has a past medical history of Diabetes Mellitus type II and hypertension. Physical examination revealed a morbidly obese Caucasian male with limited range of motion in his right shoulder and large ecchymosis on his chest. X-ray of the right shoulder showed a comminuted fracture involving the surgical neck of the humerus. Blood work revealed normocytic normochromic anemia with a hemoglobin of 8.7mg/dl and thrombocytopenia with a platelet count of 35,000/mm3. DIC workup was negative. A Bone marrow biopsy was performed from the posterior superior iliac crest approximately forty-eight hours after his presentation. Within hours of the procedure, he became hemodynamically unstable with a BP of 70/50mmHg, HR of 120 beats/min, RR 26 breaths/min and oxygen saturation of 92% on non-rebreather mask. He was volume resuscitated, started on vasopressor support and transferred to our institution. Upon arrival to our ICU, 2D echocardiogram revealed right ventricular strain with no wall motion abnormalities. CT thorax without contrast revealed extensive air embolism within the right atrium, right ventricle, main pulmonary artery and the ascending thoracic aorta. He underwent two sessions of hyperbaric oxygen therapy with complete resolution of air embolism on repeat CT thorax and hemodynamic stability was achieved after the first session of hyperbaric oxygen therapy.

DISCUSSION: Once diagnosis of AGE is confirmed, further entry of gas into vasculature must be prevented. Treatment is mainly supportive (high flow oxygen, mechanical ventilation, volume resuscitation, vasopressors, advanced cardiac life support) but in cases of hemodynamic compromise hyperbaric oxygen should be used. Our case is unique because we were unable to find any reported cases in the literature of air embolism complicating bone marrow biopsy. Another interesting finding was air in both the venous and arterial circulation, which raises the suspicion for a patent foramen ovale.

CONCLUSIONS: Clinicians should maintain a high index of suspicion for AGE in any patient who develops acute mental status changes or hemodynamic instability during or after procedures with potential for air embolism.

Reference #1: Wenham TN, Graham D. Venous gas embolism: An unusual complication of laparoscopic cholecystectomy. Journal of Minimal Access Surgery. 2009

Reference #2: Leach RM, Rees PJ, Wilmshurst P. Hyperbaric oxygen therapy. BMJ 1998; 317:1140.

Reference #3: Muth CM, Shank ES. Gas embolism. N Engl J Med 2000

DISCLOSURE: The following authors have nothing to disclose: Abdullah Al Twal, Ayodeji Olarewaju, Ioana Amzuta

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