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Venous Air Embolism

Venous Air Embolism. Pekka Talke, MD University of California, San Francisco 2009. Procedures in Sitting Position. Cervical laminectomies Posterior fossa surgeries Becoming relatively uncommon but associated with high rates of complications. Benefits of Sitting Position.

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Venous Air Embolism

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  1. Venous Air Embolism Pekka Talke, MD University of California, San Francisco 2009

  2. Procedures in Sitting Position • Cervical laminectomies • Posterior fossa surgeries • Becoming relatively uncommon but associated with high rates of complications

  3. Benefits of Sitting Position • Better surgical exposure • Less tissue retraction • Less bleeding • Less cranial nerve damage

  4. Complications of Sitting Position • Spinal cord infarct • Ulnar nerve compression • Sciatic nerve damage • Lateral peroneal nerve compression • Cardiovascular changes • Airway obstruction -tube kinking, migration • Tension pneumocephalus • Venous Air Embolism (VAE) (40%)

  5. VAE detection,sensitivity • Doppler, TEE • ET N2 • PaO2 • ET CO2, PAP • PaCO2 • CVP • CO • BP • ECG, esoph. steth.

  6. Monitoring for Sitting Position • ECG • Temperature • Muscle relaxation • Pulse oximeter • ET CO2, ET anesthetic agent, ET N2 • Arterial blood pressure (cpp) • Central venous pressure (cvp, pap) • Precordial Doppler • Esophageal stethoscope

  7. Monitoring for Sitting Position • ECG • Temperature • Muscle relaxation • Pulse oximeter • ET CO2, ET anesthetic agent, ET N2 • Arterial blood pressure (cpp) • Central venous pressure (cvp, pap) • Precordial Doppler • Esophageal stethoscope

  8. Doppler (VAE) • Very sensitive • 3-6 th interspace, right of sternum • 2.2 MHz probe • Blood, wall motion, air • Early detection/prevention

  9. Doppler equipment

  10. Doppler probe 2.25 MHz flat probe 3/4’’ ultrasound beam at surface

  11. Doppler equipment Model 915-BL or Model 614-B 2 MHz flat probe

  12. Doppler equipment

  13. Precordial Doppler Placement

  14. Doppler record keeping

  15. ET CO2 changes with VAE • Sudden decrease in ET CO2 within a few breaths after VAE • ET CO2 decrease proportional to VAE magnitude • ET CO2 starts to recover once VAE stops

  16. ET CO2 trend changes with VAE

  17. CVP catheter (VAE) • Positioning: ECG, X-ray, pressure tracing • Positioning in sitting position - migration • Can be used to confirm Doppler placement • Aspiration: confirmation of VAE, treatment? • (PA catheter: diagnosis, resolution)

  18. CVP Catheter

  19. CVP Catheter

  20. CVP Catheter

  21. CVP Catheter

  22. Placement of CVP Catheter From Clinical Neuroanesthesia, Cucchiara et al

  23. Placement of CVP Catheter From Clinical Neuroanesthesia, Cucchiara et al

  24. VAE Detection - Awake • Cough • Chest pain • Bronchospasm • Hypoxia

  25. Rapid, Large VAE • Rare • Catastrophic • Air lock in right heart • Right sided heart failure • Reduced CO • Cardiovascular collapse

  26. Slow, Continuous VAE • Common • Air bubbles entrapped in pulmonary circulation • Local hypoxemia/obstruction • Sympathetic reflex vasoconstriction • Pulmonary HTN, hypoxemia, CO2 retention, increased dead space, decreased ET CO2 • Bronchoconstriction

  27. M&M from VAE • Right heart failure • Hypoxia - immediate, delayed (ARDS) • Paradoxical Air Embolus (PAE) • incidence unknown • potential for neurologic deficits • PFO (20-30%)

  28. Treatment of VAE • 100% O2 • Flood field, bone wax • Jugular pressure • Volume, vasopressors, supine • CPR

  29. Venous Air Embolism • Prevention - avoid hypovolemia, good surgical technique • Early detection • Treatment

  30. neuroanesthesia.ucsf.edu Thank You

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