From the Guidelines
Management of venous air embolism requires immediate intervention to prevent serious complications or death, with the first step being to stop further air entry by placing the patient in the left lateral decubitus position with the head down (Durant's position) and administering 100% oxygen to treat hypoxemia and reduce the size of the air embolus 1. The left lateral decubitus position traps air in the right atrium, preventing it from entering the pulmonary circulation.
- Key aspects of management include:
- Prevention of further air entry
- Reduction in the volume of air entrained
- Hemodynamic support
- Administration of 100% oxygen to decrease bubble size by establishing a diffusion gradient that favours elimination of the gas 1
- If a central venous catheter is present, attempt to aspirate air from the right atrium, as this may be an option in cases of large amounts of central air 1.
- Hemodynamic support is crucial, including intravenous fluids to increase venous pressure and vasopressors (such as norepinephrine) if hypotension persists.
- For large air embolisms causing cardiovascular collapse, cardiopulmonary resuscitation may be necessary.
- Hyperbaric oxygen therapy should be considered for severe cases with neurological symptoms, as it reduces bubble size and improves oxygenation.
- Prevention is key in high-risk procedures, including proper patient positioning, adequate hydration, and careful surgical technique.
- Monitoring with precordial Doppler ultrasound or transesophageal echocardiography during high-risk procedures can allow for early detection and intervention. The lethal volume of air after injection in humans is estimated to range from 100 to 500 mL, and the major effect of venous air embolism is the obstruction of the right ventricular outflow tract, or of the pulmonary arterioles, by a mixture of air bubbles and fibrin 1.
From the Research
Management of Venous Air Embolism (VAE)
The management of VAE can be critical in improving patient outcomes. Some key strategies include:
- Preventing further entrainment of air 2
- Reducing the volume of air entrained 2
- Providing hemodynamic support 3, 4
- Using inotropic support to manage right heart syndromes 3
- Applying veno-arterial extracorporeal membrane oxygenation (ECMO) in critically ill patients 4
- Utilizing hyperbaric oxygen therapy to facilitate gas reabsorption and improve tissue oxygenation 5, 6
Treatment Options
Treatment options for VAE may vary depending on the severity of the condition and the availability of resources. Some options include:
- Durant's maneuver 4
- Aspiration and removal of air through venous catheters 4
- Hyperbaric oxygen therapy 5, 6
- Cardiotonic drugs and chest compressions for critically ill patients 4
- Veno-arterial ECMO for patients in obstructive shock 4
Importance of Prompt Diagnosis and Management
Prompt diagnosis and management of VAE are crucial in improving patient outcomes. A high index of clinical suspicion is necessary to diagnose VAE, and transesophageal echocardiography can be used to detect even small amounts of air in the circulation 2.