From the Guidelines
Management of air embolism requires immediate intervention with several key steps, prioritizing prevention of further air entry, reduction of the volume of air entrained, and hemodynamic support, as outlined in the 2019 ESC guidelines 1. The first step is to position the patient in the left lateral decubitus position with the head down (Durant's maneuver) to prevent air from entering the pulmonary outflow tract.
- Administer high-flow 100% oxygen to treat hypoxemia and reduce the size of the air embolus by increasing the gradient for nitrogen to diffuse out of the bubble.
- If a central venous catheter is present and suspected as the source, clamp it immediately to prevent further air entry.
- For hemodynamically unstable patients, provide supportive care including fluid resuscitation with crystalloids (normal saline or lactated Ringer's at 10-20 ml/kg) and vasopressors if needed (norepinephrine 0.1-1 mcg/kg/min), as recommended by the European Society of Cardiology 1. Key considerations in management include:
- Hyperbaric oxygen therapy at 2.5-3 atmospheres absolute for 2-4 hours should be considered for severe cases, ideally within 6 hours of the event, as it compresses air bubbles and accelerates nitrogen reabsorption.
- If cardiac arrest occurs, perform standard resuscitation protocols with the addition of chest compressions which may help fragment larger air emboli. The management approach is guided by the principles outlined in the European Heart Journal, emphasizing the importance of prompt intervention to prevent further complications and improve patient outcomes 1.
From the FDA Drug Label
• Prophylaxis and treatment of venous thrombosis and pulmonary embolism; The management of pulmonary embolism includes the use of heparin for prophylaxis and treatment.
- The dosage of heparin should be adjusted according to the patient's coagulation test results.
- Laboratory monitoring for efficacy and safety is necessary, including activated partial thromboplastin time (aPTT) and platelet count.
- The recommended adult full-dose heparin regimens for therapeutic anticoagulant effect are provided in Table 1, and may be adjusted for the individual patient according to the results of suitable laboratory tests 2.
From the Research
Management of Air Embolism
The management of air embolism involves prompt diagnosis and treatment to improve patient outcomes. The following are key aspects of management:
- Immediate placement of the patient on high-flow oxygen 3, 4
- Positioning the patient in the right lateral decubitus position for arterial air emboli or the left lateral decubitus and/or Trendelenburg position for venous air emboli 3
- Hyperbaric oxygen therapy as the definitive treatment to decrease the size of air emboli, improve tissue oxygenation, and reduce ischemic reperfusion injury 3, 5
- Aspiration of the air in some cases 4
- Surgical removal of the embolism in cases of venous gas embolisms 5
Prevention Techniques
Prevention techniques are crucial in reducing the risk of air embolism, particularly in patients undergoing endovascular procedures:
- Heightened awareness of the complication among medical practitioners 6
- Use of appropriate precautions and techniques during central venous catheter and arterial catheter placement and removal 6
- Avoidance of air entry into the vascular system during invasive procedures 6
Clinical Signs and Symptoms
Clinical signs and symptoms of air embolism vary depending on the location of the embolus:
- Right heart/pulmonary artery embolism: dyspnea, chest pain 4, 7
- Cerebral embolism: neurological symptoms 4
- Patent foramen ovale (PFO) embolism: variable symptoms 4
Treatment Outcomes
Treatment outcomes for air embolism vary depending on the severity of the condition and the promptness of treatment: