What is the management of air embolism from central lines (Central Venous Catheters) causing cardiac arrest and maternal mortality in pregnancy?

Management of Air Embolism from Central Lines Causing Cardiac Arrest in Pregnancy

The immediate management of air embolism from central venous catheters in pregnancy requires placing the patient in left lateral decubitus position, administering 100% oxygen, attempting to aspirate air from the central line, and initiating standard cardiopulmonary resuscitation protocols with consideration of hyperbaric oxygen therapy for arterial air embolism cases.

Immediate Recognition and Management

• Air embolism should be considered in the differential diagnosis for any pregnant woman with sudden cardiorespiratory collapse, particularly when associated with central venous catheter manipulation or placement 1
• If venous air embolism is suspected, immediately administer normobaric 100% oxygen to reduce the size of air bubbles and improve oxygenation 1
• Position the patient in left lateral decubitus position to prevent air from migrating to the pulmonary artery 1
• If a central line is in place, attempt to aspirate blood to remove air bubbles 1

Cardiopulmonary Resuscitation Considerations

• Initiate high-quality cardiopulmonary resuscitation immediately following standard basic cardiac life support and advanced cardiac life support protocols 1
• Use the same defibrillation protocol as in non-pregnant patients with biphasic shock energy of 120-200 J 1
• Ensure proper positioning with manual uterine displacement or left lateral tilt to relieve aortocaval compression 1
• Use a backboard for effective chest compressions 1
• Consider perimortem cesarean delivery (resuscitative hysterotomy) if no pulse after 4 minutes of resuscitation in a woman with a gravid uterus at or beyond 20 weeks gestation 1

Advanced Management

• If arterial air embolism is suspected (particularly with neurological symptoms), consider hyperbaric oxygen therapy if available 1
• Avoid excessive fluid administration to prevent volume overload, especially in the setting of right ventricular dysfunction 1
• Consider echocardiography (thoracic or esophageal) to assess for right ventricular dysfunction, which is common in air embolism 1
• For hemodynamic support:
  • Use vasopressors if needed: norepinephrine 0.05-3.3 μg/kg/min 1
  • Consider inotropes for right ventricular dysfunction: dobutamine 2.5-5.0 μg/kg/min or milrinone 0.25-0.75 μg/kg/min 1

Pulmonary Hypertension Management

• For significant pulmonary hypertension from air embolism, consider pulmonary vasodilators to unload the right ventricle 1:
  • Inhaled nitric oxide 5-40 ppm, or
  • Inhaled epoprostenol 10-50 ng/kg/min, or
  • IV epoprostenol 1-2 ng/kg/min (via central line), or
  • Sildenafil 20 mg orally (if awake/alert) 1
• Consider extracorporeal membrane oxygenation (ECMO) for prolonged CPR or refractory right heart failure 1

Multidisciplinary Team Approach

• Activate a specialized maternal code team immediately upon recognition of the emergency 1
• Involve a multidisciplinary team including anesthesia, respiratory therapy, critical care, and maternal-fetal medicine in the ongoing care 1
• Anticipate potential coagulopathy and hemorrhage, which may occur following cardiovascular collapse 1
• Consider early assessment of clotting status and aggressive management of clinical bleeding with standard massive transfusion protocols if needed 1

Prevention Strategies

• Maintain a high index of suspicion for air embolism during central line placement in pregnant women 2
• Use precautions during central line insertion including Trendelenburg position, proper patient hydration, and careful technique 2
• Flood the surgical field with normal saline during procedures to prevent air entry 2
• Consider using precordial Doppler studies for earlier diagnosis in high-risk situations 2

Common Pitfalls and Caveats

• Air embolism can be easily missed if not specifically considered in the differential diagnosis of sudden cardiovascular collapse in pregnancy 1, 3
• Delay in recognition and appropriate positioning can lead to increased mortality 3, 4
• Air embolism can occur during various procedures including central line placement, positive pressure ventilation, and surgery 3
• The risk of air embolism is increased in pregnancy due to the hypercoagulable state and increased venous pressure 5, 2
• Pregnant patients develop hypoxemia more rapidly than non-pregnant patients, making rapid airway management essential 1