What is the management of venous air embolism during shoulder arthroscopy?

Management of Venous Air Embolism During Shoulder Arthroscopy

Immediately position the patient in left lateral decubitus head-down (Trendelenburg) position and administer 100% oxygen while stopping the arthroscopic pump to prevent further air entry. 1

Immediate Recognition and Initial Actions

Stop the procedure immediately when venous air embolism is suspected, which typically presents with:

• Sudden drop in end-tidal CO₂ (most sensitive early indicator) 2
• Acute hypotension 2
• Mill wheel (waterwheel) murmur over the right heart on auscultation 2
• Cardiovascular collapse in severe cases 1

Critical first steps:

• Position patient in left lateral decubitus with head down to trap air in the right ventricular apex and prevent migration to pulmonary artery 1, 3
• Administer 100% normobaric oxygen to reduce air bubble size and improve tissue oxygenation 4, 1
• Stop arthroscopic pump and clamp all tubing immediately 1

Hemodynamic Support and Monitoring

Initiate aggressive hemodynamic support:

• Start fluid resuscitation to increase central venous pressure 1
• Administer vasopressors (norepinephrine or vasopressin) if hypotension persists to maintain coronary perfusion pressure 1, 3
• Consider inotropic support with dobutamine for right ventricular failure due to outflow tract obstruction 3
• Milrinone may be used as alternative inotrope with pulmonary vasodilatory effects 3

Continuous monitoring is essential:

• Heart rate, blood pressure, and oxygen saturation 1, 3
• End-tidal CO₂ monitoring (critical for early detection) 2
• Bedside echocardiography to assess right ventricular function and confirm air presence 1, 3

Air Aspiration Attempts

If central venous access is available:

• Attempt aspiration of air from the right atrium/right ventricle through existing central line 1, 3
• This may prevent further air migration and reduce the air burden 1

Advanced Interventions

For severe cases with neurological symptoms:

• Consider hyperbaric oxygen therapy if available, particularly if paradoxical arterial air embolism is suspected (suggesting right-to-left shunt) 4, 1
• This is most relevant when neurological deficits suggest cerebral air embolism 4

For persistent right ventricular dysfunction:

• Consider pulmonary vasodilators such as inhaled nitric oxide or sildenafil 3
• Avoid excessive fluid administration as this may worsen right ventricular distention 3

Prevention Strategies for Future Cases

Key preventive measures during shoulder arthroscopy:

• Evacuate all air from 3-L saline bags before connecting to arthroscopic pump, as these bags contain 34-85 mL of air that can be pumped into the joint 5
• Avoid air insufflation for diagnostic arthroscopy, particularly in patients with acute intra-articular fractures where venous channels may be disrupted 2
• Monitor end-tidal CO₂ continuously during all shoulder arthroscopy cases 2
• Be particularly vigilant in cases with acute fractures where bone disruption creates direct venous access 2

Common Pitfalls to Avoid

Critical errors that worsen outcomes:

• Failing to recognize subtle early signs (gradual drop in end-tidal CO₂) before cardiovascular collapse occurs 1
• Delaying position change and oxygen administration 1
• Continuing to pump fluid/air after embolism is suspected 1
• Not monitoring end-tidal CO₂ during shoulder arthroscopy 2

Important distinction: This management differs from venous thromboembolism prevention in shoulder arthroplasty, which focuses on mechanical/chemical prophylaxis for blood clots rather than acute air embolism management 4. The air embolism during arthroscopy is an acute intraoperative emergency requiring immediate intervention, whereas thromboembolic complications after shoulder surgery are rare postoperative events 6, 7, 8.