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Cerebral air embolism following the removal of a central venous catheter in the absence of intracardiac right-to-left shunting: a case report.

Eum da H, Lee SH, Kim HW, Jung MJ, Lee JG - Medicine (Baltimore) (2015)

Bottom Line: We report a case of cerebral air embolism that occurred after the removal of a CVC in a patient with an underlying idiopathic pulmonary fibrosis, subcutaneous emphysema, pneumomediastinum, and a possible intrapulmonary shunt.Although the patient had a brief period of recovery, his condition deteriorated again, and retention of carbon dioxide was sustained due to aggravation of pneumonia.We suggest that strict compliance to protocols is required even while removing the catheter.

View Article: PubMed Central - PubMed

Affiliation: From the Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.

ABSTRACT
Air embolism following central venous catheter (CVC) removal is a relatively uncommon complication. Despite its rare occurrence, an air embolism can lead to serious outcomes. One of the most fatal complications is cerebral air embolism. We report a case of cerebral air embolism that occurred after the removal of a CVC in a patient with an underlying idiopathic pulmonary fibrosis, subcutaneous emphysema, pneumomediastinum, and a possible intrapulmonary shunt. Although the patient had a brief period of recovery, his condition deteriorated again, and retention of carbon dioxide was sustained due to aggravation of pneumonia. Despite full coverage of antibiotics and maximum care with the ventilator, the patient died about 5 weeks after the removal of the CVC. We suggest that strict compliance to protocols is required even while removing the catheter. Furthermore, additional caution to avoid air embolism is demanded in high-risk patients, such as in this case.

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Related in: MedlinePlus

Brain MRI that showing signs of recent infarct with diffuse swelling and gyral enhancement in the right hemisphere. Recent infarct in the left frontal and occipital lobes is also seen. MRI = magnetic resonance imaging.
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Figure 2: Brain MRI that showing signs of recent infarct with diffuse swelling and gyral enhancement in the right hemisphere. Recent infarct in the left frontal and occipital lobes is also seen. MRI = magnetic resonance imaging.

Mentions: After being admitted into the ICU, the patient was transferred to the general ward on the same day with full recovery of consciousness and vital signs in normal range, and showed satisfactory recovery from the surgery. Although discharge was being considered, the removal of the CVC was carried out on the seventh postoperative day. For the procedure, the patient's head was placed flat on the bed, and he was asked to practice holding his breath after inspiration several times. Although the patient held his breath, direct pressure was applied to the site, and the central line was removed. Compression was carried out long enough for the bleeding to stop. An occlusive dressing was done afterwards. The complete procedure was executed according to the standard protocol. About a minute later, his hands and feet curled up, and his body twisted to the left in a seizure-like motion while oxygen saturation level fell below 80%. After applying 10 L of oxygen via oxygen mask, saturation improved to 95%–99%, and his blood pressure and pulse rate was in normal range. CT angiogram of the brain revealed air bubbles along the sulci in the right frontal area, cavernous sinus, and superior sagittal sinus as well as an area of low attenuation in the right frontal lobe, suggesting cerebral air embolism (Figure 1). Hyperbaric therapy was recommended but was not available in our institution or others as well. Therefore, high-flow oxygen therapy was continued. There was little improvement in his consciousness, and the patient remained drowsy and stuporous. Left-side weakness, rigidity, pain on the right lower limb, and right deviation of both eyes could be seen. Because of oxygen desaturation, consistent tachypnea of 30 to 50 breaths/min, and intermittent episodes of myoclonic seizure on the right side, the patient was readmitted to the ICU. Mechanical ventilation was applied during the patient's ICU stay. Transthoracic echocardiogram showed no visible intracardiac shunt, but several bubbles were seen in the left heart after 5 beats during agitated saline study, suggesting the possibilities of an intrapulmonary shunt. Brain magnetic resonance imaging revealed a recent infarct with diffuse swelling and gyral enhancement in the right hemisphere. Another recent infarct in the left frontal and occipital lobes were also noted (Figure 2). Electroencephalography was performed, and its features suggested a structural lesion in the right hemisphere and partial nonconvulsive status epilepticus arising from the right hemisphere, especially in the frontocentral region.


Cerebral air embolism following the removal of a central venous catheter in the absence of intracardiac right-to-left shunting: a case report.

Eum da H, Lee SH, Kim HW, Jung MJ, Lee JG - Medicine (Baltimore) (2015)

Brain MRI that showing signs of recent infarct with diffuse swelling and gyral enhancement in the right hemisphere. Recent infarct in the left frontal and occipital lobes is also seen. MRI = magnetic resonance imaging.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4554025&req=5

Figure 2: Brain MRI that showing signs of recent infarct with diffuse swelling and gyral enhancement in the right hemisphere. Recent infarct in the left frontal and occipital lobes is also seen. MRI = magnetic resonance imaging.
Mentions: After being admitted into the ICU, the patient was transferred to the general ward on the same day with full recovery of consciousness and vital signs in normal range, and showed satisfactory recovery from the surgery. Although discharge was being considered, the removal of the CVC was carried out on the seventh postoperative day. For the procedure, the patient's head was placed flat on the bed, and he was asked to practice holding his breath after inspiration several times. Although the patient held his breath, direct pressure was applied to the site, and the central line was removed. Compression was carried out long enough for the bleeding to stop. An occlusive dressing was done afterwards. The complete procedure was executed according to the standard protocol. About a minute later, his hands and feet curled up, and his body twisted to the left in a seizure-like motion while oxygen saturation level fell below 80%. After applying 10 L of oxygen via oxygen mask, saturation improved to 95%–99%, and his blood pressure and pulse rate was in normal range. CT angiogram of the brain revealed air bubbles along the sulci in the right frontal area, cavernous sinus, and superior sagittal sinus as well as an area of low attenuation in the right frontal lobe, suggesting cerebral air embolism (Figure 1). Hyperbaric therapy was recommended but was not available in our institution or others as well. Therefore, high-flow oxygen therapy was continued. There was little improvement in his consciousness, and the patient remained drowsy and stuporous. Left-side weakness, rigidity, pain on the right lower limb, and right deviation of both eyes could be seen. Because of oxygen desaturation, consistent tachypnea of 30 to 50 breaths/min, and intermittent episodes of myoclonic seizure on the right side, the patient was readmitted to the ICU. Mechanical ventilation was applied during the patient's ICU stay. Transthoracic echocardiogram showed no visible intracardiac shunt, but several bubbles were seen in the left heart after 5 beats during agitated saline study, suggesting the possibilities of an intrapulmonary shunt. Brain magnetic resonance imaging revealed a recent infarct with diffuse swelling and gyral enhancement in the right hemisphere. Another recent infarct in the left frontal and occipital lobes were also noted (Figure 2). Electroencephalography was performed, and its features suggested a structural lesion in the right hemisphere and partial nonconvulsive status epilepticus arising from the right hemisphere, especially in the frontocentral region.

Bottom Line: We report a case of cerebral air embolism that occurred after the removal of a CVC in a patient with an underlying idiopathic pulmonary fibrosis, subcutaneous emphysema, pneumomediastinum, and a possible intrapulmonary shunt.Although the patient had a brief period of recovery, his condition deteriorated again, and retention of carbon dioxide was sustained due to aggravation of pneumonia.We suggest that strict compliance to protocols is required even while removing the catheter.

View Article: PubMed Central - PubMed

Affiliation: From the Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.

ABSTRACT
Air embolism following central venous catheter (CVC) removal is a relatively uncommon complication. Despite its rare occurrence, an air embolism can lead to serious outcomes. One of the most fatal complications is cerebral air embolism. We report a case of cerebral air embolism that occurred after the removal of a CVC in a patient with an underlying idiopathic pulmonary fibrosis, subcutaneous emphysema, pneumomediastinum, and a possible intrapulmonary shunt. Although the patient had a brief period of recovery, his condition deteriorated again, and retention of carbon dioxide was sustained due to aggravation of pneumonia. Despite full coverage of antibiotics and maximum care with the ventilator, the patient died about 5 weeks after the removal of the CVC. We suggest that strict compliance to protocols is required even while removing the catheter. Furthermore, additional caution to avoid air embolism is demanded in high-risk patients, such as in this case.

Show MeSH
Related in: MedlinePlus