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NON FATAL VENOUS AIR EMBOLISM DURING A CESAREAN SECTION-A CASE REPORT AND REVIEW OF THE LITERATURE
Abstract Number: T-82
Abstract Type: Case Report/Case Series
INTRODUCTION Venous air embolism(VAE) is the entrainment of air commonly from the operative field into the venous system producing systemic effects. The risk of occurrence during a cesarean section(CS) is high with a reported incidence of up to 97%. Our case highlights the continued vigilance necessary to prevent morbidity and mortality from VAE.
CASE A 32 year old parturient G3P2002 with history of SLE was admitted to L&D at 33weeks gestation with preterm labor. She was scheduled for an urgent CS having had 2 prior CS for failed induction.She reported conversion to GA from spinal anesthesia in her previous delivery due to a patchy block, and requested GA for this procedure despite explanation of potential risks. She reported being NPO for about 12 hours.She was 5’2”, weighed 120 lb with an unremarkable airway exam.
After application of standard ASA monitors in the OR, an uneventful RSI and intubation of patient was done in supine position. She was maintained on 100% O2 with volatile anesthetic, with stable vital signs. After the delivery of the baby oxytocin infusion was started, and the uterus exteriorized in preparation for repair. Immediately a fall in ETCO2 to 16 mm Hg was noted, with a drop in O2 saturation to 88% and a drop in BP to 72/46 mm Hg. Due to high index of suspicion for VAE, the surgeon was informed and additional help requested. The patient was given intravenous boluses of phenylephrine and a norepinephrine infusion started at 8mcg/min. A central venous catheter was placed in the right internal jugular vein and an attempt made to aspirate air which was negative. The hemodynamics gradually improved and the norepinephrine was weaned and stopped in 1 hour. An initial ABG done showed hypoxia (PO2 49mm Hg). The patient was kept intubated after the procedure and admitted to the ICU. She was extubated about 4 hours later with no sequelae. The rest of her postoperative course was uneventful and she was discharged home on the 4th postoperative day.
DISCUSSION The incidence of VAE during a CS is reported to be higher with GA than regional anesthesia. VAE can result in gas exchange abnormalities leading to lung edema. Decompensation of right followed by left ventricle and cardiac arrest may occur. Morbidity and mortality are directly related to volume and rate of air accumulation. Understanding factors that contribute to VAE are crucial. The traditional 15 degree left lateral tilt and Trendelenburg position as well as exteriorization of the uterus and hypovolemia increase risk. Positioning to reverse Trendelenburg seems not to reduce the risk. Avoidance of nitrous oxide is suggested as has the usage of precordial Doppler and expired nitrogen concentration as monitors. (1,2) Even though lethal VAE is rare in obstetrics, the risk of occurrence should be taken seriously. Knowledge of methods of prevention, recognition and prompt treatment are key.
1.Warltier DC et al Anesthesiology 2007
2.Lew TWK et al Obstetric Anesthesia 1993