Perioperative gas embolism is a dangerous development during surgery, as it can lead to complications, morbidity, and mortality [1]. Because this condition ican arise when a patient is undergoing a procedure requiring general anesthesia or sedation, anesthesiologists and surgeons should understand the treatment for perioperative gas embolism [1].
Upon suspecting that a patient has developed an embolism, the initial response should be to halt the entry of air into the system and allow arterial pressure to push air out [2, 3]. If the patient is unresponsive, addressing airway, breathing, and circulation is a priority [3]. Moreover, patients suspected of venous air embolism should be placed in the left lateral decubitus and Trendelenburg position, known as Durant’s maneuver, when possible [3]. The appropriate treatment response for perioperative gas embolism may also depend on the type of procedure being performed. For instance, if the procedure involves a central catheter, air from the right ventricle should also be aspirated, whereas if the procedure is a cardiac bypass, stopping the machine and capping all catheters is crucial [2].
With these general guidelines established, it is worth looking into a few, more specific elements of the treatment of perioperative gas embolism. One such element is hyperbaric oxygen therapy, the primary treatment choice for embolism patients once they have been stabilized [4, 5]. This therapy should be administered within the first four to six hours following the initial presentation of embolism symptoms [4]. It is useful for combating seizures and hypotension [4]. It is important to note, however, that patients may not be able to tolerate 100% levels of oxygen treatment for longer than twelve hours, but if such treatment remains necessary, providers should continue to administer it with interim room air breaks [4].
Anticoagulants are another common component of the medical response to perioperative gas embolism. This is because anticoagulants facilitate the unopposed functioning of the body’s intrinsic fibrinolytic system which, thereby, decreases the thromboembolic burden [6]. When administering anticoagulants, it is important to note, however, that the efficacy of these substances depends on the patient’s profile. For example, unfractionated heparin can be particularly useful for patients who are very thin, morbidly obese, and pregnant, as well as those with renal insufficiency [6].
Unlike hyperbaric oxygen therapy and anticoagulants —two mainstay embolism treatments—, the use of thrombolysis for perioperative gas embolism is more controversial [6]. More recent research on the topic has found that thrombolysis produces non-significant or non-existent benefits for perioperative embolism patients when compared to anticoagulants [6]. Furthermore, thrombolysis runs the risk of heavy bleeding: in one study, 21.9% of patients in the thrombolysis group experienced major bleeding, while only 11.9% of patients in the heparin group did so [6]. Consequently, providers opting for this course of treatment should be wary [6].
Albeit uncommon, perioperative gas embolism is a potentially fatal event that all practitioners should be prepared to address when treating patients undergoing invasive procedures [3]. Therefore, medical providers should take treatment options into account as part of a systematic plan to optimize patient outcomes [3].
Sources
[1] I. R. Fromer et al., “Vascular Air Emboli During the Perioperative Period,” Current Anesthesiology Reports, vol. 10, pp. 436-48, September 2020. [Online]. Available: https://doi.org/10.1007/s40140-020-00407-4.
[2] S. Gordy and S. Rowell, “Vascular air embolism,” International Journal of Critical Illness & Injury Science, vol. 3, no. 1, pp. 73-76, January-March 2013. [Online]. Available: https://doi.org/10.4103%2F2229-5151.109428.
[3] C. J. McCarthy, “Air Embolism: Practical Tips for Prevention and Treatment,” Journal of Clinical Medicine, vol. 5, no. 11, pp. 1-13, October 2016. [Online]. Available: https://doi.org/10.3390/jcm5110093.
[4] S. J. Brull and R. C. Prielipp, “Vascular air embolism: A silent hazard to patient safety,” Journal of Critical Care, vol. 42, pp. 255-63, December 2017. [Online]. Available: https://doi.org/10.1016/j.jcrc.2017.08.010.
[5] A. K. Malhotra et al., “Intraoperative air embolism diagnosis and treatment using hyperbaric oxygen therapy after craniotomy: illustrative case,” Journal of Neurosurgery Case Lessons, vol. 5, no. 12, pp. 1-5, March 2023. [Online]. Available: https://doi.org/10.3171/CASE2342.
[6] M. C. Desciak and D. E. Martin, “Perioperative pulmonary embolism: diagnosis and anesthetic management,” Journal of Clinical Anesthesia, vol. 23, no. 2, pp. 153-65, March 2011. [Online]. Available: https://doi.org/10.1016/j.jclinane.2010.06.011.
