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University of California, San Francisco

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Presentation on theme: "University of California, San Francisco"— Presentation transcript:

1 University of California, San Francisco
Venous Air Embolism Pekka Talke, MD University of California, San Francisco 2009

2 Procedures in Sitting Position
Cervical laminectomies Posterior fossa surgeries Becoming relatively uncommon but associated with high rates of complications

3 Benefits of Sitting Position
Better surgical exposure Less tissue retraction Less bleeding Less cranial nerve damage

4 Complications of Sitting Position
Spinal cord infarct Ulnar nerve compression Sciatic nerve damage Lateral peroneal nerve compression Cardiovascular changes Airway obstruction -tube kinking, migration Tension pneumocephalus Venous Air Embolism (VAE) (40%)

5 VAE detection, sensitivity
Doppler, TEE ET N2 PaO2 ET CO2, PAP PaCO2 CVP CO BP ECG, esoph. steth.

6 Monitoring for Sitting Position
ECG Temperature Muscle relaxation Pulse oximeter ET CO2, ET anesthetic agent, ET N2 Arterial blood pressure (cpp) Central venous pressure (cvp, pap) Precordial Doppler Esophageal stethoscope

7 Monitoring for Sitting Position
ECG Temperature Muscle relaxation Pulse oximeter ET CO2, ET anesthetic agent, ET N2 Arterial blood pressure (cpp) Central venous pressure (cvp, pap) Precordial Doppler Esophageal stethoscope

8 Doppler (VAE) Very sensitive 3-6 th interspace, right of sternum
2.2 MHz probe Blood, wall motion, air Early detection/prevention

9 Doppler equipment

10 Doppler probe 2.25 MHz flat probe 3/4’’ ultrasound beam at surface

11 Doppler equipment Model 915-BL or Model 614-B 2 MHz flat probe

12 Doppler equipment

13 Precordial Doppler Placement

14 Doppler record keeping

15 ET CO2 changes with VAE Sudden decrease in ET CO2 within a few breaths after VAE ET CO2 decrease proportional to VAE magnitude ET CO2 starts to recover once VAE stops

16 ET CO2 trend changes with VAE

17 CVP catheter (VAE) Positioning: ECG, X-ray, pressure tracing
Positioning in sitting position - migration Can be used to confirm Doppler placement Aspiration: confirmation of VAE, treatment? (PA catheter: diagnosis, resolution)

18 CVP Catheter

19 CVP Catheter

20 CVP Catheter

21 CVP Catheter

22 Placement of CVP Catheter
From Clinical Neuroanesthesia, Cucchiara et al

23 Placement of CVP Catheter
From Clinical Neuroanesthesia, Cucchiara et al

24 VAE Detection - Awake Cough Chest pain Bronchospasm Hypoxia

25 Rapid, Large VAE Rare Catastrophic Air lock in right heart
Right sided heart failure Reduced CO Cardiovascular collapse

26 Slow, Continuous VAE Common
Air bubbles entrapped in pulmonary circulation Local hypoxemia/obstruction Sympathetic reflex vasoconstriction Pulmonary HTN, hypoxemia, CO2 retention, increased dead space, decreased ET CO2 Bronchoconstriction

27 M&M from VAE Right heart failure Hypoxia - immediate, delayed (ARDS)
Paradoxical Air Embolus (PAE) incidence unknown potential for neurologic deficits PFO (20-30%)

28 Treatment of VAE 100% O2 Flood field, bone wax Jugular pressure
Volume, vasopressors, supine CPR

29 Venous Air Embolism Prevention - avoid hypovolemia, good surgical technique Early detection Treatment

30 neuroanesthesia.ucsf.edu Thank You

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