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Venous Air Embolism. Pekka Talke, MD University of California, San Francisco 2009. Procedures in Sitting Position. Cervical laminectomies Posterior fossa surgeries Becoming relatively uncommon but associated with high rates of complications. Benefits of Sitting Position.

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venous air embolism
Venous Air Embolism

Pekka Talke, MD

University of California, San Francisco

2009

procedures in sitting position
Procedures in Sitting Position
  • Cervical laminectomies
  • Posterior fossa surgeries
  • Becoming relatively uncommon but associated with high rates of complications
benefits of sitting position
Benefits of Sitting Position
  • Better surgical exposure
  • Less tissue retraction
  • Less bleeding
  • Less cranial nerve damage
complications of sitting position
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%)
vae detection sensitivity
VAE detection,sensitivity
  • Doppler, TEE
  • ET N2
  • PaO2
  • ET CO2, PAP
  • PaCO2
  • CVP
  • CO
  • BP
  • ECG, esoph. steth.
monitoring for sitting position
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
monitoring for sitting position7
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
doppler vae
Doppler (VAE)
  • Very sensitive
  • 3-6 th interspace, right of sternum
  • 2.2 MHz probe
  • Blood, wall motion, air
  • Early detection/prevention
doppler probe
Doppler probe

2.25 MHz flat probe

3/4’’ ultrasound beam

at surface

doppler equipment11
Doppler equipment

Model 915-BL or

Model 614-B

2 MHz flat probe

et co 2 changes with vae
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
cvp catheter vae
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)
placement of cvp catheter
Placement of CVP Catheter

From Clinical Neuroanesthesia, Cucchiara et al

placement of cvp catheter23
Placement of CVP Catheter

From Clinical Neuroanesthesia, Cucchiara et al

vae detection awake
VAE Detection - Awake
  • Cough
  • Chest pain
  • Bronchospasm
  • Hypoxia
rapid large vae
Rapid, Large VAE
  • Rare
  • Catastrophic
  • Air lock in right heart
  • Right sided heart failure
  • Reduced CO
  • Cardiovascular collapse
slow continuous vae
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
m m from vae
M&M from VAE
  • Right heart failure
  • Hypoxia - immediate, delayed (ARDS)
  • Paradoxical Air Embolus (PAE)
    • incidence unknown
    • potential for neurologic deficits
    • PFO (20-30%)
treatment of vae
Treatment of VAE
  • 100% O2
  • Flood field, bone wax
  • Jugular pressure
  • Volume, vasopressors, supine
  • CPR
venous air embolism29
Venous Air Embolism
  • Prevention - avoid hypovolemia, good surgical technique
  • Early detection
  • Treatment