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Department of Anesthesiology, University Erlangen-Nuremberg, Germany
Address correspondence and reprint requests to Thomas M. Hemmerling, MD, DEAA, Department of Anesthesiology, CHUM–Hôtel-Dieu, 3840, rue St-Urbain, Montréal, H2Y 1T8, Canada. Address e-mail to thomashemmerling{at}hotmail.com
We studied the effect of positive end-expiratory pressure (PEEP) release and positioning on the occurrence of venous air embolism (VAE). Eighteen consecutive patients (8 women, 10 men; ASA grade I–III) undergoing neurosurgery in the sitting position were studied. After induction of anesthesia ventilation was controlled with a PEEP of 5 cm H2O in an oxygen-air gas mixture. A transesophageal echocardiographic (TEE) probe was inserted. Preoperatively, a patent foramen ovale was excluded in all patients. TEE monitoring was performed during surgery, during PEEP release at the end of surgery with the patient still in the sitting position, and during change of the patient position into the supine position. The severity of VAE was differentiated as follows: grade 1 = only microbubbles; grade 2 = microbubbles and decrease of end-tidal carbon dioxide partial pressure (PETCO2) by more than 1.5 mm Hg; grade 3 = microbubbles combined with a decrease of PETCO2 by more than 1.5 mm Hg, and a decrease of mean arterial blood pressure by at least 20 mm Hg. During surgery, VAE with a grade of 1, 2 or 3 occurred in 7, 4, and 2 patients, respectively. After PEEP release, VAE of grades 1, 2, and 3 were observed in 7, 2, and 1 patients, respectively. During repositioning from sitting to supine position, VAE of grades 1, 2, and 3 was observed in 6, 1, and 1 patients, respectively. The patient with VAE grade 3 needed inotropic support until 2 h after surgery to maintain sufficient blood pressure. No patient showed any sign of paradoxical arterial embolism or cardiac dysfunction. We conclude that VAE occurs not only during surgery in the sitting position, but also with release of PEEP and during repositioning to the supine position.
IMPLICATIONS: This study shows that venous air embolism (VAE) occurs not only during surgery in the sitting position but also during positive end-expiratory pressure release and repositioning of the patient into the supine position. Continuous monitoring for VAE should be performed until the patient is returned to the supine position.
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  J A Williamson, S C Helps, R N Westhorpe, and P Mackay Crisis management during anaesthesia: embolism Qual. Saf. Health Care, June 1, 2005; 14(3): e17 - e17. [Abstract] [Full Text] [PDF]
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 C. N. Seubert, N. Gravenstein, T. M. Hemmerling, and H. Schmitt Venous Air Embolism During Changes in Patient Position or Ventilation: An Etiology for Postoperative Cardiovascular Collapse? * Response Anesth. Analg., November 1, 2002; 95(5): 1465 - 1466. [Full Text] [PDF]
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