eMedicine Specialties > Emergency Medicine > Cardiovascular

Venous Air Embolism: Treatment & Medication

Author: Brenda Liz Natal, MD, Clinical Assistant Instructor and Staff Physician, Department of Emergency Medicine, Kings County Hospital and State University of New York Downstate, Brooklyn
Coauthor(s): Christopher I Doty, MD, FACEP, FAAEM, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center
Contributor Information and Disclosures

Updated: Jul 27, 2009

Treatment

Prehospital Care

If venous air embolism (VAE) is known about prior to ED presentation, these patients should be transported in the left lateral decubitus position.7

Emergency Department Care

Management of venous air embolism (VAE), once is suspected, includes identification of the source of air, prevention of further air entry (by clamping or disconnecting the circuit), a reduction in the volume of air entrained, and hemodynamic support.

  • Administer 100% O 2 and perform endotracheal intubation for severe respiratory distress or refractory hypoxemia or in a somnolent or comatose patient in order to maintain adequate oxygenation and ventilation. Institution of high flow (100%) O 2 will help reduce the bubble's nitrogen content and therefore size.4,11,9,21,15,7,11,8,1
  • Immediately place the patient in the left lateral decubitus (Durant maneuver) and Trendelenburg position. This helps to prevent air from traveling through the right side of the heart into the pulmonary arteries, leading to right ventricular outflow obstruction (air lock). If CPR is required, place the patient in a supine and head-down position.7,11,1,9,21,11
  • Direct removal of air from the venous circulation by aspiration from a central venous catheter in the right atrium may be attempted. However, no current data support emergent catheter placement for air aspiration during an acute setting of VAE-induced hemodynamic instability.4,11,1,9,11
  • If necessary, initiate CPR. Other than maintaining cardiac output, CPR may also serve to break large air bubbles into smaller ones and force air out of the right ventricle into the pulmonary vessels, thus improving CO. Even without the need for CPR, this rationale holds for closed-chest massage. Animal studies have shown that the benefit of cardiac massage equals that of left lateral recumbency, as well as intracardiac aspiration of air.4,1,9,11
  • Consider transfer to a hyperbaric oxygen therapy (HBOT) facility. Indications for HBOT include neurological manifestations and cardiovascular instability. Potential benefits include compression of existing bubbles, establishing a high diffusion gradient to speed resolution of existing bubbles, improved oxygenation of ischemic tissues, and lowered intracranial pressure. Immediate HBOT, once venous air embolism (VAE) is diagnosed, is recommended; however, prognosis may still be good if therapy is initiated beyond 6 hours of event. Prompt transfer to an HBOT center has been reported to decrease the mortality rate in patients with cerebral air embolism. If transfer is necessary, ground transportation is preferred. If air transportation cannot be avoided, the lowest altitude should be sought.4,7,1,11,9,13,10,28
  • Supportive therapy should include fluid resuscitation (to increase intravascular volume, increase venous pressure and venous return). Also some evidence exists that gas emboli may cause a relative hemoconcentration, which increases viscosity and impairs the already compromised circulation. Hypovolemia is less tolerated than relative anemia. In animal studies, moderate hemodilution to a hematocrit of 30% reduces neurologic damage. Crystalloids may cause cerebral edema; therefore, colloids are preferred for hemodilution.4,1,13
  • The administration of vasopressors and mechanical ventilation are two other supportive measures that may necessary.4,1,27 In a case report of a patient undergoing a craniotomy who showed cardiopulmonary findings suggestive of acute venous air embolism, inotropic treatment with ephedrine seemed to rapidly reverse the cardiopulmonary abnormalities. Early inotropic support of the right ventricle has been recommended if venous air embolism is suspected.27
  • In animal studies, the use of perfluorocarbons (FP-43) has been shown to enhance the reabsorption of bubbles and the solubility of gases, thereby decreasing both the neurologic and cardiovascular complications of systemic and coronary venous air embolism. These benefits, however, have not been validated in humans.1

Consultations

Hyperbaric medicine

More on Venous Air Embolism

Overview: Venous Air Embolism
Differential Diagnoses & Workup: Venous Air Embolism
Treatment & Medication: Venous Air Embolism
Follow-up: Venous Air Embolism
References
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References

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Further Reading

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Keywords

VAE, venous air embolism, embolus, air embolism, venous air embolism causes, venous air embolism symptoms, venous air embolism treatment, AGE, arterial gas embolism, systemic air embolism, air embolism, gas embolism, paradoxical embolism, air lock

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Contributor Information and Disclosures

Author

Brenda Liz Natal, MD, Clinical Assistant Instructor and Staff Physician, Department of Emergency Medicine, Kings County Hospital and State University of New York Downstate, Brooklyn
Brenda Liz Natal, MD is a member of the following medical societies: American College of Emergency Physicians and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher I Doty, MD, FACEP, FAAEM, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center
Christopher I Doty, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Daniel J Dire, MD, FACEP, FAAP, FAAEM, Clinical Associate Professor, Department of Emergency Medicine, University of Texas-Houston
Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, and Association of Military Surgeons of the US
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David Eitel, MD, MBA, Associate Professor, Department of Emergency Medicine, York Hospital
David Eitel, MD, MBA is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD, Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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