Medical Image of the Month: Air Embolism in Transit

 

Figure 1. A: Axial CT of the chest without contrast in a lung window demonstrates air in the peripheral vein of the right upper extremity (arrow A). B: Coronal CT demonstrates air in the peripheral vein of right upper extremity (arrow A). C: Air in the right axillary vein (arrow A) and air in the right subclavian vein (arrow B). D: Air in the right atrium (arrow A). E: air in the right ventricle (arrow A).

Case Presentation

Venous air embolism after fluid resuscitation with pressure infuser bag is rare but can occur without appropriate precautionary measures and can be fatal. We report a case of a 51-year-old male patient who presented to the emergency room (ER) with alcohol withdrawal, atrial fibrillation with rapid ventricular response, seizures, and massive aspiration leading to severe hypoxia and cardiac arrest. He was intubated, CPR was performed, and he received fluid resuscitation using the pressure infuser bag over the collapsible polypropylene (PP) based fluid bag through peripheral intravenous access in the dorsum of right hand. He was admitted to intensive care unit for further management after stabilization in the ER. Computed tomography (CT) of the chest without contrast was performed which showed air tracking along the peripheral vein in right upper extremity (Figure 1A,B) as well as in the right axillary and subclavian veins (Figure 1C). Air was also seen within the right atrium (Figure 1D) and right ventricle (Figure 1E) along with bilateral consolidative changes in the lower lobes. Retrospectively, we discovered that the IV fluid bag was lying down on the bed during CT imaging, and the fluid bag had not been primed before placing it in the pressure infuser bag – both of which were the likely reasons for air entrapment. The patient was placed in left lateral decubitus (Durant's maneuver) and Trendelenburg position, given 100% supplemental oxygen, and provided with supportive care. A central line was placed in right internal jugular vein and blood was aspirated without any air. A transthoracic echocardiogram performed three days later showed no air in the right atrium or ventricle. A repeat CT of the chest without contrast performed seven days later demonstrated resolution of the air in the veins and right heart chambers. The patient improved from this episode, but unfortunately passed way from complications related to a large subdural hematoma.

Discussion

The risk of air embolism is less with collapsible fluid bags compared to glass or plastic bottles. However, there is still a risk of air entrapment with collapsible fluid bags without appropriate priming to remove small amounts of air present in the bag (1). Also, air can enter into the vascular system when the bag position is changed to a horizontal position from an upright position - which occurred in our case. Generally, a small amount of air in the venous system is absorbed without any major side effects but fatal consequences can occur with large amount of air (>3-5 ml/kg) and rapid air entry (2).

Naga S Sirikonda, MD, FCCP and Abdulmonam Ali, MD

Pulmonary and Critical Care

Good Samaritan Hospital, SSM Health

Mount Vernon, IL USA

References

1. Bakan M, Topuz U, Esen A, Basaranoglu G, Ozturk E. Inadvertent venous air embolism during cesarean section: Collapsible intravenous fluid bags without self-sealing outlet have risks. Case report. Braz J Anesthesiol. 2013 Jul-Aug;63(4):362-5. [CrossRef] [PubMed]
2. Shamim F, Abbasi S. Fatal vascular air embolism during fluid resuscitation as a complication of pressure infuser bag. J Emerg Trauma Shock. 2016 Jan-Mar;9(1):46-7. [CrossRef] [PubMed]

Cite as: Sirikonda NS, Ali A. Medical image of the month: air embolism in transit. Southwest J Pulm Crit Care. 2019;20(1):41-2. doi: https://doi.org/10.13175/swjpcc053-19 PDF 

Medical Image of the Week: Cardiac Magnetic Resonance Imaging Findings of Severe RV Failure

  

Figure 1. Transthoracic echocardiography, short-axis view (1A) and four-chamber view (1B) demonstrating leftward deviation with flattening of interventricular septum (“D-sign”) due to increased right ventricular pressure and volume overload from severe pulmonary arterial hypertension (PAH). RV=right ventricle. RA=right atrium. LV=left ventricle.

Figure 2. Cardiac Magnetic Resonance Imaging, sagittal view (2A), and cross-sectional view (2B) show the same signs of massive right ventricular (RV) pressure and volume overload with severe RV dysfunction. RV ejection fraction of 13%. RV=right ventricle. RA=right atrium. LV=left ventricle. LA=left atrium.

A 56-year-old man with history a of alcohol abuse presents with progressive shortness of breath on exertion, bilateral lower extremity swelling and 12-pound weight gain over two weeks.

His transthoracic echocardiography (Figure 1) demonstrated severely increased global right ventricle (RV) size, severely dilated right atrium (RA), severe pulmonary artery (PA) dilation, moderate tricuspid regurgitation (TR) and right ventricular systolic pressure (RVSP) estimated at 85 + central venous pressure (CVP) in the context of severely reduced RV systolic function.  Right heart catheterization (RHC) showed PA pressure (systolic/diastolic, mean) of 94/28, 51 mmHg with a PA occlusion pressure of 12 mmHg. After extensive evaluation, our patient’s presentation of right heart failure seemed to be a manifestation of idiopathic pulmonary arterial hypertension.

Our patient subsequently had cardiac MRI (cMRI) with findings shown above (Figure 2). CMRI is a valuable, three-dimensional imaging modality that provides detailed morphology of the cardiac chambers along with accurate quantification of chamber volumes, myocardial mass and transvalvular flow (1). Cardiac MRI is an accurate tool to estimate the RV function at baseline and to follow up response to treatment. RV function at presentation and after treatment are very important determinants of prognosis independent of other hemodynamic indices (2).  

Kelly Wickstrom, DO¹, Huthayfa Ateeli, MBBS², Sachin Chaudhary, MD²

¹Internal Medicine Department and ²Pulmonary and Critical Care Division

Banner University Medical Center

Tucson, AZ USA

References

1. Grünig E, Peacock AJ. Imaging the heart in pulmonary hypertension: an update. Eur Respir Rev. 2015 Dec;24(138):653-64. [CrossRef] [PubMed]
2. Swift AJ, Wild JM, Nagle SK, et al. Quantitative magnetic resonance imaging of pulmonary hypertension: a practical approach to the current state of the art. J Thorac Imaging. 2014 Mar;29(2):68-79. [CrossRef] [PubMed]

Cite as: Wickstrom K, Ateeli H, Chaudhary S. Medical image of the week: cardiac magnetic resonance imaging findings of severe RV failure. Southwest J Pulm Crit Care. 2018;16(5):252-3. doi: https://doi.org/10.13175/swjpcc047-18 PDF

Medical Image of the Week: Mediastinal Metastases Causing Right Ventricular Outflow Obstruction

Figure 1. Computed tomography (CT) of chest showed large right mediastinal mass (arrow) causing mass effect on the heart.

Figure 2.  Echocardiography showing large extra-cardiac mass (white arrow) compressing on right ventricle and its outflow tract (black arrow).

A 36-year-old man with a history of testicular choriocarcinoma with metastases to the lung presented with a 2-days history of hemoptysis. Initial diagnosis of the malignancy was made about 5 months earlier and he was treated with platinum based chemotherapy with a partial response.

He reported two days of significant hemoptysis, associated with shortness of breath and pleuritic chest pain and rapidly developed acute hypoxic respiratory failure requiring emergent intubation and mechanical ventilation. Computed tomography (CT) of chest showed large right mediastinal mass with diffuse reticular and nodular opacities predominantly in the left lung (Figure 1).

A pulmonary angiogram was performed that showed multiple active bleeding sites in the bronchial arterial system. These were treated with embolization. He developed shock and during investigations the echocardiogram showed a significant compression of the superior vena cava, right atrium and right ventricle by the malignant mass (Figure 2). Despite aggressive therapy and resuscitative therapies he continued to deteriorate and did not survive the hospital stay.

Mediastinal tumors are a rare cause of extrinsic right ventricular outflow tract (RVOT) obstruction. Echocardiography is an important tool in the assessment of hemodynamic effects caused due to such pathology including degree of compression and pressure gradients.

Kai Rou Tey MD¹, Bhupinder Natt MD²

¹Department of Internal Medicine, University of Arizona College of Medicine- South Campus, Tucson, AZ USA

²Division of Pulmonary, Critical Care, Allergy and Sleep, University of Arizona Medical Center, Tucson, AZ USA

Cite as: Tey KR, Natt B. Medical image of the week: mediastinal metastases causing right ventricular outflow obstruction. Southwest J Pulm Crit Care. 2016:12(1):22-3. doi: http://dx.doi.org/10.13175/swjpcc145-15 PDF