P020: SEVERE VENOUS AIR EMBOLISM DURING A PERCUTANEOUS NEPHROLITHOTOMY.
Santiago Luis, MD, Marco Castillo, MD, Federico Perez Quirante, MD, Gloria Rodriguez, MD, Enrique Huertas, MD; Cleveland Clinic Florida
Intraoperative Venous Air Embolism during general anesthesia is a formidable diagnostic and management challenge.
A 53-year-old female with no significant medical history with normal physical exam, normal EKG and CXR. Scheduled for a Percutaneous Nephrolithotomy. Anesthetic management was obtained with general endotracheal anesthesia and positioned prone. During the first hour of surgery developed, a sudden and dramatic decrease in Etco2 and SpO2, mild decrease in blood pressure and tachycardia. A clinical diagnosis of Acute Pulmonary Embolism was highly suspicious. The surgery was stopped and the patient was placed in the supine-trendelenburg position . Mild decrease in blood pressure responded to phenylephrine boluses and fluid administration. A TTE was obtained showing large amount of air in the right atrium and ventricle, a TEE was obtained within minutes showing minimal amount of air in the right heart and no evidence of PFO and ABG showed hypoxemia and acidosis quickly corrected after the blood pressure and ETCO2 returned to normal. The surgical team informed a pneumopyelogram was attempted with 20 ml of air. The surgery resumed and at the end the patient was extubated without any apparent complications and was transferred to ICU for close monitoring and eventually discharged home.
This case illustrates the importance of the early diagnosis and aggressive treatment of the intraoperative massive venous air embolism and the importance of the TEE and team approach in the management of this fatal and acute pathological process.