2024 FSA Podium and Poster Abstracts
P096: VENOUS AIR EMBOLUS DURING TOTAL CALVARIAL VAULT RECONSTRUCTION IN A 2-YEAR-OLD
Emily Chung, DO1; Jessica Alonso, MD1; Fahmy Gurgis, MD2; Amy Burn, MD2; 1HCA Florida Kendall Hospital; 2Wolfson Children's Hospital
Introduction: A 2-year-old, 10.2kg male with past medical history of bicuspid aortic valve, craniosynostosis, thoracic spina bifida, myelomeningocele, hydrocephalus, and Chiari II malformation presented for elective bilateral fronto-temporo-parieto-occipital craniotomies and total calavarial vault reconstruction. Prior surgical history includes myelomeningocele repair and ventriculoperitoneal shunt placed at 3 days old.
Methods: The patient was brought into the operating room and positioned supine on the operating table. A mask was placed gas induction was performed with nitrous oxide and sevoflurane. A 3.0 cuffed endotracheal tube was placed without any complications. Placement was confirmed with bilateral breath sounds and end tidal CO2. Multiple attempts to obtain a 22g arterial line were unsuccessful.
The patient was then positioned into modified Sphynx. A precordial doppler was placed onto the left chest after positioning. The neurosurgeon then began to remove the calvaria in sections. When removing the left parietal bone, heart rate and blood pressure dropped significantly, and a “millwheel” murmur was heard on the doppler. End tidal CO2 decreased from baseline measurements.
The surgeon was notified and immediately started to flood the field with sterile saline. 20mcg of epinephrine was given with minimal change in hemodynamics. Another 10 mcg of epinephrine was given, after which, hemodynamics began to improve. Surgeon was notified and the surgery proceeded.
Results: The surgery concluded without further complications. The patient was extubated without complications and transferred to PACU. The patient was later transported to PICU for overnight observation and discharged home a few days later. The postoperative course was without complications.
Discussion/Conclusion: Venous air embolism (VAE) is a life-threatening complication of operative procedures, most commonly neurosurgery procedures with increased incidence in posterior fossa craniotomies. The development of VAE can occur in procedures where the operative site is at or above level of heart and a noncollapsible vein is open, with pressure gradients favoring air entraining rather than bleeding.
Early detection and minimizing the risk of having a VAE are crucial in its management. A prospective study done on the incidence of VAE in craniosynostosis repair in children reported that the incidence is 82.6%. Transesophageal echocardiography is the most sensitive method to detecting VAE followed by the use of precordial doppler. Other sensitive monitors include decrease in end-tidal CO2 or increase in end-tidal nitrogen levels. Other indicators of possible VAE are increase in pulmonary artery and central venous pressure, hypotension, cardiac dysrhythmias, cyanosis, and hypercapnia, though are less sensitive or specific.
Once VAE is suspected, management include notifying the surgeon, preventing further air entry into circulation by flooding the field with sterile saline, compressing the jugular veins, and providing supportive measures for hemodynamics. Supportive measures include vasopressors/inotropes, increased FiO2 to 100%, discontinuation of nitrous oxide, and aspiration of air, if possible.