Air Embolism in Sitting Position during Neurosurgical Operations and It’s Prevention: A Narrative Review
Venous air embolism (VAE) is an entrapment of air or exogenously delivered gas from the operative field or the communicated environment into the venous system due to gradient pressure. VAE and paradoxical air embolism (PAE) are potentially serious neurosurgical complications and carry high neurologic, respiratory, and cardiovascular morbidity or even may be fatal. Some procedures are at risk of developing these conditions, but the sitting and semi-sitting positions represent a higher risk. It’s occurrence during anesthesia is challenging to the anesthesiologists in terms of early discovery and management. Anesthesiologist can play an important role in detection and urgent treatment of VAE in case of occurrence. If the sitting position is needed for a neurosurgical necessity it can be used with vigilant follow up throughout the procedure to detect any occurrence of VAE.
2. Harrison E, Mackersie A, McEwan A, Facer E. The sitting position for neurosurgery in children: a review of 16 years’ experience. Br J Anaesth. 2002; 88(1):12-7.
3. Aleksic V, Radulovic D, Milakovic B, Nagulic M, Vucovic D, Antunovic V, et al. A retrospective analysis of anesthesiologic complications in pediatric neurosurgery. Pediatr Anesth. 2009; 19(9):879-86.
4. Wei S-T, Chen DC. Catastrophic venous air embolism during craniotomy in the supine position: The bleeding pattern as a warning sign? J Craniofac Surg. 2013; 24(3):e228-e9.
5. Anan'ev E, Polupan A, Savin I, Goryachev A, Troitskiy A, Kolokol'nikov A, et al. Paradoxical air embolism resulted in acute myocardial infarction and massive ischemic brain injury in a patient operated on in a sitting position. Zh Vopr Neirokhir Im NN Burdenko. 2016; 80(2):84-92.
6. Porter J, Pidgeon C, Cunningham A. The sitting position in neurosurgery: A critical appraisal. Br J Anaesth. 1999; 82(1):117-28.
7. Felema GG, Bryskin RB, Heger IM, Saswata R. Venous air embolism from Tisseel use during endoscopic cranial vault remodeling for craniosynostosis repair: A case report. Pediatr Anesth. 2013; 23(8):754-6.
8. Mirski MA, Lele AV, Fitzsimmons L, Toung TJ. Diagnosis and treatment of vascular air embolism. Anesthesiology. 2007; 106(1):164-77.
9. Kaye AH, Leslie K. The sitting position for neurosurgery: Yet another case series confirming safety. World Neurosurg. 2012; 77(1):42-3.
10. Günther F, Frank P, Nakamura M, Hermann EJ, Palmaers T. Venous air embolism in the sitting position in cranial neurosurgery: Incidence and severity according to the used monitoring. Acta Neurochirurgica. 2017; 159(2):339-46.
11. Ramina R, Tatagiba M, Soares M. Tumors of the Jugular Foramen: Springer; 2017.
12. Giraldo M, Lopera LM, Arango M. Venous air embolism in neurosurgery. Colombian Journal of Anesthesiology. 2015; 43:40-4.
13. Palmon SC, Moore LE, Lundberg J, Toung T. Venousair embolism: A review. J Clin Anesth. 1997; 9(3):251-7.
14. Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: Practical approaches to increasing safety in the intensive care unit. Ann Intern Med. 2004; 140(12):1025-33.
15. Hulst RA, Klein J, Lachmann B. Gas embolism: Pathophysiology and treatment. Clin Physiol Funct Imaging. 2003; 23(5):237-46.
16. Kapoor T, Gutierrez G. Air embolism as a cause of the systemic inflammatory response syndrome: A case report. Critical Care. 2003; 7(5):R98.
17. Sheasgreen J, Terry T, Mackey JR. Large-volume air embolism as a complication of augmented computed tomography: Case report. Can Assoc Radiol J. 2002; 53(4):199-201.
18. Albin MS. Textbook of neuroanesthesia with neurosurgical and neuroscience perspectives: McGraw-Hill; 1997.
19. Faberowski LW, Black S, Mickle JP. Incidence of venous air embolism during craniectomy for craniosynostosis repair. Anesthesiology. 2000; 92(1):20-.
20. Van Heerden P, Woods W, Sviri S. Air embolism-a case series and review. Crit Care Resusc. 2004; 6(4):271.
21. Longatti P, Marton E, Feletti A, Falzarano M, Canova G, Sorbara C. Carbon dioxide field flooding reduces the hemodynamic effects of venous air embolism occurring in the sitting position. Childs Nerv Syst. 2015; 31(8):1321-6.
22. Toung TJ, Rossberg MI, Hutchins GM. Volume of air in a lethal venous air embolism. Anesthesiology. 2001; 94(2):360-1.
23. Natal BL, Doty C. Venous air embolism. Medscape; 2012.
24. Adam Lea. Air embolism and anesthesia. Anesthesia Tortorial of the Week AOTW. 2016.
25. Balki M, Manninen PH, McGuire GP, El-Beheiry H, Bernstein M. Venous air embolism during awake craniotomy in a supine patient. Can J Anesth. 2003; 50(8):835.
26. Vesely TM. Air embolism during insertion of central venous catheters. J Vasc Interv Radiol. 2001; 12(11):1291-5.
27. Tedim R, Amorim P, Castro A. Clinical Monitoring and Automatic Detection of Venous Air Embolism. Encyclopedia of Information Science and Technology, Third Edition: IGI Global; 2015. p. 5515-22.
28. Brechner TM, Brechner VL. An audible alarm for monitoring air embolism during neurosurgery. J Neurosurg. 1977; 47(2):201-4.
29. Matjasko J, Petrozza P, Mackenzie C. Sensitivity of end-tidal nitrogen in venous air embolism detection in dogs. Anesthesiology. 1985; 63(4):418-23.
30. Stendel R, Gramm H-J, Schröder K, Lober C, Brock M. Transcranial Doppler ultrasonography as a screening technique for detection of a patent foramen ovale before surgery in the sitting position. Anesthesiology. 2000; 93(4):971-5.
31. Feigl GC, Decker K, Wurms M, Krischek B, Ritz R, Unertl K, et al. Neurosurgical procedures in the semisitting position: evaluation of the risk of paradoxical venous air embolism in patients with a patent foramen ovale. World Neurosurg. 2014; 81(1):159-64.
32. Gildenberg PL, O'Brien RP, Britt WJ, Frost EA. The efficacy of Doppler monitoring for the detection of venous air embolism. J Neurosurgery. 1981; 54(1):75-8.
33. Sale J. Prevention of air embolism during sitting neurosurgery. Anaesthesia. 1984; 39(8):795-9.
34. Lubnin A, Oskanova M. Prevention of air embolism in neurosurgical patients operated on in a sitting posture: A comparative study of 3 methods. Anesteziol Reanimatol. 1994: 22-6.
35. Navarro LHC, Bloomstone JA, Auler JOC, Cannesson M, Della Rocca G, Gan TJ, et al. Perioperative fluid therapy: A statement from the international Fluid Optimization Group. Perioper Med (Lond). 2015; 4(1):3.
36. Domaingue C. Anaesthesia for neurosurgery in the sitting position: A practical approach. Anaesth Intensive Care. 2005; 33(3):323-31.
37. Lateef F, Kelvin T. Military anti-shock garment: Historical relic or a device with unrealized potential? J Emerg Trauma Shock. 2008; 1(2):63-9.
38. Loubieres Y, Vieillard-Baron A, Beauchet A, Fourme T, Page B, Jardin F. Echocardiographic evaluation of left ventricular function in critically ill patients: Dynamic loading challenge using medical antishock trousers. CHEST. 2000; 118(6):1718-23.
39. Schmitt HJ, Hemmerling TM. Venous air emboli occur during release of positive end-expiratory pressure and repositioning after sitting position surgery. Anesth Analg. 2002;94(2):400-3.
40. Giebler R, Kollenberg B, Pohlen G, Peters J. Effect of positive end-expiratory pressure on the incidence of venous air embolism and on the cardiovascular response to the sitting position during neurosurgery. Br J Anaesth. 1998;80(1):30-5.
41. Zentner J, Albrecht T, Hassler W. Prevention of an air embolism by moderate hypoventilation during surgery in the sitting position. Neurosurgery. 1991; 28(5):705-8.
42. Junghans T, Böhm B, Meyer E. Influence of nitrous oxide anesthesia on venous gas embolism with carbon dioxide andhelium during pneumoperitoneum. Surg Endosc. 2000; 14(12):1167-70.
43. Eckle V, Neumann B, Greiner T, Wendel H, Grasshoff C. Intrajugular balloon catheter reduces air embolism in vitro and in vivo. Br J Anaesth. 2015; 114(6):973-8.
44. McCarthy CJ, Behravesh S, Naidu SG, Oklu R. Air embolism: practical tips for prevention and treatment. J Clin Med. 2016; 5(11):93.
45. Jardin F, Genevray B, Brun-ney D, Margairaz A. Dobutamine: a hemodynamic evaluation in pulmonary embolism shock. Critical Care Medicine. 1985; 13(12):1009-12.
46. Archer DP, Pash MP, Macrae ME. Successful management of venous air embolism with inotropic support. Can J Anaesth. 2001; 48(2):204-8.
47. Argoti-Velasco Y, Carrillo-Torres O, Sandoval-Mendoza R, Paez-Amaya W, CAhuantzi-Caballero X. Proper electrocardiography-guided placement of a central venous catheter. Revista Médica del Hospital General de México. 2016.
48. Ericsson JA, Gottlieb JD, Sweet RB. Closed-chest cardiac massage in the treatment of venous air embolism. N Engl J Med. 1964; 270(25):1353-4.
49. Eoh EJ, Derrick B, Moon R. Cerebral arterial gas embolism during upper endoscopy. A A Case Rep. 2015; 5(6):93-4.
50. McCarthy CJ, Behravesh S, Naidu SG, Oklu R. Air embolism: Diagnosis, clinical management and outcomes. Diagnostics. 2017; 7(1):5.
51. Blanc P, Boussuges A, Henriette K, Sainty J, Deleflie M. Iatrogenic cerebral air embolism: importance of an early hyperbaric oxygenation. Intensive Care Med. 2002; 28(5):559-63.
52. Mehta V, De A, Balachandran C. Hyperbaric oxygen therapy. Journal of Pakistan Association of Dermatology. 2016;19(3):164-7.
53. Dilmen OK, Akcil EF, Tureci E, Tunali Y, Bahar M, Tanriverdi T, et al. Neurosurgery in the sitting position: retrospective analysis of 692 adult and pediatric cases. Turk Neurosurg. 2011; 21(4):634-40.
54. Ganslandt O, Merkel A, Schmitt H, Tzabazis A, Buchfelder M, Eyupoglu I, et al. The sitting position in neurosurgery: indications, complications and results. a single institution experience of 600 cases. Acta Neurochir (Wien). 2013; 155(10):1887-93.