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 Month: Idiopathic Right Lower Lobe Pulmonary Vein Thrombus

Figure 1. CT angiogram chest sagittal view: showing low density filling defect consistent with pulmonary vein thrombus (yellow arrow).

Figure 2. A: CT angiogram chest axial view showing right lower lobe pulmonary vein thrombus. B: the vein (red arrow) is well differentiated by his lower contrast than the adjacent artery (blue arrows).

A 62-year-old man with a medical history notable only for a seasonal allergy, presented to the emergency department with complaints of shortness of breath with productive cough for 2 months which were worsening for the last 2 weeks. CTA chest revealed low density filling defect in the RLL vein consistent with RLL vein thrombus (Figures 1 and 2). After a comprehensive work up to rule out malignancy and hypercoagulable disorders, a diagnosis of idiopathic pulmonary vein thrombosis was made. The patient received heparin and was discharged with rivaroxaban.

Pulmonary vein thrombosis is a rare disease but can be fatal, usually patient presents with non-specific symptoms such as cough and shortness of breath (1). The etiology in most of cases is hypercoagulable disorders, malignancies, atrial fibrillation, post lung operations such as lobectomy and lung transplantation, or could be idiopathic as in our patient.

Timothy Jon Rolle MD¹ and Mohammad Abdelaziz Mahmoud MD, DO^2
1Department of Radiology and the ²Internal Medicine Residency

Midwestern University Arizona College of Osteopathic Medicine

Canyon Vista Medical Center
Tucson, AZ USA

Reference

1. Chaaya G, Vishnubhotla P. Pulmonary vein thrombosis: a recent systematic review. Cureus. 2017 Jan 23;9(1):e993. [CrossRef] [PubMed]

Cite as: Rolle TJ, Mahmoud MA. Medical image of the month: idiopathic right lower lobe pulmonary vein thrombus. Southwest J Pulm Crit Care. 2020;20(1):7-8. doi: https://doi.org/10.13175/swjpcc048-19 PDF