Tiirk Kardiyol Dem Arş 1996: 24: 538-539

Massive Air Embolism at the Initiation of Cardiopulmonary Bypass: Case report

Nihan YAPICI, MD, Cem ALHAN, MD, Hüseyin MA ÇİKA, MD, Türkan KUDSİOGLU, MD, Zuhal A YKAÇ, MD Departmen/s of Anesthesiology and Cardiothoracic Surgery Siyami Ersek Thoracic and Cardioi'Gswlar Surgery Center. İstanbul. Turkey

KARDiYOPULMONER BYPASS ÖNCESiNDE nary vcin. Suddcnly the hcart was distcndcd and hypotcn­ OLUŞAN MASiF HA VA EMBOLiSi: sion oecurcd. When wc want to initiatc CPB a large aıno­ OLGUSUNUMU unt of air was detcctcd in aortic eannula. Wc disconııccıcd the aortic cannula and rcal izcd that the lcf't heart was full Masif haı·a embolisi kardiyopulmoner bypass'a (KPB) gi­ of air. When wc wcrc tryi ng to purge the air from the hcart ren olgu/ann yaklaş1k %0.1-0.2'sinde oluşabilir. Bu has­ through the diseonncctcd aorıic cannula; the hcart fibrilla­ ta/ann yaklaş1k yansmda kallCI niiro/ojik hasar veya tcd. At this time bilateral pupillary dilatation oceurrcd, ho­ ölüm giiriilmektedir. Pe1jiizyon sistemine biiyiik miktar­ wcvcr as wc do not use EEG ınon i toring routinly, no data larda lıai'G çeşitli yollarla girebilir. Masif hava embolisi­ is available in rcgard of the c lcetrical activity of the brain. nin kalic1 hasarlanndan korunmak amaciyla derin lıipo­ The paticnt was brought to hcad-down position at about 20 termi ı •e serehral koruyucu ajanlar kullamlmaktaclir. KPB dcgrcc angle and the carotid artcrics wcrc coınprcsscd. His sirasuıda oluşan haı•a embolilerinin tedavisi için superior hcad and ncek wcrc surfacc coolcd. The aorıa was claın­ vena kava yoluyla retrograt serebral pe1ji'izyon kullanmu pcd and CPB initiatcd al'ıcr priming of aorıic cannula. At ve etkin/i_~ i bildirilmiştir o!. the same time wc adınini stcrcd thiopental 5 ıng/kg bolus, ınann i tol 20 %- a- 2ıng/kg, ıncthy l prcdnisolonc -2 ıng/kg, Biz bu yaz"la KPB öncesinde oluşan masif hava embolisi­ and thcn thiopcntal was infuscd 1 ıng/kg/hourduring the nin başan/i tedavisini sunuyoruz. CPB and continucd for 12 hours. The most probablc site Allalıtar kelimeler: Hai'G embolisi. Ilipotermik dolaşm1 for air to enter the hcaı·ı could be the ve nt line. Bceausc the m'l'esti. retrograf serebra/ pe1jüzyon. claınp on the vcnt line was looscncd, wc rcc laınpcd the li­ ne and at the same time the pcrfusionist rcal izcd that the circuit of the vcnt was impropcrly plaecd to the roller head and instcad of crcating a suctiorı it causcd a positivc prcs­ Embolization of air intraoperatively isa potential ca­ sure and MAE. use of cerebral vascular accidents. Air embolizatian rınıncdiatcly arıcr the initiation of CPB, aortie eross-claınp may occur with residual bubbles infused through the was applicd and antcgradc/rctrogradc blood cardioplcgia was eoınmcnccd. The paticnt was startcd ıo eool and du­ at1erial inflow line, inadequate deairing of the aorta ring ı his time wc changcd from singlc to ı w o vcııous ean­ following removal of sitle-biting exclusion clanıp, nulas. When nasopharyngca l tcmpcraturc rcaehcd 18 oc, venting of the Jeft ventricle, of following combined the pump was stopped, the aortie claınp was removcd and rctrogradc ccrcbral pcrfusion was initiatcd ata llow ratc of valve and coronary operations (4). 0.3 Ilmin, kccping the prcssurc of supcrior vena eava be­ W e report the successful management of an acciden­ law 25 mmHg. Rctrograde ccrcbral perfus ion was eontinu­ cd for 15 minules to purge the cnıbolizcd air coınplctcly tal MAE at the initiation of CPB. from the ecrcbral artcry system. By the ıncan time caro ı id artcrics wcrc compressed i ntcrın i ııcnı ly to purge the a ir CASEREPORT from the vcrtcbrobassilary system. Aftcr ılıesc ınaııipulati­ ons aorıa was rcclamped and antegraele pcrfusion rceoın­ A 56-ycar old man who had aortic insufficicncy under­ ıncnced. Aortic valvc rcp laccın eıı t was aceomplishcd with wcnt aortie valvc rcplaccmcnt. Ancstlıcsia was induced a Carboıncdies 23 A valvc (Carboıncdies Ine .. Ausıin Te­ with fcntaııyl 50 ıng/kg, ınidazo l aın O. I mg/kg, and pancu­ xas). Twclvc hours al'ı c r operation he awakcııcd complc­ roniuın O. 1 ıng/kg/min. A pulınonary catlıetcr w as inscrtcd tcly having no paralysis or sensory disturbancc o r convul­ via the riglıt internal jugular vcin, nasopharyngcal and rcc­ sion, and he was cxtubatcd w iıhout any complieaıion. tal tcınpcraturc probcs wcre placcd.

Arter aortic cannulation, two stagcd singlc vcııous caıınula was iııscrtcd into the riglıt atrium. Yenı catlıctcr was iıı scr­ DISCUSSION tcd into the lcl't atrium through the riglıt supcrior pulıno- Neurologic and neuropsychological dysfunction are Recieved: April 18. revision acapted Septeıııher 25.1996 significant and undeniable risks of cardiac surgery Correspnndence address: Dr. Nihan Yapıcı. Tophııııelioglu cad. Köşk sitesi. C- Blok No: 14 81020 Koşuyolu - lstanbul - Turkey (3), There are several causes for neurologic injury

538 N. Yapıcı et ol.: Massil'e Air Embolism attlıe lnitiation ofCordiop11lmonary Bypass: Casereport

during CPB. Accidental mass ive air embolism frequ­ hocreatin levels in priınates when used to induce and ently leads to a lethal outcome. Stoney and associa­ maintain anesthesia before norınothermic cerebral tes( l) estimated the prevalence of air embolism to be ischemia. Additional studies have confirmed the pro­ 0.11%. tectiv effects of barbiturate administration against normothermic regional ischemic injuries in priınates Hypothermic cerebral protection such as perfusion (9). The use of barbiturates as an adjunct to hypot­ hypothermia with or without selective brain cooling herınia to obtain a grater cerebro protective effect using and antegrade or retrograde approach or circu­ was investigated in a prospective randonı i zed elini­ latory arrest of the brain has been widely used (4). cal study ( ı O). This study demonstrated the efficacy The safety of hypothermic c ircul atory aıTesi (HCA) of thiopental administered in a sufficient dose before is largely due to a temperature dependent reduction the initiation of hypothennic CPB. W e al so adıninis­ of metabolic rate. Tncreased solubility of gas bubbles tered thiopental with continuous infusion in CPB into solution is clearly another advantage of hypot­ and rcu. w recoınmend to adınin i s ter the barbitura­ heııııia besides reduction of metabol ic ra te (5). Neu­ tes before cooling of brain in all patients undergoing rologic injury is the most feared complication of HCA. HCA. The central nevous system is very sensitive to anoxia; traditionally this sensivity has limited the We conclude that retrograde cerebral perfusion is use of HCA to durations less than 60 minules at 18 convenient with the adjunctive pharmacological the­ to 20 °C. The optimal temperature for cerebral pro­ rapy for MAE, in all situations of MAE during car­ tection during HCA is not known. An experimental diac surgery. study suggested that deeper levels of cerebral hypot­ hermia confer belter protection against neurologic REFERENCES injury during prolonged HCA (6). Currently the most 1. Baue AE: Glenn's Thoraeic and Cardiovascular Sur­ effective ınean s of protecting the brain is hypother­ gcry, Sınınford Co nnc cıicut , Applcton and Langc, 1996, p. 1646 mia. Hypothe ııni a reduces cerebral blood flow, me­ 2. Mori A: Rctrogradc ccrcbral pcrfusion using pu lsatilc tabolism and preserves cellular s t oı·es of high-energy now under conditions profound hypotherınia. Ann Thorac phosphates (7). Surg ı993; 56: 1497-8 3. S ıo gof S, Girgis KZ, Keats AS: Et i o ı og i c factors in nc­ Retrograde cerebral perfusion through the superior uropsychiatric complicati on associaıcd w iıh cardiopulmo­ vena cava has been used for the treatment of cerebral nary bypass. Ancsth Ana lg ı 982; 6 ı : 903- ı ı air embolism during CPB. Clinically this method 4. Mohri H, Sadahiro M, Akimoto H, et al: Pro ı ecıion of the brain during h ypo th erın i c perfusion Ann Thorne using profound hypothetmia has also been e ınployed Surg ı993; 56: ı49 3-6 for the protection of the brain during surgical treat­ 5. Mezrow CK, Sadeghi AM, Gandsas A, et al: Cerebral ment for diseased aortic arehes (2). Watanabe and as­ blood now and ıne t abolisın in hypothermie c ircu ı atory ar­ sociates reported successful treatment of MAE by rest. Ann Thorac Surg 1992; 54: 609- ı 6 using retrograde cerebral perfusion (8). In !heir re­ 6. Gillinov MA, Rcdmond :vt.J, Zchr K.J, et al: Superior cerebraı protceıion during profound hypothcrınia during pot1, the patient was already cooled when the MAE circulatory arrest. Ann T horae Surg ı993; 55: ı4 32 - 39 occurred. However, in our case MAE occurred when 7. Grccley W.J, Kern FH, Melioncs .JN, Ungerleidcr the patient was nornıothe rmi c and before the initiati­ RM: Effcet ordcep hypolherıni a and cireulatory aJTCSt on on of CPB. We believe that immediale initiation of ecrcbra ı blood flow and nıctabo l isın. Ann Thorac Surg 1993; 56: 1464-6 deep hypothermia in our case, resulted in increased 8. Watanabe T, Shimasaki T, Kuraoka S, ct al: Reırog­ solubilty of air bubbles into soluti on and decreased rade ccrcbral perfu sion againsı massive air enıbolism du­ cerebral metabolic rate; thus causing no severe ce­ ring cardiopulmonary bypass. 1 Thorae Cardiovase Surg rebral daınage. 1992; 104: 532-3 9. Sicgman MG, Anderson RV, Balaban RS, ct al: Bar­ Another approach to reduce cerebral injury is phar­ biturates iınpair cerebral ınctabolisın during h ypothcrınic ınaco l og i ca l. Barbiturates represent one of the earli­ c irculaıory aıTesı. Ann Thorae Surg. ı 992; 54: ı ı 3 ı -6 est and most extensively studied agents. Sodium 10. Nussmcicr NA, Ariund C, Slogofl' S. Neuropsychiat­ ri c eoınp li cat i ons a fı cr eardiopulınoııary bypass: cerebral pentobarbital was shown to decrease lactate accuınu­ proıccıion by a barbit uraıc. Anesthesiology ı 986: 64: ı 65 - lation and iınprove maintenance of ATP and phosp- 70

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