Case report BMJ Case Rep: first published as 10.1136/bcr-2021-244006 on 29 July 2021. Downloaded from Cerebral air embolism after indwelling pleural catheter insertion in a chronic hydropneumothorax secondary to epithelioid mesothelioma Dissanayake Mudiyanselage Chanaka Jayawardena , Rakesh K Panchal, Sanjay Agrawal, Indrajeet Das Respiratory Medicine, Glenfield SUMMARY The patient was Eastern Cooperative Oncology Hospital, Leicester, UK A 75- year- old man with a history of epithelioid Group performance status 0 and was under the mesothelioma and a right-sided indwelling pleural ambulatory pleural service but managed his pleural Correspondence to catheter (IPC) presented with a history of a purulent fluid collections independently in the community. The Dr Dissanayake Mudiyanselage Chanaka Jayawardena; drainage via the IPC. The pleural fluid cultured Klebsiella IPC had been inserted 3½ years ago for a right- Chanj858@ gmail. com oxytoca and Enterococcus faecalis. He was treated with sided loculated hydropneumothorax that had a course of oral fluoroquinolone followed by uneventful developed after a radical extended pleurectomy, Accepted 13 July 2021 IPC replacement. One and half hours postprocedure, decortication and diaphragmatic patch surgery for the patient had a witnessed drop in conscious level mesothelioma. The rationale for the IPC was recur- accompanied by seizure like activity. Acute stroke was rent effusions and associated infections requiring suspected and a CT head was performed. CT head repeat chest drains in the area of the postoperative revealed multiple serpiginous pockets of air along the hydropneumothorax. cerebral fissure, with features that were highly suggestive The patient was asymptomatic and apyrexial. of cerebral air embolism and multiple wedge-shaped The pleural fluid cultured Klebsiella oxytoca and areas of infarction involving the cerebral hemispheres. Enterococcus faecalis. He was treated with the Further imaging revealed satisfactory position of the oral fluoroquinolone, ciprofloxacin and given replaced IPC. The patient was admitted to the intensive advice and guidance on infection prevention strat- care unit for high flow oxygen therapy and head down egies when handling the IPC and pleural drainage ventilation. However, his condition deteriorated and he apparatus. A couple of weeks later it was decided died later. to replace the IPC as an elective procedure due to the long duration of the IPC, a persistent low-grade purulent discharge, concerns about bacterial colo- http://casereports.bmj.com/ BACKGROUND nisation and history of a similar infection episode Indwelling pleural catheters (IPC) are used in the a year ago. management of benign and malignant pleural effu- On the day of the procedure, the patient reported sions. The procedure is usually carried out as a day that the IPC had partially migrated out of the case under local anaesthesia. IPC insertion may be pleural cavity and the tunnelled subcutaneous tract associated with complications such as pleural infec- due to loss of integrity of the IPC cuff and thus tion, bleeding, pneumothorax, chest pain, blockage came out easily without any intervention. The IPC and leakage but the procedure may be associated tip was sent for culture. with more serious complications. On clinical examination, blood pressure was Cerebral air embolism (CAE) is a rare but 133/77 mm Hg, pulse rate was 77 beats per minute, on October 1, 2021 by guest. Protected copyright. important complication of pleural procedures that respiratory rate was 18 breaths/min and the body has not been previously reported after IPC inser- temperature was 36.6°C with oxygen saturation tion. CAE is induced by barotrauma, chest injuries 98% on room air. Lung auscultation revealed inspi- and iatrogenic causes such as cardiovascular surgery ratory crackles at the right lower lung zone. The laboratory test revealed white cell count (WCC) and invasive procedures. Pleural procedures such as 9 pleural fluid aspiration, chest drain insertion and count 11.3×10 /L, haemoglobin 108 g/L, plate- thoracoscopy have also been recognised as causes lets 430 x10ˆ9/L and C reactive protein 71 mg/L. of CAE. Bedside thoracic ultrasound scan was consistent © BMJ Publishing Group We report a case of CAE that occurred after with a hydropneumothorax. Limited 2021. Re- use the routine exchange of an IPC in a patient with a The same day the patient underwent an permitted under CC BY- NC. No chronic complex hydropneumothorax secondary to uneventful IPC insertion under local anaesthesia commercial re- use. See rights and mild sedation with 1 mg of intravenous midaz- and permissions. Published epithelioid malignant mesothelioma by BMJ. olam. Satisfactory IPC placement was confirmed on a post procedure chest radiograph (figure 1). To cite: Jayawardena DMC, CASE PRESENTATION One and half hours postprocedure, the patient Panchal RK, Agrawal S, et al. BMJ Case Rep A- 75- year old man with a 7-year history of epithe- had a witnessed sudden drop in conscious level 2021;14:e244006. lioid mesothelioma and a right sided IPC presented with associated seizure like activity. The patient doi:10.1136/bcr-2021- to the pleural clinic with a history of 2–3 weeks of was immediately assessed by the cardiac arrest 244006 a malodourous, purulent fluid drainage via the IPC. team where blood pressure, heart rate and oxygen Jayawardena DMC, et al. BMJ Case Rep 2021;14:e244006. doi:10.1136/bcr-2021-244006 1 Case report BMJ Case Rep: first published as 10.1136/bcr-2021-244006 on 29 July 2021. Downloaded from Figure 1 Postprocedure chest radiograph showing satisfactory IPC placement in chronic right hydropneumothorax (marked by red arrow). IPC, indwelling pleural catheter. Figure 3 CT chest showing satisfactory placement of IPC (white saturations were maintained within the reference range arrow) and old diaphragmatic construction (black arrow). IPC, throughout. Glasgow Coma Scale (GCS) was 4 (eyes opening indwelling pleural catheter. 1, verbal response 1 and motor response 2). General examina- tion did not demonstrate any peripheral stigmata of systemic air embolism and no retinal air bubbles were seen in fundus- the event of any deterioration was respected and he was palli- copic examination. An acute stroke was suspected and an urgent ated. The patient died 6 days later. CT head was performed. Repeat blood tests revealed WCC 9.4×109/L, haemoglobin 107 g/L, platelet 408x10ˆ9/L, blood DISCUSSION urea 4.0 mmol/L, serum creatinine 73 umol/L, estimated glomer- Air embolism is defined as entry of air into the arterial or venous ular filtration rate >90, C reactive protein 70 mg/L, alanine system. It may result from invasive procedures, trauma and baro- 1 transaminase 9 iu/L. ECG was in sinus rhythm and no ischaemic trauma to the lungs. Arterial air has direct access to the cerebral changes were noted. CT head revealed multiple serpiginous circulation and venous air is thought to be shunted through a pockets of air along the cerebral fissure, with features that were patent foramen ovale (PFO). In the absence of a PFO, systemic highly suggestive of an embolism and multiple wedge- shaped venous air needs to traverse the pulmonary vasculature. Pulmo- areas of infarction involving the cerebral hemispheres (figure 2). nary arterioles and capillaries act as a physical barrier for various http://casereports.bmj.com/ CT chest revealed satisfactory positioning of the IPC with no substances entering in to the arterial circulation, but some parti- 2 aetiology for the acute deterioration (figure 3). The patient was cles can still get through pulmonary capillary filter. CAE of admitted to the intensive care unit for high flow oxygen therapy venous origin has occurred in the absence of intracardiac septal 3 and head down ventilation. defects. Air directly entering into pulmonary veins, which drain into the left atrium can result in CAE without any of the mecha- OUTCOME AND FOLLOW-UP nisms described above. Our patient’s condition slowly deteriorated and his GCS was not Pleural procedures can result in lung puncture and introduce improved. Following a discussion with the multidisciplinary team gas bubbles into a pulmonary vein. Air bubbles can flow in when and family, a previous decision to manage him conservatively in a needle tip enters a pulmonary vein while its base is opened to the atmosphere. The atmospheric pressure exceeds the pulmo- on October 1, 2021 by guest. Protected copyright. nary venous pressure during inspiration and air gets sucked into the pulmonary venous system. It may also occur when a needle penetrates both an air-containing space and a nearby pulmonary vein, causing a broncho- venous fistula. Coughing or a Valsalva manoeuvre may increase airway pressure and air enters the pulmonary vein.4 5 One cannot be sure of the exact incidence of iatrogenic air embolism but it has been reported to be as low as 2.65/100 000 and is therefore not routinely consented for at the time of pleural procedures.6 The fatality rate in CAE has been reported to be as high as 21% although there are very few case reports of CAE in the literature.7 Knowledge of CAE is important for patients and operators given the large volume of commonly performed thoracic procedures in which CAE could occur such as percuta- neous transthoracic needle lung biopsy, thoracentesis, chest drain insertion, intrapleural fibrinolytic therapy and pleural lavage.1 CAE occurring after IPC insertion has not been reported. Figure 2 CT head showing multiple serpiginous pockets of air along At 7 years postdiagnosis, our patient had defied the odds in the cerebral fissure (white arrows) suggestive of air embolism. terms of his survival from mesothelioma. Mean 1- year survival 2 Jayawardena DMC, et al. BMJ Case Rep 2021;14:e244006. doi:10.1136/bcr-2021-244006 Case report BMJ Case Rep: first published as 10.1136/bcr-2021-244006 on 29 July 2021. Downloaded from rate for mesothelioma in men aged above 75 years in UK is 8 Learning points 29.8% and 5- year survival rate for the same group is 3%.