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Percutaneous Transthoracic Needle Biopsy Complicated by Air Embolism

Western Deep Levels Hospital Western Levels 2501, South Africa

In their excellent article, "Percutaneous Transthoracic Needle Biopsy Complicated by Air Embolism" [1], the authors state that "if it had been recognized that gas was present in the left ventricle before it embolized to the brain, the patient might have been quickly placed in Trendelenburg's position and right-side down." I have always understood that treatment of air embolism involved turning a patient onto the left side with the head lowered.

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —54-year-old woman with mild retropatellar osteoarthritis. Axial three-dimensional spoiled gradient-echo MR image was obtained using imaging time of 8 min 2 sec (TR/TE, 45/11; flip angle, 50°; number of excitations, 1; slice thickness, 2 mm; no interslice gap; slab thickness, 92 mm; field of view, 145 x 145; matrix, 256 x 256).

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —54-year-old woman with mild retropatellar osteoarthritis. Axial fat-suppressed proton density–weighted MR image was obtained using imaging time of 6 min 15 sec (TR/TE, 3433/15; flip angle, 180°; number of excitations, 3; slice thickness, 2 mm; no interslice gap; slab thickness, 92 mm; field of view, 145 x 145; matrix 256 x 256). Depiction of edema in retropatellar cartilage is superior compared with A. Note internal cartilage edema (solid arrow) and arthrographic effect of joint fluid (open arrows).

According to the Merck Manual [2], the recommended treatment for air embolism is "turning the patient on the left side, head down, to allow the air to escape a little at a time from the right atrium." Perhaps the authors or an editorial authority could clarify this important aspect of emergency treatment.

References

1. Arnold BW, Zwiebel WJ. Percutaneous transthoracic needle biopsy complicated by air embolism. AJR2002; 178:1400 –1402[Free Full Text]
2. Merck manual of diagnosis and therapy, 16th ed. Rahway, NJ: Merck Research Laboratories, 1991

Reply

VA Salt Lake City Health Care System Salt Lake City, UT 84148

We thank Dr. Emby for his thoughts regarding treatment of air embolism. In the letter, the author describes the treatment for right-sided venous air embolism, which involves turning a patient onto the left side with the head lowered. The reference Emby cites, from the 16th edition of the Merck Manual, supports this statement but indicates that this treatment is for venous air embolism because it describes allowing "air to escape a little at a time from the right atrium" [1].

Our case, instead, involved an arterial air embolism arising from air in the left ventricle and not the right atrium or ventricle [2]. MacLean and Bachman [3] state:

It had long been believed that further embolism could be minimized by positioning the patient in such a way as to keep intracardiac air away from the ventricular outflow tracts. These positions are the left lateral decubitus and Trendelenburg position for right ventricular air and the right lateral decubitus and Trendelenburg position for left ventricular air. In addition, it was thought that Trendelenburg position would allow intracranial bubbles to float toward a more central vascular position.

This was the opinion we also found in our review of the literature before submission of our case report. However, a recent review of the literature by Muth and Shank [4] indicates that a horizontal, supine position is preferable for treatment of air embolism within either the venous or arterial circulation.

References

1. Merck manual of diagnosis and therapy, 16th ed. Rahway, NJ: Merck Research Laboratories, 1991
2. Arnold BW, Zwiebel WJ. Percutaneous transthoracic needle biopsy complicated by air embolism. AJR2002; 178:1400 –1402
3. MacLean CA, Bachman DT. Documented arterial gas embolism after spinal epidural injection. Ann Emerg Med2001; 38:592 –595[Medline]
4. Muth CM, Shank ES. Gas embolism. N Engl J Med 2000;342:476 –482[Free Full Text]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Emby, D. J. Articles by Zwiebel, W. J. Search for Related Content PubMed PubMed Citation Articles by Emby, D. J. Articles by Zwiebel, W. J. Social Bookmarking                      What's this?