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The Journal of Thoracic and Cardiovascular Surgery, Vol 80, 708-717, Copyright © 1980 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
NL Mills and JL Ochsner
Massive air embolism during cardiopulmonary bypass is a frightening
complication requiring immediate response and carrying strong medicolegal
implications. From July, 1971, to July, 1979, there were eight instances of
massive air embolism during 3,620 cardiopulmonary bypass operations. Five
such accidents from other institutions are included in this report. Causes
were (1) inattention to reservoir level, (2) reversal of pump head tubing
or direction of pump head rotation, (3) unexpected resumption of heartbeat,
(4) inadequate steps to remove air after cardiotomy, (5) high-flow suction
deep in a pulmonary artery, (6) defective oxygenator, (7) use of a
pressurized cardiotomy reservoir, and (8) inadvertent detachment of
oxygenator during bypass. Prevention includes a systematic check of pump
suckers and perfusion lines before bypass, a sensing device on the
oxygenator reservoir, secure fixation of the oxygenator and avoidance of
traffic around pump equipment, immediate cessation of pump and inspection
for abnormal noise, use of standard maneuvers to remove air from the heart,
and carotid compression with resumption of heartbeat. Immediate management
of massive air embolism consists of placing the patient in a deep
Trendelenburg position and making a large stab wound in the ascending aorta
for retrograde drainage from the cerebrovascular bed. Temporary retrograde
perfusion through the superior vena cava (SVC) may also be used. Subsequent
steps are hypothermia with the resumption of cardiopulmonary bypass,
elevation of blood pressure, steroids, ventilation with 100% oxygen, and
deep barbiturate anesthesia. Among the 13 patients, there were four
instantaneous deaths. Cerebral injury which resolved within a 2 month
period occurred in three patients. The remainder had no neurologic
sequelae. Nonfatal cerebral air injury may be associated with prolonged
convalescence yet complete recovery, as compared to embolism from debris or
clot, which offers a poorer prognosis.
ARTICLES
Massive air embolism during cardiopulmonary bypass. Causes, prevention, and management
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A. Usui, K. Oohara, T.-l. Liu, M. Murase, M. Tanaka, E. Takeuchi, and T. Abe Comparative experimental study between retrograde cerebral perfusion and circulatory arrest J. Thorac. Cardiovasc. Surg., May 1, 1994; 107(5): 1228 - 1236. [Abstract] [Full Text]
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