Page 5 - CASA Bulletin of Anesthesiology 2022; 9(3)-1 (1)

Vol. 9, No 3, 2022

本期专题

Fatal venous air embolism and cardiac arrest during hepatectomy
-A Case Discussion

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1
Ning Miao, MD ，Xiaowei Lu, MD ，Andrew Mannes, MD ，Kevin Driscoll, DNP, CRNA
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1
Khanh Nghiem, BS, MT
2

1 Department of Perioperative Medicine
2 Department of Laboratory Medicine
Clinical Center, NIH, Bethesda, MD

Abstract

Venous air embolism (VAE) during hepatectomy is routinely regarded as a “low risk” in
patients. We present a case of VAE-induced fatal cardiopulmonary collapse and death during
hepatic large tumor resection in a 36 year old female, scheduled for resection of multiple hepatic
metastatic tumors from pancreatic neuroendocrine tumor. During the parenchymal transection
for tumor resection, the patient suffered a pulseless electrical activity (PEA) cardiac arrest. A
diagnosis of VAE was made by withdrawal of air from a central line and ultrasound visualization
of air bubbles in the patient's right heart. Prompt cardiorespiratory resuscitation with chest
compression was initiated and IV boluses of vasopressors, blood products transfusion were
administered, and air was withdrawn directly from the right heart. Her EKG changed quickly
from pulseless ventricular tachycardia (VT), ventricular fibrillation (VF) and then asystole.
Despite maximal care for 45 minutes, heart electrical activity and spontaneous circulation never
returned, and resuscitative care was discontinued.

Introduction

VAE is a rare but life-threatening accident that has been encountered in the operating room.
The critical volume of air that is fatal in humans is debated but the estimated adult acute lethal
dose of air has been reported to be between 100 and 300 mL . Large amounts of air, if
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entraining into veins without discovery, can lead to right ventricle air lock leading to right
ventricular outflow tract obstruction, cardiovascular collapse and death . Unfortunately, air
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embolism may be difficult to detect, and a high index of suspicion will be critical for inclusion in
the differential diagnoses. Although some surgical procedures are at high risk for VAE, most
episodes of VAE are preventable and could be diagnosed with vigilance and could be more
effectively treated with early intervention.

Over the decades, more complicated liver surgeries emerged due to new techniques and
strategies . The anesthesia for liver surgeries need to maintain perioperative hemodynamic
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stability to ensure proper end organ perfusion, limit blood loss to decrease blood transfusion, and
preserve metabolic balance to keep hemostasis. To reach these goals, surgeons have to employ
different maneuvers to occlude hepatic blood inflow and/or outflow continuously or
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