Nephrology Hypertension

Hemodialysis: Acute Complications - Air Embolism

Does this patient have air embolism?

Symptoms depend on amount, speed, and site of introduced air, as well as patient's position

Sitting position - venous emboli in cerebral circulation

Seizure, coma

Supine position

Impaired right ventricular function (decreased cardiac output and hypotension)

Microemboli to pulmonary vasculature (dyspnea, dry cough, chest tightness or pain, hypoxia, respiratory failure)

Sudden cardiac arrest (> 50 mL)

Left trendelenburg position

Lower extremity venous occlusion, and arterial ischemia from increased outflow resistance.

What tests to perform?

  • Diagnosis suspected by clinical judgment

  • Pulse oximetry or arterial blood gas

  • Foam may be visible in the extracorporeal circuit line.

How should patients with air embolism be managed?

Acute management

Clamp venous blood line

Stop blood pump

Place patient in the left Trendelenburg position

Cardiovascular support

  • High flow oxygen administration

  • Endotracheal intubation

  • Mechanical ventilation

Aspirate air from right ventricle using percutaneously-inserted needle or right atrial dialysis catheter

Consider hyperbaric oxygenation treatment if available

Prevention

Aspirate blood and flush with saline before connection

Perform good priming of extracorporeal circuit including dialyzer (there should be no residual air bubbles)

Check dialysis machine’s air detector

Avoid the use of the arterial line during dialysis for additional infusions

What happens to patients with air embolism?

  • Acute respiratory failure

  • Hypotension/obstructive shock

  • Sudden cardiac arrest

  • Death

  • Neurological deficit

  • Limb ischemia

How to utilize team care?

  1. Specialty consultations - Cardiology for emergent transthoracic echocardiography and possible aspiration of air from right ventricle; Pulmonology/critical care medicine for supportive care and to provide hyperbaric oxygenation therapy if indicated

  2. Nurses – Adherence to proper techniques for gaining access to the vascular access (e.g., central venous dialysis catheter)

Are there clinical practice guidelines to inform decision making?

Applications- no

Other considerations

ICD-10-CM diagnosis code T80.0XXA: Air embolism following infusion, transfusion and therapeutic injection, initial encounter

What is the evidence?

Palmon, SC, Moore, LE, Lundberg, J, Tuong, T. "Venous Air Embolism: A Review". J Clin Anesth. vol. 9. 1997. pp. 251-257.

Mirski, MA, Lele, AV, Fitzsimmons, L, Tuong, T. "Diagnosis and Treatment of Vascular Air Embolism". Anesthesiology. vol. 106. 2007. pp. 164-77.

Orebaugh, SL. "Venous air embolism: Clinical and experimental considerations". Crit Care Med.. vol. 20. 1992. pp. 1169-77.

Gordy, S, Rowell, S. "Vascular air embolism". Int J Crit Illn Inj Sci. vol. 3. 2013. pp. 73-76.

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