A High-pressure Solution for a High-pressure Situation: Management of Cerebral Air Embolism with Hyperbaric Oxygen Therapy

Abstract

Cerebral air embolism can complicate many medical procedures, including cardiac surgery, venous and arterial access, and laparoscopic surgery. It can be a devastating diagnosis and can cause a life-threatening compromise to the cardiac, respiratory, or cerebrovascular system. It is a rare complication of central venous vascular access manipulation. A cerebral air embolism can lead to acute ischemic and cerebral oedema, which mimics other stroke syndromes, but the acute treatment differs, with prompt administration of hyperbaric oxygen therapy being the mainstay of treatment. A 59-year-old male became acutely unresponsive followed by the emergence of evolving neurology with fixed gaze palsy and a dense 0/5 left-sided hemiparesis. This occurred shortly after a right internal jugular central venous catheter (CVC) was removed (against protocol) during inspiration and sitting upright. Computed tomography (CT) imaging showed air in the right internal jugular vein, as well as intraparenchymal air. Treatment with hyperbaric oxygen was instituted within six hours. There was an excellent recovery of neurologic function, with power improving to 4+/5 over the course of the following week. Clinical staff need to be aware of the policy for central line removal, as well as having a high index of suspicion for air embolism in patients with evolving neurology immediately post-line removal. Early consideration of hyperbaric oxygen can result in improved functional outcomes.

Keywords: air embolism; hyperbaric oxygen therapy; stroke.

Figure 1. Coronal slice of computed tomography (CT) of the brain with a red arrow demonstrating intraparenchymal air

Figure 2. Coronal slice from the computed tomography (CT) angiogram at the level of the trachea with a red arrow showing air in the right internal jugular vein

Figure 3. Description of the United States (US) Navy table pressure

Oxygen (O₂) is delivered to the patient during the time periods indicated by the blue bars with air delivered as indicated by the white bars. ATA stands for 'atmospheres absolute' and is a term used to measure the pressure of the air surrounding us at any given time.