Successful Resuscitation and Management of a Patient with
Massive Venous Air
Embolism During Liver Resection
Robert Covington, DO and Victor Zhang, MD,
PhD.
Department of Anesthesiology, University of Florida, Gainesville, Florida
The occurrence of minor venous air embolisms during liver resection is
probably a common and often overlooked event in patients who are able to
hemodynamically compensate for such assaults. Predisposition to massive
hemodynamic instability and the need for targeted resuscitation lies with
the patient population that is either intrinsically or intraoperatively
placed at risk for disastrous outcomes.
Our 64 year old patient presented with a complex cystic mass within the
right lobe of the liver and subsequently underwent resection of this lesion
under general anesthesia. The patient’s medical history was significant for
sarcoidosis (with known involvement of the lungs and skin) and type 2
diabetes mellitus (well controlled with oral medications). After induction
of anesthesia, a left radial arterial line and right internal jugular vein
9F double lumen catheter were placed. The patient’s initial central venous
pressures (CVP’s) of 10-12 mmHg were reduced to between 2-5 mmHg with large
doses of narcotics in order to establish favorable surgical conditions.
Approximately two hours into the procedure, the patient’s systolic blood
pressure (SBP) decreased to 65-70 mmHg and the end tidal carbon dioxide
levels decreased from around 35 to nearly 20 mmHg. Suspecting venous air
embolism, an attempt to increase CVP with fluid boluses and pressors was
initiated. This initial resuscitation proved successful and the patient’s
blood pressure began to increase and stabilize. Soon after the initial
stabilization, the patient’s SBP fell to 30-35 mmHg. The surgeons were
immediately notified and subsequently discovered a tear in the splenic
capsule as well as a perforation in the right hepatic vein, resulting in
acute blood loss. Resuscitation with packed red blood cells, fresh frozen
plasma and normal saline was initiated and pressors (epinephrine,
neosynephrine, vasopressin and ephedrine) were begun. Inspired oxygen was
increased to 100% and the patient was placed in a head down position with
the right atrium up. Transesophageal echocardiogram (TEE) revealed a large
amount of air within the right ventricle, right ventricular hypokinesis,
decreased left ventricular filling and possible air within the aortic arch
and pulmonary veins; raising suspicion for a possible paradoxical air
embolism. Adequate resuscitation efforts were guided, in part, by
observation of the left ventricular end diastolic filling volumes using TEE.
The patient’s blood pressure and vital signs stabilized and all pressors
were discontinued over the ensuing 90 minutes. The patient remained
intubated and was taken to the SICU in stable condition. Elevated cardiac
enzymes were noted on post operative day one, but ECG and transthoracic
echocardio-graphy were normal (LVEF 55-60%). The cardiac enzymes normalized
with no indication for further follow-up. The patient was discharged home 15
days post liver resection with a normal neurological and cardiac exam.
Suffering the initial, most likely minor, venous air embolism predisposed
our patient to massive hemodynamic instability and cardiac collapse. The use
of transesophageal echocardiography to guide resuscitation efforts targeted
at increasing left ventricular volumes and right ventricular function proved
to be successful.
