Air Embolisms by Central Line Removal

MmacFN · May 7, 2006

hey :)

if an air embolism or clot does occur, place patient in trendelenburg (head down) position and rotate toward the left lateral decubitus position. this maneuver helps trap air in the apex of the ventricle, prevents its ejection into the pulmonary arterial system, and maintains right ventricular output. you can attempt to aspirate the air through the line as well though this has little proof behind it.

in circulatory collapse, cpr should be started to maintain cardiac output as well as to potentially break large air bubbles into smaller ones and force air out of the right ventricle into the pulmonary vessels. in arrest that is refractory to cpr, emergency thoracotomy may be indicated. hilar injury and bronchovenous fistulae should be ruled out by the absence of bloody froth during positive-pressure ventilation, and then needle aspiration of intracardiac air from the ventricles should be performed. consider cross-clamping the aorta in hypotensive patients.

as a last resort hyperbarics can be considered as well. ive only seen this used once and it was to no avail.

now that the standard for removal of a central line is confirmed, what is the usual treatment for air embolus a patient receives after line removal. i have heard they need heparin immediately, and i have heard to lay them left lateral. any other suggestions??
also, have you heard that air embolus actually cause blood clots to form in the capillaries and arteries of the lungs?
thanks

London88 · May 7, 2006

Nobody uses a finder needle where i work. we have specially made kits where the needle through which you thread the guide wire is bigger than the finder needle, but smaller than the needles used for threading the guide wire in a standard kit. That way if you unfortunately hit the carotid, which of course i have, it is not as big of a puncture.

MmacFN · May 7, 2006

When I place a central its not with the guide wire (Seldinger Tech)

I do it with a syringe attached to a 14 guage long needle, once in i pull the needle and use the cath.

Very straight forward.

TopherSRN · May 7, 2006

When I place a central its not with the guide wire.
I do it with a syringe attached to a 14 guage long needle, once in i pull the needle and use the cath.
Very straight forward.

The guide wire/dilator (Seldinger technique) is used with Cordis/TLCs, correct? Whereas Mmac is just doing basic IJ cannulation with a PIV catheter?

MmacFN · May 7, 2006

Exactly

I have trained in seldinger but I only use the tech. when its an interfacility and the doc isnt comfortable doing one. When I do a crash central line int he field the time to use seldinger simply isnt available.

The guide wire/dilator (Seldinger technique) is used with Cordis/TLCs, correct? Whereas Mmac is just doing basic IJ cannulation with a PIV catheter?

chadash · May 7, 2006

Wow! Great post, this even makes sense to me!

London88 · May 8, 2006

MmacFan;

Are you doing a stick on the EJ or the IJ because I cannot imagine using a 14g needle to locate the IJ?

MmacFN · May 8, 2006

hey london

I have used a 14 or 16 for all my central lines. IJ SC and Fem. I often use an 18 guage iv for EJs just to try and decrease the pain the patient may feel.

jwk · May 9, 2006

hey london
I have used a 14 or 16 for all my central lines. IJ SC and Fem. I often use an 18 guage iv for EJs just to try and decrease the pain the patient may feel.

Are you using an IV catheter or one made specifically for central lines?

MmacFN · May 9, 2006

hey jwk

Its a central line kit, its made specifically for central lines, supposedly. Though in the past we were also taught to do it with a basic long 16 guage IV and a syringe. Seemed to work OK and the trauma docs felt it was a good way to get it done quickly.

Here is the Kit

http://online.boundtree.com/store/product_index.asp?Cat=&SubCat=&Prod=351609

But its essentially the same as a 16 guage long with a cath

danursern · Mar 5, 2011

I just finished a class in Infusion therapy. We were told to remove a CL the patient needed to/must be flat, and do V maneuver. No exceptions. A nurse noted a CL was not removed prior and up to D/C of patient. Anyway she removed a CL while the man was sitting in a W/C waiting for his wife who was out getting the car for transport home. When she came back in the man was dead. Why, a air embolism. This was a story told to us in class today.

I understood her to say it is removed slowly and carefully while patient is flat.

Does anyone have and good book resources or CL DVD's that actually demonstrates this process?

This class was excellent, and it last 16 hours, 2 days, but I it was fast pace and I do want to remember everything I was taught. We talked about arm circumference, which is very important part of assessment, verifying tip placement etc.,. There was so much info. :nurse:

Lynne

remifentanil · Mar 18, 2011

I just finished a class in Infusion therapy. We were told to remove a CL the patient needed to/must be flat, and do V maneuver. No exceptions. A nurse noted a CL was not removed prior and up to D/C of patient. Anyway she removed a CL while the man was sitting in a W/C waiting for his wife who was out getting the car for transport home. When she came back in the man was dead. Why, a air embolism. This was a story told to us in class today.
I understood her to say it is removed slowly and carefully while patient is flat.
Does anyone have and good book resources or CL DVD's that actually demonstrates this process?
This class was excellent, and it last 16 hours, 2 days, but I it was fast pace and I do want to remember everything I was taught. We talked about arm circumference, which is very important part of assessment, verifying tip placement etc.,. There was so much info.
Lynne

I would like to talk to the person who taught this class...

A human being,absent a PFO VSD etc can easily absorb more IV air than you think with no ill effects... This sounds like an urban legend. With a Valsalva the interthroacic and thus the venous pressure will NOT go below atmospheric.. and you cannot have air entering the vasculature without this condition existing.

IIRC amounts up to apporx .25ml/Kg can be absorbed with no ill effect.

It is common to inject a small amount of air into an RA line to trace the flow with ultrasound and to demonstrate the 'Mill Wheel' sound heard on a percodial doppler used to detect air emboli during sitting position craniotomies.

The skin, underlying tissue and most importantly the vein are very elastic structures and would close off any hole left by the catheter... not to mention a central line is not inserted at a 90 degree angle to the skin...the air would have to enter though the tract of the line...My ******** meter is pegged on this one.

Unless it was a HUGE central line...say a Cordis..and even then it would be difficult in the extreme. It sounds like that nurse was blowing smoke... or .. does not understand physics and anatomy.