Air Embolus?

P_RN, ADN, RN · Apr 4, 2006

once again from our member mark hammerschmidt, rn's icu faq, http://www.icufaqs.org/pulmonaryembolism.doc

other kinds of embolisms

48- what is an air embolus?

a big bubble of air injected into the circulation will travel along the vessels as a blob, and you can effectively plug off pulmonary circulation with big bubbles just as well as you can with clots. in the icu you want to worry about this happening in connection with central lines, and a couple of main points should be made:

- remember that at times the pressure inside the chest can go negative. if you have an uncapped port on a central line, it will suck air into the patient.

- if you’ve removed the pa line from one of the introducers with the little black membrane, then you need to remember that the membrane isn’t airtight anymore, and unless you cover it with a tegaderm or insert an obturator, it will suck air into the patient.

- if you remove a central line and forget to slap an air-occlusive dressing over the site, it may remain patent and suck air into the patient.

just don’t let this happen.

49- what does a patient with an air embolus look like?

usually awful – like someone with a big pe. blue, short of breath, chest pain – and what’s that horrible sucking sound?

that’s if it goes to the lungs. everybody see that nasty thing down there on the lower right? according to the u of iowa’s website, this is an image of somebody who managed to send an air embolus to his/her head. left-sided-circulation embolus. scuba diver maybe? don’t hold your breath on the way back up! pwing!

http://www.uiowa.edu/~c064s01/nr320%20copy.jpg

apparently the big risk for air embolism is during surgery – and it’s pretty dangerous: something like 50cc can displace most of the blood on the right side of the heart, and 300c can be lethal.

50- an incredibly important point: rapid iv boluses.

this raises a point that does come up fairly frequently in the micu. giving a rapid fluid bolus from a liter bag of saline involves putting the iv solution into one of the while compression bags that we use for arterial and central lines. hold a liter bag of ns up to the light – how much air is in that bag? if you don’t vent that air, the compression bag will pump it right into your patient. don’t let this happen. spike the bag upside down and squeeze the air out through the tubing. every time.

51- what should i do if i think my patient has just pulled in an air embolus?

a little tricky – let’s see if i can remember this right. what you want to do is try to trap the air in the rv in such a way that it won’t get pumped out towards the lungs, so you’re supposed to:

- get the person into trendelenburg position with the right side up, which will trap the air in the right atrium (ventricle?) and prevent it from getting into the circulation.

- apply oxygen.

- get the team. the maneuver is to try and aspirate the air from the ra (rv?) through a cvp line until no more can be removed.

soliant12 · Apr 4, 2006

Takes about 60cc to actually kill a patient

How long do the symptoms of an air embolus take to show up? I've heard nurses say not to worry about air in IV tubing b/c it takes a lot to harm a patient. Is this true. Is this a big risk w/ PICC lines, or is infection that's more concerning? Confused..... Need good advice.

WVUturtle514 · Apr 5, 2006

During surgery, venous air emblous can be potentially huge problems and the effects can be seen almost immediately. There is increased risk for this any time the site of surgery is above the level of the heart.

Irishgirl · Apr 5, 2006

Wow! 60 cc? That's a hell of a lot of air to inject into a patient. I was worried about leaving a PICC line uncapped for, like, ten seconds. Is it possible for air to "suck in" that fast? I saw the blood sitting in the line, and it hadn't moved.

soliant12 · Apr 5, 2006

Nah, should't have any problems leaving it open like that.

Wow! 60 cc? That's a hell of a lot of air to inject into a patient. I was worried about leaving a PICC line uncapped for, like, ten seconds. Is it possible for air to "suck in" that fast? I saw the blood sitting in the line, and it hadn't moved.

celeste7767 · Apr 5, 2006

All the info offered by P RN, Super Moderator were excellent and on the money as far as avoiding air emboli. I would only add one more CRUCIAL point: When removing any type of central line, make certain that the patient's position is flat during the time that the catheter is being removed. If the patient does not tolerate that position, remove dressing, sutures, and have an assistant to stabilize the catheter using sterile gloves while you lower the patient to the supine position just long enough to withdraw the catheter and place a sterile dressing over the site; the patient may be returned to his previous position while you maintain manual pressure until hemostasis is achieved. It is also recommended, if possible, that the patient avoid taking a breath during catheter removal since the normal physiologic increase in negative intrathoracic pressure that occurs with inspiration is a mechanism that can result in intraduction of air into the vessel when a breath coincides with the moment that the tip of the catheter exits the vessel opening. If the patient is ventilator dependent, your assistant can disconnect the patient from the vent for the few seconds required to actually remove the catheter and apply the dresing. At one hospital in which I worked, an intern removed a subclavian line from a young man who was due to go home the next day or two. He had survived a severe case of rhabdomyolysis and his hospital course had been long and complicated. He had been in the intermediate care unit and was no longer on any IV fluids or meds. Unfortunately, the intern removed the central line while the young man was in a recliner with his head elevated. I was the ICU nurse who answered the Code Blue and according to the intern, within seconds after he removed the catheter, the patient QUIT TALKING, lost consciousness, and suffered a full cardiorespiratory arrest. We were unable to resusitate him. All of our Critical Care nurses must review annually the procedures for more than 20 competencies and be tested on their abilities to perform them correctly and safely and I know that this is a requirement in most if not all Critical Care units. I do not know why the intern failed to follow the protocol for this procedure but it was a memorable lesson to me to review procedures more often than once a year, especially when it is one that I haven't performed recently.

Irishgirl · Apr 6, 2006

What happened to that nurse intern?? She must have been devestated. Did she quit? (I assume she did). I don't think I could live w/ myself if a patient died b/c of me. I don't know how a person could get through that.

ICRN2008, BSN, RN · Apr 6, 2006

Was this a medical intern or a nursing intern? Do ICU RNs remove central lines routinely?

sonessrna · Apr 6, 2006

Was this a medical intern or a nursing intern? Do ICU RNs remove central lines routinely?

WHen I worked in ICU we routinely removed central lines.

P_RN, ADN, RN · Apr 6, 2006

I've removed dozens on our floor (not critical care) without any problems. That is such a sad story about the patient in the recliner. We'd have the patient valsalva (grunt loudly) at the moment it exited and have a vaseline or xeroform gauze available for the underside of the pressure dressing. Was this intern new? Was it a nursing intern??

Mississippi_RN · Apr 7, 2006

Takes about 60cc to actually kill a patient

Hmm.... Well, that very well may be true. Interesting... but I wonder who they tested that on to find out EXACTLY how much air it would take??