A M P Death by “air”ror RESENTATION AIR EMBOLISM · cerebral air embolism is 23%Heckmann 35%...
Transcript of A M P Death by “air”ror RESENTATION AIR EMBOLISM · cerebral air embolism is 23%Heckmann 35%...
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Death by ldquoairrdquoror
How much is too much
Daphne Broadhurst RN BScN
President-Elect Canadian Vascular Access Association
Clinical Specialist Medical Pharmacies Ottawa
3
A MEDICAL PHARMACIES PRESENTATION
AIR EMBOLISM
Daphne Broadhurst RN BScN CVAA(c)
LONG TERM CARE PHARMACY SERVICES
1 Case Reports
2 How lethal is air When air turns bad
3 Itrsquos invisible- how do you know
4 Howrsquos the air getting in
5 Stop the air flow
6 No air allowed
LINE UP
5
LONG TERM CARE PHARMACY SERVICES
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LONG TERM CARE PHARMACY SERVICES
LONG TERM CARE PHARMACY SERVICES
Air embolism is a rare potentially catastrophic and often underappreciated complication of vascular access devices
Entry of air into the venous or arterial vasculatureGorski Odowd
What is an AIR EMBOLISM
I
Case Reports
10
LONG TERM CARE PHARMACY SERVICES
8 mth old jugular IV started for hydration
Family reported to nurse air bubbles seen in the line after nurse squeezed IV bag
Baby then screamed turned blue arrested and died
Cause of death cerebral air embolism
Kendyll Bliss
httpwwwsptimescom20030209ColumnsA_
couple_s_loss_may_oshtml
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LONG TERM CARE PHARMACY SERVICES
4 wk old infant peripheral IV infusion via pump started
1 minute later IV set seen to be 23 empty
Levy
Cyanotic with grunting mottled skin and unmeasurable BP
Full recovery
Causation inadequate priming of administration set
LONG TERM CARE PHARMACY SERVICES
14 yo boy received 2 infusions of pantolac in 100mL NS amp lactated ringers via peripheral IV
Autopsy revealed copious fine frothy red blood found in svc ivc neck veins heart sc emphysema over upper parts of body
Cause of death venous air embolism following iv infusionAgarwal
LONG TERM CARE PHARMACY SERVICES
62 yo female with long-term PN via tunnelled silicone catheter
Turned in bed and ldquosuddenly felt generally uncomfortable with severe air hungerrdquo and became cyanotic but no other signssymptoms
Recovered rapidly with O2 8Lm and placement in left lateral decubitus position
Catheter was torn in 2 at a point between the sutures and the catheter hubHaavik
LONG TERM CARE PHARMACY SERVICES
72 year-old patient unintentionally disconnected the cvad
Found unresponsive with severe tetraparesis and akinetic mutism with stable cardiopulmonary status
No neurologic improvement 3 months later Heckmann
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LONG TERM CARE PHARMACY SERVICES
65 yo male 20 min after IJ CVAD removed up to bathroom to defecate
Found on floor unconscious uarrHRuarrPuarrBP diffuse wheezes amp crackles
Intubated Hyperbaric oxygen (Patent foramen ovale)
Hours later uarrcardiac outputuarrR uarrTdeg gthematemesis IJ site bleedinggt DIC
Several days later patient discharged home Kapoor T Gutierrez G Critical Care 20037(5)98-100 Retrieved from httpebookbrowsecom4-air-embolism-pdf-d218188205
LONG TERM CARE PHARMACY SERVICES
James Tyree
53yo male treated for
stomach cancer
Dialysis catheter removed
Patient died from air
embolism during CVAD
removal
LONG TERM CARE PHARMACY SERVICES
httpwwwromeomediacomcategoryLegal20
Marketingpage=5
httpwwwinsiderexclusivecomshow-
content289-medical-malpractice--the-narin-bun-
storyhtml
Nurse prepared to remove CVAD used to deliver antibiotics
Nurse inadvertently pulled catheter out causing air embolism
Narin Bun
Patient resuscitated catastrophic brain damage
HOW LETHAL IS AIR
Air Embolism
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LONG TERM CARE PHARMACY SERVICES
DEATH BY AIR
httpdigitallibraryadelaideeduaudspacebitstr
eam244041890102wholepdf
LONG TERM CARE PHARMACY SERVICES
Is it common Mortality rates due to catheters range
from 5-30Natal Bessereau
Mortality associated with CVAD-related cerebral air embolism is 23Heckmann
35 survived with severe neurologic deficits
38 with good or complete recovery
True incidence unknown Crude prevalence 265 cases per 100000 admissionsBessereau
Prognostic factors of mortality cardiac arrest ICU admissionBessereau
LONG TERM CARE PHARMACY SERVICES
Incidence LONG TERM CARE PHARMACY SERVICES
httpswwwyoutubecomwatchv=oZ1_TA
wCUWw
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LONG TERM CARE PHARMACY SERVICES
Right Heart Outflow Obstruction
bull cardiac output
bull Cardiovascular collapse MI
LONG TERM CARE PHARMACY SERVICES
Pathophysiologyhellip
Air in R ventricle Turbulence
Inflammatory response
RBC platelets fibrin amp
fat globules
Endothelial damage
Ischemia
Pulmonary edema
httpebookbrowsecom2
001-11-28-code-blue-in-
the-ct-suite-air-embolism-
pdf-d159139478
LONG TERM CARE PHARMACY SERVICES
It dependshellip
Location bull Point of entry bull Embolus lodges
Volume amp Rate
bull High volume bull High rate
Patient Variables
bull Position bull Cardiac amp lung fx bull + pressure gradient
How Much is Too Much LONG TERM CARE PHARMACY SERVICES
Size (amp rate) matters
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LONG TERM CARE PHARMACY SERVICES
48 PIVs flushed with saline demonstrated small air emboli on CT in right heart pulmonary trunk and L brachiocephalic vein
Source air in syringe or cannulaGroell
Peripheral IV
Portal of
entry
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
Atmospheric
pressure
Intrathoracic
pressure
darr Intrathoracic
pressure
bull Upright position
bull Dyspnea
bull Deep inspiration
bull Hypovolemia
+ Pressure
Gradient
Air entry is more likely if pressure in veins is below atmospheric pressure
Upright position particularly favours the rapid entry of air bubblesOdowd Andrews
LONG TERM CARE PHARMACY SERVICES
The minimum volume of air lethal to humans is not yet knownToung Pant Agarwal
2 fatal cases of 100-200 mL air with 1 author stating lethal volume may be greater if normal cardiac functionToung
Infusion of 50 mL in healthy patients has been reported to cause hypotension dysrhythmias and sometimes deathTorres
Volume
How Much is Too Muchhellip
Rate
LONG TERM CARE PHARMACY SERVICES
Volume How Much is Too Muchhellip
It has been estimated from studies with dogs that as little as 20 mLsec of air will be associated with symptoms of air embolism and 70 to 150 mLsec or 3-5 mlkg of air can be fatalECRI Mirski Natal Wilkins Pant
It has been suggested that the heart may be able to withstand large quantities of air if injected slowly as dogs have been able to withstand up to 1400 mL of air over a several-hour period
MirskI Groell
Exposing an opened IV line for only a second (ie when disconnecting tubing or changing the needleless connector) can let in 100mL of airMasoorli
The closer the entry into the venous system to the right heart is and the faster the air entry the smaller the amount of air is needed to cause a fatal outcomeMirskI Natal von Jurgenson
Rate
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LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
Infusion-related Air Embolism
Little available data in relation to how much air is tolerated through an infusion system The passage of a few air bubbles into the patient is a common occurrence with no substantial evidence of adverse consequences
Pump air detector standard = 05mL71mm
Suggested lethal volume of ~225 mL in healthy adult is equivalent to gt1 m air bubble in standard IV tubingWilkins
Rate
LONG TERM CARE PHARMACY SERVICES
A 2 or 3 mL bolus of air in the cerebral circulation can be fatal
As little as 05 mL of air in a coronary artery can cause ventricular fibrillation NataL von Jurgenson Levy
Tiny but lethal
A small air embolus can be fatal
Volume
LONG TERM CARE PHARMACY SERVICES
Patent Foramen Ovale (PFO)
10-35 of patients have a subclinical PFO
LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism
The lungs are able to filter air to prevent the air from travelling from the venous to arterial circulation up to a threshold of about 035 mLkgmin
after which air cannot be filtered and may enter arterial system with arterial bubbles detected in 50 of patients where air entry exceeds this threshold Wilkins
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LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism LONG TERM CARE PHARMACY SERVICES
PFO Increasing the risk of air embolism
40 of 26 cases of cerebral air embolism patients had a patent foramen ovale
1531 patients with neurological symptoms following air embolism had right-to-left shunting via intrapulmonary shunt or patent foramen ovaleWilkins Besserau
05 mL has been reported as lethal in the left-side arterial circulationPant
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
ITrsquoS INVISIBLE- HOW DO YOU KNOW
Air Embolism
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LONG TERM CARE PHARMACY SERVICES
Respiratory
Dyspnea
Tachypnea
Cough
Hypoxia
Wheezing
Signs amp Symptoms
Cardiac
Chest pain
Hypotension
Cyanosis
Tachycardia
Tachyarrhythmia bradyarrhthymia
PAH
Ward Armstrong Haavik Natal Ruskin Pant Andrews Odowd
Subclinical to mild to catastrophic SS
LONG TERM CARE PHARMACY SERVICES
Respiratory
Cardiac
Signs amp Symptomshellip
CNS (cerebral arterial embolism) Heckmann
Sense of impending doom
Focal Lesions
Hemiparesis
Loss of vision
Mortality rate 8
Encephalopathic
Acute confusional state
Decreased consciousness
Coma
Seizures
Akinetic mutism
High mortality rate - 36 Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
CNS
Signs amp Symptomshellip
Likely to suffer long-term neurological deficits if present on ICU admission with
focal motor deficits
Babinski sign
On mechanical ventilation of 5 days or more
(OR = 1278 398ndash4109 OR = 676 224ndash 2033 OR = 1514 292ndash7852 respectively) Bessereau
Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
Financial Consequences
httpwwwsafeinfusiontherapycomcpsrdex
chghc-safeinfusion-en-inthsxsl7241html
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LONG TERM CARE PHARMACY SERVICES
Air Embolism Liability
Bhananker
LONG TERM CARE PHARMACY SERVICES
Anesthesiology legal claimsBhananker
Peripheral vascular catheters =2 of claims
Air embolism one of the most common complications ndash 8
Air embolism claims had highest median payment and a rate of 100 payment-per-claim
($325000 2007 with a range of $25800ndash $4120200)
Financial Consequenceshellip
LONG TERM CARE PHARMACY SERVICES
httpwwwmlivecomnewsgrand-
rapidsindexssf201208parents_sue_devos_childrens_hohtml
HOWrsquoS THE AIR GETTING IN
Air Embolism
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LONG TERM CARE PHARMACY SERVICES
Type of VADs
CVAD PIV
55
LONG TERM CARE PHARMACY SERVICES
feil
LONG TERM CARE PHARMACY SERVICES
VADs accounted for 14 gas embolism (n=29125 at Hyperbaric oxygen center)Besserreau
Removal (n=9)
Accidental removal (n=8)
Manipulation and usual care (n=7)
Insertion (n=5)
Peripheral venous catheterization (n=2)
Causes of Air Embolism
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LONG TERM CARE PHARMACY SERVICES
ACCIDENTAL DISCONNECTION
Cause of almost half of cerebral air embolism cases in a review of 1426 published case reports (1975-1998)Heckmann
Air embolism due to catheter disconnection has a mortality rate between 29 and 43
LONG TERM CARE PHARMACY SERVICES
Air embolism caused by a laceration to
central venous catheter during shaving Pearson
Causes of Air Embolismhellip
LONG TERM CARE PHARMACY SERVICES
Ward
Causes of Air Embolismhellip
Ward
LONG TERM CARE PHARMACY SERVICES
httpwwwfdagovMedicalDevicesSafetyAlertsandNoticesTubingandLuerM
isconnectionsucm313275htm
Causes of Air Embolismhellip
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LONG TERM CARE PHARMACY SERVICES
CASE STUDY
An ER patient had an IV heparin lock but no IV fluids had been started The
patient also had a noninvasive automatic BP cuff placed for continuous
monitoring
The BP cuff tubing was disconnected when the patient went to the bathroom
When she returned her spouse mistakenly connected the BP cuff tubing to the
IV catheter and approximately 15 mL of air was delivered to the IV catheter
The patient died from a fatal air embolus despite resuscitation efforts
Causeshellip LONG TERM CARE PHARMACY SERVICES
Causes
Infusion-related Air Embolism
Improper priming of administration set (4 fatal cases in literature)
Air vented bottles
Fluid infusions that are finished
Fluid infusions with rapid infusion through an air-filled drip chamber and the administration set remains open pose threats for air entrySingh Gardner von Jurgenson
(A one-litre sized crystalloid IV infusion bag can contain up to 60 mL of air)Schnoor
Rate
STOP THE FLOW
Air Embolism
LONG TERM CARE PHARMACY SERVICES
Early detection and treatment are critical to prevent or minimize cardiovascular pulmonary and neurologic damageAndrew
Stop air entryWilkins Garg Heckman
Notify MD Call 911 if in alternate care setting stay with patient and provide reassurance von
Jurgenson Natal
Left lateral decubitus and trendelenburg position
Treatment
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LONG TERM CARE PHARMACY SERVICES
100 O2 artificial ventilation with airbagendotracheal intubation
CPR closed cardiac massage
Fluid resuscitation (to increase intravascular volume venous pressure and venous return)Levy Clark Natal
Inotropic support (eg dobutamine) if cardiovascular collapse to increase CVPMirski Feil
Aspiration of air through distal lumen of CVP line or pulmonary artery catheter if catheter already in placePant Garg Odowd
Treatmenthellip LONG TERM CARE PHARMACY SERVICES
Hyperbaric oxygen therapy which is the main therapy for massive arterial air embolism preferably initiated within 3-5 hours of the event (reduces size of air bubbles accelerates nitrogen resorption and increases oxygen content of arterial blood) AndrewsTorres Heckman Mirski
Diagnostic measures include ABGs CXREKG pulse oximetry ventilation-perfusion scan CT of chest and head echocardiography pulmonary artery catheter Andrews Heckman Natal
Treatmenthellip
NO AIR ALLOWED
Air Embolism
AIR
LONG TERM CARE PHARMACY SERVICES
Insertion of VADS
Hydrate patient prior to insertion to correct hypovolemia whenever possible Feil
Occlude needle hub and catheter during insertion removalMirskiNatal
PREVENTION
Education practice guidelines amp protocols
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LONG TERM CARE PHARMACY SERVICES
During CVAD insertion stop ventilation during insertion of needle increase right atrial pressure during tunnelling of catheterMirski
During peripheral cannulation and removal place the arm below the level of the heartBBraun
PREVENTION LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Minimize IV manipulationsGroel
Supine or Trendelenburg position during daily management of scalp vein infusionFortrat
Remove air from add-on devices (syringes tubings needleless connectors stopcocks and all other devices added to the catheter)INS Wilkins Ensure stopcocks that are not in use are switched off and covered with a Luer-Lok capneedleless devicevon Jurgenson
Always use luer-lock connections to avoid accidental disconnectionsPant von Jorgenson INS
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADs Air detectorsfilters
Air sensors in infusion pumps Wilklins Pant ECRI Feil Adult infusion systems should be designed to prevent infusion of volumes of air gt50 μL in normal use and to prevent infusion of volumes of air gt1 mL in failure mode The smallest volume of air possible for neonates with a maximum air infusion volumes of 10 μL in failure modeWilkins
Air elimination filter on administration setsWilkins
Gardner Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Priming
Careful filling and handling of administration sets and thorough priming of filters (with filter in proper position) as per manufacturerrsquos guidelinesGardner Wilkins von Jurgenson
Check for air bubbles prior to starting the infusion
Close clamps of the administration set prior to priming then spike the fluid container and gently squeeze the drip chamber until it is half-filledvon Jurgenosn
If a burette is used ensure the tubing btw containerbag and burette is clamped offvon Jurgenson
Remove air from infusion bags when infusing fluids using inflatable pressure infusors Feil
PREVENTIONhellip
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LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
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LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
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LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
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LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
2
LONG TERM CARE PHARMACY SERVICES
LONG TERM CARE PHARMACY SERVICES
Air embolism is a rare potentially catastrophic and often underappreciated complication of vascular access devices
Entry of air into the venous or arterial vasculatureGorski Odowd
What is an AIR EMBOLISM
I
Case Reports
10
LONG TERM CARE PHARMACY SERVICES
8 mth old jugular IV started for hydration
Family reported to nurse air bubbles seen in the line after nurse squeezed IV bag
Baby then screamed turned blue arrested and died
Cause of death cerebral air embolism
Kendyll Bliss
httpwwwsptimescom20030209ColumnsA_
couple_s_loss_may_oshtml
522015
3
LONG TERM CARE PHARMACY SERVICES
4 wk old infant peripheral IV infusion via pump started
1 minute later IV set seen to be 23 empty
Levy
Cyanotic with grunting mottled skin and unmeasurable BP
Full recovery
Causation inadequate priming of administration set
LONG TERM CARE PHARMACY SERVICES
14 yo boy received 2 infusions of pantolac in 100mL NS amp lactated ringers via peripheral IV
Autopsy revealed copious fine frothy red blood found in svc ivc neck veins heart sc emphysema over upper parts of body
Cause of death venous air embolism following iv infusionAgarwal
LONG TERM CARE PHARMACY SERVICES
62 yo female with long-term PN via tunnelled silicone catheter
Turned in bed and ldquosuddenly felt generally uncomfortable with severe air hungerrdquo and became cyanotic but no other signssymptoms
Recovered rapidly with O2 8Lm and placement in left lateral decubitus position
Catheter was torn in 2 at a point between the sutures and the catheter hubHaavik
LONG TERM CARE PHARMACY SERVICES
72 year-old patient unintentionally disconnected the cvad
Found unresponsive with severe tetraparesis and akinetic mutism with stable cardiopulmonary status
No neurologic improvement 3 months later Heckmann
522015
4
LONG TERM CARE PHARMACY SERVICES
65 yo male 20 min after IJ CVAD removed up to bathroom to defecate
Found on floor unconscious uarrHRuarrPuarrBP diffuse wheezes amp crackles
Intubated Hyperbaric oxygen (Patent foramen ovale)
Hours later uarrcardiac outputuarrR uarrTdeg gthematemesis IJ site bleedinggt DIC
Several days later patient discharged home Kapoor T Gutierrez G Critical Care 20037(5)98-100 Retrieved from httpebookbrowsecom4-air-embolism-pdf-d218188205
LONG TERM CARE PHARMACY SERVICES
James Tyree
53yo male treated for
stomach cancer
Dialysis catheter removed
Patient died from air
embolism during CVAD
removal
LONG TERM CARE PHARMACY SERVICES
httpwwwromeomediacomcategoryLegal20
Marketingpage=5
httpwwwinsiderexclusivecomshow-
content289-medical-malpractice--the-narin-bun-
storyhtml
Nurse prepared to remove CVAD used to deliver antibiotics
Nurse inadvertently pulled catheter out causing air embolism
Narin Bun
Patient resuscitated catastrophic brain damage
HOW LETHAL IS AIR
Air Embolism
522015
5
LONG TERM CARE PHARMACY SERVICES
DEATH BY AIR
httpdigitallibraryadelaideeduaudspacebitstr
eam244041890102wholepdf
LONG TERM CARE PHARMACY SERVICES
Is it common Mortality rates due to catheters range
from 5-30Natal Bessereau
Mortality associated with CVAD-related cerebral air embolism is 23Heckmann
35 survived with severe neurologic deficits
38 with good or complete recovery
True incidence unknown Crude prevalence 265 cases per 100000 admissionsBessereau
Prognostic factors of mortality cardiac arrest ICU admissionBessereau
LONG TERM CARE PHARMACY SERVICES
Incidence LONG TERM CARE PHARMACY SERVICES
httpswwwyoutubecomwatchv=oZ1_TA
wCUWw
522015
6
LONG TERM CARE PHARMACY SERVICES
Right Heart Outflow Obstruction
bull cardiac output
bull Cardiovascular collapse MI
LONG TERM CARE PHARMACY SERVICES
Pathophysiologyhellip
Air in R ventricle Turbulence
Inflammatory response
RBC platelets fibrin amp
fat globules
Endothelial damage
Ischemia
Pulmonary edema
httpebookbrowsecom2
001-11-28-code-blue-in-
the-ct-suite-air-embolism-
pdf-d159139478
LONG TERM CARE PHARMACY SERVICES
It dependshellip
Location bull Point of entry bull Embolus lodges
Volume amp Rate
bull High volume bull High rate
Patient Variables
bull Position bull Cardiac amp lung fx bull + pressure gradient
How Much is Too Much LONG TERM CARE PHARMACY SERVICES
Size (amp rate) matters
522015
7
LONG TERM CARE PHARMACY SERVICES
48 PIVs flushed with saline demonstrated small air emboli on CT in right heart pulmonary trunk and L brachiocephalic vein
Source air in syringe or cannulaGroell
Peripheral IV
Portal of
entry
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
Atmospheric
pressure
Intrathoracic
pressure
darr Intrathoracic
pressure
bull Upright position
bull Dyspnea
bull Deep inspiration
bull Hypovolemia
+ Pressure
Gradient
Air entry is more likely if pressure in veins is below atmospheric pressure
Upright position particularly favours the rapid entry of air bubblesOdowd Andrews
LONG TERM CARE PHARMACY SERVICES
The minimum volume of air lethal to humans is not yet knownToung Pant Agarwal
2 fatal cases of 100-200 mL air with 1 author stating lethal volume may be greater if normal cardiac functionToung
Infusion of 50 mL in healthy patients has been reported to cause hypotension dysrhythmias and sometimes deathTorres
Volume
How Much is Too Muchhellip
Rate
LONG TERM CARE PHARMACY SERVICES
Volume How Much is Too Muchhellip
It has been estimated from studies with dogs that as little as 20 mLsec of air will be associated with symptoms of air embolism and 70 to 150 mLsec or 3-5 mlkg of air can be fatalECRI Mirski Natal Wilkins Pant
It has been suggested that the heart may be able to withstand large quantities of air if injected slowly as dogs have been able to withstand up to 1400 mL of air over a several-hour period
MirskI Groell
Exposing an opened IV line for only a second (ie when disconnecting tubing or changing the needleless connector) can let in 100mL of airMasoorli
The closer the entry into the venous system to the right heart is and the faster the air entry the smaller the amount of air is needed to cause a fatal outcomeMirskI Natal von Jurgenson
Rate
522015
8
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
Infusion-related Air Embolism
Little available data in relation to how much air is tolerated through an infusion system The passage of a few air bubbles into the patient is a common occurrence with no substantial evidence of adverse consequences
Pump air detector standard = 05mL71mm
Suggested lethal volume of ~225 mL in healthy adult is equivalent to gt1 m air bubble in standard IV tubingWilkins
Rate
LONG TERM CARE PHARMACY SERVICES
A 2 or 3 mL bolus of air in the cerebral circulation can be fatal
As little as 05 mL of air in a coronary artery can cause ventricular fibrillation NataL von Jurgenson Levy
Tiny but lethal
A small air embolus can be fatal
Volume
LONG TERM CARE PHARMACY SERVICES
Patent Foramen Ovale (PFO)
10-35 of patients have a subclinical PFO
LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism
The lungs are able to filter air to prevent the air from travelling from the venous to arterial circulation up to a threshold of about 035 mLkgmin
after which air cannot be filtered and may enter arterial system with arterial bubbles detected in 50 of patients where air entry exceeds this threshold Wilkins
522015
9
LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism LONG TERM CARE PHARMACY SERVICES
PFO Increasing the risk of air embolism
40 of 26 cases of cerebral air embolism patients had a patent foramen ovale
1531 patients with neurological symptoms following air embolism had right-to-left shunting via intrapulmonary shunt or patent foramen ovaleWilkins Besserau
05 mL has been reported as lethal in the left-side arterial circulationPant
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
ITrsquoS INVISIBLE- HOW DO YOU KNOW
Air Embolism
522015
10
LONG TERM CARE PHARMACY SERVICES
Respiratory
Dyspnea
Tachypnea
Cough
Hypoxia
Wheezing
Signs amp Symptoms
Cardiac
Chest pain
Hypotension
Cyanosis
Tachycardia
Tachyarrhythmia bradyarrhthymia
PAH
Ward Armstrong Haavik Natal Ruskin Pant Andrews Odowd
Subclinical to mild to catastrophic SS
LONG TERM CARE PHARMACY SERVICES
Respiratory
Cardiac
Signs amp Symptomshellip
CNS (cerebral arterial embolism) Heckmann
Sense of impending doom
Focal Lesions
Hemiparesis
Loss of vision
Mortality rate 8
Encephalopathic
Acute confusional state
Decreased consciousness
Coma
Seizures
Akinetic mutism
High mortality rate - 36 Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
CNS
Signs amp Symptomshellip
Likely to suffer long-term neurological deficits if present on ICU admission with
focal motor deficits
Babinski sign
On mechanical ventilation of 5 days or more
(OR = 1278 398ndash4109 OR = 676 224ndash 2033 OR = 1514 292ndash7852 respectively) Bessereau
Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
Financial Consequences
httpwwwsafeinfusiontherapycomcpsrdex
chghc-safeinfusion-en-inthsxsl7241html
522015
11
LONG TERM CARE PHARMACY SERVICES
Air Embolism Liability
Bhananker
LONG TERM CARE PHARMACY SERVICES
Anesthesiology legal claimsBhananker
Peripheral vascular catheters =2 of claims
Air embolism one of the most common complications ndash 8
Air embolism claims had highest median payment and a rate of 100 payment-per-claim
($325000 2007 with a range of $25800ndash $4120200)
Financial Consequenceshellip
LONG TERM CARE PHARMACY SERVICES
httpwwwmlivecomnewsgrand-
rapidsindexssf201208parents_sue_devos_childrens_hohtml
HOWrsquoS THE AIR GETTING IN
Air Embolism
522015
12
LONG TERM CARE PHARMACY SERVICES
Type of VADs
CVAD PIV
55
LONG TERM CARE PHARMACY SERVICES
feil
LONG TERM CARE PHARMACY SERVICES
VADs accounted for 14 gas embolism (n=29125 at Hyperbaric oxygen center)Besserreau
Removal (n=9)
Accidental removal (n=8)
Manipulation and usual care (n=7)
Insertion (n=5)
Peripheral venous catheterization (n=2)
Causes of Air Embolism
522015
13
LONG TERM CARE PHARMACY SERVICES
ACCIDENTAL DISCONNECTION
Cause of almost half of cerebral air embolism cases in a review of 1426 published case reports (1975-1998)Heckmann
Air embolism due to catheter disconnection has a mortality rate between 29 and 43
LONG TERM CARE PHARMACY SERVICES
Air embolism caused by a laceration to
central venous catheter during shaving Pearson
Causes of Air Embolismhellip
LONG TERM CARE PHARMACY SERVICES
Ward
Causes of Air Embolismhellip
Ward
LONG TERM CARE PHARMACY SERVICES
httpwwwfdagovMedicalDevicesSafetyAlertsandNoticesTubingandLuerM
isconnectionsucm313275htm
Causes of Air Embolismhellip
522015
14
LONG TERM CARE PHARMACY SERVICES
CASE STUDY
An ER patient had an IV heparin lock but no IV fluids had been started The
patient also had a noninvasive automatic BP cuff placed for continuous
monitoring
The BP cuff tubing was disconnected when the patient went to the bathroom
When she returned her spouse mistakenly connected the BP cuff tubing to the
IV catheter and approximately 15 mL of air was delivered to the IV catheter
The patient died from a fatal air embolus despite resuscitation efforts
Causeshellip LONG TERM CARE PHARMACY SERVICES
Causes
Infusion-related Air Embolism
Improper priming of administration set (4 fatal cases in literature)
Air vented bottles
Fluid infusions that are finished
Fluid infusions with rapid infusion through an air-filled drip chamber and the administration set remains open pose threats for air entrySingh Gardner von Jurgenson
(A one-litre sized crystalloid IV infusion bag can contain up to 60 mL of air)Schnoor
Rate
STOP THE FLOW
Air Embolism
LONG TERM CARE PHARMACY SERVICES
Early detection and treatment are critical to prevent or minimize cardiovascular pulmonary and neurologic damageAndrew
Stop air entryWilkins Garg Heckman
Notify MD Call 911 if in alternate care setting stay with patient and provide reassurance von
Jurgenson Natal
Left lateral decubitus and trendelenburg position
Treatment
522015
15
LONG TERM CARE PHARMACY SERVICES
100 O2 artificial ventilation with airbagendotracheal intubation
CPR closed cardiac massage
Fluid resuscitation (to increase intravascular volume venous pressure and venous return)Levy Clark Natal
Inotropic support (eg dobutamine) if cardiovascular collapse to increase CVPMirski Feil
Aspiration of air through distal lumen of CVP line or pulmonary artery catheter if catheter already in placePant Garg Odowd
Treatmenthellip LONG TERM CARE PHARMACY SERVICES
Hyperbaric oxygen therapy which is the main therapy for massive arterial air embolism preferably initiated within 3-5 hours of the event (reduces size of air bubbles accelerates nitrogen resorption and increases oxygen content of arterial blood) AndrewsTorres Heckman Mirski
Diagnostic measures include ABGs CXREKG pulse oximetry ventilation-perfusion scan CT of chest and head echocardiography pulmonary artery catheter Andrews Heckman Natal
Treatmenthellip
NO AIR ALLOWED
Air Embolism
AIR
LONG TERM CARE PHARMACY SERVICES
Insertion of VADS
Hydrate patient prior to insertion to correct hypovolemia whenever possible Feil
Occlude needle hub and catheter during insertion removalMirskiNatal
PREVENTION
Education practice guidelines amp protocols
522015
16
LONG TERM CARE PHARMACY SERVICES
During CVAD insertion stop ventilation during insertion of needle increase right atrial pressure during tunnelling of catheterMirski
During peripheral cannulation and removal place the arm below the level of the heartBBraun
PREVENTION LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Minimize IV manipulationsGroel
Supine or Trendelenburg position during daily management of scalp vein infusionFortrat
Remove air from add-on devices (syringes tubings needleless connectors stopcocks and all other devices added to the catheter)INS Wilkins Ensure stopcocks that are not in use are switched off and covered with a Luer-Lok capneedleless devicevon Jurgenson
Always use luer-lock connections to avoid accidental disconnectionsPant von Jorgenson INS
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADs Air detectorsfilters
Air sensors in infusion pumps Wilklins Pant ECRI Feil Adult infusion systems should be designed to prevent infusion of volumes of air gt50 μL in normal use and to prevent infusion of volumes of air gt1 mL in failure mode The smallest volume of air possible for neonates with a maximum air infusion volumes of 10 μL in failure modeWilkins
Air elimination filter on administration setsWilkins
Gardner Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Priming
Careful filling and handling of administration sets and thorough priming of filters (with filter in proper position) as per manufacturerrsquos guidelinesGardner Wilkins von Jurgenson
Check for air bubbles prior to starting the infusion
Close clamps of the administration set prior to priming then spike the fluid container and gently squeeze the drip chamber until it is half-filledvon Jurgenosn
If a burette is used ensure the tubing btw containerbag and burette is clamped offvon Jurgenson
Remove air from infusion bags when infusing fluids using inflatable pressure infusors Feil
PREVENTIONhellip
522015
17
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
522015
18
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
3
LONG TERM CARE PHARMACY SERVICES
4 wk old infant peripheral IV infusion via pump started
1 minute later IV set seen to be 23 empty
Levy
Cyanotic with grunting mottled skin and unmeasurable BP
Full recovery
Causation inadequate priming of administration set
LONG TERM CARE PHARMACY SERVICES
14 yo boy received 2 infusions of pantolac in 100mL NS amp lactated ringers via peripheral IV
Autopsy revealed copious fine frothy red blood found in svc ivc neck veins heart sc emphysema over upper parts of body
Cause of death venous air embolism following iv infusionAgarwal
LONG TERM CARE PHARMACY SERVICES
62 yo female with long-term PN via tunnelled silicone catheter
Turned in bed and ldquosuddenly felt generally uncomfortable with severe air hungerrdquo and became cyanotic but no other signssymptoms
Recovered rapidly with O2 8Lm and placement in left lateral decubitus position
Catheter was torn in 2 at a point between the sutures and the catheter hubHaavik
LONG TERM CARE PHARMACY SERVICES
72 year-old patient unintentionally disconnected the cvad
Found unresponsive with severe tetraparesis and akinetic mutism with stable cardiopulmonary status
No neurologic improvement 3 months later Heckmann
522015
4
LONG TERM CARE PHARMACY SERVICES
65 yo male 20 min after IJ CVAD removed up to bathroom to defecate
Found on floor unconscious uarrHRuarrPuarrBP diffuse wheezes amp crackles
Intubated Hyperbaric oxygen (Patent foramen ovale)
Hours later uarrcardiac outputuarrR uarrTdeg gthematemesis IJ site bleedinggt DIC
Several days later patient discharged home Kapoor T Gutierrez G Critical Care 20037(5)98-100 Retrieved from httpebookbrowsecom4-air-embolism-pdf-d218188205
LONG TERM CARE PHARMACY SERVICES
James Tyree
53yo male treated for
stomach cancer
Dialysis catheter removed
Patient died from air
embolism during CVAD
removal
LONG TERM CARE PHARMACY SERVICES
httpwwwromeomediacomcategoryLegal20
Marketingpage=5
httpwwwinsiderexclusivecomshow-
content289-medical-malpractice--the-narin-bun-
storyhtml
Nurse prepared to remove CVAD used to deliver antibiotics
Nurse inadvertently pulled catheter out causing air embolism
Narin Bun
Patient resuscitated catastrophic brain damage
HOW LETHAL IS AIR
Air Embolism
522015
5
LONG TERM CARE PHARMACY SERVICES
DEATH BY AIR
httpdigitallibraryadelaideeduaudspacebitstr
eam244041890102wholepdf
LONG TERM CARE PHARMACY SERVICES
Is it common Mortality rates due to catheters range
from 5-30Natal Bessereau
Mortality associated with CVAD-related cerebral air embolism is 23Heckmann
35 survived with severe neurologic deficits
38 with good or complete recovery
True incidence unknown Crude prevalence 265 cases per 100000 admissionsBessereau
Prognostic factors of mortality cardiac arrest ICU admissionBessereau
LONG TERM CARE PHARMACY SERVICES
Incidence LONG TERM CARE PHARMACY SERVICES
httpswwwyoutubecomwatchv=oZ1_TA
wCUWw
522015
6
LONG TERM CARE PHARMACY SERVICES
Right Heart Outflow Obstruction
bull cardiac output
bull Cardiovascular collapse MI
LONG TERM CARE PHARMACY SERVICES
Pathophysiologyhellip
Air in R ventricle Turbulence
Inflammatory response
RBC platelets fibrin amp
fat globules
Endothelial damage
Ischemia
Pulmonary edema
httpebookbrowsecom2
001-11-28-code-blue-in-
the-ct-suite-air-embolism-
pdf-d159139478
LONG TERM CARE PHARMACY SERVICES
It dependshellip
Location bull Point of entry bull Embolus lodges
Volume amp Rate
bull High volume bull High rate
Patient Variables
bull Position bull Cardiac amp lung fx bull + pressure gradient
How Much is Too Much LONG TERM CARE PHARMACY SERVICES
Size (amp rate) matters
522015
7
LONG TERM CARE PHARMACY SERVICES
48 PIVs flushed with saline demonstrated small air emboli on CT in right heart pulmonary trunk and L brachiocephalic vein
Source air in syringe or cannulaGroell
Peripheral IV
Portal of
entry
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
Atmospheric
pressure
Intrathoracic
pressure
darr Intrathoracic
pressure
bull Upright position
bull Dyspnea
bull Deep inspiration
bull Hypovolemia
+ Pressure
Gradient
Air entry is more likely if pressure in veins is below atmospheric pressure
Upright position particularly favours the rapid entry of air bubblesOdowd Andrews
LONG TERM CARE PHARMACY SERVICES
The minimum volume of air lethal to humans is not yet knownToung Pant Agarwal
2 fatal cases of 100-200 mL air with 1 author stating lethal volume may be greater if normal cardiac functionToung
Infusion of 50 mL in healthy patients has been reported to cause hypotension dysrhythmias and sometimes deathTorres
Volume
How Much is Too Muchhellip
Rate
LONG TERM CARE PHARMACY SERVICES
Volume How Much is Too Muchhellip
It has been estimated from studies with dogs that as little as 20 mLsec of air will be associated with symptoms of air embolism and 70 to 150 mLsec or 3-5 mlkg of air can be fatalECRI Mirski Natal Wilkins Pant
It has been suggested that the heart may be able to withstand large quantities of air if injected slowly as dogs have been able to withstand up to 1400 mL of air over a several-hour period
MirskI Groell
Exposing an opened IV line for only a second (ie when disconnecting tubing or changing the needleless connector) can let in 100mL of airMasoorli
The closer the entry into the venous system to the right heart is and the faster the air entry the smaller the amount of air is needed to cause a fatal outcomeMirskI Natal von Jurgenson
Rate
522015
8
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
Infusion-related Air Embolism
Little available data in relation to how much air is tolerated through an infusion system The passage of a few air bubbles into the patient is a common occurrence with no substantial evidence of adverse consequences
Pump air detector standard = 05mL71mm
Suggested lethal volume of ~225 mL in healthy adult is equivalent to gt1 m air bubble in standard IV tubingWilkins
Rate
LONG TERM CARE PHARMACY SERVICES
A 2 or 3 mL bolus of air in the cerebral circulation can be fatal
As little as 05 mL of air in a coronary artery can cause ventricular fibrillation NataL von Jurgenson Levy
Tiny but lethal
A small air embolus can be fatal
Volume
LONG TERM CARE PHARMACY SERVICES
Patent Foramen Ovale (PFO)
10-35 of patients have a subclinical PFO
LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism
The lungs are able to filter air to prevent the air from travelling from the venous to arterial circulation up to a threshold of about 035 mLkgmin
after which air cannot be filtered and may enter arterial system with arterial bubbles detected in 50 of patients where air entry exceeds this threshold Wilkins
522015
9
LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism LONG TERM CARE PHARMACY SERVICES
PFO Increasing the risk of air embolism
40 of 26 cases of cerebral air embolism patients had a patent foramen ovale
1531 patients with neurological symptoms following air embolism had right-to-left shunting via intrapulmonary shunt or patent foramen ovaleWilkins Besserau
05 mL has been reported as lethal in the left-side arterial circulationPant
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
ITrsquoS INVISIBLE- HOW DO YOU KNOW
Air Embolism
522015
10
LONG TERM CARE PHARMACY SERVICES
Respiratory
Dyspnea
Tachypnea
Cough
Hypoxia
Wheezing
Signs amp Symptoms
Cardiac
Chest pain
Hypotension
Cyanosis
Tachycardia
Tachyarrhythmia bradyarrhthymia
PAH
Ward Armstrong Haavik Natal Ruskin Pant Andrews Odowd
Subclinical to mild to catastrophic SS
LONG TERM CARE PHARMACY SERVICES
Respiratory
Cardiac
Signs amp Symptomshellip
CNS (cerebral arterial embolism) Heckmann
Sense of impending doom
Focal Lesions
Hemiparesis
Loss of vision
Mortality rate 8
Encephalopathic
Acute confusional state
Decreased consciousness
Coma
Seizures
Akinetic mutism
High mortality rate - 36 Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
CNS
Signs amp Symptomshellip
Likely to suffer long-term neurological deficits if present on ICU admission with
focal motor deficits
Babinski sign
On mechanical ventilation of 5 days or more
(OR = 1278 398ndash4109 OR = 676 224ndash 2033 OR = 1514 292ndash7852 respectively) Bessereau
Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
Financial Consequences
httpwwwsafeinfusiontherapycomcpsrdex
chghc-safeinfusion-en-inthsxsl7241html
522015
11
LONG TERM CARE PHARMACY SERVICES
Air Embolism Liability
Bhananker
LONG TERM CARE PHARMACY SERVICES
Anesthesiology legal claimsBhananker
Peripheral vascular catheters =2 of claims
Air embolism one of the most common complications ndash 8
Air embolism claims had highest median payment and a rate of 100 payment-per-claim
($325000 2007 with a range of $25800ndash $4120200)
Financial Consequenceshellip
LONG TERM CARE PHARMACY SERVICES
httpwwwmlivecomnewsgrand-
rapidsindexssf201208parents_sue_devos_childrens_hohtml
HOWrsquoS THE AIR GETTING IN
Air Embolism
522015
12
LONG TERM CARE PHARMACY SERVICES
Type of VADs
CVAD PIV
55
LONG TERM CARE PHARMACY SERVICES
feil
LONG TERM CARE PHARMACY SERVICES
VADs accounted for 14 gas embolism (n=29125 at Hyperbaric oxygen center)Besserreau
Removal (n=9)
Accidental removal (n=8)
Manipulation and usual care (n=7)
Insertion (n=5)
Peripheral venous catheterization (n=2)
Causes of Air Embolism
522015
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LONG TERM CARE PHARMACY SERVICES
ACCIDENTAL DISCONNECTION
Cause of almost half of cerebral air embolism cases in a review of 1426 published case reports (1975-1998)Heckmann
Air embolism due to catheter disconnection has a mortality rate between 29 and 43
LONG TERM CARE PHARMACY SERVICES
Air embolism caused by a laceration to
central venous catheter during shaving Pearson
Causes of Air Embolismhellip
LONG TERM CARE PHARMACY SERVICES
Ward
Causes of Air Embolismhellip
Ward
LONG TERM CARE PHARMACY SERVICES
httpwwwfdagovMedicalDevicesSafetyAlertsandNoticesTubingandLuerM
isconnectionsucm313275htm
Causes of Air Embolismhellip
522015
14
LONG TERM CARE PHARMACY SERVICES
CASE STUDY
An ER patient had an IV heparin lock but no IV fluids had been started The
patient also had a noninvasive automatic BP cuff placed for continuous
monitoring
The BP cuff tubing was disconnected when the patient went to the bathroom
When she returned her spouse mistakenly connected the BP cuff tubing to the
IV catheter and approximately 15 mL of air was delivered to the IV catheter
The patient died from a fatal air embolus despite resuscitation efforts
Causeshellip LONG TERM CARE PHARMACY SERVICES
Causes
Infusion-related Air Embolism
Improper priming of administration set (4 fatal cases in literature)
Air vented bottles
Fluid infusions that are finished
Fluid infusions with rapid infusion through an air-filled drip chamber and the administration set remains open pose threats for air entrySingh Gardner von Jurgenson
(A one-litre sized crystalloid IV infusion bag can contain up to 60 mL of air)Schnoor
Rate
STOP THE FLOW
Air Embolism
LONG TERM CARE PHARMACY SERVICES
Early detection and treatment are critical to prevent or minimize cardiovascular pulmonary and neurologic damageAndrew
Stop air entryWilkins Garg Heckman
Notify MD Call 911 if in alternate care setting stay with patient and provide reassurance von
Jurgenson Natal
Left lateral decubitus and trendelenburg position
Treatment
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LONG TERM CARE PHARMACY SERVICES
100 O2 artificial ventilation with airbagendotracheal intubation
CPR closed cardiac massage
Fluid resuscitation (to increase intravascular volume venous pressure and venous return)Levy Clark Natal
Inotropic support (eg dobutamine) if cardiovascular collapse to increase CVPMirski Feil
Aspiration of air through distal lumen of CVP line or pulmonary artery catheter if catheter already in placePant Garg Odowd
Treatmenthellip LONG TERM CARE PHARMACY SERVICES
Hyperbaric oxygen therapy which is the main therapy for massive arterial air embolism preferably initiated within 3-5 hours of the event (reduces size of air bubbles accelerates nitrogen resorption and increases oxygen content of arterial blood) AndrewsTorres Heckman Mirski
Diagnostic measures include ABGs CXREKG pulse oximetry ventilation-perfusion scan CT of chest and head echocardiography pulmonary artery catheter Andrews Heckman Natal
Treatmenthellip
NO AIR ALLOWED
Air Embolism
AIR
LONG TERM CARE PHARMACY SERVICES
Insertion of VADS
Hydrate patient prior to insertion to correct hypovolemia whenever possible Feil
Occlude needle hub and catheter during insertion removalMirskiNatal
PREVENTION
Education practice guidelines amp protocols
522015
16
LONG TERM CARE PHARMACY SERVICES
During CVAD insertion stop ventilation during insertion of needle increase right atrial pressure during tunnelling of catheterMirski
During peripheral cannulation and removal place the arm below the level of the heartBBraun
PREVENTION LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Minimize IV manipulationsGroel
Supine or Trendelenburg position during daily management of scalp vein infusionFortrat
Remove air from add-on devices (syringes tubings needleless connectors stopcocks and all other devices added to the catheter)INS Wilkins Ensure stopcocks that are not in use are switched off and covered with a Luer-Lok capneedleless devicevon Jurgenson
Always use luer-lock connections to avoid accidental disconnectionsPant von Jorgenson INS
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADs Air detectorsfilters
Air sensors in infusion pumps Wilklins Pant ECRI Feil Adult infusion systems should be designed to prevent infusion of volumes of air gt50 μL in normal use and to prevent infusion of volumes of air gt1 mL in failure mode The smallest volume of air possible for neonates with a maximum air infusion volumes of 10 μL in failure modeWilkins
Air elimination filter on administration setsWilkins
Gardner Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Priming
Careful filling and handling of administration sets and thorough priming of filters (with filter in proper position) as per manufacturerrsquos guidelinesGardner Wilkins von Jurgenson
Check for air bubbles prior to starting the infusion
Close clamps of the administration set prior to priming then spike the fluid container and gently squeeze the drip chamber until it is half-filledvon Jurgenosn
If a burette is used ensure the tubing btw containerbag and burette is clamped offvon Jurgenson
Remove air from infusion bags when infusing fluids using inflatable pressure infusors Feil
PREVENTIONhellip
522015
17
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
522015
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LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
4
LONG TERM CARE PHARMACY SERVICES
65 yo male 20 min after IJ CVAD removed up to bathroom to defecate
Found on floor unconscious uarrHRuarrPuarrBP diffuse wheezes amp crackles
Intubated Hyperbaric oxygen (Patent foramen ovale)
Hours later uarrcardiac outputuarrR uarrTdeg gthematemesis IJ site bleedinggt DIC
Several days later patient discharged home Kapoor T Gutierrez G Critical Care 20037(5)98-100 Retrieved from httpebookbrowsecom4-air-embolism-pdf-d218188205
LONG TERM CARE PHARMACY SERVICES
James Tyree
53yo male treated for
stomach cancer
Dialysis catheter removed
Patient died from air
embolism during CVAD
removal
LONG TERM CARE PHARMACY SERVICES
httpwwwromeomediacomcategoryLegal20
Marketingpage=5
httpwwwinsiderexclusivecomshow-
content289-medical-malpractice--the-narin-bun-
storyhtml
Nurse prepared to remove CVAD used to deliver antibiotics
Nurse inadvertently pulled catheter out causing air embolism
Narin Bun
Patient resuscitated catastrophic brain damage
HOW LETHAL IS AIR
Air Embolism
522015
5
LONG TERM CARE PHARMACY SERVICES
DEATH BY AIR
httpdigitallibraryadelaideeduaudspacebitstr
eam244041890102wholepdf
LONG TERM CARE PHARMACY SERVICES
Is it common Mortality rates due to catheters range
from 5-30Natal Bessereau
Mortality associated with CVAD-related cerebral air embolism is 23Heckmann
35 survived with severe neurologic deficits
38 with good or complete recovery
True incidence unknown Crude prevalence 265 cases per 100000 admissionsBessereau
Prognostic factors of mortality cardiac arrest ICU admissionBessereau
LONG TERM CARE PHARMACY SERVICES
Incidence LONG TERM CARE PHARMACY SERVICES
httpswwwyoutubecomwatchv=oZ1_TA
wCUWw
522015
6
LONG TERM CARE PHARMACY SERVICES
Right Heart Outflow Obstruction
bull cardiac output
bull Cardiovascular collapse MI
LONG TERM CARE PHARMACY SERVICES
Pathophysiologyhellip
Air in R ventricle Turbulence
Inflammatory response
RBC platelets fibrin amp
fat globules
Endothelial damage
Ischemia
Pulmonary edema
httpebookbrowsecom2
001-11-28-code-blue-in-
the-ct-suite-air-embolism-
pdf-d159139478
LONG TERM CARE PHARMACY SERVICES
It dependshellip
Location bull Point of entry bull Embolus lodges
Volume amp Rate
bull High volume bull High rate
Patient Variables
bull Position bull Cardiac amp lung fx bull + pressure gradient
How Much is Too Much LONG TERM CARE PHARMACY SERVICES
Size (amp rate) matters
522015
7
LONG TERM CARE PHARMACY SERVICES
48 PIVs flushed with saline demonstrated small air emboli on CT in right heart pulmonary trunk and L brachiocephalic vein
Source air in syringe or cannulaGroell
Peripheral IV
Portal of
entry
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
Atmospheric
pressure
Intrathoracic
pressure
darr Intrathoracic
pressure
bull Upright position
bull Dyspnea
bull Deep inspiration
bull Hypovolemia
+ Pressure
Gradient
Air entry is more likely if pressure in veins is below atmospheric pressure
Upright position particularly favours the rapid entry of air bubblesOdowd Andrews
LONG TERM CARE PHARMACY SERVICES
The minimum volume of air lethal to humans is not yet knownToung Pant Agarwal
2 fatal cases of 100-200 mL air with 1 author stating lethal volume may be greater if normal cardiac functionToung
Infusion of 50 mL in healthy patients has been reported to cause hypotension dysrhythmias and sometimes deathTorres
Volume
How Much is Too Muchhellip
Rate
LONG TERM CARE PHARMACY SERVICES
Volume How Much is Too Muchhellip
It has been estimated from studies with dogs that as little as 20 mLsec of air will be associated with symptoms of air embolism and 70 to 150 mLsec or 3-5 mlkg of air can be fatalECRI Mirski Natal Wilkins Pant
It has been suggested that the heart may be able to withstand large quantities of air if injected slowly as dogs have been able to withstand up to 1400 mL of air over a several-hour period
MirskI Groell
Exposing an opened IV line for only a second (ie when disconnecting tubing or changing the needleless connector) can let in 100mL of airMasoorli
The closer the entry into the venous system to the right heart is and the faster the air entry the smaller the amount of air is needed to cause a fatal outcomeMirskI Natal von Jurgenson
Rate
522015
8
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
Infusion-related Air Embolism
Little available data in relation to how much air is tolerated through an infusion system The passage of a few air bubbles into the patient is a common occurrence with no substantial evidence of adverse consequences
Pump air detector standard = 05mL71mm
Suggested lethal volume of ~225 mL in healthy adult is equivalent to gt1 m air bubble in standard IV tubingWilkins
Rate
LONG TERM CARE PHARMACY SERVICES
A 2 or 3 mL bolus of air in the cerebral circulation can be fatal
As little as 05 mL of air in a coronary artery can cause ventricular fibrillation NataL von Jurgenson Levy
Tiny but lethal
A small air embolus can be fatal
Volume
LONG TERM CARE PHARMACY SERVICES
Patent Foramen Ovale (PFO)
10-35 of patients have a subclinical PFO
LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism
The lungs are able to filter air to prevent the air from travelling from the venous to arterial circulation up to a threshold of about 035 mLkgmin
after which air cannot be filtered and may enter arterial system with arterial bubbles detected in 50 of patients where air entry exceeds this threshold Wilkins
522015
9
LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism LONG TERM CARE PHARMACY SERVICES
PFO Increasing the risk of air embolism
40 of 26 cases of cerebral air embolism patients had a patent foramen ovale
1531 patients with neurological symptoms following air embolism had right-to-left shunting via intrapulmonary shunt or patent foramen ovaleWilkins Besserau
05 mL has been reported as lethal in the left-side arterial circulationPant
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
ITrsquoS INVISIBLE- HOW DO YOU KNOW
Air Embolism
522015
10
LONG TERM CARE PHARMACY SERVICES
Respiratory
Dyspnea
Tachypnea
Cough
Hypoxia
Wheezing
Signs amp Symptoms
Cardiac
Chest pain
Hypotension
Cyanosis
Tachycardia
Tachyarrhythmia bradyarrhthymia
PAH
Ward Armstrong Haavik Natal Ruskin Pant Andrews Odowd
Subclinical to mild to catastrophic SS
LONG TERM CARE PHARMACY SERVICES
Respiratory
Cardiac
Signs amp Symptomshellip
CNS (cerebral arterial embolism) Heckmann
Sense of impending doom
Focal Lesions
Hemiparesis
Loss of vision
Mortality rate 8
Encephalopathic
Acute confusional state
Decreased consciousness
Coma
Seizures
Akinetic mutism
High mortality rate - 36 Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
CNS
Signs amp Symptomshellip
Likely to suffer long-term neurological deficits if present on ICU admission with
focal motor deficits
Babinski sign
On mechanical ventilation of 5 days or more
(OR = 1278 398ndash4109 OR = 676 224ndash 2033 OR = 1514 292ndash7852 respectively) Bessereau
Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
Financial Consequences
httpwwwsafeinfusiontherapycomcpsrdex
chghc-safeinfusion-en-inthsxsl7241html
522015
11
LONG TERM CARE PHARMACY SERVICES
Air Embolism Liability
Bhananker
LONG TERM CARE PHARMACY SERVICES
Anesthesiology legal claimsBhananker
Peripheral vascular catheters =2 of claims
Air embolism one of the most common complications ndash 8
Air embolism claims had highest median payment and a rate of 100 payment-per-claim
($325000 2007 with a range of $25800ndash $4120200)
Financial Consequenceshellip
LONG TERM CARE PHARMACY SERVICES
httpwwwmlivecomnewsgrand-
rapidsindexssf201208parents_sue_devos_childrens_hohtml
HOWrsquoS THE AIR GETTING IN
Air Embolism
522015
12
LONG TERM CARE PHARMACY SERVICES
Type of VADs
CVAD PIV
55
LONG TERM CARE PHARMACY SERVICES
feil
LONG TERM CARE PHARMACY SERVICES
VADs accounted for 14 gas embolism (n=29125 at Hyperbaric oxygen center)Besserreau
Removal (n=9)
Accidental removal (n=8)
Manipulation and usual care (n=7)
Insertion (n=5)
Peripheral venous catheterization (n=2)
Causes of Air Embolism
522015
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LONG TERM CARE PHARMACY SERVICES
ACCIDENTAL DISCONNECTION
Cause of almost half of cerebral air embolism cases in a review of 1426 published case reports (1975-1998)Heckmann
Air embolism due to catheter disconnection has a mortality rate between 29 and 43
LONG TERM CARE PHARMACY SERVICES
Air embolism caused by a laceration to
central venous catheter during shaving Pearson
Causes of Air Embolismhellip
LONG TERM CARE PHARMACY SERVICES
Ward
Causes of Air Embolismhellip
Ward
LONG TERM CARE PHARMACY SERVICES
httpwwwfdagovMedicalDevicesSafetyAlertsandNoticesTubingandLuerM
isconnectionsucm313275htm
Causes of Air Embolismhellip
522015
14
LONG TERM CARE PHARMACY SERVICES
CASE STUDY
An ER patient had an IV heparin lock but no IV fluids had been started The
patient also had a noninvasive automatic BP cuff placed for continuous
monitoring
The BP cuff tubing was disconnected when the patient went to the bathroom
When she returned her spouse mistakenly connected the BP cuff tubing to the
IV catheter and approximately 15 mL of air was delivered to the IV catheter
The patient died from a fatal air embolus despite resuscitation efforts
Causeshellip LONG TERM CARE PHARMACY SERVICES
Causes
Infusion-related Air Embolism
Improper priming of administration set (4 fatal cases in literature)
Air vented bottles
Fluid infusions that are finished
Fluid infusions with rapid infusion through an air-filled drip chamber and the administration set remains open pose threats for air entrySingh Gardner von Jurgenson
(A one-litre sized crystalloid IV infusion bag can contain up to 60 mL of air)Schnoor
Rate
STOP THE FLOW
Air Embolism
LONG TERM CARE PHARMACY SERVICES
Early detection and treatment are critical to prevent or minimize cardiovascular pulmonary and neurologic damageAndrew
Stop air entryWilkins Garg Heckman
Notify MD Call 911 if in alternate care setting stay with patient and provide reassurance von
Jurgenson Natal
Left lateral decubitus and trendelenburg position
Treatment
522015
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LONG TERM CARE PHARMACY SERVICES
100 O2 artificial ventilation with airbagendotracheal intubation
CPR closed cardiac massage
Fluid resuscitation (to increase intravascular volume venous pressure and venous return)Levy Clark Natal
Inotropic support (eg dobutamine) if cardiovascular collapse to increase CVPMirski Feil
Aspiration of air through distal lumen of CVP line or pulmonary artery catheter if catheter already in placePant Garg Odowd
Treatmenthellip LONG TERM CARE PHARMACY SERVICES
Hyperbaric oxygen therapy which is the main therapy for massive arterial air embolism preferably initiated within 3-5 hours of the event (reduces size of air bubbles accelerates nitrogen resorption and increases oxygen content of arterial blood) AndrewsTorres Heckman Mirski
Diagnostic measures include ABGs CXREKG pulse oximetry ventilation-perfusion scan CT of chest and head echocardiography pulmonary artery catheter Andrews Heckman Natal
Treatmenthellip
NO AIR ALLOWED
Air Embolism
AIR
LONG TERM CARE PHARMACY SERVICES
Insertion of VADS
Hydrate patient prior to insertion to correct hypovolemia whenever possible Feil
Occlude needle hub and catheter during insertion removalMirskiNatal
PREVENTION
Education practice guidelines amp protocols
522015
16
LONG TERM CARE PHARMACY SERVICES
During CVAD insertion stop ventilation during insertion of needle increase right atrial pressure during tunnelling of catheterMirski
During peripheral cannulation and removal place the arm below the level of the heartBBraun
PREVENTION LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Minimize IV manipulationsGroel
Supine or Trendelenburg position during daily management of scalp vein infusionFortrat
Remove air from add-on devices (syringes tubings needleless connectors stopcocks and all other devices added to the catheter)INS Wilkins Ensure stopcocks that are not in use are switched off and covered with a Luer-Lok capneedleless devicevon Jurgenson
Always use luer-lock connections to avoid accidental disconnectionsPant von Jorgenson INS
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADs Air detectorsfilters
Air sensors in infusion pumps Wilklins Pant ECRI Feil Adult infusion systems should be designed to prevent infusion of volumes of air gt50 μL in normal use and to prevent infusion of volumes of air gt1 mL in failure mode The smallest volume of air possible for neonates with a maximum air infusion volumes of 10 μL in failure modeWilkins
Air elimination filter on administration setsWilkins
Gardner Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Priming
Careful filling and handling of administration sets and thorough priming of filters (with filter in proper position) as per manufacturerrsquos guidelinesGardner Wilkins von Jurgenson
Check for air bubbles prior to starting the infusion
Close clamps of the administration set prior to priming then spike the fluid container and gently squeeze the drip chamber until it is half-filledvon Jurgenosn
If a burette is used ensure the tubing btw containerbag and burette is clamped offvon Jurgenson
Remove air from infusion bags when infusing fluids using inflatable pressure infusors Feil
PREVENTIONhellip
522015
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LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
522015
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LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
5
LONG TERM CARE PHARMACY SERVICES
DEATH BY AIR
httpdigitallibraryadelaideeduaudspacebitstr
eam244041890102wholepdf
LONG TERM CARE PHARMACY SERVICES
Is it common Mortality rates due to catheters range
from 5-30Natal Bessereau
Mortality associated with CVAD-related cerebral air embolism is 23Heckmann
35 survived with severe neurologic deficits
38 with good or complete recovery
True incidence unknown Crude prevalence 265 cases per 100000 admissionsBessereau
Prognostic factors of mortality cardiac arrest ICU admissionBessereau
LONG TERM CARE PHARMACY SERVICES
Incidence LONG TERM CARE PHARMACY SERVICES
httpswwwyoutubecomwatchv=oZ1_TA
wCUWw
522015
6
LONG TERM CARE PHARMACY SERVICES
Right Heart Outflow Obstruction
bull cardiac output
bull Cardiovascular collapse MI
LONG TERM CARE PHARMACY SERVICES
Pathophysiologyhellip
Air in R ventricle Turbulence
Inflammatory response
RBC platelets fibrin amp
fat globules
Endothelial damage
Ischemia
Pulmonary edema
httpebookbrowsecom2
001-11-28-code-blue-in-
the-ct-suite-air-embolism-
pdf-d159139478
LONG TERM CARE PHARMACY SERVICES
It dependshellip
Location bull Point of entry bull Embolus lodges
Volume amp Rate
bull High volume bull High rate
Patient Variables
bull Position bull Cardiac amp lung fx bull + pressure gradient
How Much is Too Much LONG TERM CARE PHARMACY SERVICES
Size (amp rate) matters
522015
7
LONG TERM CARE PHARMACY SERVICES
48 PIVs flushed with saline demonstrated small air emboli on CT in right heart pulmonary trunk and L brachiocephalic vein
Source air in syringe or cannulaGroell
Peripheral IV
Portal of
entry
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
Atmospheric
pressure
Intrathoracic
pressure
darr Intrathoracic
pressure
bull Upright position
bull Dyspnea
bull Deep inspiration
bull Hypovolemia
+ Pressure
Gradient
Air entry is more likely if pressure in veins is below atmospheric pressure
Upright position particularly favours the rapid entry of air bubblesOdowd Andrews
LONG TERM CARE PHARMACY SERVICES
The minimum volume of air lethal to humans is not yet knownToung Pant Agarwal
2 fatal cases of 100-200 mL air with 1 author stating lethal volume may be greater if normal cardiac functionToung
Infusion of 50 mL in healthy patients has been reported to cause hypotension dysrhythmias and sometimes deathTorres
Volume
How Much is Too Muchhellip
Rate
LONG TERM CARE PHARMACY SERVICES
Volume How Much is Too Muchhellip
It has been estimated from studies with dogs that as little as 20 mLsec of air will be associated with symptoms of air embolism and 70 to 150 mLsec or 3-5 mlkg of air can be fatalECRI Mirski Natal Wilkins Pant
It has been suggested that the heart may be able to withstand large quantities of air if injected slowly as dogs have been able to withstand up to 1400 mL of air over a several-hour period
MirskI Groell
Exposing an opened IV line for only a second (ie when disconnecting tubing or changing the needleless connector) can let in 100mL of airMasoorli
The closer the entry into the venous system to the right heart is and the faster the air entry the smaller the amount of air is needed to cause a fatal outcomeMirskI Natal von Jurgenson
Rate
522015
8
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
Infusion-related Air Embolism
Little available data in relation to how much air is tolerated through an infusion system The passage of a few air bubbles into the patient is a common occurrence with no substantial evidence of adverse consequences
Pump air detector standard = 05mL71mm
Suggested lethal volume of ~225 mL in healthy adult is equivalent to gt1 m air bubble in standard IV tubingWilkins
Rate
LONG TERM CARE PHARMACY SERVICES
A 2 or 3 mL bolus of air in the cerebral circulation can be fatal
As little as 05 mL of air in a coronary artery can cause ventricular fibrillation NataL von Jurgenson Levy
Tiny but lethal
A small air embolus can be fatal
Volume
LONG TERM CARE PHARMACY SERVICES
Patent Foramen Ovale (PFO)
10-35 of patients have a subclinical PFO
LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism
The lungs are able to filter air to prevent the air from travelling from the venous to arterial circulation up to a threshold of about 035 mLkgmin
after which air cannot be filtered and may enter arterial system with arterial bubbles detected in 50 of patients where air entry exceeds this threshold Wilkins
522015
9
LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism LONG TERM CARE PHARMACY SERVICES
PFO Increasing the risk of air embolism
40 of 26 cases of cerebral air embolism patients had a patent foramen ovale
1531 patients with neurological symptoms following air embolism had right-to-left shunting via intrapulmonary shunt or patent foramen ovaleWilkins Besserau
05 mL has been reported as lethal in the left-side arterial circulationPant
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
ITrsquoS INVISIBLE- HOW DO YOU KNOW
Air Embolism
522015
10
LONG TERM CARE PHARMACY SERVICES
Respiratory
Dyspnea
Tachypnea
Cough
Hypoxia
Wheezing
Signs amp Symptoms
Cardiac
Chest pain
Hypotension
Cyanosis
Tachycardia
Tachyarrhythmia bradyarrhthymia
PAH
Ward Armstrong Haavik Natal Ruskin Pant Andrews Odowd
Subclinical to mild to catastrophic SS
LONG TERM CARE PHARMACY SERVICES
Respiratory
Cardiac
Signs amp Symptomshellip
CNS (cerebral arterial embolism) Heckmann
Sense of impending doom
Focal Lesions
Hemiparesis
Loss of vision
Mortality rate 8
Encephalopathic
Acute confusional state
Decreased consciousness
Coma
Seizures
Akinetic mutism
High mortality rate - 36 Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
CNS
Signs amp Symptomshellip
Likely to suffer long-term neurological deficits if present on ICU admission with
focal motor deficits
Babinski sign
On mechanical ventilation of 5 days or more
(OR = 1278 398ndash4109 OR = 676 224ndash 2033 OR = 1514 292ndash7852 respectively) Bessereau
Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
Financial Consequences
httpwwwsafeinfusiontherapycomcpsrdex
chghc-safeinfusion-en-inthsxsl7241html
522015
11
LONG TERM CARE PHARMACY SERVICES
Air Embolism Liability
Bhananker
LONG TERM CARE PHARMACY SERVICES
Anesthesiology legal claimsBhananker
Peripheral vascular catheters =2 of claims
Air embolism one of the most common complications ndash 8
Air embolism claims had highest median payment and a rate of 100 payment-per-claim
($325000 2007 with a range of $25800ndash $4120200)
Financial Consequenceshellip
LONG TERM CARE PHARMACY SERVICES
httpwwwmlivecomnewsgrand-
rapidsindexssf201208parents_sue_devos_childrens_hohtml
HOWrsquoS THE AIR GETTING IN
Air Embolism
522015
12
LONG TERM CARE PHARMACY SERVICES
Type of VADs
CVAD PIV
55
LONG TERM CARE PHARMACY SERVICES
feil
LONG TERM CARE PHARMACY SERVICES
VADs accounted for 14 gas embolism (n=29125 at Hyperbaric oxygen center)Besserreau
Removal (n=9)
Accidental removal (n=8)
Manipulation and usual care (n=7)
Insertion (n=5)
Peripheral venous catheterization (n=2)
Causes of Air Embolism
522015
13
LONG TERM CARE PHARMACY SERVICES
ACCIDENTAL DISCONNECTION
Cause of almost half of cerebral air embolism cases in a review of 1426 published case reports (1975-1998)Heckmann
Air embolism due to catheter disconnection has a mortality rate between 29 and 43
LONG TERM CARE PHARMACY SERVICES
Air embolism caused by a laceration to
central venous catheter during shaving Pearson
Causes of Air Embolismhellip
LONG TERM CARE PHARMACY SERVICES
Ward
Causes of Air Embolismhellip
Ward
LONG TERM CARE PHARMACY SERVICES
httpwwwfdagovMedicalDevicesSafetyAlertsandNoticesTubingandLuerM
isconnectionsucm313275htm
Causes of Air Embolismhellip
522015
14
LONG TERM CARE PHARMACY SERVICES
CASE STUDY
An ER patient had an IV heparin lock but no IV fluids had been started The
patient also had a noninvasive automatic BP cuff placed for continuous
monitoring
The BP cuff tubing was disconnected when the patient went to the bathroom
When she returned her spouse mistakenly connected the BP cuff tubing to the
IV catheter and approximately 15 mL of air was delivered to the IV catheter
The patient died from a fatal air embolus despite resuscitation efforts
Causeshellip LONG TERM CARE PHARMACY SERVICES
Causes
Infusion-related Air Embolism
Improper priming of administration set (4 fatal cases in literature)
Air vented bottles
Fluid infusions that are finished
Fluid infusions with rapid infusion through an air-filled drip chamber and the administration set remains open pose threats for air entrySingh Gardner von Jurgenson
(A one-litre sized crystalloid IV infusion bag can contain up to 60 mL of air)Schnoor
Rate
STOP THE FLOW
Air Embolism
LONG TERM CARE PHARMACY SERVICES
Early detection and treatment are critical to prevent or minimize cardiovascular pulmonary and neurologic damageAndrew
Stop air entryWilkins Garg Heckman
Notify MD Call 911 if in alternate care setting stay with patient and provide reassurance von
Jurgenson Natal
Left lateral decubitus and trendelenburg position
Treatment
522015
15
LONG TERM CARE PHARMACY SERVICES
100 O2 artificial ventilation with airbagendotracheal intubation
CPR closed cardiac massage
Fluid resuscitation (to increase intravascular volume venous pressure and venous return)Levy Clark Natal
Inotropic support (eg dobutamine) if cardiovascular collapse to increase CVPMirski Feil
Aspiration of air through distal lumen of CVP line or pulmonary artery catheter if catheter already in placePant Garg Odowd
Treatmenthellip LONG TERM CARE PHARMACY SERVICES
Hyperbaric oxygen therapy which is the main therapy for massive arterial air embolism preferably initiated within 3-5 hours of the event (reduces size of air bubbles accelerates nitrogen resorption and increases oxygen content of arterial blood) AndrewsTorres Heckman Mirski
Diagnostic measures include ABGs CXREKG pulse oximetry ventilation-perfusion scan CT of chest and head echocardiography pulmonary artery catheter Andrews Heckman Natal
Treatmenthellip
NO AIR ALLOWED
Air Embolism
AIR
LONG TERM CARE PHARMACY SERVICES
Insertion of VADS
Hydrate patient prior to insertion to correct hypovolemia whenever possible Feil
Occlude needle hub and catheter during insertion removalMirskiNatal
PREVENTION
Education practice guidelines amp protocols
522015
16
LONG TERM CARE PHARMACY SERVICES
During CVAD insertion stop ventilation during insertion of needle increase right atrial pressure during tunnelling of catheterMirski
During peripheral cannulation and removal place the arm below the level of the heartBBraun
PREVENTION LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Minimize IV manipulationsGroel
Supine or Trendelenburg position during daily management of scalp vein infusionFortrat
Remove air from add-on devices (syringes tubings needleless connectors stopcocks and all other devices added to the catheter)INS Wilkins Ensure stopcocks that are not in use are switched off and covered with a Luer-Lok capneedleless devicevon Jurgenson
Always use luer-lock connections to avoid accidental disconnectionsPant von Jorgenson INS
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADs Air detectorsfilters
Air sensors in infusion pumps Wilklins Pant ECRI Feil Adult infusion systems should be designed to prevent infusion of volumes of air gt50 μL in normal use and to prevent infusion of volumes of air gt1 mL in failure mode The smallest volume of air possible for neonates with a maximum air infusion volumes of 10 μL in failure modeWilkins
Air elimination filter on administration setsWilkins
Gardner Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Priming
Careful filling and handling of administration sets and thorough priming of filters (with filter in proper position) as per manufacturerrsquos guidelinesGardner Wilkins von Jurgenson
Check for air bubbles prior to starting the infusion
Close clamps of the administration set prior to priming then spike the fluid container and gently squeeze the drip chamber until it is half-filledvon Jurgenosn
If a burette is used ensure the tubing btw containerbag and burette is clamped offvon Jurgenson
Remove air from infusion bags when infusing fluids using inflatable pressure infusors Feil
PREVENTIONhellip
522015
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LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
522015
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LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
6
LONG TERM CARE PHARMACY SERVICES
Right Heart Outflow Obstruction
bull cardiac output
bull Cardiovascular collapse MI
LONG TERM CARE PHARMACY SERVICES
Pathophysiologyhellip
Air in R ventricle Turbulence
Inflammatory response
RBC platelets fibrin amp
fat globules
Endothelial damage
Ischemia
Pulmonary edema
httpebookbrowsecom2
001-11-28-code-blue-in-
the-ct-suite-air-embolism-
pdf-d159139478
LONG TERM CARE PHARMACY SERVICES
It dependshellip
Location bull Point of entry bull Embolus lodges
Volume amp Rate
bull High volume bull High rate
Patient Variables
bull Position bull Cardiac amp lung fx bull + pressure gradient
How Much is Too Much LONG TERM CARE PHARMACY SERVICES
Size (amp rate) matters
522015
7
LONG TERM CARE PHARMACY SERVICES
48 PIVs flushed with saline demonstrated small air emboli on CT in right heart pulmonary trunk and L brachiocephalic vein
Source air in syringe or cannulaGroell
Peripheral IV
Portal of
entry
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
Atmospheric
pressure
Intrathoracic
pressure
darr Intrathoracic
pressure
bull Upright position
bull Dyspnea
bull Deep inspiration
bull Hypovolemia
+ Pressure
Gradient
Air entry is more likely if pressure in veins is below atmospheric pressure
Upright position particularly favours the rapid entry of air bubblesOdowd Andrews
LONG TERM CARE PHARMACY SERVICES
The minimum volume of air lethal to humans is not yet knownToung Pant Agarwal
2 fatal cases of 100-200 mL air with 1 author stating lethal volume may be greater if normal cardiac functionToung
Infusion of 50 mL in healthy patients has been reported to cause hypotension dysrhythmias and sometimes deathTorres
Volume
How Much is Too Muchhellip
Rate
LONG TERM CARE PHARMACY SERVICES
Volume How Much is Too Muchhellip
It has been estimated from studies with dogs that as little as 20 mLsec of air will be associated with symptoms of air embolism and 70 to 150 mLsec or 3-5 mlkg of air can be fatalECRI Mirski Natal Wilkins Pant
It has been suggested that the heart may be able to withstand large quantities of air if injected slowly as dogs have been able to withstand up to 1400 mL of air over a several-hour period
MirskI Groell
Exposing an opened IV line for only a second (ie when disconnecting tubing or changing the needleless connector) can let in 100mL of airMasoorli
The closer the entry into the venous system to the right heart is and the faster the air entry the smaller the amount of air is needed to cause a fatal outcomeMirskI Natal von Jurgenson
Rate
522015
8
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
Infusion-related Air Embolism
Little available data in relation to how much air is tolerated through an infusion system The passage of a few air bubbles into the patient is a common occurrence with no substantial evidence of adverse consequences
Pump air detector standard = 05mL71mm
Suggested lethal volume of ~225 mL in healthy adult is equivalent to gt1 m air bubble in standard IV tubingWilkins
Rate
LONG TERM CARE PHARMACY SERVICES
A 2 or 3 mL bolus of air in the cerebral circulation can be fatal
As little as 05 mL of air in a coronary artery can cause ventricular fibrillation NataL von Jurgenson Levy
Tiny but lethal
A small air embolus can be fatal
Volume
LONG TERM CARE PHARMACY SERVICES
Patent Foramen Ovale (PFO)
10-35 of patients have a subclinical PFO
LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism
The lungs are able to filter air to prevent the air from travelling from the venous to arterial circulation up to a threshold of about 035 mLkgmin
after which air cannot be filtered and may enter arterial system with arterial bubbles detected in 50 of patients where air entry exceeds this threshold Wilkins
522015
9
LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism LONG TERM CARE PHARMACY SERVICES
PFO Increasing the risk of air embolism
40 of 26 cases of cerebral air embolism patients had a patent foramen ovale
1531 patients with neurological symptoms following air embolism had right-to-left shunting via intrapulmonary shunt or patent foramen ovaleWilkins Besserau
05 mL has been reported as lethal in the left-side arterial circulationPant
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
ITrsquoS INVISIBLE- HOW DO YOU KNOW
Air Embolism
522015
10
LONG TERM CARE PHARMACY SERVICES
Respiratory
Dyspnea
Tachypnea
Cough
Hypoxia
Wheezing
Signs amp Symptoms
Cardiac
Chest pain
Hypotension
Cyanosis
Tachycardia
Tachyarrhythmia bradyarrhthymia
PAH
Ward Armstrong Haavik Natal Ruskin Pant Andrews Odowd
Subclinical to mild to catastrophic SS
LONG TERM CARE PHARMACY SERVICES
Respiratory
Cardiac
Signs amp Symptomshellip
CNS (cerebral arterial embolism) Heckmann
Sense of impending doom
Focal Lesions
Hemiparesis
Loss of vision
Mortality rate 8
Encephalopathic
Acute confusional state
Decreased consciousness
Coma
Seizures
Akinetic mutism
High mortality rate - 36 Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
CNS
Signs amp Symptomshellip
Likely to suffer long-term neurological deficits if present on ICU admission with
focal motor deficits
Babinski sign
On mechanical ventilation of 5 days or more
(OR = 1278 398ndash4109 OR = 676 224ndash 2033 OR = 1514 292ndash7852 respectively) Bessereau
Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
Financial Consequences
httpwwwsafeinfusiontherapycomcpsrdex
chghc-safeinfusion-en-inthsxsl7241html
522015
11
LONG TERM CARE PHARMACY SERVICES
Air Embolism Liability
Bhananker
LONG TERM CARE PHARMACY SERVICES
Anesthesiology legal claimsBhananker
Peripheral vascular catheters =2 of claims
Air embolism one of the most common complications ndash 8
Air embolism claims had highest median payment and a rate of 100 payment-per-claim
($325000 2007 with a range of $25800ndash $4120200)
Financial Consequenceshellip
LONG TERM CARE PHARMACY SERVICES
httpwwwmlivecomnewsgrand-
rapidsindexssf201208parents_sue_devos_childrens_hohtml
HOWrsquoS THE AIR GETTING IN
Air Embolism
522015
12
LONG TERM CARE PHARMACY SERVICES
Type of VADs
CVAD PIV
55
LONG TERM CARE PHARMACY SERVICES
feil
LONG TERM CARE PHARMACY SERVICES
VADs accounted for 14 gas embolism (n=29125 at Hyperbaric oxygen center)Besserreau
Removal (n=9)
Accidental removal (n=8)
Manipulation and usual care (n=7)
Insertion (n=5)
Peripheral venous catheterization (n=2)
Causes of Air Embolism
522015
13
LONG TERM CARE PHARMACY SERVICES
ACCIDENTAL DISCONNECTION
Cause of almost half of cerebral air embolism cases in a review of 1426 published case reports (1975-1998)Heckmann
Air embolism due to catheter disconnection has a mortality rate between 29 and 43
LONG TERM CARE PHARMACY SERVICES
Air embolism caused by a laceration to
central venous catheter during shaving Pearson
Causes of Air Embolismhellip
LONG TERM CARE PHARMACY SERVICES
Ward
Causes of Air Embolismhellip
Ward
LONG TERM CARE PHARMACY SERVICES
httpwwwfdagovMedicalDevicesSafetyAlertsandNoticesTubingandLuerM
isconnectionsucm313275htm
Causes of Air Embolismhellip
522015
14
LONG TERM CARE PHARMACY SERVICES
CASE STUDY
An ER patient had an IV heparin lock but no IV fluids had been started The
patient also had a noninvasive automatic BP cuff placed for continuous
monitoring
The BP cuff tubing was disconnected when the patient went to the bathroom
When she returned her spouse mistakenly connected the BP cuff tubing to the
IV catheter and approximately 15 mL of air was delivered to the IV catheter
The patient died from a fatal air embolus despite resuscitation efforts
Causeshellip LONG TERM CARE PHARMACY SERVICES
Causes
Infusion-related Air Embolism
Improper priming of administration set (4 fatal cases in literature)
Air vented bottles
Fluid infusions that are finished
Fluid infusions with rapid infusion through an air-filled drip chamber and the administration set remains open pose threats for air entrySingh Gardner von Jurgenson
(A one-litre sized crystalloid IV infusion bag can contain up to 60 mL of air)Schnoor
Rate
STOP THE FLOW
Air Embolism
LONG TERM CARE PHARMACY SERVICES
Early detection and treatment are critical to prevent or minimize cardiovascular pulmonary and neurologic damageAndrew
Stop air entryWilkins Garg Heckman
Notify MD Call 911 if in alternate care setting stay with patient and provide reassurance von
Jurgenson Natal
Left lateral decubitus and trendelenburg position
Treatment
522015
15
LONG TERM CARE PHARMACY SERVICES
100 O2 artificial ventilation with airbagendotracheal intubation
CPR closed cardiac massage
Fluid resuscitation (to increase intravascular volume venous pressure and venous return)Levy Clark Natal
Inotropic support (eg dobutamine) if cardiovascular collapse to increase CVPMirski Feil
Aspiration of air through distal lumen of CVP line or pulmonary artery catheter if catheter already in placePant Garg Odowd
Treatmenthellip LONG TERM CARE PHARMACY SERVICES
Hyperbaric oxygen therapy which is the main therapy for massive arterial air embolism preferably initiated within 3-5 hours of the event (reduces size of air bubbles accelerates nitrogen resorption and increases oxygen content of arterial blood) AndrewsTorres Heckman Mirski
Diagnostic measures include ABGs CXREKG pulse oximetry ventilation-perfusion scan CT of chest and head echocardiography pulmonary artery catheter Andrews Heckman Natal
Treatmenthellip
NO AIR ALLOWED
Air Embolism
AIR
LONG TERM CARE PHARMACY SERVICES
Insertion of VADS
Hydrate patient prior to insertion to correct hypovolemia whenever possible Feil
Occlude needle hub and catheter during insertion removalMirskiNatal
PREVENTION
Education practice guidelines amp protocols
522015
16
LONG TERM CARE PHARMACY SERVICES
During CVAD insertion stop ventilation during insertion of needle increase right atrial pressure during tunnelling of catheterMirski
During peripheral cannulation and removal place the arm below the level of the heartBBraun
PREVENTION LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Minimize IV manipulationsGroel
Supine or Trendelenburg position during daily management of scalp vein infusionFortrat
Remove air from add-on devices (syringes tubings needleless connectors stopcocks and all other devices added to the catheter)INS Wilkins Ensure stopcocks that are not in use are switched off and covered with a Luer-Lok capneedleless devicevon Jurgenson
Always use luer-lock connections to avoid accidental disconnectionsPant von Jorgenson INS
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADs Air detectorsfilters
Air sensors in infusion pumps Wilklins Pant ECRI Feil Adult infusion systems should be designed to prevent infusion of volumes of air gt50 μL in normal use and to prevent infusion of volumes of air gt1 mL in failure mode The smallest volume of air possible for neonates with a maximum air infusion volumes of 10 μL in failure modeWilkins
Air elimination filter on administration setsWilkins
Gardner Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Priming
Careful filling and handling of administration sets and thorough priming of filters (with filter in proper position) as per manufacturerrsquos guidelinesGardner Wilkins von Jurgenson
Check for air bubbles prior to starting the infusion
Close clamps of the administration set prior to priming then spike the fluid container and gently squeeze the drip chamber until it is half-filledvon Jurgenosn
If a burette is used ensure the tubing btw containerbag and burette is clamped offvon Jurgenson
Remove air from infusion bags when infusing fluids using inflatable pressure infusors Feil
PREVENTIONhellip
522015
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LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
522015
18
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
7
LONG TERM CARE PHARMACY SERVICES
48 PIVs flushed with saline demonstrated small air emboli on CT in right heart pulmonary trunk and L brachiocephalic vein
Source air in syringe or cannulaGroell
Peripheral IV
Portal of
entry
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
Atmospheric
pressure
Intrathoracic
pressure
darr Intrathoracic
pressure
bull Upright position
bull Dyspnea
bull Deep inspiration
bull Hypovolemia
+ Pressure
Gradient
Air entry is more likely if pressure in veins is below atmospheric pressure
Upright position particularly favours the rapid entry of air bubblesOdowd Andrews
LONG TERM CARE PHARMACY SERVICES
The minimum volume of air lethal to humans is not yet knownToung Pant Agarwal
2 fatal cases of 100-200 mL air with 1 author stating lethal volume may be greater if normal cardiac functionToung
Infusion of 50 mL in healthy patients has been reported to cause hypotension dysrhythmias and sometimes deathTorres
Volume
How Much is Too Muchhellip
Rate
LONG TERM CARE PHARMACY SERVICES
Volume How Much is Too Muchhellip
It has been estimated from studies with dogs that as little as 20 mLsec of air will be associated with symptoms of air embolism and 70 to 150 mLsec or 3-5 mlkg of air can be fatalECRI Mirski Natal Wilkins Pant
It has been suggested that the heart may be able to withstand large quantities of air if injected slowly as dogs have been able to withstand up to 1400 mL of air over a several-hour period
MirskI Groell
Exposing an opened IV line for only a second (ie when disconnecting tubing or changing the needleless connector) can let in 100mL of airMasoorli
The closer the entry into the venous system to the right heart is and the faster the air entry the smaller the amount of air is needed to cause a fatal outcomeMirskI Natal von Jurgenson
Rate
522015
8
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
Infusion-related Air Embolism
Little available data in relation to how much air is tolerated through an infusion system The passage of a few air bubbles into the patient is a common occurrence with no substantial evidence of adverse consequences
Pump air detector standard = 05mL71mm
Suggested lethal volume of ~225 mL in healthy adult is equivalent to gt1 m air bubble in standard IV tubingWilkins
Rate
LONG TERM CARE PHARMACY SERVICES
A 2 or 3 mL bolus of air in the cerebral circulation can be fatal
As little as 05 mL of air in a coronary artery can cause ventricular fibrillation NataL von Jurgenson Levy
Tiny but lethal
A small air embolus can be fatal
Volume
LONG TERM CARE PHARMACY SERVICES
Patent Foramen Ovale (PFO)
10-35 of patients have a subclinical PFO
LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism
The lungs are able to filter air to prevent the air from travelling from the venous to arterial circulation up to a threshold of about 035 mLkgmin
after which air cannot be filtered and may enter arterial system with arterial bubbles detected in 50 of patients where air entry exceeds this threshold Wilkins
522015
9
LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism LONG TERM CARE PHARMACY SERVICES
PFO Increasing the risk of air embolism
40 of 26 cases of cerebral air embolism patients had a patent foramen ovale
1531 patients with neurological symptoms following air embolism had right-to-left shunting via intrapulmonary shunt or patent foramen ovaleWilkins Besserau
05 mL has been reported as lethal in the left-side arterial circulationPant
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
ITrsquoS INVISIBLE- HOW DO YOU KNOW
Air Embolism
522015
10
LONG TERM CARE PHARMACY SERVICES
Respiratory
Dyspnea
Tachypnea
Cough
Hypoxia
Wheezing
Signs amp Symptoms
Cardiac
Chest pain
Hypotension
Cyanosis
Tachycardia
Tachyarrhythmia bradyarrhthymia
PAH
Ward Armstrong Haavik Natal Ruskin Pant Andrews Odowd
Subclinical to mild to catastrophic SS
LONG TERM CARE PHARMACY SERVICES
Respiratory
Cardiac
Signs amp Symptomshellip
CNS (cerebral arterial embolism) Heckmann
Sense of impending doom
Focal Lesions
Hemiparesis
Loss of vision
Mortality rate 8
Encephalopathic
Acute confusional state
Decreased consciousness
Coma
Seizures
Akinetic mutism
High mortality rate - 36 Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
CNS
Signs amp Symptomshellip
Likely to suffer long-term neurological deficits if present on ICU admission with
focal motor deficits
Babinski sign
On mechanical ventilation of 5 days or more
(OR = 1278 398ndash4109 OR = 676 224ndash 2033 OR = 1514 292ndash7852 respectively) Bessereau
Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
Financial Consequences
httpwwwsafeinfusiontherapycomcpsrdex
chghc-safeinfusion-en-inthsxsl7241html
522015
11
LONG TERM CARE PHARMACY SERVICES
Air Embolism Liability
Bhananker
LONG TERM CARE PHARMACY SERVICES
Anesthesiology legal claimsBhananker
Peripheral vascular catheters =2 of claims
Air embolism one of the most common complications ndash 8
Air embolism claims had highest median payment and a rate of 100 payment-per-claim
($325000 2007 with a range of $25800ndash $4120200)
Financial Consequenceshellip
LONG TERM CARE PHARMACY SERVICES
httpwwwmlivecomnewsgrand-
rapidsindexssf201208parents_sue_devos_childrens_hohtml
HOWrsquoS THE AIR GETTING IN
Air Embolism
522015
12
LONG TERM CARE PHARMACY SERVICES
Type of VADs
CVAD PIV
55
LONG TERM CARE PHARMACY SERVICES
feil
LONG TERM CARE PHARMACY SERVICES
VADs accounted for 14 gas embolism (n=29125 at Hyperbaric oxygen center)Besserreau
Removal (n=9)
Accidental removal (n=8)
Manipulation and usual care (n=7)
Insertion (n=5)
Peripheral venous catheterization (n=2)
Causes of Air Embolism
522015
13
LONG TERM CARE PHARMACY SERVICES
ACCIDENTAL DISCONNECTION
Cause of almost half of cerebral air embolism cases in a review of 1426 published case reports (1975-1998)Heckmann
Air embolism due to catheter disconnection has a mortality rate between 29 and 43
LONG TERM CARE PHARMACY SERVICES
Air embolism caused by a laceration to
central venous catheter during shaving Pearson
Causes of Air Embolismhellip
LONG TERM CARE PHARMACY SERVICES
Ward
Causes of Air Embolismhellip
Ward
LONG TERM CARE PHARMACY SERVICES
httpwwwfdagovMedicalDevicesSafetyAlertsandNoticesTubingandLuerM
isconnectionsucm313275htm
Causes of Air Embolismhellip
522015
14
LONG TERM CARE PHARMACY SERVICES
CASE STUDY
An ER patient had an IV heparin lock but no IV fluids had been started The
patient also had a noninvasive automatic BP cuff placed for continuous
monitoring
The BP cuff tubing was disconnected when the patient went to the bathroom
When she returned her spouse mistakenly connected the BP cuff tubing to the
IV catheter and approximately 15 mL of air was delivered to the IV catheter
The patient died from a fatal air embolus despite resuscitation efforts
Causeshellip LONG TERM CARE PHARMACY SERVICES
Causes
Infusion-related Air Embolism
Improper priming of administration set (4 fatal cases in literature)
Air vented bottles
Fluid infusions that are finished
Fluid infusions with rapid infusion through an air-filled drip chamber and the administration set remains open pose threats for air entrySingh Gardner von Jurgenson
(A one-litre sized crystalloid IV infusion bag can contain up to 60 mL of air)Schnoor
Rate
STOP THE FLOW
Air Embolism
LONG TERM CARE PHARMACY SERVICES
Early detection and treatment are critical to prevent or minimize cardiovascular pulmonary and neurologic damageAndrew
Stop air entryWilkins Garg Heckman
Notify MD Call 911 if in alternate care setting stay with patient and provide reassurance von
Jurgenson Natal
Left lateral decubitus and trendelenburg position
Treatment
522015
15
LONG TERM CARE PHARMACY SERVICES
100 O2 artificial ventilation with airbagendotracheal intubation
CPR closed cardiac massage
Fluid resuscitation (to increase intravascular volume venous pressure and venous return)Levy Clark Natal
Inotropic support (eg dobutamine) if cardiovascular collapse to increase CVPMirski Feil
Aspiration of air through distal lumen of CVP line or pulmonary artery catheter if catheter already in placePant Garg Odowd
Treatmenthellip LONG TERM CARE PHARMACY SERVICES
Hyperbaric oxygen therapy which is the main therapy for massive arterial air embolism preferably initiated within 3-5 hours of the event (reduces size of air bubbles accelerates nitrogen resorption and increases oxygen content of arterial blood) AndrewsTorres Heckman Mirski
Diagnostic measures include ABGs CXREKG pulse oximetry ventilation-perfusion scan CT of chest and head echocardiography pulmonary artery catheter Andrews Heckman Natal
Treatmenthellip
NO AIR ALLOWED
Air Embolism
AIR
LONG TERM CARE PHARMACY SERVICES
Insertion of VADS
Hydrate patient prior to insertion to correct hypovolemia whenever possible Feil
Occlude needle hub and catheter during insertion removalMirskiNatal
PREVENTION
Education practice guidelines amp protocols
522015
16
LONG TERM CARE PHARMACY SERVICES
During CVAD insertion stop ventilation during insertion of needle increase right atrial pressure during tunnelling of catheterMirski
During peripheral cannulation and removal place the arm below the level of the heartBBraun
PREVENTION LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Minimize IV manipulationsGroel
Supine or Trendelenburg position during daily management of scalp vein infusionFortrat
Remove air from add-on devices (syringes tubings needleless connectors stopcocks and all other devices added to the catheter)INS Wilkins Ensure stopcocks that are not in use are switched off and covered with a Luer-Lok capneedleless devicevon Jurgenson
Always use luer-lock connections to avoid accidental disconnectionsPant von Jorgenson INS
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADs Air detectorsfilters
Air sensors in infusion pumps Wilklins Pant ECRI Feil Adult infusion systems should be designed to prevent infusion of volumes of air gt50 μL in normal use and to prevent infusion of volumes of air gt1 mL in failure mode The smallest volume of air possible for neonates with a maximum air infusion volumes of 10 μL in failure modeWilkins
Air elimination filter on administration setsWilkins
Gardner Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Priming
Careful filling and handling of administration sets and thorough priming of filters (with filter in proper position) as per manufacturerrsquos guidelinesGardner Wilkins von Jurgenson
Check for air bubbles prior to starting the infusion
Close clamps of the administration set prior to priming then spike the fluid container and gently squeeze the drip chamber until it is half-filledvon Jurgenosn
If a burette is used ensure the tubing btw containerbag and burette is clamped offvon Jurgenson
Remove air from infusion bags when infusing fluids using inflatable pressure infusors Feil
PREVENTIONhellip
522015
17
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
522015
18
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
8
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
Infusion-related Air Embolism
Little available data in relation to how much air is tolerated through an infusion system The passage of a few air bubbles into the patient is a common occurrence with no substantial evidence of adverse consequences
Pump air detector standard = 05mL71mm
Suggested lethal volume of ~225 mL in healthy adult is equivalent to gt1 m air bubble in standard IV tubingWilkins
Rate
LONG TERM CARE PHARMACY SERVICES
A 2 or 3 mL bolus of air in the cerebral circulation can be fatal
As little as 05 mL of air in a coronary artery can cause ventricular fibrillation NataL von Jurgenson Levy
Tiny but lethal
A small air embolus can be fatal
Volume
LONG TERM CARE PHARMACY SERVICES
Patent Foramen Ovale (PFO)
10-35 of patients have a subclinical PFO
LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism
The lungs are able to filter air to prevent the air from travelling from the venous to arterial circulation up to a threshold of about 035 mLkgmin
after which air cannot be filtered and may enter arterial system with arterial bubbles detected in 50 of patients where air entry exceeds this threshold Wilkins
522015
9
LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism LONG TERM CARE PHARMACY SERVICES
PFO Increasing the risk of air embolism
40 of 26 cases of cerebral air embolism patients had a patent foramen ovale
1531 patients with neurological symptoms following air embolism had right-to-left shunting via intrapulmonary shunt or patent foramen ovaleWilkins Besserau
05 mL has been reported as lethal in the left-side arterial circulationPant
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
ITrsquoS INVISIBLE- HOW DO YOU KNOW
Air Embolism
522015
10
LONG TERM CARE PHARMACY SERVICES
Respiratory
Dyspnea
Tachypnea
Cough
Hypoxia
Wheezing
Signs amp Symptoms
Cardiac
Chest pain
Hypotension
Cyanosis
Tachycardia
Tachyarrhythmia bradyarrhthymia
PAH
Ward Armstrong Haavik Natal Ruskin Pant Andrews Odowd
Subclinical to mild to catastrophic SS
LONG TERM CARE PHARMACY SERVICES
Respiratory
Cardiac
Signs amp Symptomshellip
CNS (cerebral arterial embolism) Heckmann
Sense of impending doom
Focal Lesions
Hemiparesis
Loss of vision
Mortality rate 8
Encephalopathic
Acute confusional state
Decreased consciousness
Coma
Seizures
Akinetic mutism
High mortality rate - 36 Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
CNS
Signs amp Symptomshellip
Likely to suffer long-term neurological deficits if present on ICU admission with
focal motor deficits
Babinski sign
On mechanical ventilation of 5 days or more
(OR = 1278 398ndash4109 OR = 676 224ndash 2033 OR = 1514 292ndash7852 respectively) Bessereau
Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
Financial Consequences
httpwwwsafeinfusiontherapycomcpsrdex
chghc-safeinfusion-en-inthsxsl7241html
522015
11
LONG TERM CARE PHARMACY SERVICES
Air Embolism Liability
Bhananker
LONG TERM CARE PHARMACY SERVICES
Anesthesiology legal claimsBhananker
Peripheral vascular catheters =2 of claims
Air embolism one of the most common complications ndash 8
Air embolism claims had highest median payment and a rate of 100 payment-per-claim
($325000 2007 with a range of $25800ndash $4120200)
Financial Consequenceshellip
LONG TERM CARE PHARMACY SERVICES
httpwwwmlivecomnewsgrand-
rapidsindexssf201208parents_sue_devos_childrens_hohtml
HOWrsquoS THE AIR GETTING IN
Air Embolism
522015
12
LONG TERM CARE PHARMACY SERVICES
Type of VADs
CVAD PIV
55
LONG TERM CARE PHARMACY SERVICES
feil
LONG TERM CARE PHARMACY SERVICES
VADs accounted for 14 gas embolism (n=29125 at Hyperbaric oxygen center)Besserreau
Removal (n=9)
Accidental removal (n=8)
Manipulation and usual care (n=7)
Insertion (n=5)
Peripheral venous catheterization (n=2)
Causes of Air Embolism
522015
13
LONG TERM CARE PHARMACY SERVICES
ACCIDENTAL DISCONNECTION
Cause of almost half of cerebral air embolism cases in a review of 1426 published case reports (1975-1998)Heckmann
Air embolism due to catheter disconnection has a mortality rate between 29 and 43
LONG TERM CARE PHARMACY SERVICES
Air embolism caused by a laceration to
central venous catheter during shaving Pearson
Causes of Air Embolismhellip
LONG TERM CARE PHARMACY SERVICES
Ward
Causes of Air Embolismhellip
Ward
LONG TERM CARE PHARMACY SERVICES
httpwwwfdagovMedicalDevicesSafetyAlertsandNoticesTubingandLuerM
isconnectionsucm313275htm
Causes of Air Embolismhellip
522015
14
LONG TERM CARE PHARMACY SERVICES
CASE STUDY
An ER patient had an IV heparin lock but no IV fluids had been started The
patient also had a noninvasive automatic BP cuff placed for continuous
monitoring
The BP cuff tubing was disconnected when the patient went to the bathroom
When she returned her spouse mistakenly connected the BP cuff tubing to the
IV catheter and approximately 15 mL of air was delivered to the IV catheter
The patient died from a fatal air embolus despite resuscitation efforts
Causeshellip LONG TERM CARE PHARMACY SERVICES
Causes
Infusion-related Air Embolism
Improper priming of administration set (4 fatal cases in literature)
Air vented bottles
Fluid infusions that are finished
Fluid infusions with rapid infusion through an air-filled drip chamber and the administration set remains open pose threats for air entrySingh Gardner von Jurgenson
(A one-litre sized crystalloid IV infusion bag can contain up to 60 mL of air)Schnoor
Rate
STOP THE FLOW
Air Embolism
LONG TERM CARE PHARMACY SERVICES
Early detection and treatment are critical to prevent or minimize cardiovascular pulmonary and neurologic damageAndrew
Stop air entryWilkins Garg Heckman
Notify MD Call 911 if in alternate care setting stay with patient and provide reassurance von
Jurgenson Natal
Left lateral decubitus and trendelenburg position
Treatment
522015
15
LONG TERM CARE PHARMACY SERVICES
100 O2 artificial ventilation with airbagendotracheal intubation
CPR closed cardiac massage
Fluid resuscitation (to increase intravascular volume venous pressure and venous return)Levy Clark Natal
Inotropic support (eg dobutamine) if cardiovascular collapse to increase CVPMirski Feil
Aspiration of air through distal lumen of CVP line or pulmonary artery catheter if catheter already in placePant Garg Odowd
Treatmenthellip LONG TERM CARE PHARMACY SERVICES
Hyperbaric oxygen therapy which is the main therapy for massive arterial air embolism preferably initiated within 3-5 hours of the event (reduces size of air bubbles accelerates nitrogen resorption and increases oxygen content of arterial blood) AndrewsTorres Heckman Mirski
Diagnostic measures include ABGs CXREKG pulse oximetry ventilation-perfusion scan CT of chest and head echocardiography pulmonary artery catheter Andrews Heckman Natal
Treatmenthellip
NO AIR ALLOWED
Air Embolism
AIR
LONG TERM CARE PHARMACY SERVICES
Insertion of VADS
Hydrate patient prior to insertion to correct hypovolemia whenever possible Feil
Occlude needle hub and catheter during insertion removalMirskiNatal
PREVENTION
Education practice guidelines amp protocols
522015
16
LONG TERM CARE PHARMACY SERVICES
During CVAD insertion stop ventilation during insertion of needle increase right atrial pressure during tunnelling of catheterMirski
During peripheral cannulation and removal place the arm below the level of the heartBBraun
PREVENTION LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Minimize IV manipulationsGroel
Supine or Trendelenburg position during daily management of scalp vein infusionFortrat
Remove air from add-on devices (syringes tubings needleless connectors stopcocks and all other devices added to the catheter)INS Wilkins Ensure stopcocks that are not in use are switched off and covered with a Luer-Lok capneedleless devicevon Jurgenson
Always use luer-lock connections to avoid accidental disconnectionsPant von Jorgenson INS
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADs Air detectorsfilters
Air sensors in infusion pumps Wilklins Pant ECRI Feil Adult infusion systems should be designed to prevent infusion of volumes of air gt50 μL in normal use and to prevent infusion of volumes of air gt1 mL in failure mode The smallest volume of air possible for neonates with a maximum air infusion volumes of 10 μL in failure modeWilkins
Air elimination filter on administration setsWilkins
Gardner Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Priming
Careful filling and handling of administration sets and thorough priming of filters (with filter in proper position) as per manufacturerrsquos guidelinesGardner Wilkins von Jurgenson
Check for air bubbles prior to starting the infusion
Close clamps of the administration set prior to priming then spike the fluid container and gently squeeze the drip chamber until it is half-filledvon Jurgenosn
If a burette is used ensure the tubing btw containerbag and burette is clamped offvon Jurgenson
Remove air from infusion bags when infusing fluids using inflatable pressure infusors Feil
PREVENTIONhellip
522015
17
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
522015
18
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
9
LONG TERM CARE PHARMACY SERVICES
Arterial Air Embolism LONG TERM CARE PHARMACY SERVICES
PFO Increasing the risk of air embolism
40 of 26 cases of cerebral air embolism patients had a patent foramen ovale
1531 patients with neurological symptoms following air embolism had right-to-left shunting via intrapulmonary shunt or patent foramen ovaleWilkins Besserau
05 mL has been reported as lethal in the left-side arterial circulationPant
LONG TERM CARE PHARMACY SERVICES
How Much is Too Muchhellip
ITrsquoS INVISIBLE- HOW DO YOU KNOW
Air Embolism
522015
10
LONG TERM CARE PHARMACY SERVICES
Respiratory
Dyspnea
Tachypnea
Cough
Hypoxia
Wheezing
Signs amp Symptoms
Cardiac
Chest pain
Hypotension
Cyanosis
Tachycardia
Tachyarrhythmia bradyarrhthymia
PAH
Ward Armstrong Haavik Natal Ruskin Pant Andrews Odowd
Subclinical to mild to catastrophic SS
LONG TERM CARE PHARMACY SERVICES
Respiratory
Cardiac
Signs amp Symptomshellip
CNS (cerebral arterial embolism) Heckmann
Sense of impending doom
Focal Lesions
Hemiparesis
Loss of vision
Mortality rate 8
Encephalopathic
Acute confusional state
Decreased consciousness
Coma
Seizures
Akinetic mutism
High mortality rate - 36 Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
CNS
Signs amp Symptomshellip
Likely to suffer long-term neurological deficits if present on ICU admission with
focal motor deficits
Babinski sign
On mechanical ventilation of 5 days or more
(OR = 1278 398ndash4109 OR = 676 224ndash 2033 OR = 1514 292ndash7852 respectively) Bessereau
Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
Financial Consequences
httpwwwsafeinfusiontherapycomcpsrdex
chghc-safeinfusion-en-inthsxsl7241html
522015
11
LONG TERM CARE PHARMACY SERVICES
Air Embolism Liability
Bhananker
LONG TERM CARE PHARMACY SERVICES
Anesthesiology legal claimsBhananker
Peripheral vascular catheters =2 of claims
Air embolism one of the most common complications ndash 8
Air embolism claims had highest median payment and a rate of 100 payment-per-claim
($325000 2007 with a range of $25800ndash $4120200)
Financial Consequenceshellip
LONG TERM CARE PHARMACY SERVICES
httpwwwmlivecomnewsgrand-
rapidsindexssf201208parents_sue_devos_childrens_hohtml
HOWrsquoS THE AIR GETTING IN
Air Embolism
522015
12
LONG TERM CARE PHARMACY SERVICES
Type of VADs
CVAD PIV
55
LONG TERM CARE PHARMACY SERVICES
feil
LONG TERM CARE PHARMACY SERVICES
VADs accounted for 14 gas embolism (n=29125 at Hyperbaric oxygen center)Besserreau
Removal (n=9)
Accidental removal (n=8)
Manipulation and usual care (n=7)
Insertion (n=5)
Peripheral venous catheterization (n=2)
Causes of Air Embolism
522015
13
LONG TERM CARE PHARMACY SERVICES
ACCIDENTAL DISCONNECTION
Cause of almost half of cerebral air embolism cases in a review of 1426 published case reports (1975-1998)Heckmann
Air embolism due to catheter disconnection has a mortality rate between 29 and 43
LONG TERM CARE PHARMACY SERVICES
Air embolism caused by a laceration to
central venous catheter during shaving Pearson
Causes of Air Embolismhellip
LONG TERM CARE PHARMACY SERVICES
Ward
Causes of Air Embolismhellip
Ward
LONG TERM CARE PHARMACY SERVICES
httpwwwfdagovMedicalDevicesSafetyAlertsandNoticesTubingandLuerM
isconnectionsucm313275htm
Causes of Air Embolismhellip
522015
14
LONG TERM CARE PHARMACY SERVICES
CASE STUDY
An ER patient had an IV heparin lock but no IV fluids had been started The
patient also had a noninvasive automatic BP cuff placed for continuous
monitoring
The BP cuff tubing was disconnected when the patient went to the bathroom
When she returned her spouse mistakenly connected the BP cuff tubing to the
IV catheter and approximately 15 mL of air was delivered to the IV catheter
The patient died from a fatal air embolus despite resuscitation efforts
Causeshellip LONG TERM CARE PHARMACY SERVICES
Causes
Infusion-related Air Embolism
Improper priming of administration set (4 fatal cases in literature)
Air vented bottles
Fluid infusions that are finished
Fluid infusions with rapid infusion through an air-filled drip chamber and the administration set remains open pose threats for air entrySingh Gardner von Jurgenson
(A one-litre sized crystalloid IV infusion bag can contain up to 60 mL of air)Schnoor
Rate
STOP THE FLOW
Air Embolism
LONG TERM CARE PHARMACY SERVICES
Early detection and treatment are critical to prevent or minimize cardiovascular pulmonary and neurologic damageAndrew
Stop air entryWilkins Garg Heckman
Notify MD Call 911 if in alternate care setting stay with patient and provide reassurance von
Jurgenson Natal
Left lateral decubitus and trendelenburg position
Treatment
522015
15
LONG TERM CARE PHARMACY SERVICES
100 O2 artificial ventilation with airbagendotracheal intubation
CPR closed cardiac massage
Fluid resuscitation (to increase intravascular volume venous pressure and venous return)Levy Clark Natal
Inotropic support (eg dobutamine) if cardiovascular collapse to increase CVPMirski Feil
Aspiration of air through distal lumen of CVP line or pulmonary artery catheter if catheter already in placePant Garg Odowd
Treatmenthellip LONG TERM CARE PHARMACY SERVICES
Hyperbaric oxygen therapy which is the main therapy for massive arterial air embolism preferably initiated within 3-5 hours of the event (reduces size of air bubbles accelerates nitrogen resorption and increases oxygen content of arterial blood) AndrewsTorres Heckman Mirski
Diagnostic measures include ABGs CXREKG pulse oximetry ventilation-perfusion scan CT of chest and head echocardiography pulmonary artery catheter Andrews Heckman Natal
Treatmenthellip
NO AIR ALLOWED
Air Embolism
AIR
LONG TERM CARE PHARMACY SERVICES
Insertion of VADS
Hydrate patient prior to insertion to correct hypovolemia whenever possible Feil
Occlude needle hub and catheter during insertion removalMirskiNatal
PREVENTION
Education practice guidelines amp protocols
522015
16
LONG TERM CARE PHARMACY SERVICES
During CVAD insertion stop ventilation during insertion of needle increase right atrial pressure during tunnelling of catheterMirski
During peripheral cannulation and removal place the arm below the level of the heartBBraun
PREVENTION LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Minimize IV manipulationsGroel
Supine or Trendelenburg position during daily management of scalp vein infusionFortrat
Remove air from add-on devices (syringes tubings needleless connectors stopcocks and all other devices added to the catheter)INS Wilkins Ensure stopcocks that are not in use are switched off and covered with a Luer-Lok capneedleless devicevon Jurgenson
Always use luer-lock connections to avoid accidental disconnectionsPant von Jorgenson INS
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADs Air detectorsfilters
Air sensors in infusion pumps Wilklins Pant ECRI Feil Adult infusion systems should be designed to prevent infusion of volumes of air gt50 μL in normal use and to prevent infusion of volumes of air gt1 mL in failure mode The smallest volume of air possible for neonates with a maximum air infusion volumes of 10 μL in failure modeWilkins
Air elimination filter on administration setsWilkins
Gardner Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Priming
Careful filling and handling of administration sets and thorough priming of filters (with filter in proper position) as per manufacturerrsquos guidelinesGardner Wilkins von Jurgenson
Check for air bubbles prior to starting the infusion
Close clamps of the administration set prior to priming then spike the fluid container and gently squeeze the drip chamber until it is half-filledvon Jurgenosn
If a burette is used ensure the tubing btw containerbag and burette is clamped offvon Jurgenson
Remove air from infusion bags when infusing fluids using inflatable pressure infusors Feil
PREVENTIONhellip
522015
17
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
522015
18
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
10
LONG TERM CARE PHARMACY SERVICES
Respiratory
Dyspnea
Tachypnea
Cough
Hypoxia
Wheezing
Signs amp Symptoms
Cardiac
Chest pain
Hypotension
Cyanosis
Tachycardia
Tachyarrhythmia bradyarrhthymia
PAH
Ward Armstrong Haavik Natal Ruskin Pant Andrews Odowd
Subclinical to mild to catastrophic SS
LONG TERM CARE PHARMACY SERVICES
Respiratory
Cardiac
Signs amp Symptomshellip
CNS (cerebral arterial embolism) Heckmann
Sense of impending doom
Focal Lesions
Hemiparesis
Loss of vision
Mortality rate 8
Encephalopathic
Acute confusional state
Decreased consciousness
Coma
Seizures
Akinetic mutism
High mortality rate - 36 Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
CNS
Signs amp Symptomshellip
Likely to suffer long-term neurological deficits if present on ICU admission with
focal motor deficits
Babinski sign
On mechanical ventilation of 5 days or more
(OR = 1278 398ndash4109 OR = 676 224ndash 2033 OR = 1514 292ndash7852 respectively) Bessereau
Ward Haavik Heckmann Odowd Natal Odowd Feil
LONG TERM CARE PHARMACY SERVICES
Financial Consequences
httpwwwsafeinfusiontherapycomcpsrdex
chghc-safeinfusion-en-inthsxsl7241html
522015
11
LONG TERM CARE PHARMACY SERVICES
Air Embolism Liability
Bhananker
LONG TERM CARE PHARMACY SERVICES
Anesthesiology legal claimsBhananker
Peripheral vascular catheters =2 of claims
Air embolism one of the most common complications ndash 8
Air embolism claims had highest median payment and a rate of 100 payment-per-claim
($325000 2007 with a range of $25800ndash $4120200)
Financial Consequenceshellip
LONG TERM CARE PHARMACY SERVICES
httpwwwmlivecomnewsgrand-
rapidsindexssf201208parents_sue_devos_childrens_hohtml
HOWrsquoS THE AIR GETTING IN
Air Embolism
522015
12
LONG TERM CARE PHARMACY SERVICES
Type of VADs
CVAD PIV
55
LONG TERM CARE PHARMACY SERVICES
feil
LONG TERM CARE PHARMACY SERVICES
VADs accounted for 14 gas embolism (n=29125 at Hyperbaric oxygen center)Besserreau
Removal (n=9)
Accidental removal (n=8)
Manipulation and usual care (n=7)
Insertion (n=5)
Peripheral venous catheterization (n=2)
Causes of Air Embolism
522015
13
LONG TERM CARE PHARMACY SERVICES
ACCIDENTAL DISCONNECTION
Cause of almost half of cerebral air embolism cases in a review of 1426 published case reports (1975-1998)Heckmann
Air embolism due to catheter disconnection has a mortality rate between 29 and 43
LONG TERM CARE PHARMACY SERVICES
Air embolism caused by a laceration to
central venous catheter during shaving Pearson
Causes of Air Embolismhellip
LONG TERM CARE PHARMACY SERVICES
Ward
Causes of Air Embolismhellip
Ward
LONG TERM CARE PHARMACY SERVICES
httpwwwfdagovMedicalDevicesSafetyAlertsandNoticesTubingandLuerM
isconnectionsucm313275htm
Causes of Air Embolismhellip
522015
14
LONG TERM CARE PHARMACY SERVICES
CASE STUDY
An ER patient had an IV heparin lock but no IV fluids had been started The
patient also had a noninvasive automatic BP cuff placed for continuous
monitoring
The BP cuff tubing was disconnected when the patient went to the bathroom
When she returned her spouse mistakenly connected the BP cuff tubing to the
IV catheter and approximately 15 mL of air was delivered to the IV catheter
The patient died from a fatal air embolus despite resuscitation efforts
Causeshellip LONG TERM CARE PHARMACY SERVICES
Causes
Infusion-related Air Embolism
Improper priming of administration set (4 fatal cases in literature)
Air vented bottles
Fluid infusions that are finished
Fluid infusions with rapid infusion through an air-filled drip chamber and the administration set remains open pose threats for air entrySingh Gardner von Jurgenson
(A one-litre sized crystalloid IV infusion bag can contain up to 60 mL of air)Schnoor
Rate
STOP THE FLOW
Air Embolism
LONG TERM CARE PHARMACY SERVICES
Early detection and treatment are critical to prevent or minimize cardiovascular pulmonary and neurologic damageAndrew
Stop air entryWilkins Garg Heckman
Notify MD Call 911 if in alternate care setting stay with patient and provide reassurance von
Jurgenson Natal
Left lateral decubitus and trendelenburg position
Treatment
522015
15
LONG TERM CARE PHARMACY SERVICES
100 O2 artificial ventilation with airbagendotracheal intubation
CPR closed cardiac massage
Fluid resuscitation (to increase intravascular volume venous pressure and venous return)Levy Clark Natal
Inotropic support (eg dobutamine) if cardiovascular collapse to increase CVPMirski Feil
Aspiration of air through distal lumen of CVP line or pulmonary artery catheter if catheter already in placePant Garg Odowd
Treatmenthellip LONG TERM CARE PHARMACY SERVICES
Hyperbaric oxygen therapy which is the main therapy for massive arterial air embolism preferably initiated within 3-5 hours of the event (reduces size of air bubbles accelerates nitrogen resorption and increases oxygen content of arterial blood) AndrewsTorres Heckman Mirski
Diagnostic measures include ABGs CXREKG pulse oximetry ventilation-perfusion scan CT of chest and head echocardiography pulmonary artery catheter Andrews Heckman Natal
Treatmenthellip
NO AIR ALLOWED
Air Embolism
AIR
LONG TERM CARE PHARMACY SERVICES
Insertion of VADS
Hydrate patient prior to insertion to correct hypovolemia whenever possible Feil
Occlude needle hub and catheter during insertion removalMirskiNatal
PREVENTION
Education practice guidelines amp protocols
522015
16
LONG TERM CARE PHARMACY SERVICES
During CVAD insertion stop ventilation during insertion of needle increase right atrial pressure during tunnelling of catheterMirski
During peripheral cannulation and removal place the arm below the level of the heartBBraun
PREVENTION LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Minimize IV manipulationsGroel
Supine or Trendelenburg position during daily management of scalp vein infusionFortrat
Remove air from add-on devices (syringes tubings needleless connectors stopcocks and all other devices added to the catheter)INS Wilkins Ensure stopcocks that are not in use are switched off and covered with a Luer-Lok capneedleless devicevon Jurgenson
Always use luer-lock connections to avoid accidental disconnectionsPant von Jorgenson INS
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADs Air detectorsfilters
Air sensors in infusion pumps Wilklins Pant ECRI Feil Adult infusion systems should be designed to prevent infusion of volumes of air gt50 μL in normal use and to prevent infusion of volumes of air gt1 mL in failure mode The smallest volume of air possible for neonates with a maximum air infusion volumes of 10 μL in failure modeWilkins
Air elimination filter on administration setsWilkins
Gardner Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Priming
Careful filling and handling of administration sets and thorough priming of filters (with filter in proper position) as per manufacturerrsquos guidelinesGardner Wilkins von Jurgenson
Check for air bubbles prior to starting the infusion
Close clamps of the administration set prior to priming then spike the fluid container and gently squeeze the drip chamber until it is half-filledvon Jurgenosn
If a burette is used ensure the tubing btw containerbag and burette is clamped offvon Jurgenson
Remove air from infusion bags when infusing fluids using inflatable pressure infusors Feil
PREVENTIONhellip
522015
17
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
522015
18
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
11
LONG TERM CARE PHARMACY SERVICES
Air Embolism Liability
Bhananker
LONG TERM CARE PHARMACY SERVICES
Anesthesiology legal claimsBhananker
Peripheral vascular catheters =2 of claims
Air embolism one of the most common complications ndash 8
Air embolism claims had highest median payment and a rate of 100 payment-per-claim
($325000 2007 with a range of $25800ndash $4120200)
Financial Consequenceshellip
LONG TERM CARE PHARMACY SERVICES
httpwwwmlivecomnewsgrand-
rapidsindexssf201208parents_sue_devos_childrens_hohtml
HOWrsquoS THE AIR GETTING IN
Air Embolism
522015
12
LONG TERM CARE PHARMACY SERVICES
Type of VADs
CVAD PIV
55
LONG TERM CARE PHARMACY SERVICES
feil
LONG TERM CARE PHARMACY SERVICES
VADs accounted for 14 gas embolism (n=29125 at Hyperbaric oxygen center)Besserreau
Removal (n=9)
Accidental removal (n=8)
Manipulation and usual care (n=7)
Insertion (n=5)
Peripheral venous catheterization (n=2)
Causes of Air Embolism
522015
13
LONG TERM CARE PHARMACY SERVICES
ACCIDENTAL DISCONNECTION
Cause of almost half of cerebral air embolism cases in a review of 1426 published case reports (1975-1998)Heckmann
Air embolism due to catheter disconnection has a mortality rate between 29 and 43
LONG TERM CARE PHARMACY SERVICES
Air embolism caused by a laceration to
central venous catheter during shaving Pearson
Causes of Air Embolismhellip
LONG TERM CARE PHARMACY SERVICES
Ward
Causes of Air Embolismhellip
Ward
LONG TERM CARE PHARMACY SERVICES
httpwwwfdagovMedicalDevicesSafetyAlertsandNoticesTubingandLuerM
isconnectionsucm313275htm
Causes of Air Embolismhellip
522015
14
LONG TERM CARE PHARMACY SERVICES
CASE STUDY
An ER patient had an IV heparin lock but no IV fluids had been started The
patient also had a noninvasive automatic BP cuff placed for continuous
monitoring
The BP cuff tubing was disconnected when the patient went to the bathroom
When she returned her spouse mistakenly connected the BP cuff tubing to the
IV catheter and approximately 15 mL of air was delivered to the IV catheter
The patient died from a fatal air embolus despite resuscitation efforts
Causeshellip LONG TERM CARE PHARMACY SERVICES
Causes
Infusion-related Air Embolism
Improper priming of administration set (4 fatal cases in literature)
Air vented bottles
Fluid infusions that are finished
Fluid infusions with rapid infusion through an air-filled drip chamber and the administration set remains open pose threats for air entrySingh Gardner von Jurgenson
(A one-litre sized crystalloid IV infusion bag can contain up to 60 mL of air)Schnoor
Rate
STOP THE FLOW
Air Embolism
LONG TERM CARE PHARMACY SERVICES
Early detection and treatment are critical to prevent or minimize cardiovascular pulmonary and neurologic damageAndrew
Stop air entryWilkins Garg Heckman
Notify MD Call 911 if in alternate care setting stay with patient and provide reassurance von
Jurgenson Natal
Left lateral decubitus and trendelenburg position
Treatment
522015
15
LONG TERM CARE PHARMACY SERVICES
100 O2 artificial ventilation with airbagendotracheal intubation
CPR closed cardiac massage
Fluid resuscitation (to increase intravascular volume venous pressure and venous return)Levy Clark Natal
Inotropic support (eg dobutamine) if cardiovascular collapse to increase CVPMirski Feil
Aspiration of air through distal lumen of CVP line or pulmonary artery catheter if catheter already in placePant Garg Odowd
Treatmenthellip LONG TERM CARE PHARMACY SERVICES
Hyperbaric oxygen therapy which is the main therapy for massive arterial air embolism preferably initiated within 3-5 hours of the event (reduces size of air bubbles accelerates nitrogen resorption and increases oxygen content of arterial blood) AndrewsTorres Heckman Mirski
Diagnostic measures include ABGs CXREKG pulse oximetry ventilation-perfusion scan CT of chest and head echocardiography pulmonary artery catheter Andrews Heckman Natal
Treatmenthellip
NO AIR ALLOWED
Air Embolism
AIR
LONG TERM CARE PHARMACY SERVICES
Insertion of VADS
Hydrate patient prior to insertion to correct hypovolemia whenever possible Feil
Occlude needle hub and catheter during insertion removalMirskiNatal
PREVENTION
Education practice guidelines amp protocols
522015
16
LONG TERM CARE PHARMACY SERVICES
During CVAD insertion stop ventilation during insertion of needle increase right atrial pressure during tunnelling of catheterMirski
During peripheral cannulation and removal place the arm below the level of the heartBBraun
PREVENTION LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Minimize IV manipulationsGroel
Supine or Trendelenburg position during daily management of scalp vein infusionFortrat
Remove air from add-on devices (syringes tubings needleless connectors stopcocks and all other devices added to the catheter)INS Wilkins Ensure stopcocks that are not in use are switched off and covered with a Luer-Lok capneedleless devicevon Jurgenson
Always use luer-lock connections to avoid accidental disconnectionsPant von Jorgenson INS
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADs Air detectorsfilters
Air sensors in infusion pumps Wilklins Pant ECRI Feil Adult infusion systems should be designed to prevent infusion of volumes of air gt50 μL in normal use and to prevent infusion of volumes of air gt1 mL in failure mode The smallest volume of air possible for neonates with a maximum air infusion volumes of 10 μL in failure modeWilkins
Air elimination filter on administration setsWilkins
Gardner Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Priming
Careful filling and handling of administration sets and thorough priming of filters (with filter in proper position) as per manufacturerrsquos guidelinesGardner Wilkins von Jurgenson
Check for air bubbles prior to starting the infusion
Close clamps of the administration set prior to priming then spike the fluid container and gently squeeze the drip chamber until it is half-filledvon Jurgenosn
If a burette is used ensure the tubing btw containerbag and burette is clamped offvon Jurgenson
Remove air from infusion bags when infusing fluids using inflatable pressure infusors Feil
PREVENTIONhellip
522015
17
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
522015
18
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
12
LONG TERM CARE PHARMACY SERVICES
Type of VADs
CVAD PIV
55
LONG TERM CARE PHARMACY SERVICES
feil
LONG TERM CARE PHARMACY SERVICES
VADs accounted for 14 gas embolism (n=29125 at Hyperbaric oxygen center)Besserreau
Removal (n=9)
Accidental removal (n=8)
Manipulation and usual care (n=7)
Insertion (n=5)
Peripheral venous catheterization (n=2)
Causes of Air Embolism
522015
13
LONG TERM CARE PHARMACY SERVICES
ACCIDENTAL DISCONNECTION
Cause of almost half of cerebral air embolism cases in a review of 1426 published case reports (1975-1998)Heckmann
Air embolism due to catheter disconnection has a mortality rate between 29 and 43
LONG TERM CARE PHARMACY SERVICES
Air embolism caused by a laceration to
central venous catheter during shaving Pearson
Causes of Air Embolismhellip
LONG TERM CARE PHARMACY SERVICES
Ward
Causes of Air Embolismhellip
Ward
LONG TERM CARE PHARMACY SERVICES
httpwwwfdagovMedicalDevicesSafetyAlertsandNoticesTubingandLuerM
isconnectionsucm313275htm
Causes of Air Embolismhellip
522015
14
LONG TERM CARE PHARMACY SERVICES
CASE STUDY
An ER patient had an IV heparin lock but no IV fluids had been started The
patient also had a noninvasive automatic BP cuff placed for continuous
monitoring
The BP cuff tubing was disconnected when the patient went to the bathroom
When she returned her spouse mistakenly connected the BP cuff tubing to the
IV catheter and approximately 15 mL of air was delivered to the IV catheter
The patient died from a fatal air embolus despite resuscitation efforts
Causeshellip LONG TERM CARE PHARMACY SERVICES
Causes
Infusion-related Air Embolism
Improper priming of administration set (4 fatal cases in literature)
Air vented bottles
Fluid infusions that are finished
Fluid infusions with rapid infusion through an air-filled drip chamber and the administration set remains open pose threats for air entrySingh Gardner von Jurgenson
(A one-litre sized crystalloid IV infusion bag can contain up to 60 mL of air)Schnoor
Rate
STOP THE FLOW
Air Embolism
LONG TERM CARE PHARMACY SERVICES
Early detection and treatment are critical to prevent or minimize cardiovascular pulmonary and neurologic damageAndrew
Stop air entryWilkins Garg Heckman
Notify MD Call 911 if in alternate care setting stay with patient and provide reassurance von
Jurgenson Natal
Left lateral decubitus and trendelenburg position
Treatment
522015
15
LONG TERM CARE PHARMACY SERVICES
100 O2 artificial ventilation with airbagendotracheal intubation
CPR closed cardiac massage
Fluid resuscitation (to increase intravascular volume venous pressure and venous return)Levy Clark Natal
Inotropic support (eg dobutamine) if cardiovascular collapse to increase CVPMirski Feil
Aspiration of air through distal lumen of CVP line or pulmonary artery catheter if catheter already in placePant Garg Odowd
Treatmenthellip LONG TERM CARE PHARMACY SERVICES
Hyperbaric oxygen therapy which is the main therapy for massive arterial air embolism preferably initiated within 3-5 hours of the event (reduces size of air bubbles accelerates nitrogen resorption and increases oxygen content of arterial blood) AndrewsTorres Heckman Mirski
Diagnostic measures include ABGs CXREKG pulse oximetry ventilation-perfusion scan CT of chest and head echocardiography pulmonary artery catheter Andrews Heckman Natal
Treatmenthellip
NO AIR ALLOWED
Air Embolism
AIR
LONG TERM CARE PHARMACY SERVICES
Insertion of VADS
Hydrate patient prior to insertion to correct hypovolemia whenever possible Feil
Occlude needle hub and catheter during insertion removalMirskiNatal
PREVENTION
Education practice guidelines amp protocols
522015
16
LONG TERM CARE PHARMACY SERVICES
During CVAD insertion stop ventilation during insertion of needle increase right atrial pressure during tunnelling of catheterMirski
During peripheral cannulation and removal place the arm below the level of the heartBBraun
PREVENTION LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Minimize IV manipulationsGroel
Supine or Trendelenburg position during daily management of scalp vein infusionFortrat
Remove air from add-on devices (syringes tubings needleless connectors stopcocks and all other devices added to the catheter)INS Wilkins Ensure stopcocks that are not in use are switched off and covered with a Luer-Lok capneedleless devicevon Jurgenson
Always use luer-lock connections to avoid accidental disconnectionsPant von Jorgenson INS
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADs Air detectorsfilters
Air sensors in infusion pumps Wilklins Pant ECRI Feil Adult infusion systems should be designed to prevent infusion of volumes of air gt50 μL in normal use and to prevent infusion of volumes of air gt1 mL in failure mode The smallest volume of air possible for neonates with a maximum air infusion volumes of 10 μL in failure modeWilkins
Air elimination filter on administration setsWilkins
Gardner Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Priming
Careful filling and handling of administration sets and thorough priming of filters (with filter in proper position) as per manufacturerrsquos guidelinesGardner Wilkins von Jurgenson
Check for air bubbles prior to starting the infusion
Close clamps of the administration set prior to priming then spike the fluid container and gently squeeze the drip chamber until it is half-filledvon Jurgenosn
If a burette is used ensure the tubing btw containerbag and burette is clamped offvon Jurgenson
Remove air from infusion bags when infusing fluids using inflatable pressure infusors Feil
PREVENTIONhellip
522015
17
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
522015
18
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
13
LONG TERM CARE PHARMACY SERVICES
ACCIDENTAL DISCONNECTION
Cause of almost half of cerebral air embolism cases in a review of 1426 published case reports (1975-1998)Heckmann
Air embolism due to catheter disconnection has a mortality rate between 29 and 43
LONG TERM CARE PHARMACY SERVICES
Air embolism caused by a laceration to
central venous catheter during shaving Pearson
Causes of Air Embolismhellip
LONG TERM CARE PHARMACY SERVICES
Ward
Causes of Air Embolismhellip
Ward
LONG TERM CARE PHARMACY SERVICES
httpwwwfdagovMedicalDevicesSafetyAlertsandNoticesTubingandLuerM
isconnectionsucm313275htm
Causes of Air Embolismhellip
522015
14
LONG TERM CARE PHARMACY SERVICES
CASE STUDY
An ER patient had an IV heparin lock but no IV fluids had been started The
patient also had a noninvasive automatic BP cuff placed for continuous
monitoring
The BP cuff tubing was disconnected when the patient went to the bathroom
When she returned her spouse mistakenly connected the BP cuff tubing to the
IV catheter and approximately 15 mL of air was delivered to the IV catheter
The patient died from a fatal air embolus despite resuscitation efforts
Causeshellip LONG TERM CARE PHARMACY SERVICES
Causes
Infusion-related Air Embolism
Improper priming of administration set (4 fatal cases in literature)
Air vented bottles
Fluid infusions that are finished
Fluid infusions with rapid infusion through an air-filled drip chamber and the administration set remains open pose threats for air entrySingh Gardner von Jurgenson
(A one-litre sized crystalloid IV infusion bag can contain up to 60 mL of air)Schnoor
Rate
STOP THE FLOW
Air Embolism
LONG TERM CARE PHARMACY SERVICES
Early detection and treatment are critical to prevent or minimize cardiovascular pulmonary and neurologic damageAndrew
Stop air entryWilkins Garg Heckman
Notify MD Call 911 if in alternate care setting stay with patient and provide reassurance von
Jurgenson Natal
Left lateral decubitus and trendelenburg position
Treatment
522015
15
LONG TERM CARE PHARMACY SERVICES
100 O2 artificial ventilation with airbagendotracheal intubation
CPR closed cardiac massage
Fluid resuscitation (to increase intravascular volume venous pressure and venous return)Levy Clark Natal
Inotropic support (eg dobutamine) if cardiovascular collapse to increase CVPMirski Feil
Aspiration of air through distal lumen of CVP line or pulmonary artery catheter if catheter already in placePant Garg Odowd
Treatmenthellip LONG TERM CARE PHARMACY SERVICES
Hyperbaric oxygen therapy which is the main therapy for massive arterial air embolism preferably initiated within 3-5 hours of the event (reduces size of air bubbles accelerates nitrogen resorption and increases oxygen content of arterial blood) AndrewsTorres Heckman Mirski
Diagnostic measures include ABGs CXREKG pulse oximetry ventilation-perfusion scan CT of chest and head echocardiography pulmonary artery catheter Andrews Heckman Natal
Treatmenthellip
NO AIR ALLOWED
Air Embolism
AIR
LONG TERM CARE PHARMACY SERVICES
Insertion of VADS
Hydrate patient prior to insertion to correct hypovolemia whenever possible Feil
Occlude needle hub and catheter during insertion removalMirskiNatal
PREVENTION
Education practice guidelines amp protocols
522015
16
LONG TERM CARE PHARMACY SERVICES
During CVAD insertion stop ventilation during insertion of needle increase right atrial pressure during tunnelling of catheterMirski
During peripheral cannulation and removal place the arm below the level of the heartBBraun
PREVENTION LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Minimize IV manipulationsGroel
Supine or Trendelenburg position during daily management of scalp vein infusionFortrat
Remove air from add-on devices (syringes tubings needleless connectors stopcocks and all other devices added to the catheter)INS Wilkins Ensure stopcocks that are not in use are switched off and covered with a Luer-Lok capneedleless devicevon Jurgenson
Always use luer-lock connections to avoid accidental disconnectionsPant von Jorgenson INS
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADs Air detectorsfilters
Air sensors in infusion pumps Wilklins Pant ECRI Feil Adult infusion systems should be designed to prevent infusion of volumes of air gt50 μL in normal use and to prevent infusion of volumes of air gt1 mL in failure mode The smallest volume of air possible for neonates with a maximum air infusion volumes of 10 μL in failure modeWilkins
Air elimination filter on administration setsWilkins
Gardner Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Priming
Careful filling and handling of administration sets and thorough priming of filters (with filter in proper position) as per manufacturerrsquos guidelinesGardner Wilkins von Jurgenson
Check for air bubbles prior to starting the infusion
Close clamps of the administration set prior to priming then spike the fluid container and gently squeeze the drip chamber until it is half-filledvon Jurgenosn
If a burette is used ensure the tubing btw containerbag and burette is clamped offvon Jurgenson
Remove air from infusion bags when infusing fluids using inflatable pressure infusors Feil
PREVENTIONhellip
522015
17
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
522015
18
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
14
LONG TERM CARE PHARMACY SERVICES
CASE STUDY
An ER patient had an IV heparin lock but no IV fluids had been started The
patient also had a noninvasive automatic BP cuff placed for continuous
monitoring
The BP cuff tubing was disconnected when the patient went to the bathroom
When she returned her spouse mistakenly connected the BP cuff tubing to the
IV catheter and approximately 15 mL of air was delivered to the IV catheter
The patient died from a fatal air embolus despite resuscitation efforts
Causeshellip LONG TERM CARE PHARMACY SERVICES
Causes
Infusion-related Air Embolism
Improper priming of administration set (4 fatal cases in literature)
Air vented bottles
Fluid infusions that are finished
Fluid infusions with rapid infusion through an air-filled drip chamber and the administration set remains open pose threats for air entrySingh Gardner von Jurgenson
(A one-litre sized crystalloid IV infusion bag can contain up to 60 mL of air)Schnoor
Rate
STOP THE FLOW
Air Embolism
LONG TERM CARE PHARMACY SERVICES
Early detection and treatment are critical to prevent or minimize cardiovascular pulmonary and neurologic damageAndrew
Stop air entryWilkins Garg Heckman
Notify MD Call 911 if in alternate care setting stay with patient and provide reassurance von
Jurgenson Natal
Left lateral decubitus and trendelenburg position
Treatment
522015
15
LONG TERM CARE PHARMACY SERVICES
100 O2 artificial ventilation with airbagendotracheal intubation
CPR closed cardiac massage
Fluid resuscitation (to increase intravascular volume venous pressure and venous return)Levy Clark Natal
Inotropic support (eg dobutamine) if cardiovascular collapse to increase CVPMirski Feil
Aspiration of air through distal lumen of CVP line or pulmonary artery catheter if catheter already in placePant Garg Odowd
Treatmenthellip LONG TERM CARE PHARMACY SERVICES
Hyperbaric oxygen therapy which is the main therapy for massive arterial air embolism preferably initiated within 3-5 hours of the event (reduces size of air bubbles accelerates nitrogen resorption and increases oxygen content of arterial blood) AndrewsTorres Heckman Mirski
Diagnostic measures include ABGs CXREKG pulse oximetry ventilation-perfusion scan CT of chest and head echocardiography pulmonary artery catheter Andrews Heckman Natal
Treatmenthellip
NO AIR ALLOWED
Air Embolism
AIR
LONG TERM CARE PHARMACY SERVICES
Insertion of VADS
Hydrate patient prior to insertion to correct hypovolemia whenever possible Feil
Occlude needle hub and catheter during insertion removalMirskiNatal
PREVENTION
Education practice guidelines amp protocols
522015
16
LONG TERM CARE PHARMACY SERVICES
During CVAD insertion stop ventilation during insertion of needle increase right atrial pressure during tunnelling of catheterMirski
During peripheral cannulation and removal place the arm below the level of the heartBBraun
PREVENTION LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Minimize IV manipulationsGroel
Supine or Trendelenburg position during daily management of scalp vein infusionFortrat
Remove air from add-on devices (syringes tubings needleless connectors stopcocks and all other devices added to the catheter)INS Wilkins Ensure stopcocks that are not in use are switched off and covered with a Luer-Lok capneedleless devicevon Jurgenson
Always use luer-lock connections to avoid accidental disconnectionsPant von Jorgenson INS
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADs Air detectorsfilters
Air sensors in infusion pumps Wilklins Pant ECRI Feil Adult infusion systems should be designed to prevent infusion of volumes of air gt50 μL in normal use and to prevent infusion of volumes of air gt1 mL in failure mode The smallest volume of air possible for neonates with a maximum air infusion volumes of 10 μL in failure modeWilkins
Air elimination filter on administration setsWilkins
Gardner Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Priming
Careful filling and handling of administration sets and thorough priming of filters (with filter in proper position) as per manufacturerrsquos guidelinesGardner Wilkins von Jurgenson
Check for air bubbles prior to starting the infusion
Close clamps of the administration set prior to priming then spike the fluid container and gently squeeze the drip chamber until it is half-filledvon Jurgenosn
If a burette is used ensure the tubing btw containerbag and burette is clamped offvon Jurgenson
Remove air from infusion bags when infusing fluids using inflatable pressure infusors Feil
PREVENTIONhellip
522015
17
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
522015
18
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
15
LONG TERM CARE PHARMACY SERVICES
100 O2 artificial ventilation with airbagendotracheal intubation
CPR closed cardiac massage
Fluid resuscitation (to increase intravascular volume venous pressure and venous return)Levy Clark Natal
Inotropic support (eg dobutamine) if cardiovascular collapse to increase CVPMirski Feil
Aspiration of air through distal lumen of CVP line or pulmonary artery catheter if catheter already in placePant Garg Odowd
Treatmenthellip LONG TERM CARE PHARMACY SERVICES
Hyperbaric oxygen therapy which is the main therapy for massive arterial air embolism preferably initiated within 3-5 hours of the event (reduces size of air bubbles accelerates nitrogen resorption and increases oxygen content of arterial blood) AndrewsTorres Heckman Mirski
Diagnostic measures include ABGs CXREKG pulse oximetry ventilation-perfusion scan CT of chest and head echocardiography pulmonary artery catheter Andrews Heckman Natal
Treatmenthellip
NO AIR ALLOWED
Air Embolism
AIR
LONG TERM CARE PHARMACY SERVICES
Insertion of VADS
Hydrate patient prior to insertion to correct hypovolemia whenever possible Feil
Occlude needle hub and catheter during insertion removalMirskiNatal
PREVENTION
Education practice guidelines amp protocols
522015
16
LONG TERM CARE PHARMACY SERVICES
During CVAD insertion stop ventilation during insertion of needle increase right atrial pressure during tunnelling of catheterMirski
During peripheral cannulation and removal place the arm below the level of the heartBBraun
PREVENTION LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Minimize IV manipulationsGroel
Supine or Trendelenburg position during daily management of scalp vein infusionFortrat
Remove air from add-on devices (syringes tubings needleless connectors stopcocks and all other devices added to the catheter)INS Wilkins Ensure stopcocks that are not in use are switched off and covered with a Luer-Lok capneedleless devicevon Jurgenson
Always use luer-lock connections to avoid accidental disconnectionsPant von Jorgenson INS
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADs Air detectorsfilters
Air sensors in infusion pumps Wilklins Pant ECRI Feil Adult infusion systems should be designed to prevent infusion of volumes of air gt50 μL in normal use and to prevent infusion of volumes of air gt1 mL in failure mode The smallest volume of air possible for neonates with a maximum air infusion volumes of 10 μL in failure modeWilkins
Air elimination filter on administration setsWilkins
Gardner Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Priming
Careful filling and handling of administration sets and thorough priming of filters (with filter in proper position) as per manufacturerrsquos guidelinesGardner Wilkins von Jurgenson
Check for air bubbles prior to starting the infusion
Close clamps of the administration set prior to priming then spike the fluid container and gently squeeze the drip chamber until it is half-filledvon Jurgenosn
If a burette is used ensure the tubing btw containerbag and burette is clamped offvon Jurgenson
Remove air from infusion bags when infusing fluids using inflatable pressure infusors Feil
PREVENTIONhellip
522015
17
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
522015
18
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
16
LONG TERM CARE PHARMACY SERVICES
During CVAD insertion stop ventilation during insertion of needle increase right atrial pressure during tunnelling of catheterMirski
During peripheral cannulation and removal place the arm below the level of the heartBBraun
PREVENTION LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Minimize IV manipulationsGroel
Supine or Trendelenburg position during daily management of scalp vein infusionFortrat
Remove air from add-on devices (syringes tubings needleless connectors stopcocks and all other devices added to the catheter)INS Wilkins Ensure stopcocks that are not in use are switched off and covered with a Luer-Lok capneedleless devicevon Jurgenson
Always use luer-lock connections to avoid accidental disconnectionsPant von Jorgenson INS
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADs Air detectorsfilters
Air sensors in infusion pumps Wilklins Pant ECRI Feil Adult infusion systems should be designed to prevent infusion of volumes of air gt50 μL in normal use and to prevent infusion of volumes of air gt1 mL in failure mode The smallest volume of air possible for neonates with a maximum air infusion volumes of 10 μL in failure modeWilkins
Air elimination filter on administration setsWilkins
Gardner Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Priming
Careful filling and handling of administration sets and thorough priming of filters (with filter in proper position) as per manufacturerrsquos guidelinesGardner Wilkins von Jurgenson
Check for air bubbles prior to starting the infusion
Close clamps of the administration set prior to priming then spike the fluid container and gently squeeze the drip chamber until it is half-filledvon Jurgenosn
If a burette is used ensure the tubing btw containerbag and burette is clamped offvon Jurgenson
Remove air from infusion bags when infusing fluids using inflatable pressure infusors Feil
PREVENTIONhellip
522015
17
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
522015
18
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
17
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Priminghellip
If the set has a roller clamp move
it up to the drip chamber
close the clamp
spike the bag
half-fill the drip chamber
open the clamp and prime the lineDick
Preventionhellip
httpwwwjemscomarticlepatient-
carebubbles-air-proofing-your-iv-l
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance Infusion
Inspect all parts of the infusion system for defects damage or leakagevon Jurgenson
Ensure administration set junctions are secure especially before patients get out of bedGorski
Check the infusion system regularly for air bubbles empty solution container (containers should not run dry) iv tubing that runs dry leakage or disconnectionon
Jurgenson
Close tubing clamps prior to changing fluid containersvon
Jurgenson
Clamp off air-vented containers before they are completely empty von Jurgenson
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Air in line
Remove any air bubbles in an infusion system detected during infusion using a syringe at a downstream injection site (or alternatively by disconnecting the infusion set an allowing free flow to clear the air bubble although this may increase the infection risk due to the disconnection) On occasion it may be preferable to discard the entire system and start again In rare circumstances it may be necessary to use a new set to re-spike the infusion bag but this should be avoided ldquoInfrequent tiny pin head bubbles even though not desirable can be left without action but should be monitoredrdquo von Jorgenson
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS
Never using scissors near the venous access device as this could result in accidental severing of the catheterGorski
Avoid the use of hemostats which can crack the catheter hubAndrews
Careful observation during shaving if a cvad is in the neckSchimp
PREVENTIONhellip
522015
18
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
18
LONG TERM CARE PHARMACY SERVICES
Care amp Maintenance of VADS Patient Education
catheter displacement and disconnection
to properly prime tubing
to check connections frequently
to clamp the CVAD at appropriate times
to avoid the use of sharp objects (such as scissors) near the catheter
to avoid pulling on the line
how to manage air embolism
AndrewsINS Gorski
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Place the patient in the Trendelenburg position when possible (although this is somehat controversial in the literature) If not possible the supine position is sufficientFeil
Position the catheter exit site (eg neck arm) at a height lower than the height of the patientrsquos heartFeil
PREVENTIONhellip
LONG TERM CARE PHARMACY SERVICES
Removal of VADS
Instruct the patient to hold his or her breath and perform a Valsalva maneuver as the last portion of the catheter is removed
If Valsalva contraindicated with aortic stenosis recent myocardial infarction glaucoma and retinopathy ensure that a catheter clamp is present before changing administration sets or needleless connectors and time the removal during patient expirationINS Feil
PREVENTIONhellip LONG TERM CARE PHARMACY SERVICES
Removal of VADs
Place digital pressure on the site until hemostasis is achieved One to five minutes is suggestedFeil
Apply a sterile occlusive dressing upon CVAD or scalp vein removal such as gauze impregnated with petroleum jelly or an antiseptic ointment and cover with a transparent film dressing (a dressing alone or gauze and a dressing is not occlusive)
Leave dressing in place for at least 24 hours Change the dressing every 24 hours until the exit site has healed ( a scab has formed)
Instruct the patient to remain lying flat for 30 minutes after removal of the catheter Feil
Schlimp Natal Mirski INS Feil Masoorli Fortrat Clark
PREVENTIONhellip
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
19
LONG TERM CARE PHARMACY SERVICES
lsquolsquoNo medical tragedy is greater than the
avoidable iatrogenic death
Perhaps saddest of all is the occurrence
of venous air embolism which is almost
always the result of a therapeutic error or
carelessness
There is no instance in which a needle is placed
in the venous system when the hazard of air
embolism does not existrsquorsquo Sowell et al
SUMMARY
Incidence of air embolism may be low and likely most cases
may be subclinical
Potential for severe neurologic respiratory and cardiovascular
morbidity and mortality with high mortality rates attributed to
CVAD-related air embolism ranging from 23-50Feil Natal The
clinical relevance of a small air embolism is uncertain as is the
amount of air required to cause harm
Any patient with a vascular access may be at a higher risk than
expected due to the incidence of silent patent foramen ovale
increasing the risk of even a small amount of air entry
Healthcare professionals and carers manipulating vascular
access devices must be aware of the danger of air embolism
and adopt good practice to identify and manage air embolism
and keep air out of our patientsrsquo lines
AIR
LONG TERM CARE PHARMACY SERVICES
References
Sowell MW Lovelady CL Brogdon BG Wecht CH Infant death due to air embolism
from peripheral venous infusion J Forensic Sci 200752(1)183-8
Levy I Mosseri R Garty B Peripheral intravenous infusionmdashanother cause of air
embolism Acta Paediatr 200685(3)385ndash6
Fortrat JO Saumet M Savagner C Leblanc M Bouderlique C Bubbles in the brain
veins as a complication of daily management of a scalp vein catheter Am J
Perinatol 200522(7)361-3
Torres Martiacutenez FJ Kuffler DP Hyperbaric oxygen treatment to eliminate a large
venous air embolism a case study Undersea Hyperb Med 201138(4)297-304
Haavik PE Steen PA Air embolism caused by rupture of a silicone-central venous
catheter Journal of Parenteral and Enteral Nutrition19848(5)579-580
Agarwal SS Lavlesh Kumar Krishnadutt Harishankar Chavali Shashidhar
Chennamallapa Mestri Fatal venous air embolism following intravenous infusion
Journal of Forensic Sciences 200954(3)682-4
Insider Exclusive Medical Malpractice ndash The Narin Bun Story 2011 Retrieved from
httpwwwinsiderexclusivecomshow-content289-medical-malpractice--the-narin-bun-
storyhtml
Heckmann JG Lang CJG Kindler KHuk W Erbguth FJ Neundoumlrfer B Neurologic
manifestations of cerebral air embolism as a complication of central venous
catheterization Critical Care Medicine 200028(5)1621-1625
Unsure which is first and last name therefore not abbreviated
522015
20
LONG TERM CARE PHARMACY SERVICES
Feil M Reducing risk of air embolism associated with central venous access devices PA
Safety Advisory 2012 Jun9(2)58-64 Retrieved from
httppatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Jun9(2)Pages58asp
x
Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
Neurosci Nurs 201143(4)193-6 quiz 197-8
Gorski L Reducing the Risk of Air Embolism Journal of Infusion Nursing 2009 32(2)71-
72
Odowd LC Kelley MA Air Embolism Retrieved from
httpcmbibjmueducnuptodatecritical20careembolic20diseaseair20embolismhtm
or 2009 Accessed at httpwwwuptodatecomcontentsair-
embolismsource=search_resultampselectedTitle=1257E71
Canadian Agency for Drugs and Technologies in Health Risk of Air Embolus for Air in
Intravenous Tubing Clinical Evidence and Guidelines 13 October 2010 Retrieved from
httpwwwcadthcamediapdfJ0481_Risk_Embolus_with_IV_Tubing_HTIS-1pdf
Bessereau J Genotelle N Chabbaut C Huon A Tabah A Aboab J Chevret S Annane D
Long-term outcome of iatrogenic gas embolism Intensive Care Med 201036(7)1180-7
Vesely TM Air embolism during insertion of central venous catheters J Vasc Interv Radiol
2001 121291ndash5
Groell R Schaffler GJ Rienmueller R The peripheral intravenous cannulamdash a cause of
venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
httpjournalslwwcomamjmedsciAbstract199711000The_Peripheral_Intravenous_Can
nula__A_Cause_of6aspx
LONG TERM CARE PHARMACY SERVICES
Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
during cardiac catheterization in tetralogy of fallot an aborted sudden death Journal of
Invasive Cardiology 201224(11)E294-E296 Retrieved from
httpwwwinvasivecardiologycomarticlesintracardiac-aspiration-life-threatening-air-
embolism-during-cardiac-catheterization-tetral
Natal BL Venous Air Embolism [online] Medscape April 16 2012 Retrieved from
httpemedicinemedscapecomarticle761367-overview
Andrews C Preventing air embolism emergency management related to central venous
catheterization American Journal of Nursing 2002102(1)34-36
Armstrong RF Peters JL Cohen SL Air embolism caused by fractured central-venous
catheter Lancet 1977 April 30954 Letter to the editor
Infusion Nurses Society (INS) Infusion nursing standards of practice 2011 Hagerstown
(MD) INS
Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
embolism Anesthesiology 2007106(1)164-77
Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
Anaesth 201054(1) 49ndash51 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC2876914
Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
1971 3(5766)74-8
LONG TERM CARE PHARMACY SERVICES
Ruskin KJ Venous Air Embolism[online] 30 July 1996 Retrieved from
httpanestitunipaitgtavaehtml
Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
catheter removal J R Soc Med 200093(11)592-3 Retrieved from
httpwwwncbinlmnihgovpmcarticlesPMC1298153
Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
httppubmedcentralcanadacaarticlerendercgiaccid=PMC3029402
Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
Novack V Shefer A Almog Y Images in cardiology Coronary air embolism after removal
of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
Nurs 2010 2719(10)S28-S30
ECRI Institute Air embolism through central venous catheters Hazard [Health Devices
Dec 198514(14)436-7] Retrieved from
httpwwwmdsrecriorgsummarydetailaspxdoc_id=8149
Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
Approach 3rd edn St LouisMO ElsevierSaunders 2010
Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
Journal of Infusion Nursing 201235(6)404-408
LONG TERM CARE PHARMACY SERVICES
Bhananker SM Liau DW Kooner PK Posner KL Caplan RA Domino KB Liability
related to peripheral venous and arterial catheterization a closed claims analysis
Anesth Analg 2009109(1)124-9
Gardner RM Bond EL Clark JS Safety and efficacy of continuous flush systems for
arterial and pulrnonary artery catheters The Annals of Thoracic Surgery 1977 23 (6)
534-538 Retrieved from httpatsctsnetjournalsorgcgireprint236534
Schnoor J Macko S Weber I Rossaint R The air elimination capabilities of pressure
infusion devices and fluid-warmers Anaesthesia 200459(8)817ndash821 Retrieved from
httponlinelibrarywileycomdoi101111j1365-2044200403841xfull
Yeakel AE Lethal air embolism from plastic blood-storage container
JAMA 1968204(3)267-9
Perivascular Nurse Consultants Air Embolism A Silent Killer Presented at the 22nd
Annual Scientific Meeting of the Association for Vascular Access Sept 2008 Savannah
Georgia Retrieved from httpwwwavainfoorgwebsitedownloadaspid=205574
Masoorli S Air embolism RN Magazine 199962(11)32-34
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Melsungen AG 032011 Retrieved from
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usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011
522015
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Feil M Reducing risk of air embolism associated with central venous access devices PA
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Clark DK Plaizier E Devastating cerebral air embolism after central line removal J
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Odowd LC Kelley MA Air Embolism Retrieved from
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or 2009 Accessed at httpwwwuptodatecomcontentsair-
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venous air embolism Am J Med Sci1997314(5)300ndash2 Retrieved from
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Garg N Moorthy N Goel PK Intracardiac aspiration for life-threatening air embolism
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Mirski MA Lele AV Fitzsimmons L et al Diagnosis and treatment of vascular air
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Pant D Kumar Narani K amp Sood J Significant air embolism a possibility even with
collapsible intravenous fluid containers when used with rapid infuser system Indian J
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Ward MK Shadforth M Hill AV Kerr DN Air embolism during haemodialysis Br Med J
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Madden B Paruchuru P Kunst H Sucking noise and collapse after central venous
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Schlimp CJ Loimer T Schmidts MB Rieger M Lederer W Venous air embolism through
central venous access BMJ Case Rep 2009 Jun 26 Retrieved from
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Willis J Duncan C Gottschalk S Paraplegia due to peripheral venous air embolus in a
neonate a case report Pediatrics 198167(4)472-3
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of central venous catheter Heart 200692(1)39
von Juumlrgensonn S Prevention and management of air in an IV infusion system Br J
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Alexander M Corrigan A GorskiL et al editors Infusion Nursing An Evidence-Based
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Singh H Tewari A Kaur B Garg S U turn to venous air embolism Indian J Crit Care
Med 200913(2)92-3
Bajanowski T Kohler H DuChense A Koops E Brinkmann B Proof of air embolism
after exhumation Int J Legal 19981122-7
Wilkins R Unverdorben M Accidental intravenous infusion of air a concise review
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Masoorli S Air embolism RN Magazine 199962(11)32-34
Toung TK Rossber MI Hutchins GM Volume of air in a lethal venous air embolism
Anesthesiology 200194(2)360-361 Retrieved from
httpjournalslwwcomanesthesiologypagesarticlevieweraspxyear=2001ampissue=020
00amparticle=00031amptype=fulltext
BBraun Air Embolism Risk Prevention in Infusion Therapy [online] B Braun
Melsungen AG 032011 Retrieved from
httpfrancaisbbraunchdocumentsKnowledgeContent_Wissen_Risikopraevention_Inf
usionstheraphie_Air_Embolismpdf
Dick T Bubbles air-proofing your IV lines-pronto JEMS 200934(2)32
Infusion Nurses Society Policies and Procedures for Infusion Nursing 4th edition2011