Is the Incidence of Venous Air Embolism Under-Estimated During Spine Surgery in the Prone Position?

Venous air embolism (VAE) is a known neurosurgical complication classically and most frequently occurring in patients undergoing posterior cranial fossa or cervical spine surgery in a sitting or semi-sitting position. The authors present a case of VAE that occurred during posterior cervical spine surgery in a patient in the prone position, a rare intraoperative complication. The patient was a 65-year-old man who was undergoing a C1–2 fusion for a nonunion of a Type II dens fracture and developed a VAE. While VAE in the prone position is uncommon, it is a neurosurgical complication that may have significant clinical implications both intraoperatively and postoperatively. The aim of this review is 2-fold: 1) to improve the general knowledge of this complication among surgeons and anesthesiologists who may not otherwise suspect air embolism in patients positioned prone for posterior cervical spine operations, and 2) to formulate preventive measures as well as a plan for prompt diagnosis and treatment should this complication occur.

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Effects of positive end-expiratory pressure ventilation on cerebral venous pressure with head elevation in dogs

Journal of Applied Physiology ◽

10.1152/jappl.2000.88.2.655 ◽

2000 ◽

Vol 88 (2) ◽

pp. 655-661 ◽

Cited By ~ 29

Author(s):

Thomas J. K. Toung ◽

H. Aizawa ◽

Richard J. Traystman

Keyword(s):

Prone Position ◽

Venous Pressure ◽

Air Embolism ◽

Right Atrial ◽

Sitting Position ◽

Positive End Expiratory Pressure ◽

Jugular Veins ◽

Venous Air Embolism ◽

Head Elevation ◽

Cerebral Venous Pressure

Mechanical ventilation with positive end-expiratory pressure (PEEP) may prevent venous air embolism in the sitting position because cerebral venous pressure (Pcev) could be increased by the PEEP-induced increase in right atrial pressure (Pra). Whereas it is clear that there is a linear transmission of the PEEP-induced increase in Pra to Pcev while the dog is in the prone position, the mechanism of the transmission with the dog in the head-elevated position is unclear. We tested the hypothesis that a Starling resistor-type mechanism exists in the jugular veins when the head is elevated. In one group of dogs, increasing PEEP linearly increased Pcev with the dog in the prone position (head at heart level, slope = 0.851) but did not increase Pcev when the head was elevated. In another group of dogs, an external chest binder was used to produce a larger PEEP-induced increase in Pra. Further increasing Pra increased Pcev only after Pra exceeded a pressure of 19 mmHg (break pressure). This sharp inflection in the upstream (Pcev)-downstream (Pra) relationship suggests that this may be caused by a Starling resistor-type mechanism. We conclude that jugular venous collapse serves as a significant resistance in the transmission of Pra to Pcev in the head-elevated position.

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Venous Air Embolism During Spinal Instrumentation and Fusion in the Prone Position

Anesthesia & Analgesia ◽

10.1213/00000539-199207000-00047 ◽

1992 ◽

Vol 75 (1) ◽

pp. 153 ◽

Cited By ~ 1

Author(s):

Maurice S. Albin ◽

Richard R. Ritter ◽

Leon Bunegin

Keyword(s):

Prone Position ◽

Spinal Instrumentation ◽

Air Embolism ◽

Venous Air Embolism

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Venous Air Embolism During Spinal Instrumentation and Fusion in the Prone Position

Anesthesia & Analgesia ◽

10.1213/00000539-199207000-00046 ◽

1992 ◽

Vol 75 (1) ◽

pp. 152???153

Author(s):

Terry W. Latson

Keyword(s):

Prone Position ◽

Spinal Instrumentation ◽

Air Embolism ◽

Venous Air Embolism

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POGOSTOST ZRAČNE EMBOLIJE IN POOPERATIVNI ZAPLETI PRI NEVROKIRURŠKIH POSEGIH V SEDEČEM POLOŽAJU Skrajšana verzija naslova: ZRAČNA EMBOLIJA PRI NEVROKIRURŠKIH POSEGIH V SEDEČEM POLOŽAJU

Slovenian Medical Journal ◽

10.6016/zdravvestn.1274 ◽

2015 ◽

Vol 84 (9) ◽

Author(s):

Alenka Spindler Vesel ◽

Nina Pirc ◽

Božidar Visočnik ◽

Jasmina Markovič - Božič

Keyword(s):

Cervical Spine ◽

Posterior Fossa ◽

Spine Surgery ◽

Air Embolism ◽

Neck Surgery ◽

Postoperative Treatment ◽

Posterior Fossa Surgery ◽

Cervical Spine Surgery ◽

Venous Air Embolism ◽

Doppler Probe

Background: Posterior fossa surgery and cervical spine surgery are at risk for venous air embolism (VAE) occurrence. Mostly air emboli are small and asymptomatic, but invasion of large quantity of air in the circulation is symptomatic and potentially lethal. Transesophageal echocardiography is the most sensitive method for detection of air emboli in the heart, followed by the precordial Doppler probe, end tidal carbon dioxide monitoring (etCO2) and others.Methods: In our 14- years retrospective review we evaluated the incidence of VAE and postoperative complications in patients with posterior fossa surgery or cervical spine surgery. VAE was recognized by using Doppler probe and/or drop of etCO2. If VAE occurred, aspiration of air through the CVC was used to prevent or to minimized VAE occurrence, the surgeon was warned about the incident. VAE treatment was supportive.Results: VAE was recognized in 74 patients. Two patients after head surgery and four patients after neck surgery needed postoperative treatment in intensive care unit and controled mechanical ventilation. In six patients after head surgery and in four patients after neck surgery new neurological symptoms occurred. Two patients after head surgery died due to complications of massive VAE.Conclusions: VAE is rare, but serious complication of neurosurgery in sitting position. Preventive treatment, early detection of VAE, supportive treatment and treatment of cardiovascular complications are necessary for survival of patients with VAE.

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Is the ???Kneeling??? Prone Position as Dangerous as the Sitting Position for the Development of Venous Air Embolism?

Anesthesia & Analgesia ◽

10.1213/00000539-199209000-00038 ◽

1992 ◽

Vol 75 (3) ◽

pp. 467???468 ◽

Cited By ~ 3

Author(s):

Ren?? Tempelhoff ◽

E. L. Williams ◽

D. G. Vollmer

Keyword(s):

Prone Position ◽

Air Embolism ◽

Sitting Position ◽

Venous Air Embolism

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Venous Air Embolism during Anterior Lumbar Surgery

Journal of Perioperative Echocardiography ◽

10.5005/jp-journals-10034-1006 ◽

2013 ◽

Vol 1 (1) ◽

pp. 30-32

Author(s):

Stephen O Bader ◽

Susie J Cho ◽

James W Heitz

Keyword(s):

Lumbar Spine ◽

Cardiac Function ◽

Transesophageal Echocardiography ◽

Spine Surgery ◽

Air Embolism ◽

Volume Status ◽

Lumbar Spine Surgery ◽

Lumbar Surgery ◽

Venous Air Embolism ◽

Clinical Changes

ABSTRACT The use of transesophageal echocardiography (TEE) has improved the detection of venous air embolism (VAE), especially in the case of small VAE where clinical changes can be subtle and erroneously attributed to volume status or cardiac function. We present a case of VAE in a 62 years old female that occurred during anterior lumbar spine surgery that was diagnosed with the aid of TEE. As anterior lumbar spines surgery is traditionally not associated with VAE, we believe this is the first reported case of VAE in this type of procedure. How to cite this article Cho SJ, Bader SO, Heitz JW. Venous Air Embolism during Anterior Lumbar Surgery. J Perioper Echocardiogr 2013;1(1):30-32.

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