Venous Air Embolism through a Groshong Catheter

Individuals with cancer frequently require long-term central venous access to deliver chemotherapy, blood products, and other fluids. A rare, but potentially lethal complication associated with central venous catheterization is venous air embolism which occurs most commonly after damage or disconnection at the catheter hub. The Groshong (Bard Access Systems, UT) catheter is a device with a unique three-position valve at its distal tip which eliminates the need for routine heparin flushing and minimizes the risk of venous air embolism. This report describes for the first time a near fatal venous air embolism in a patient with an externally accessed Groshong catheter.     

Air emboli in the intracranial venous sinuses of neonates

Air bubbles in the intracranial venous sinuses are known as a consequence to different causes including trauma, infection, and administration of intravenous contrast. Most of the previous reports demonstrated such cases in adults, with subsequent complications. We are presenting two premature babies who developed asymptomatic air bubbles in the right cavernous and left transverse sinuses, introduced accidentally upon cannulation of scalp veins. In both babies the air embolism disappeared in a few days without complications. Our cases suggest that these accidents could happen more frequently in neonates following scalp vein cannulation, which is a common procedure in sick babies, but they were overlooked as the outcome was uneventful. However, the precise nature and clinical significance of this lesion is not well understood in neonates.     

Venous thromboembolism in pregnancy

Venous thromboembolism (VTE) includes deep vein thrombosis (DVT) and pulmonary embolism (PE). In pregnancy, deep vein thrombosis accounts for 75–80% of venous thromboembolism, the remainder are pulmonary embolisms. One half of these VTEs occur during pregnancy and the other half in the postpartum period. Venous thromboembolism is one of the leading causes of maternal mortality worldwide and is also the cause of significant maternal morbidity. This article discusses the risk factors for VTE in pregnancy, the management of the pregnant woman at risk both antenatally and postpartum and the acute management of VTE when it occurs during pregnancy.     

Embolism of air and gas in hysteroscopic procedures: pathophysiology and implication for daily practice

Hysteroscopic surgery has gained in popularity and has become the method of choice for diagnostic and therapeutic interventions of intrauterine pathology. Advantages consist of short operating time, rapid postoperative recovery, and low morbidity. However, there are concerns about the potential serious complications that can occur, such as venous air and gas embolism. These are rare but hazardous complications, which can occur in all surgical procedures. In hysteroscopic surgery, large uterine veins may be exposed and are, therefore, a point of entry for gas or air. A number of fatal and nonfatal cases have been described as case reports. Although awareness for air and gas embolism is raised this way, proper guidelines as to how to reduce the risk of venous gas or air embolism are lacking. The pathophysiologic difference between gas and air embolism is described herein because composition of the gases differs as does their physiologic effects. A gas embolism is likely to be derived from electrosurgical vapors whereas air embolism seems to arise from improper purging of lines or reinsertion of hysteroscopic instruments. Treatment regimens must, therefore, be designed to address the specific gases involved. Signs and symptoms of these different embolisms are described, as early detection and intervention are crucial for survival. Furthermore, we provide guidelines for operating department personnel, surgeons, and anesthesiologists to reduce the risk of venous gas or air embolism during hysteroscopic procedures. Potential complications of these procedures may be prevented this way.     

Gas embolism and hyperbaric oxygen treatment during pregnancy: a case report and a review of the literature

We report the first case of a pregnant woman presenting with a paradoxical air embolism due to accidental removal of a central venous catheter. Secondary right hemiplegia associated with a confused state justified emergency hyperbaric oxygen therapy, which was followed by complete neurological recovery. The aim of this case report is to assess risk situations of gas embolism during pregnancy and puerperium, as well as indications and fetal effects of hyperbaric oxygen therapy.     

Dural arteriovenous malformation of the transverse sinus with sinus occlusion: report of a case.

We report a case of dural arteriovenous malformation (AVM) of the transverse sinus with sinus occlusion. This 49-year-old man developed right parietal lobe dysfunction with acute onset. Computed tomography and magnetic resonance imaging (MRI) showed a non-hemorrhagic venous infarct in the subcortical white matter of the right parietal lobe, and diffusely dilated subcortical veins. Thrombosis of the right internal jugular bulb was also revealed on MRI. Cerebral angiography showed a dural AVM in the posterior fossa with occlusion of the right transverse sinus and retrograde venous drainage into the superior sagittal sinus, causing diffuse engorgement of the superficial cortical and the deep intramedullary veins. The focal neurologic deficits in this case were due to a non-hemorrhagic venous infarct in the subcortical white matter of the right parietal lobe secondary to retrograde cortical venous drainage.     

Cerebral Venous Sinus Thrombosis in a Woman Using the Etonogestrel-Ethinyl Estradiol Vaginal Contraceptive Ring: A Case Report

BackgroundThe vaginal contraceptive ring is a hormonal contraceptive that releases etonogestrel and ethinyl estradiol. Cerebral venous sinus thrombosis (CVST) is a rare but serious complication of hormonal contraceptive use.CaseWe present a case of CVST in a 33-year-old nulligravid woman who was using a vaginal contraceptive ring. At the time of presentation, she had been using the ring for 18 months, having previously used oral contraceptives for 13 years. She had no additional risk factors for thrombosis apart from cigarette smoking. Despite vigorous management, the patient died from the effects of the CVST.ConclusionThe serious adverse effects of the vaginal contraceptive ring are not well known, although deep vein thrombosis, pulmonary embolism, and aortic thrombosis in association with use of the ring have been reported to Health Canada. Continuing post-market surveillance of thrombotic risk in users of the vaginal contraceptive ring is critical.     

Extravasation of parenteral alimentation fluid into the renal pelvis--a complication of central venous catheter in a neonate.

Many complications of central venous catheters, which include perforation of the vessel walls and extravasation of the infusate into pericardial, pleural, and peritoneal cavities, have been reported. We report an infant with a central venous catheter in inferior vena cava who experienced extravasation of parenteral alimentation fluid into the right renal pelvis secondary to perforation of the renal vein. To our knowledge, this rare complication has not been reported earlier.     

An unusual case presentation: pericardial tamponade complicating central venous catheter

The use of central venous catheters in very low birthweight infants to provide adequate calories for growth is an integral part of the care of the high-risk neonate. The use of surgically placed Broviac catheters has been associated with infectious and mechanical complications. Recently, there has been increasing use of silastic central venous catheters inserted through a peripheral vein and advanced to the right atrium. These catheters have a reported low rate of complications. However, we report a case of a very low birthweight infant in whom a peripherally inserted silastic catheter perforated the wall of the right atrial appendage and led to fatal pericardial tamponade. This is a very rare but nearly always fatal complication. It is potentially avoidable by careful placement of the tip of the central venous catheter, so that it is not impinging on a wall of the heart. Serial venograms may be useful to reconfirm the position of the catheter.     

Prenatal MR imaging of dural sinus malformation: a case report

OBJECTIVE: To describe prenatal magnetic resonance imaging (MRI) findings of dural sinus malformation (DSM), a very rare, congenital form of dural arteriovenous shunt (DAVS), typically affecting newborns. METHODS: Ultrasound (US) and MRI were performed at 34 weeks' gestation, and the findings of these examinations were compared with postnatal MRI studies performed at 2 days and 1 month. RESULTS: US showed an anechoic, midline posterior fossa collection with irregular internal echodensities. Color Doppler showed prominent arterial vascularity at the lesion margins. The prenatal MRI showed a large, profoundly hypointense, midline retrocerebellar mass. Postnatal MRI, complemented with magnetic resonance (MR) angiography, showed the lesion to be a giant dural venous pouch fed by multiple mural arteriovenous shunts. Follow-up MRI at 1 month suggested latent venous hypertension and prompted endovascular treatment. CONCLUSION: Prenatal MR imaging is useful to establish the diagnosis, to assess complications such as hydrocephalus and tonsillar prolapse, and to help plan perinatal management, postnatal follow-up, and treatment decision-making.     

Vascular access in gynecologic cancer using the Groshong right atrial catheter

From December 1986 through July 1987, forty-one Groshong catheters were inserted in 38 patients with invasive gynecologic cancer for a cumulative total of 4170 days of patient use. (mean catheter indwelling time: 93 days; range: 3-300 days). A supraclavicular approach was used to cannulate the brachiocephalic vein in 31 patients. In 6 patients, the subclavian vein was cannulated via an infraclavicular approach, while 4 patients had the catheters placed via external jugular venous cutdown. Thirty-seven catheters were inserted at the bedside without fluoroscopy using the Seldinger technique and a peel-away catheter introducer sheath. A chest x-ray was used to confirm the right atrial position of the catheter. Major complications included two pneumothoraces, and three catheter-related cases of sepsis. A unique feature of the Groshong catheter is a pressure-sensitive two-way valve at the intravascular end, minimizing the potential for air embolism and back-bleeding. This eliminates the need for a heparin flush or external clamping, but permits blood sampling. Catheter insertion and maintenance procedures at bedside are simple, time saving, and cost effective. With the increasing use of continuous chemotherapy infusion protocols, use of vesicant drugs, hyperalimentation, and the need for outpatient therapy, we recommend early placement of the Groshong catheter in the oncology patient.     

Improved subclavian cannulation technique

An improved subclavian cannulation technique using a 3 milliliter syringe attached to a No. 16 gauge needle and a guide wire is presented. Major complications, such as air embolism, vein laceration and retained catheter fragments, are eliminated by using this method of catheterization.     

Trombosis del seno venoso cerebral en gestante con síndrome de Job

Cerebral venous sinus thrombosis is uncommon. Pregnancy is a major risk factor for the development of this entity. We report the case of a patient with Job’s syndrome and protein C and S deficiency who developed cerebral venous sinus thrombosis and dural fistula at 36 weeks’ gestation. After heparinization, the treatment of choice, pregnancy termination to eliminate the prothrombotic status and embolization of the dural fistula were required to obtain complete remission of the neurological symptoms.     

宫腔镜气体栓塞的认识

宫腔镜手术是一项微创、安全的术式,已成为妇科的一项诊疗常规。其优点包括手术时间短、术后恢复快、并发症少。然而,宫腔镜手术存在一些潜在、致命的并发症,如TURP综合征、空气或气体栓塞。气体栓塞发病率较低,但危险性极高,整个手术过程均可发病,发病隐匿,临床症状缺乏特异性,容易被手术医师忽略而导致灾难性后果。在宫腔镜手术过程中,大的子宫静脉的暴露会为气体的进入提供入口,临床上已有许多致死病例的报道。近年来手术医师对气体栓塞的意识有所增强,但关于如何减少其发生率仍缺乏相应的指南。另外,不同气体组成不同,其病理生理改变也不同。术中密切监测症状及体征,及时发现、尽早干预能明显提高患者存活率。该文章旨在提高妇科医师对宫腔镜手术气体栓塞的认识,为术者、手术室人员及麻醉医师提供相应指南,减少术中气体栓塞的危险性,尽最大可能阻止灾难性并发症的发生。     

Sinus venous thrombosis: a differential diagnosis of postpartum headache

In this report, we describe a patient who developed severe headache following epidural analgesia for labor and delivery. Although the epidural puncture had been reported to be uneventful, headache was initially suspected to result from an accidental dural puncture. After the headache worsened, a sinus venous thrombosis was suspected and subsequently confirmed by magnetic resonance imaging. This case highlights the difficulty of differential diagnosis of headache in the postnatal period in patients after EDA and stresses the necessity of considering alternative pathologies.     

Circumaortic left renal vein: report of a case.

Circumaortic left renal vein is an uncommon anomaly which has not been previously reported in Taiwan. We describe a case of circumaortic left renal vein in a 15-year-old girl who presented with intermittent hematuria. Angiogram revealed double left renal veins in the form of a venous collar. Computed tomography depicted the preaortic and retroaortic left renal veins clearly. In a survey of hematuria, circumaortic renal vein should be taken into consideration in a differential diagnosis, and an appreciation of the specific radiologic findings can help to establish the diagnosis easily. In addition, preoperative recognition of this uncommon anomaly is of supreme importance in a retroperitoneal operation in order to avoid massive bleeding.     

Central venous catheter-induced atrial ectopic tachycardia with reverse alternating Wenckebach periods.

A centrally inserted venous catheter may cause atrial ectopic tachycardia. The association of atrial ectopic tachycardia with spontaneous reverse alternating Wenckebach periodicity has rarely been reported. We describe a 4-year-old boy with tetralogy of Fallot who developed atrial ectopic tachycardia with reverse alternating Wenckebach periods postoperatively after central venous catheter placement. All such episodes emerged from a 3:2 atrioventricular block, followed by runs of 2:1 atrioventricular block with progressive shortening of the conducted PR intervals. Normal sinus rhythm returned after the catheter was withdrawn to the superior vena cava. Reverse alternating Wenckebach periodicity may be a tachycardia-dependent physiologic phenomenon.     

Catheter-directed thrombolysis for thromboembolic disease during pregnancy: a viable option

Anticoagulation with intravenous heparin has been the standard treatment for the management of gestational thromboembolic complications. Catheter-directed thrombolysis is an encouraging approach for the treatment of thromboembolic disease and has not been previously reported during pregnancy. One gravid woman with pulmonary embolism, critically ill, and hemodynamically compromised, and two gravid women with iliofemoral venous thrombosis, who failed to respond to standard treatment with intravenous heparin, were treated with catheter-directed urokinase. All three patients experienced rapid resolution of symptoms and successful pregnancy outcomes. In our three patients, catheter-directed thrombolysis for thromboembolic disease during pregnancy allowed rapid resolution of hemodynamic abnormalities and/or resolution of thrombus. Catheter-directed thrombolysis offered a reasonably safe alternative to prolonged medical management in these young, otherwise healthy, patients. Long-term, it may prevent the postphlebitic syndrome.     

Effects of outflow pressure on fetal lymph flow

The purpose of this study was to determine to what extent fetal thoracic duct lymph flow may be reduced by increases in fetal venous pressure. In pregnant sheep the fetal left thoracic lymph duct was catheterized at the base of the neck and this catheter was connected to a jugular-vein catheter so the lymph could spontaneously return to the fetal circulation. At 5 days after catheter implantation in nine unanesthetized fetuses at 133 +/- 1 (SE) days' gestation, lymph flow was measured by disconnecting the lymphatic catheter from that in the jugular vein and varying outflow pressure of the lymphatic catheter independent of venous pressure. Whenever outflow pressure was negative, lymph flow was independent of outflow pressure and averaged 0.66 +/- 0.05 ml/min. When outflow pressure of the left thoracic duct was increased above zero, lymph flow decreased linearly with outflow pressure and flow stopped at an outflow pressure of 11.5 +/- 0.6 mm Hg. At a normal venous pressure of 3 mm Hg, the lymph-flow sensitivity to venous pressure was such that a 1 mm Hg rise in venous pressure reduced lymph flow by 12.7% +/- 1.2%. Thus it appears that fetal lymph flow is very sensitive to outflow pressure and only moderate elevations in venous pressure potentially may lead to fetal edema.     

Air embolism after central venous catheterization

Air embolism--the most dangerous complication of central venous catheterization--may occur in several ways. The most frequent is from disconnection of the catheter from the related intravenous tubing. An embolism may present with a sucking sound, tachypnea, air hunger, wheezing, hypotension and a "mill wheel" murmur. A later manifestation is severe pulmonary edema. In a review of 24 patients, the mortality was 50 per cent. Among the survivors, five (42 per cent) had neurologic damage. Immediate treatment includes placing the patient in the left lateral and Trendelenberg positions, administration of oxygen and aspiration of air from the heart. Cardiac massage and emergency cardiopulmonary bypass may be necessary. Most instances can be prevented by inserting the cannula with the patient in the Trendelenberg position, occluding the cannula hub except briefly while the catheter is inserted, fixation of the catheter hub to its connections and occlusive dressing over the track after removal of the catheter.