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Too much air can kill PEARLS 1. Cerebral air embolism is a rare but potentially catastrophic consequence of central venous catheter removal. 2. Treatment is often supportive; hyperbaric therapy should be considered but is not readily available in most hospitals and its efficacy for cerebral venous air embolism is unknown. OY-STERS1. Place the patient in the Trendelenburg position before removing the catheter to minimize the risk of air emboli going to the brain. 2. Clinical suspicion of this diagnosis is essential, as signs and symptoms are not specific and brain imaging may not show the presence of air in the cerebral vasculature. 3. Even patients without patent foramen ovale are at risk for cerebral air embolism.CASE REPORT A 95-year-old woman with a history of hypertension presented from a long-term care facility for altered mental status in the context of dehydration and hypoglycemia. Multiple attempts to obtain a peripheral IV failed, and a triple lumen catheter was placed into the right internal jugular vein using the Seldinger technique under ultrasound guidance. No complications followed the procedure. The patient was then rehydrated and given multiple ampules of D50, leading to prompt resolution of the hypoglycemia and improvement in her mental status. After resolution of symptoms, the central line was removed, with the head of the bed at 30°. Within minutes of removal of the central line, the patient developed severe respiratory distress and hypoxia with desaturation to 80% on a nonrebreather mask with 100% oxygen. On examination, the patient was unconscious and gasping for air with severe suprasternal retractions; she was tachypneic and tachycardic, and her blood pressure was 210/100 mm Hg. All limbs were flaccid. She was placed in the left lateral decubitus position as resuscitation efforts were activated. She was then intubated and transferred to the intensive care unit.A stat CT angiogram of the head and neck did not show signs of stroke, bleeding, or vascular occlusion. Chest CT with contrast showed dilation of the distal esophagus with fluid and debris within the distal trachea and left mainstem bronchus, without evidence of pulmonary embolism, and consistent with aspiration. An echocardiogram revealed an ejection fraction of 79%, normal left ventricular function, and mildly dilated left atrium, but no thrombi, vegetations, or evidence of patent foramen ovale (PFO) with agitated saline contrast. Troponin I peaked about 8 hours after the event (0.468, normal range 0-0.034), simultaneous creatine kinase MB was elevated (4.92, normal range 0-2.30), and multiple EKGs were consistent with non-ST elevation myocardial infarction. Prolonged cardiac telemetry failed to show atrial fibrillation. Brain MRI showed areas of restricted diffusion bilaterally in the cerebellum, temporal lobes, frontal lobes, left occipital lobe, and thalami, consistent with different arterial vascular territories, including middle, anterior, and posterior cerebral arteries. It also showed restricted diffusion in the left more th...

SummaryA 66-year-old patient scheduled for elective shoulder surgery underwent a brachial plexus block using the posterior approach. Shortly after injection of the local anaesthetic, he rapidly became unresponsive and apnoeic. We identify the possible reasons for this occurrence and discuss the place of the posterior approach in brachial plexus anaesthesia. There are a number of approaches to the upper trunk of the brachial plexus that anaesthetists can use to provide anaesthesia and analgesia for shoulder surgery. The lateral interscalene or Winnie approach is currently the most popular. However, recent articles on the posterior approach have provoked a discussion about the preferred approach and the better technique [1]. Although the approaches are generally safe, significant complications have been described with both. Total spinal anaesthesia is very rare with the posterior approach and may be due to anatomical variations, technical performance or both [1,2]. An understanding of the factors associated with these complications may help to decrease their incidence. Case reportA 66-year-old man (weight: 93 kg; height: 1.83 m) presented for elective left shoulder hemi-arthroplasty. His medical history included hypertension and an episode of acute coronary syndrome for which he had undergone angioplasty. His routine medication comprised carbasalate calcium, metoprolol, isosorbide-5 mononitrate, diltiazem, captopril, oxazepam, pravastatin and omeprazole. He had not previously undergone surgery or anaesthesia.An 18G intravenous cannula was inserted in the anaesthetic room and an ECG, pulse oximeter and blood pressure cuff were attached. After the subcutaneous injection of lidocaine 1% 2 ml, a brachial plexus block was to be performed by an experienced anaesthetist using the posterior approach with the patient in the sitting position [3]. A Contiplex Tuohy needle (B Braun, Melsungen, Germany) attached to a Stimuplex HNS 11 stimulator (B Braun, Melsungen, Germany) was used with initial stimulator settings of: frequency ¼ 2 Hz; stimulus duration ¼ 0.2 ms; current ¼ 5 mA.Before the needle could be inserted, the patient developed a bradycardia for which intravenous atropine 0.5 mg was given. After the heart rate had returned to normal, he was laid down in the right lateral position. After insertion of the needle, evoked contractions of biceps brachialis and the wrist flexors were produced at a current of 0.3 mA. Levobupivacaine 0.5% 40 ml were injected after negative aspiration before and after every 5 ml of solution injected. The evoked contractions ceased immediately after the start of the local anaesthetic injection. During the injection of the last 5 ml of local anaesthetic, the patient suddenly became unresponsive and apnoeic. The injection was stopped immediately.His blood pressure at this time was 60 ⁄ 30 mmHg with a heart rate of 60 beats.min )1 . His lungs were ventilated with oxygen 100% with a bag, mask and valve. His trachea was then intubated without the need for a neuromuscular blocking drug. He was put in...