Air embolism and pulmonary interstitial emphysema in a preterm infant with hyaline membrane disease

Abstract

A preterm infant with severe hyaline membrane disease requiring extreme mechanical ventilation developed pulmonary air leaks with consecutive shock. The chest roentgenogram showed bilateral pulmonary interstitial emphysema and gas within the heart silhouette as well as in the hepatic veins, inferior v. cava, portal vein, and many abdominal vessels. The respiratory and circulatory failure by massive systemic gas embolism resulted in death.

Air Embolism in the Newborn: Rare Complication of Intensive Care Therapy in Children

“…27,28 In premature infants, SAE is always due to respiratory-assisted ventilation, such as insertion of central venous lines, 12,28 intravenous injections during resuscitation, 22 and, most of all, long-standing mechanical high-pressure ventilation. [1][2][3][4][5][6][7][8][9][10][11]19,21,22,29 Moreover, it has also been reported in one full-term infant suffering from Figure 2 The first chest-abdomen X-ray taken (A) shows bilateral lung opacities, partially hyperlucent right-lower lobe, tip of the umbilical venous catheter slightly bent to the right above the diaphragm, and signs of free air within the liver. The second chest-abdomen X-ray (B) shows left pneumothorax, diffuse interstitial emphysema, and free air in hepatic, iliac, femoral, and popliteal veins as well as in the upper-arm veins and, bilaterally, the jugular veins.…”

“…2,5 Physiological intravascular air can appear as early as 25 minutes after death, so postmortem X-ray films have to be evaluated with caution when an embolic event is suspected 19,30 However, because it is well known that absorption of intravascular gas, especially oxygen, occurs rapidly after death, the diagnosis of SAE can be overlooked and undetected at postmortem examination. 3,5,8,9 In the preultrasound era, air in the fetal circulation was described as a sign of intrauterine fetal demise, appearing within 3 days of the estimated time of death. 31 Clinical signs of SAE are sudden and dramatic 19,20,23 : cardiovascular collapse, sudden deterioration in respiratory status, pallor, cyanosis, irregularities in cardiac rhythm, as well as seizures and/or the development of neurological defects in non-fatal central nervous system emboli.…”

“…Both SAE and pulmonary vein air embolism are rare, [1][2][3][4][5][7][8][9][10][11][12][13][18][19][20][21][22][23] and there are only a few reported patients who have survived these usually fatal complications. 4,5,18 In the surviving case reported by Kogutt, the patient had no clinical symptoms and the diagnosis was based on radiographic findings only, 4 and an infant with such a condition treated by Weiner et al survived 13 days.…”

“…[1][2][3][4][5][6][7][8][9][10][11][12][13] SAE can also be found in necrotizing enterocolitis 14,15 and following surgical procedures, trauma, 16 and asthmatic spells. This dramatic complication is related to pressure and dissection of air into the pulmonary veins and the systemic circulation, although the mechanism of intravascular air embolism is still not very clear.…”

Fatal air embolism in an extremely low birth weight infant: can it be caused by intravenous injections during resuscitation?

“…From the same sources paradoxical embolism into the systemic arterial circulation may provene via a patent foramen ovale. Systemic air embolism can also result from direct air entry into the arterial side of the pulmonary circulation, as may happen after long-term ventilation with high insufflation pressures, for example, in severe hyaline membrane disease [4,5]. A causal relationship with staphylococcal pneumonia has also been suggested [6].…”