Mechanism of fatal air embolism after gastrointestinal endoscopy

Abstract

Although venous air embolism is a known complication in medical practice in general, only a single case of upper gastrointestinal endoscopy complicated by venous air embolism with consecutive acute cardiovascular failure has so far been described in literature. Here we show that gastroscopy may be accompanied by massive, i.e. fatal venous air embolism. If a vessel in the gastrointestinal tract is exposed but does not collapse (in the case of a gastric ulcer, for example) air insufflated under pressure by the gastroscope may lead to a fatal air embolism. Our tests using a commercial gastroscope revealed that an overpressure of up to 43 kPa (kiloPascals) is reached without the rinsing function while an overpressure of up to 45 kPa is measured if the rinsing function is operated simultaneously. The maximum flow rates without resistance were 100 ml/min for rinsing liquid (purified water) and 2000 ml/min for air. Our results suggest that air insufflation by the gastroscope may result in a critical air embolism within very few seconds on condition that a connection with the vascular system exists. However, this complication is extremely rarely encountered. We propose that CO2 should be administered in place of air or alternatively the maximum pressure should be considerably reduced to avoid a fatal outcome in routinely performed gastroscopical examinations.

Carbon dioxide insufflation in esophageal endoscopic submucosal dissection reduces mediastinal emphysema: A randomized, double-blind, controlled trial

“…Air insufflation is associated with rare but serious adverse events of endoscopic procedures, such as air embolism and tension pneumothorax [23][24][25][26][27] . As a matter of fact, several fatal air embolisms caused by endoscopic procedures have been reported.…”

Safety and efficacy of carbon dioxide insufflation during gastric endoscopic submucosal dissection

“…Although air is commonly used for insufflation, it results in the retention of a large amount of residual gas after ESD. Residual gas in the gastrointestinal tract can induce post-ESD pain or discomfort, and in rare cases can give rise to life-threatening complications such as air embolism and tension pneumothorax [9][10][11][12][13][14][15][16][17] . It is well known that carbon dioxide (CO2) is absorbed faster in the body than air and is also rapidly excreted through the lungs, except in cases of pulmonary dysfunction.…”

Infarto encefálico por embolia aérea: Caso clínico

“…Nuestra paciente presentó una embolia aérea arterial asociada a una endoscopia digestiva alta, lo que está descrito como una rara complicación de este procedimiento, principalmente cuando es insuflado aire bajo presión por el gastroscopio o cuando se realizan procedimientos como biopsia, proponiéndose como mecanismos la embolia paradójica o la fístula esófago-vena pulmonar [1][2][3][4]10,17 . El mecanismo por el cual nuestra paciente presentó una embolia aérea arterial encefálica no fue estudiado debido a su manejo conservador.…”