Successful Management of Massive Air Embolism During Cardiopulmonary Bypass Using Multimodal Neuroprotection Strategies

Abstract

Complications and critical events during cardiopulmonary bypass (CPB) are very challenging, difficult to manage, and in some instances have the potential to lead to fatal outcomes. Massive cerebral air embolism is undoubtedly a feared complication during CPB. If not diagnosed and managed early, its effects are devastating and even fatal. It is a catastrophic complication and its early diagnosis and intraoperative management are still controversial. This is why the decision-making process during a massive cerebral air embolism represents a challenge for the entire surgical, anesthetic, and perfusion team. All caregivers involved in this event must synchronize their responses quickly, harmoniously, and in such a way that all interventions lead to minimizing the impact of this complication. Its occurrence leaves important lessons to the surgical team that faces it. The best management strategy for a complication of this type is prevention. Nevertheless, a surgical team may ultimately be confronted with such an occurrence at some point despite all the prevention strategies, as was the case with our patient. That is why, in each institution, no effort should be spared to establish cost-effective strategies for early detection and a clear and concise management protocol to guide actions once this complication is detected. It is the duty of each surgical team to determine and clearly organize which strategies will be followed. The purpose of this case study was to demonstrate that a massive air embolism can be rapidly detected using near-infrared spectroscopy monitoring and can be successfully corrected with a multimodal neuroprotection strategy.

Effect of aortic cannulation depth on air emboli transport during cardiopulmonary bypass: A computational study

“…However, a constant concern for the clinical team is to avert CPB related neurological injury, which can range from cognitive deficits (in up to 50% of cases) to stroke and mortality (1–5%). 2,15 The causes of cerebral damage are complex and multifactorial; however, gaseous cerebral emboli are often considered the instigator of ischaemic injury. 26 The reduction of emboli involves surgical procedures, perfusion technology and CPB management.…”

“…14 Therefore, avoiding the initiation of microemboli is a part of the clinician’s concern, a thorough analysis would additionally include management of persistent microemboli. 15…”

“…14 Therefore, avoiding the initiation of microemboli is a part of the clinician's concern, a thorough analysis would additionally include management of persistent microemboli. 15 Besides the cannula type and position, flow can affect microembolic load and thus its trajectories. Sungurtekin et al in their study of dogs, found that the CPB pump flow is a factor of cerebral embolisation.…”

Improving Trendelenburg position effectiveness by varying cardiopulmonary bypass flow

“…1,3,4 The TP is incorporated with the cessation of pump flow as a common CPB protocol. 1,5,6 Investigations have described procedures with TP as having a slight benefit in reducing air emboli from the cerebral network, yet TP is not always fully considered. 3,4,7 For instance, Borger et al 8 compared distal aortic arch to central cannulation with patients placed in TP and concluded that a significantly lower embolic load occurred, but the contribution of TP was not analysed.…”

Managing Critical Events During Cardiothoracic and Transplant Surgery

“…The clinical challenges forum concludes this issue of the Seminars in Cardiothoracic and Vascular Anesthesia , and our readers will have the opportunity to learn more about some of the potential complications and their respective managements that could occur in our practice such as tracheal injury prior to sternotomy, 9 massive air embolism during cardiopulmonary bypass, 10 removal of retained bronchial tissue glue after repair of a disrupted left main bronchus, 11 and a rare case of inferior vena cava stenosis after heart transplantation. 12 In summary, we present our readers with a highly pertinent set of articles with the ultimate objective on how to manage critical events that present themselves during or immediately after cardiothoracic and transplant surgery.…”