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297: SUCCESSFUL RESUSCITATION WITH HYPERBARIC OXYGEN THERAPY AFTER CATASTROPHIC VENOUS AIR EMBOLISM

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Severe venous air embolism (VAE) following removal of a central venous catheter (CVC) is a rare but serious complication. Early use of hyperbaric oxygen therapy (HBOT) may lead to improved clinical outcomes, especially in patients with evidence of severe right ventricular (RV) dysfunction. Methods: A 55-year old male with oropharyngeal cancer who had previously undergone radical neck dissection and tracheostomy was admitted to the ICU with new-onset episodic, severe oropharyngeal bleeding and underwent successful carotid artery stent placement on hospital day (HD) 5. Following the procedure, the patient developed symptomatic bradycardia and a temporary transvenous pacemaker was placed through the right internal jugular vein. By HD 9, his bradycardia had resolved and the pacemaker was removed. Approximately 5 minutes after pacemaker removal, the patient developed acute, severe hypotension, hypoxemia and dyspnea requiring mechanical ventilation and inotropic support. CT scan demonstrated massive air embolism with involvement of bilateral upper lobes and right middle lobe. The patient was transported to HBOT approximately 2 hours after onset of VAE and was successfully treated with 2 ATM for 90 minutes. On HD 10, the patient underwent a second HBOT because he continued to have evidence of RV dysfunction. On HD 11, repeat CT scan demonstrated complete resolution of VAE. He was weaned from mechanical ventilation and inotropic support within 36 hours of VAE and transferred out of the ICU on HD 12. Results: VAE related to CVC is a rare occurrence, with an estimated incidence of 1/3000 catheterizations. In this case, VAE most likely occurred after the removal of a transvenous pacemaker and venous introducer. The patient was reportedly sitting upright in a chair when the catheter was removed and the site was poorly covered and dressed after removal. The acute onset of severe hypotension and hypoxemia/dyspnea suggests a large amount of air was rapidly entrained, resulting in acute, severe VAE with resulting RV failure from several physiologic processes. In this case, the patient was temporized with conventional therapies utilizing routine ACLS protocols, including mechanical ventilation and inotropic support. Early HBOT was used to reduce the size of pulmonary air bubbles to improve both lung and heart function. In patients with VAE, the early use of HBOT, including transfer to a hospital with HBOT services, is associated with improved clinical outcomes.