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Pearls & Oy-sters: Cerebral venous air embolism after central catheter removal

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 non-rebreather 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.