Air EmbolismAir Embolism (AE) is often a life-threatening complication of large bore intravascular device insertion and removal. Although much focus has been with the insertion phase, device removal is just as potentially dangerous.

There is becoming an increased awareness of AE through patient advocacy groups and from a patient safety perspective taught by experienced healthcare clinicians. There are more frequent publications related to AE and certainly this complication is getting a wider girth of awareness.

Essentially, ANY intravascular device – intravenous (IV) or intra-arterial (IA), can cause an AE. Although IA is potentially a lesser risk, it does not mean that it doesn’t occur.

Devices, particularly IV, should be removed with the patient satisfying the following criteria;

  1. The patient/client should be in a supine (flat) or slight Trendelenburg position (15-20° head-down) – particularly for CVADs and PICCs.
  2. Should be removed at end-expiration – for all devices.
  3. Should have an air-occlusive, paraffin or petroleum-based dressing over the removal site for 48 hours, until the exit site wound has sealed closed.

Many clinicians who remove these types of devices MUST be educated and aware of potential for AE to occur, and need to ensure that preventative measures are in place BEFORE a device is removed.

Following the three actions listed above will reduce the risk of AE in most situations.
An easy to remember way is to think, ‘the patient should be in the same position for removal of the device as for the insertion of the device’. Easy.

When air embolism is suspected, the patient should be placed on 100% oxygen and on the left lateral decubitus position, which may improve right ventricular outflow by keeping air in the right atrium or in the apex of the right ventricle, away from the pulmonary artery and right ventricular outflow tract.

AE should also be included during ‘mock’ codes – simulated scenarios for training purposes. This is one way of ensuring the education is met on a regular (or even mandatory) level within healthcare facilities for clinicians who are associated with intravascular device removal.

Here are several links to recent articles on air embolism prevention (courtesy of JVA);

Tunneled central venous catheter exchange: techniques to improve prevention of air embolism

Over-catheter tract suture to prevent bleeding and air embolism after tunnelled catheter removal

Cerebral air embolism after central dialysis line removal: the role of the fibrin sheath as portal (mechanism) of air entry

#vascularaccess #FOAMva

4 Comments

  1. Great reminder Tim. We recently revised our vascular access care/maintenance policy to include petroleum dressing over picc site when removed.

  2. I fight every time there is a PICC removal sent to us that patient needs to be supine. I always get an argument. I also have the patient take a deep breath prior to start , hold while I am pulling, if it is taking a while, I stop, exert pressure at the insertion site to allow them to breathe, them begin again with deep breath, hold, pull. A&D ointment and occlusive dressing to the site. I had always thought 24 hours, I will recommend 48 going forward. Thanks for. An informative post.

    1. Can you provide references for these recommendations? Any specific research to support these recommendations? I also teach 24 hours Not 48 hours for dressing change following PICC removal.

  3. So Ellen, I did a quick literature search – much of the cases describing AE are in the hemodialysis/CVAD populations, but it is not just limited to these groups. AE can occur even with a relatively small bore peripheral device, as well as PICCs and midlines.
    Google Scholar search: https://scholar.google.com.au/scholar?q=CVC+air+embolism+treatment&hl=en&as_sdt=1%2C5&as_ylo=2016&as_vis=1&oq=CVC+air+embolism+tre

    Often the degree of morbidity and mortality in venous air emboli is associated with the volume of gas, the rate of accumulation, and the patient’s position at the time of the event. The estimated adult lethal dose of air has been estimated at between 200 and 300 mL (3–5 mL/kg), an amount which can be introduced in just 2–3 secs with a 14-gauge needle and a pressure gradient of 5 cm H2O. Essentially, the closer the air entry is to the right heart, the less volume of air is required to have fatal consequences.

    I think that although the majority of literature says cover the site with an air-occlusive dressing, leaving it insitu for 48hrs guarantees that there should be a complete closure of the exit site and subcutaneous tract through the skin. We cannot however guarantee that this occurs within the first 24hr period.

    A couple of references for your interest;

    http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2011.06.016

    http://journals.lww.com/md-journal/pages/articleviewer.aspx?year=2015&issue=04010&article=00005&type=abstract

    https://www.ncbi.nlm.nih.gov/pubmed/9365331

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