Air embolism

A 63-year-old man suffered from severe musculoskeletal deformity due to scoliosis, left renal stone, old stroke and on long term nasogastric tube. He presented with hydronephrosis, urosepsis, pneumonia, septic shock and gastrointestinal bleeding. His heart rate was 145 bpm and blood pressure was 88/67 mmHg, and his hemoglobin dropped from 180 g/L to 108 g/L after 700 ml bloody gastric fluid drainage from the nasal gastric tube. Then he underwent right axillary vein catheter insertion which showed central venous pressure (CVP) was only 2 mmHg, upper endoscopy and percutaneous left nephrostomy. He became hemodynamically very unstable, his heart rate dropped to 40 bpm, his blood pressure dropped to 60/30 mmHg,and noradrenaline was incresed from 0.55 ug/kg/min to 2.2 ug/kg/min to maintain MAP>65 mmHg. CT was repeated showing systemic air embolism. We detected air emboli in the pulmonary artery and aorta (Figure 1), right atrium (Figure 2) and right scapula and vertebral arch. His CT brain revealed intraparenchymal gas and diffuse edema (Figure 3). Agitated saline test did not reveal any right to left shunt on Transesophageal Echocardiogram study. Mediastinum appeared unremarkable on contrast CT Thorax, except for the presence of an esophageal diverticulum. Unfortunately, no definite cause could be attributed for the air embolism although each of the invasive procedure that he received posed the risk. This patient’s BAL culture and blood culture both yielded MDRPA, and pus from percutaneous nephrostomy