Massive venous air embolism with bleeding caused by femoral vein injury during total hip arthroplasty

Venous air embolism (VAE) from vascular injuries, is of rare occurrence but can result in catastrophic complications during total hip arthroplasty (THA). Early recognition and prompt management of vascular injury are required to avoid severe complications. Especially, bleeding is generally associated with profound hypotension in venous injury. We report an unusual complication of venous air embolism induced by femoral vein rupture during THA. Patient concerns: A 54-year-old male patient with a history of old left acetabular fracture was scheduled for THA. We experienced massive bleeding and VAE induced by femoral vein rupture during total hip arthroplasty. The BP suddenly dropped from 100/70 mm Hg to 80/50 mm Hg with massive bleeding. ETCO 2 and SaO 2 decreased profoundly. Diagnosis: The VAE was diagnosed by the change in end- tidal CO 2 (ETCO 2 ) and change of vital signs, so we performed ABGA and inserted TEE for confirmination. Interventions: For treatment, patient was managed by oxygen therapy, inotropics, vasopressor, transfusion and surgical repair. Outcomes: Upon consulting with a cardiologist, the patient was extubated the next day and was transferred to the general ward and recovered without serious complications. He stayed for 17 days until finally discharged without complications Conclusion: Preoperative vascular imaging may be recommended in the revisional case of THA or in patients with the history of hip trauma. The monitoring of ETCO 2 and TEE might be helpful to recognize VAE earlier and therefore to avoid catastrophic complications through adequate treatment.