Wośko Jarosław, Dąbrowski Wojciech, Zadora Przemysław, Sawulski Sławomir, Tomaszewski Andrzej
1st Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin.
Anaesthesiol Intensive Ther. 2012 Jan-Mar;44(1):21-4.
Acute air embolism has been described during central venous cannulation, but it may also occur during catheter removal in a spontaneously breathing patient. We describe an episode of acute coronary ischaemia that occurred during CV catheter removal.
A 23-year-old male, multiple trauma patient was treated over 27 days in an ITU. He required a tracheostomy, two weeks of mechanical ventilation, and several surgical interventions. On the 27th day, he was scheduled to be transferred to a low-dependency area and his CVC was removed from the left subclavian vein. After five minutes, the pressure pad was released from the site of cannulation; the patient started coughing and became dyspnoeic. He developed tachyarrhythmia with ST depression in the 2nd, 3rd and aVF leads, followed by marked ST elevation, and subsequently, ventricular fibrillation. The patient was placed in the Trendelenburg position and CPR was started. Normal sinus rhythm returned after three defibrillations. Echocardiography revealed the presence of a large amount of air bubbles within the left ventricle, which disappeared spontaneously within one minute. The patient quickly regained consciousness and his condition returned to normal within 12 h, with transient elevation of heart enzymes. Five days later, he was decannulated and transferred to the orthopaedic ward in a satisfactory condition.
Air embolism during CV catheter removal is a rare event, but it may occur when a persistent tunnel remains after prolonged cannulation, associated with negative intrathoracic pressure created by a spontaneously breathing or coughing patient. In the case described, acute myocardial ischaemia occurred in the region supplied by the right coronary artery, which is located higher than the left one and is therefore more exposed to air bubbles. We could not demonstrate, however, the presence of a persistent foramen ovale, however some connection had to exist between the right and left sides of the heart in our patient.
Special caution should be exercised during CV catheter removal, and the procedure should be always done with the patient placed in the Trendelenburg position.
急性空气栓塞在中心静脉置管期间已有报道，但在自主呼吸患者拔除导管时也可能发生。我们描述了一例在拔除中心静脉导管期间发生的急性冠状动脉缺血事件。
一名23岁的多发伤男性患者在重症监护病房接受了27天的治疗。他需要气管切开、两周的机械通气以及多次外科手术干预。在第27天，他计划转至低依赖病房，并从左锁骨下静脉拔除中心静脉导管。五分钟后，压迫垫从置管部位移除；患者开始咳嗽并出现呼吸困难。他出现快速心律失常，Ⅱ、Ⅲ和aVF导联ST段压低，随后ST段显著抬高，继而发生心室颤动。患者被置于头低脚高位并开始进行心肺复苏。三次除颤后恢复正常窦性心律。超声心动图显示左心室内存在大量气泡，这些气泡在一分钟内自行消失。患者很快恢复意识，12小时内病情恢复正常，心肌酶短暂升高。五天后，他拔除导管并以良好状态转至骨科病房。
拔除中心静脉导管期间的空气栓塞是一种罕见事件，但在长时间置管后存在持续通道时可能发生，与自主呼吸或咳嗽患者产生的胸内负压有关。在所描述的病例中，右冠状动脉供血区域发生急性心肌缺血，右冠状动脉位置高于左冠状动脉，因此更容易暴露于气泡。然而，我们未能证实存在持续存在的卵圆孔未闭，不过我们的患者心脏左右两侧之间必定存在某种联系。
拔除中心静脉导管时应格外小心，该操作应始终在患者处于头低脚高位的情况下进行。
