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October 11, 2006
new NEJM advice on Tx of air embolism 8)
brian & jodi:
i miss you greatly today as on cards consults we are trying to devise ways to remove a patients fairly large volume air embolus.
i feel confident that if he were to live in the radiology department for 1 week not only would his air embolus be cured, but so would his hepatitis, ascited, varicies and hiv.
i did come up with a few ideas, we started with the simple things like blindly needling someones heart (like john travolta in pulp fiction) and sucking out....now of course you would want to have available approximately 20 U PRBC as you may have to aspirate a lot to get the air you want. and being that it is the VA we would be able to get the first unit in a mere 5 hours.
we thougth more and decided that potentially this blood issue could be a problem. so we came up with a few other ideas, the one that i am leaning towards at this point is beginning with median sternotomy (of course, cardiology can do this, no reason to bother these surgeons), when we are in the chest go ahead and put the needle in the RV and start aspirating (the air is in the RA, RV and PA), now, since this particular patient also has a significant ASD I thought it would be valuable to get a malleable retractor, as you are needling the RV go ahead and cut into the RA and just set the malleable up next to the ASD. the only this is this does NEED to be a malleable retractor, cause....its malleable, so it will bend and move with the heart and surely not cause any problems. i invision this procedure being done at the bedside.
we have been wanting to TEE this patient to better characterize his ASD, we also toyed with doing a TEE on this guy (of course, careful not to move his body so it doesnt dislodge), we also invisioned watching his air embolus cross his ASD while the TEE was in, we figured that surely we could just pull the scope out and turn it around, and tunnel through his pallet and watch it cause an ischemic stroke.
a few other ideas were batted around, surely none that would be as efficacious as radiation therapy.
if you have any specific suggestions regarding the radiation dose required or the best method of administration (intracardiac seeds?) to cure his air emboli, just let me know 8)
---BRIAN'S REPLY----
Maggie,
Hope things are going well for you.
Things are going swimingly. I'm on neuro right now, desperately trying to disguise the fact that I only know a few things about neuro:
1. Ativan for any signs of seizure. If someone does rapid alternating hand movements too fast on my neuro exam, I generally just jump to a propofol gtt. Why waste time with pansy ativan and dilantin - when you can fix it and forget it? ...plus I get another intubation.
2. Weakness, numbness, confusion, cortical blindness, left sided neglect, whatever - can be treated with a simple aspirin.
3. TPA first, ask time course and get the CT later. If you hit someone with tpa and they have a hemorrhagic bleed, chances are that a good thin slice CT can close the vascular insult anyway...
On to your problem. Air is tricky! Suprisingly, you actually can damage other tissues with the radiation dose needed to eliminate air. The risk is low, but I think I have a better way.
Simply start an IV (a central line might be faster) and hook it up to continuous wall suction. You may need to crank up the suction in order to overcome cardiac output. When you are getting close to sucking out the air, you may need to chemically stop the heart - that's something you'll have to discuss with the cardiologists - they're the experts in that sort of stuff. Once you have the air, simply replace the blood. Due to the theoretical risk of hypotension with this method, you should place the patient on ice and chill the patient below 92 degrees (yes, that's rectal, NOT axillary or oral!) prior to starting.
As for the septal defects, I believe there is some interesting work being done with gene therapy. In essesense, we can develop a drug to induce the genetic disease asymmetric septal hypertrophy. Done and done!
Thank you for this interesting consult. Will follow peripherally, please call with questions.
later,
Brian
---JODI'S REPLY--
Maggie,
I've been thinking about your predicament. Here is what I've come up with (and no worries, this could totally be done at the bedside. 20 minutes tops). I say go for the median sternotomy and the malleable retractor is a must. I like the aspirating from the RV too, but instead of cutting into the RA here is what I think you should do. Do you know those toothpaste tube roller upper things? You know, the ones that squeeze the toothpaste from the bottom of the tube up? I think you should apply one of those to the PA and roll it along until the embolus is in the RV, then put a clamp on the site, so the air can't move back into the PA. Now luckily, you will have that malleable in place, so the air in the RA can't possibly travel through the ASD. Then I would recommend having the patient stand on his head, so that the air from the RA keeps with the laws of physics and travels to the RV, then it should be absolutely no problem to suck that air out. Also, since blood is liquid!
you would have the added advantage of it following the laws of gravity, and traveling in the opposite direction of the air (down) making it easier to suck the air without getting the blood. Problem solved! I would finish up by applying some radiation to the sternotomy site, for good measure.
Posted by Maggie at October 11, 2006 6:57 PM