Air Embolism

Advancements in technology and equipment have significantly decreased the chances of air embolism during hemodialysis. Air embolism during renal dialysis is extremely rare due to the safeguards built into the equipment and procedures that are currently used.  In a study by Tennankore et. Al the number of treatments to have one event was less than 1 in 20,000 (1).  Although air embolism is rare, it is important to understand how it develops in order to properly treat it and prevent it.

Etiology

  • Can be venous or less commonly, arterial
  • Three vulnerable areas of air entry in dialysis patients:
    • Between patient and blood pump
      • Due to high negative pressure and leaks in the circuit in this segment
    • Air in the dialysate fluid (uncommon, mostly gets trapped in venous chamber)
    • During central venous catheter insertion or removal
  • Upright body position and hypovolemia both reduce venous pressure and are significant contributing factors

Patient Presentation

  • Coughing, shortness of breath
  • Chest pain or pressure
  • Tachycardia
  • Distended neck veins
  • Cyanosis/gray color
  • Slight paralysis on one side of the body (cerebral)
  • Confusion, convulsions, coma
  • Possible cardiac/respiratory arrest

Treatment

  • Prevent further air entry by clamping and disconnecting the circuit (2–4)
  • Flat supine position may be better over traditionally advocated left lateral (Duran’s position) and Trendelenburg position (2–4)
  • Oxygen with FiO2 100% (4)
  • Hyperbaric oxygen (prevents cerebral edema) (4,5)
  • Use of Luer-lock syringes for blood draw from catheters (6)

Prevention

  • Test machine prior to use to ensure that the air detector alarm system is working effectively
  • Catheter insertion or removal should be in a head low position (insertion site 5 cm below right atrium).  Patient can assist by holding their breath or doing a Valsalva maneuver that will increase central venous pressure (4)

References

  1. Tennankore KK, D’Gama C, Faratro R, Fung S, Wong E, Chan CT. Adverse Technical Events in Home Hemodialysis. Am J Kidney Dis. 2015;65(1):116-121. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25441436.
  2. Vesely TM. Air embolism during insertion of central venous catheters. J Vasc Interv Radiol. 2001;12(11):1291-1295. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11698628.
  3. Muth CM, Shank ES. Gas Embolism. N Engl J Med. 2000;342(7):476-482. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10675429.
  4. Palmon SC, Moore LE, Lundberg J, Toung T. Venous air embolism: a review. J Clin Anesth. 1997;9(3):251-257. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9172037.
  5. Baskin SE, Wozniak RF. Hyperbaric oxygenation in the treatment of hemodialysis-associated air embolism. N Engl J Med. 1975;293(4):184-185. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1134531.
  6. McCarthy C, Behravesh S, Naidu S, Oklu R. Air Embolism: Practical Tips for Prevention and Treatment. J Clin Med. 2016;5(11):93. Available from: /pmc/articles/PMC5126790/.

P/N 103061-01 Rev A 03/2021