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 by reducing venous pressure, are significant contributing factors
Treatment
Prevent further air entry by clamping and disconnecting the circuit
Flat supine position may be better over traditionally advocated left lateral (Duran’s position) and Trendelenburg position1,2
Oxygen with FiO2 100%
Hyperbaric oxygen3 (prevents cerebral edema)
Use of Luer-lock syringes for blood draw from catheters
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 pressure4.
References:
Vesely TM. Air embolism during insertion of central venous catheters. J Vasc Interv Radiol 12:1291-1295, 2001
Muth CM, Shank ES. Gas embolism. N Engl J Med 342:476-482, 2000
Baskin SF, Woznizk RF. Hyperbaric oxygenation in the treatment of hemodialysis-associated air embolism. N Engl J Med 293:184-185, 1975
Palmon SC, Moore LE, Lundberg J, Toung T. Venous air embolism: A review. J Clin Anesth 9:251-257, 1997
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