CORRESPONDENCE
Dear Editor, Jennifer Campbell should be applauded on a very thorough review of air embolism, titled ‘Recognising air embolism as a complication of vascular access’ (Br J Nurs 23(14): S4-8). The fact that retrograde cerebral venous air embolism is mentioned is commendable, as it is only recently identified and is often ignored (Schlimp et al, 2005). We have to comment, though, that cerebral gas embolism has not been given the appropriate prominence that it deserves. Several of the authors that she quoted have highlighted the importance of hyperbaric treatment (Muth and Shanks, 2000; Moon, 2003; Mirski et al, 2007). Persistent neurological symptoms after a period of arrest or haemodynamic compromise could easily be blamed on hypoxic or ischaemic cerebral damage resulting from global hypoperfusion and/or hypoxia of the brain. However, in this context, the possibility of damage to the cerebral vasculature endothelium by air bubbles
should always be paramount in our differential diagnosis. Particularly so because cerebral gas embolism is eminently treatable if referred and transferred to a hyperbaric chamber within reasonable time. The fact that hyperbaric oxygen therapy has not been mentioned at all is the major shortcoming of this review. Two large retrospective studies from France have shown that recompression in a hyperbaric chamber within 6 or 7 hours have a significant better chance of complete recovery than later referral (Blanc et al, 2002; Bessereau et al, 2010). However, there are a number of cases where much later treatment has still produced significant improvement in the neurological status of the patient (Bitterman and Melamed, 1993). Preventive measures are our paramount aim. If one sees a ‘periprocedural stroke’ diagnosed after resuscitation or stabilisation from haemodynamic compromise related to air embolism, urgent referral for BJN hyperbaric therapy is essential.
Bella Guirindola Critical Care Nurse, Hyperbaric Nurse, James Paget University Hospital, Great Yarmouth
Pieter Bothma Consultant Anaesthetist, Medical Director of London and East of England Hyperbaric Unit, James Paget University Hospital, Great Yarmouth Bessereau J, Genotelle N, Chabbaut C et al (2010) Long-term outcome of iatrogenic gas embolism. Intensive Care Med 36(7): 1180-7. doi: 10.1007/s00134-010-1821-9 Bitterman H, Melamed Y (1993) Delayed hyperbaric treatment of cerebral air embolism. Isr J Med Sci 29(1): 22-6 Blanc P, Boussuges A, Henriette K, Sainty JM, Deleflie M(2002). Iatrogenic cerebral air embolism: importance of an early hyperbaric oxygenation. Intensive Care Med 28(5): 559-63 Mirski MA, LeleAV, Fitzsimmons L, Toung TJ (2007) Diagnosis and treatment of vascular air embolism. Anesthesiology 106(1): 164-77 Moon RE (2003) Air or Gas Embolism. In: Fieldmeier JJ, ed, Hyperbaric Oxygen 2003: Indications and Results, The Hyperbaric Oxygen Therapy Committee Report. Undersea and Hyperbaric Medical Society, Inc., Kensington Muth CM, Shank ES (2000) Gas embolism. N Engl J Med 342(7): 476-82 Schlimp CJ, Loimer T, Rieger M, Lederer W, Schmidts MB (2005). The potential of venous air embolism ascending retrograde to the brain. J Forensic Sci 50(4): 906-9
Response from the author
© 2015 MA Healthcare Ltd
I would like to thank the authors for their constructive letter explaining the role of hyperbaric treatment for cerebral air embolism. While I was aware of this treatment option, I elected not to include it in this short review, focusing instead on the preventative measures that can be taken during the vascular access procedure. Of course, hyperbaric treatment requires more prominence in the literature, and I am grateful to you both for raising this very valid point. Jennifer Campbell
British Journal of Nursing, 2015 (IV Therapy Supplement), Vol 24, No 2
S17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on August 20, 2015. For personal use only. No other uses without permission. . All rights reserved.
Dear Editor, Jennifer Campbell should be applauded on a very thorough review of air embolism, titled ‘Recognising air embolism as a complication of vascular access’ (Br J Nurs 23(14): S4-8). The fact that retrograde cerebral venous air embolism is mentioned is commendable, as it is only recently identified and is often ignored (Schlimp et al, 2005). We have to comment, though, that cerebral gas embolism has not been given the appropriate prominence that it deserves. Several of the authors that she quoted have highlighted the importance of hyperbaric treatment (Muth and Shanks, 2000; Moon, 2003; Mirski et al, 2007). Persistent neurological symptoms after a period of arrest or haemodynamic compromise could easily be blamed on hypoxic or ischaemic cerebral damage resulting from global hypoperfusion and/or hypoxia of the brain. However, in this context, the possibility of damage to the cerebral vasculature endothelium by air bubbles
should always be paramount in our differential diagnosis. Particularly so because cerebral gas embolism is eminently treatable if referred and transferred to a hyperbaric chamber within reasonable time. The fact that hyperbaric oxygen therapy has not been mentioned at all is the major shortcoming of this review. Two large retrospective studies from France have shown that recompression in a hyperbaric chamber within 6 or 7 hours have a significant better chance of complete recovery than later referral (Blanc et al, 2002; Bessereau et al, 2010). However, there are a number of cases where much later treatment has still produced significant improvement in the neurological status of the patient (Bitterman and Melamed, 1993). Preventive measures are our paramount aim. If one sees a ‘periprocedural stroke’ diagnosed after resuscitation or stabilisation from haemodynamic compromise related to air embolism, urgent referral for BJN hyperbaric therapy is essential.
Bella Guirindola Critical Care Nurse, Hyperbaric Nurse, James Paget University Hospital, Great Yarmouth
Pieter Bothma Consultant Anaesthetist, Medical Director of London and East of England Hyperbaric Unit, James Paget University Hospital, Great Yarmouth Bessereau J, Genotelle N, Chabbaut C et al (2010) Long-term outcome of iatrogenic gas embolism. Intensive Care Med 36(7): 1180-7. doi: 10.1007/s00134-010-1821-9 Bitterman H, Melamed Y (1993) Delayed hyperbaric treatment of cerebral air embolism. Isr J Med Sci 29(1): 22-6 Blanc P, Boussuges A, Henriette K, Sainty JM, Deleflie M(2002). Iatrogenic cerebral air embolism: importance of an early hyperbaric oxygenation. Intensive Care Med 28(5): 559-63 Mirski MA, LeleAV, Fitzsimmons L, Toung TJ (2007) Diagnosis and treatment of vascular air embolism. Anesthesiology 106(1): 164-77 Moon RE (2003) Air or Gas Embolism. In: Fieldmeier JJ, ed, Hyperbaric Oxygen 2003: Indications and Results, The Hyperbaric Oxygen Therapy Committee Report. Undersea and Hyperbaric Medical Society, Inc., Kensington Muth CM, Shank ES (2000) Gas embolism. N Engl J Med 342(7): 476-82 Schlimp CJ, Loimer T, Rieger M, Lederer W, Schmidts MB (2005). The potential of venous air embolism ascending retrograde to the brain. J Forensic Sci 50(4): 906-9
Response from the author
© 2015 MA Healthcare Ltd
I would like to thank the authors for their constructive letter explaining the role of hyperbaric treatment for cerebral air embolism. While I was aware of this treatment option, I elected not to include it in this short review, focusing instead on the preventative measures that can be taken during the vascular access procedure. Of course, hyperbaric treatment requires more prominence in the literature, and I am grateful to you both for raising this very valid point. Jennifer Campbell
British Journal of Nursing, 2015 (IV Therapy Supplement), Vol 24, No 2
S17
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on August 20, 2015. For personal use only. No other uses without permission. . All rights reserved.
