Ehab Kaiser M.D.             Washington University
Paradoxic air embolism from a hemodialysis catheter
         
 

A 50-year-old man was admitted to the ICU after having hemopneumothorax secondary to cocaine abuse. The next day, he was found to have thrombocytopenia, hemolytic anemia with schistocytes on a peripheral blood smear and change in mental status. Thrombotic thrombocytopenic purpura was considered likely and therefore a hemodialysis catheter was inserted and plasmapheresis was started right away.

On the 10^th hospital day, the patient pulled out the hemodialysis catheter and immediately had a cardiopulmonary arrest. He was resuscitated within 4 minutes and a surface echo-cardiogram was done within 20 minutes after arrest demonstrated air in all four cardiac chambers as well as the aorta. He exhibited decerebrate posturing for approximately 4 hours without focal neurologic deficits. This was most likely secondary to air deposits in the CNS vs. hypoxic encephalopathy. By the next morning, his neurologic status returned to normal.

This case illustrates the potentially devastating consequences of venous air embolism if it gains access to the arterial system. The author will discuss the cause, clinical manifestations, mechanism (cardiac & non-cardiac) and treatment of venous air embolism. It is a good reminder to clinicians to exercise caution each time a central venous catheter is accessed or removed, especially if it has been in place for a long time.