Correspondence  |   November 2007
Hair Splitting, Air Embolism, and Transesophageal Echocardiography
Author Notes
  • Evangelisch-Freikirchliches Krankenhaus und Herzzentrum Brandenburg in Bernau, Bernau, Germany.
Article Information
Correspondence   |   November 2007
Hair Splitting, Air Embolism, and Transesophageal Echocardiography
Anesthesiology 11 2007, Vol.107, 852. doi:10.1097/01.anes.0000287531.35507.89
Anesthesiology 11 2007, Vol.107, 852. doi:10.1097/01.anes.0000287531.35507.89
To the Editor:—
The continuing medical education–accredited article “Diagnosis and Treatment of Vascular Air Embolism” by Dr. Mirski et al  .1 in the January 2007 issue of this journal merits some comments. The term vascular air embolism  was new to me, and the PubMed search with the search term vascular air embolism  yielded 7 results. The search term venous air embolism  , however, with which I am more familiar, yielded 432 hits. In Dr. Mirski’s article, there are 150 references, but in only one of the cited articles, which is a radiologic article, is the term vascular air embolism  used.2 The Merriam-Webster Online Dictionary defines embolism as “sudden obstruction of a blood vessel.”1Therefore, by definition, there is no embolism other than vascular. The abbreviation VAE  that Dr. Mirski uses for vascular air embolism  in the literature is generally attributed to venous air embolism  .
This is no semantic hair splitting. It has rather a fundamental clinical impact as a consequence of various pathophysiologic mechanisms and distinct clinical sequelae. The term venous air embolism  (VAE) describes the entrainment of air into the venous blood system leading to right ventricular constraint, elevation of pulmonary pressure and an increase in pulmonary vascular resistance, and it eventually ends in right heart failure and death. The sudden increase of right ventricular pressure might cause an reopening of the foramen ovale with consecutive transition of air bubbles from the right to left ventricle, leading to an obstruction of cerebral vessels, coronary arteries, the ophthalmic artery, or other branches of the arterial system, resulting in cerebral infarction, myocardial ischemia, blindness, or other symptoms of hypoperfusion or nonperfusion. In contrast to VAE, the entrainment of air into the arterial system, either directly or secondary through a persistent or a reopened foramen ovale, is termed arterial  or paradoxical air embolism  (PAE).
These considerations and the fact that VAE occurs in up to 100% all of operations in the sitting position3,4 lead to question which preoperative tests are necessary to identify patients with an increased risk to experience VAE and PAE intraoperatively. The persistent permanent foramen ovale, which is found in an unselected population with a prevalence of approximately 25%,5 is as such a major risk factor for PAE. Transesophageal echocardiography (TEE) and transcranial Doppler ultrasound are equally effective in the detection of a permanent foramen ovale before surgery in the sitting position.6 There is broad consensus that patients with a permanent foramen ovale should be excluded from surgery in the sitting position; at least the advantages of the sitting position should be carefully weighed against the risk of the potentially hazardous consequences of massive VAE and PAE in the sitting position.
With respect to intraoperative monitoring, TEE is considered to be the accepted standard in detecting VAE, with an indisputable high sensitivity and specificity. Moreover, it is the only monitor to intraoperatively detect PAE, persistent foramen ovale, and pulmonary passage of air bubbles during massive VAE.7 There is no intraoperative monitoring device other than TEE to reliably and quickly clarify the cause of sudden hypotension and acute hemodynamic instability, which can be due to VAE, hypovolemia, and left or right ventricular failure of any other cause.
Transesophageal echocardiography requires some expertise and, for various reasons, it is not readily available everywhere. Nobody, however, would seriously have doubted the usefulness of intraoperative pulse oximetry, even in the early years after its introduction in clinical practice when it was not on hand in every operating room on the planet. Of course, anesthesiologists strongly advocate the use of pulse oximetry because it is a highly useful and an even life-saving monitoring device even if the incidence of intraoperative hypoxia is definitely not as high as VAE during operations in the sitting position. At least for procedures where one has to face potential life-threatening complications such as VAE and PAE with an incidence of up to 100%, the use of a monitor, such as TEE, with a nearly 100% specificity, sensitivity, and accuracy, has to be strongly recommended.
Recently, a task force of expert neuroanesthesiologists has been entrusted by the Scientific Neuroanesthesia Subcommittee of the German Society of Anesthesiology and Intensive Care Medicine to update the recommendations regarding neurosurgical operations in the sitting and semisitting positions. Preoperative assessment and intraoperative monitoring in patients scheduled to undergo operations in the sitting or semisitting position is of paramount importance. For the task force, the usefulness of TEE in this setting is beyond any doubt, even if there are no prospective, controlled studies to answer the questions whether and how far the use of TEE has a positive impact on clinical outcome parameters such as reduction in complications and mortality.
Evangelisch-Freikirchliches Krankenhaus und Herzzentrum Brandenburg in Bernau, Bernau, Germany.
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