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Education  |   October 2017
Point-of-care Ultrasound Detection of Intraoperative Venous Air Embolism
Author Notes
  • From the Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts.
  • Address correspondence to Dr. Vo: daniel.vo@childrens.harvard.edu
Article Information
Education / Images in Anesthesiology / Radiological and Other Imaging
Education   |   October 2017
Point-of-care Ultrasound Detection of Intraoperative Venous Air Embolism
Anesthesiology 10 2017, Vol.127, 711. doi:10.1097/ALN.0000000000001711
Anesthesiology 10 2017, Vol.127, 711. doi:10.1097/ALN.0000000000001711
POINT-OF-CARE ultrasound is used widely in emergency medicine departments and intensive care units to reduce diagnostic delay and guide medical decision-making in real time.1,2  We present ultrasound images of a basic perioperative transthoracic echocardiogram examination performed during the resuscitation of a 16- month-old girl who presented for an open hip reduction and experienced an acute decrease in her end-tidal carbon dioxide, heart rate, and blood pressure shortly after standard induction, intubation, and caudal block. The images are a subcostal, four-chamber view of the heart obtained shortly after the initiation of resuscitation. There are copious air bubbles giving a snowstorm appearance to the right ventricle (RV) (panel A). The mitral valve, left atrium (LA), and right atrium (RA) are obscured by acoustic shadowing.
The use of transthoracic echocardiography during this event allowed us to narrow the differential diagnosis and promptly initiate therapy for an air embolism discovered to be caused by an unprimed IV line. The ultrasound provided real-time diagnostics, monitoring, and confirmation of resolution. Panel B shows the resolution of air over time with subsequent improvements in left ventricle (LV) function.
As ultrasound competency becomes routine in anesthesia training, expanding its indications to include intraoperative monitoring and assessment is the next necessary step.3  However, care must be taken to develop systematic credentialing processes ensuring that our interpretations are accurate and within our scope of practice. Here, we provide an example of how point-of-care ultrasound was used intraoperatively to efficiently diagnose and treat acute onset of hemodynamic instability.
Competing Interests
The authors declare no competing interests.
References
Jones, AE, Tayal, VS, Sullivan, DM, Kline, JA . Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med 2004; 32:1703–8 [Article] [PubMed]
Pershad, J, Myers, S, Plouman, C, Rosson, C, Elam, K, Wan, J, Chin, T . Bedside limited echocardiography by the emergency physician is accurate during evaluation of the critically ill patient. Pediatrics 2004; 114:e667–71 [Article] [PubMed]
Royse, C, Canty, D, Faris, J, Haji, D, Veltman, M, Royse, A . Core review: Physician-performed ultrasound: The time has come for routine use in acute care medicine. Anesth Analg 2012; 115(5): 1007–28 [Article] [PubMed]