Massive Transient Pulmonary Air Embolism During Pacemaker Implantation Under Mild Sedation:. An Unrecognized Hazard of Snoring

Department of Cardiology, Ha'Emek Medical Center, Afula, Israel.
Pacing and Clinical Electrophysiology (Impact Factor: 1.13). 06/2004; 27(5):684-5. DOI: 10.1111/j.1540-8159.2004.00510.x
Source: PubMed


We present a case of a massive pulmonary air embolism during permanent pacemaker lead implantation under mild sedation in a 73-year-old woman. We used a peel-away sheath that is devoid of a hemostatic valve. The air embolism occurred after deep inspiration associated with loud snoring sounds and resolved after short chest massage and administration of adrenaline. Temporary closure of the intravenous entrance route of the peel-away sheath before inserting the lead may prevent this potentially lethal complication.

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    ABSTRACT: Pacemaker implantation is associated with the potential for various acute and late complications. Though they rarely occur, massive pulmonary air embolisms are lethal. We report the case of a 72-year old male with sick sinus syndrome who underwent permanent pacemaker implantation. Sedation was administered due to back pain with the resultant appearance of snoring. The procedure was complicated with repeated massive pulmonary air embolisms. The events occurred after the leads had been placed in the sheaths. The patient was successfully resuscitated with fluid challenge, O(2) supplement, vasopressor and catheter aspiration. This case illustrates that in a heavily sedated, snoring patient, the marked negative intrathoracic pressure can overcome the frictional resistance of air to being sucked into the gap between the lead body and sheath's wall. Careful manipulation alone is not enough to prevent pulmonary air embolisms. Aggressive treatment for upper airway obstruction is important. The use of a sheath with a haemostatic valve is strongly recommended if the upper airway obstruction cannot be treated adequately.
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    • "Three main issues are important in diagnosis and management of this problem: (1) deep inspiration should be avoided in the presence of an open intravenous route; (2) when using a peal-away sheath, temporarily close the intravenous entrance route before inserting the lead; and (3) snoring may be an alarm sound! (Turgeman et al., 2004). "

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    ABSTRACT: To assess the patterns of injury and liability associated with monitored anesthesia care (MAC) compared with general and regional anesthesia, the authors reviewed closed malpractice claims in the American Society of Anesthesiologists Closed Claims Database since 1990. All surgical anesthesia claims associated with MAC (n = 121) were compared with those associated with general (n = 1,519) and regional (n = 312) anesthesia. A detailed analysis of MAC claims was performed to identify causative mechanisms and liability patterns. MAC claims involved older and sicker patients compared with general anesthesia claims (P < 0.025), often undergoing elective eye surgery (21%) or facial plastic surgery (26%). More than 40% of claims associated with MAC involved death or permanent brain damage, similar to general anesthesia claims. In contrast, the proportion of regional anesthesia claims with death or permanent brain damage was less (P < 0.01). Respiratory depression, after absolute or relative overdose of sedative or opioid drugs, was the most common (21%, n = 25) specific damaging mechanism in MAC claims. Nearly half of these claims were judged as preventable by better monitoring, including capnography, improved vigilance, or audible alarms. On-the-patient operating room fires, from the use of electrocautery, in the presence of supplemental oxygen during facial surgery, resulted in burn injuries in 20 MAC claims (17%). Oversedation leading to respiratory depression was an important mechanism of patient injuries during MAC. Appropriate use of monitoring, vigilance, and early resuscitation could have prevented many of these injuries. Awareness and avoidance of the fire triad (oxidizer, fuel, and ignition source) is essential to prevent on-the-patient fires.
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