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A quality review of the occurrence of a non-fatal venous air embolism event following CT contrast enhanced administration for the purpose of radiation therapy planning

Published online by Cambridge University Press:  23 April 2013

Y. Bayliss ,
A. Balogh ,
P. Burrowes ,
G. Brunet  and
K. Jensen
Y. Bayliss
Affiliation:
Department of Radiation Oncology, Tom Baker Cancer Centre, Alberta Health Services, University of Calgary, Alberta, Canada
A. Balogh
Affiliation:
Department of Radiation Oncology, Tom Baker Cancer Centre, Alberta Health Services, University of Calgary, Alberta, Canada Department of Radiology, Foothills Medical Centre, Alberta Health Services, University of Calgary, Alberta, Canada
P. Burrowes
Affiliation:
Department of Radiology, Foothills Medical Centre, Alberta Health Services, University of Calgary, Alberta, Canada
G. Brunet
Affiliation:
Department of Radiology, Foothills Medical Centre, Alberta Health Services, University of Calgary, Alberta, Canada
K. Jensen*
Affiliation:
Department of Radiation Oncology, Tom Baker Cancer Centre, Alberta Health Services, University of Calgary, Alberta, Canada
*
Correspondence to: Katherine Jensen, Department of Radiation Oncology, Tom Baker Cancer Center, 1331-29 Street, N.W. Calgary, Alberta, Canada T2N4N2. Tel: 403-521-3786. E-mail: katherine.jensen@albertahealthservices.ca
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Abstract

Background

The incidence of venous air embolism (VAE) during and following diagnostic and interventional radiographic procedures utilizing contrast media has been well documented in the literature. However to date a case report of a venous air embolism occurring within an outpatient healthcare facility during a contrast enhanced computer tomography radiation therapy planning procedure remains under reported.

Purpose

Healthcare professionals must remain alerted to the fact that iatrogenic VAE may occur unexpectedly during and following diagnostic and interventional radiographic procedures utilizing the injection of contrast media. The action by all healthcare professionals to implement rapid and clear acute care guidelines will increase the probability of the patient recovering from the event.

Materials and methods

A review of the aetiology and associated pathophysiology of VAE is provided. This is followed by a detailed case report of the occurrence of a non-fatal VAE event (patient consent was obtained and the consent form template was reviewed by a Research Ethics Board).

Conclusion

We conclude with a discussion of quality assurance recommendations that should be considered for implementation in an outpatient facility setting that is performing contrast enhanced computer tomography diagnostic, interventional or radiation therapy planning radiographic procedures.

Keywords

CT contrastradiation therapy planningvenous air embolism
Type
Original Articles
Information
Journal of Radiotherapy in Practice , Volume 13 , Issue 1 , March 2014 , pp. 29 - 34
Copyright
Copyright © Cambridge University Press 2013 

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References

1.Palmon, S C, Moore, L E, Lundberg, J, Toung, T. Venous air embolism: a review. J Clin Anesth 1997; 9 (3): 251–257.Google Scholar
2.Muth, C M, Shank, E S. Gas embolism. New Engl J Med 2000; 342 (7): 476–482.Google Scholar
3.Andrews, C M. Emergency: preventing air embolism. Am J Nurs 2002; 102 (1): 34–36.Google Scholar
4.Pham, K L, Cohen, A L. Iatrogenic air embolism during contrast enhanced computerized tomography: a report of two cases. Emerg Radiol 2003; 10: 147–151.Google Scholar
5.Mirski, M A, Lele, A V, Fitzsimmons, L, Toung, T. Diagnosis and treatment of vascular air embolism. Anesthesiology 2007; 106 (1): 164–177.Google Scholar
6.Bessereau, J, Genotelle, N, Chabbaut, Cet al. Long term outcome of iatrogenic air embolism. Intensive Care Med 2010; 36: 1180–1187.CrossRefGoogle Scholar
7.Kizer, K W, Goodman, P C. Radiographic manifestations of venous air embolism. Radiology 1982; 144: 35–39.Google Scholar
8.Yeakel, A E. Lethal air embolism from plastic blood storage container. J Am Med Assoc 1968; 204: 267–279.Google Scholar
9.Toung, T J, Rossberg, M I, Hutchins, G M. Volume of air in a lethal venous air embolism. Anesthesiology 2001; 94: 360–361.Google Scholar
10.Durant, T M, Long, J, Oppenheimer, J. Pulmonary (venous) air embolism. Am Heart J 1947; 33: 269–281.CrossRefGoogle ScholarPubMed
11.Sviri, S, Woods, W P D, Van Heerden, P V. Air embolism – a case series and review. Crit Care Resusc 2004; 6 (4): 271–276.Google Scholar
12.IE, S R, Rozans, M H, Szerlip, H M. Air embolism after intravenous injection of contrast material. South Med J 1999; 92 (9): 930–933.CrossRefGoogle ScholarPubMed
13.Aurora, T, Ward, K R, Garza, R, Rivers, E. Visual diagnosis in emergency medicine: iatrogenic venous air embolism. J Emerg Med 2000; 18 (2): 255–256.CrossRefGoogle Scholar
14.Fargo, R A, Specht, L, Anholm, J. Massive venous air embolism complicating automated injection prior to CT scan. Chest 2000; 118 (4) (suppl): 300S.Google Scholar
15.Sheasgreen, J, Terry, T, Mackey, J R. Large volume air embolism as a complication of augmented computed tomography: case report. Can Assoc Radiol J 2002; 53 (4): 199–201.Google Scholar
16.Imai, S, Tamada, T, Gyoten, M, Yamashita, T, Kajihara, Y. Iatrogenic venous air embolism caused by CT injector – from a risk management point of view. Radiat Med 2004; 22 (4): 269–271.Google ScholarPubMed
17.Husain, S, Ahmed, L, Al-Sawwaf, M. Venous air embolism from intravenous CT contrast administration. J Am Coll of Surg 2006; 202 (1): 197.CrossRefGoogle ScholarPubMed
18.Cuvelier, A, Muir, J F. Venous air embolism. N Engl J Med 2006; 354 (25): e26.Google Scholar
19.Mendenhall, M L, Spain, D A. Venous air embolism and pressure infusion devices. J Trauma 2007; 63: 246.Google ScholarPubMed
20.Sodhi, K S, Das, P J, Malhotra, P, Khandelwal, N. Venous air embolism after intravenous contrast administration for computed tomography. J Emerg Med 2009; 42 (4): 450–451.Google Scholar
21.Ball, C G, Rajani, R R, Feliciano, D V, Nicholas, J M. Venous air emboli and computed axial tomography power contrast injectors. Am J Surg 2009; 197: e57–e58.Google Scholar
22.Oppenheimer, M J, Durant, T M, Lynch, P. Body Position in relation to venous air embolism and associated cardiovascular-respiratory changes. Am J Med Sci 1953; 225: 362–373.Google Scholar
23.Woodring, J H, Fried, A M. Nonfatal venous air embolism after contrast enhanced CT. Radiology 1988; 167: 405–407.CrossRefGoogle ScholarPubMed
24.Groell, R, Schaffler, G J, Rienmueller, R, Kern, R. Vascular air embolism: location, frequency, and cause on electron beam CT studies of the chest. Radiology 1997; 202: 459–462.Google Scholar
25.Burrowes, P, Wallace, C, Davies, J M, Campbell, L. Pulmonary edema as a radiologic manifestation of venous air embolism secondary to dental implant surgery. Chest 1992; 101: 561–562.Google Scholar
26. Canadian Patient Safety Institute, Institute for Safe Medication Practices Canada, Saskatchewan Health. Canadian Root Cause Analysis Framework, Edmonton: Canadian Patient Safety Institute, 2006.Google Scholar
27.Jensen, K, Bayliss, Y. A radiation therapy venipuncture certification education program. J Med Imag Radiat Sciences 2008; 39: 144–148.Google Scholar