Venous air embolism during neurosurgery: Rapid overview

Risk factors

Surgical site above the level of the heart; most common in the sitting position
Surgery involving major intracranial venous structures

Clinical and monitoring signs/symptoms

Immediate:
- Air visible on TEE
- Change in precordial Doppler tone
- Cough, in awake patient
May occur:*
- Decrease in ETCO₂
- Decreased blood pressure
- Oxygen desaturation

Management

Immediate:
- Flood surgical field with saline; repair site of air entry
- Administer IV fluid bolus
- Administer 100% oxygen; discontinue nitrous oxide
If blood pressure falls:
- Call for help
- Administer vasopressors
- Aspirate air from CVC
Lower head of the operating table if any of the following occur:
- Air is visible in left heart on TEE
- Significant hemodynamic compromise; need for or impending CPR
- New neurologic deficit in awake patient

This table shows initial management of intraoperative VAE. Once VAE resolves, the decision to proceed with surgery should be multidisciplinary, considering the severity of the event, likelihood of recurrence, urgency of the surgery, and patient factors. For further information, refer to UpToDate content on intraoperative VAE.

TEE: transesophageal echocardiography; IV: intravenous; CVC: central venous catheter; VAE: venous air embolism; CPR: cardiopulmonary resuscitation.
* Manifestations depend on the severity of VAE. Decrease in ETCO₂ is nonspecific, and magnitude of change may not correlate with severity of VAE.

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Venous air embolism during neurosurgery: Rapid overview