Intravascular Air Emboli: Patient Complaints and Patient Safety

As I have said in the past, there is no one more acutely aware of the hazards of gaseous microemboli (GME) than the Cardiovascular Perfusionist. They avoid it, worry about it, research it, understand it and take extraordinary measures to prevent GME every day of their career.

For more than two decades I have been researching, writing and speaking about the potential hazards and pathophysiology of intravascular air emboli in health care (LinkedIn posts/articles, peer reviewed journal articles and books), but over the last ten years I have been trying to bring attention to the problems associated with intravenous air bubbles through central and peripheral intravenous (IV) lines. The lack of knowledge, attention and concern over this microembolic health care issue by some practitioners is simply astounding. A true failure of didactic and clinical education.

Although mortality is always a possibility with large venous air volumes, the biggest concern should be placed on the potential morbidity (stroke) associated with any venous air entering through central and peripheral IV lines. Patient concerns and patient safety should never be dismissed or ignored by any health care professional. The unfortunate truth is; there are many manufacturers and types of intravenous line air filters that can simply be placed into any IV line to prevent air from entering the patients circulation.

In this article I will address two subjects. The first one is many of the non-edited comments about IV line air bubbles I have received (some from other sources) from patients and professionals over the last few years. The dates and names have been removed for obvious privacy reasons. These comments are in italics below.

The second issue in this article is about a very recent article that appeared in the Journal of Forensic Sciences (June, 2021). This published case report by Bradley et al, is an excellent discussion of the topic of cerebral and paradoxical air emboli from a Pathologist's point of view. For the first time, the authors also include actual post mortem pictures of air bubbles in the brain and air bubbles in the retinal artery, both of which originated from paradoxical air (venous to arterial shunting). Part of their case report is presented here and the full article is recommended reading.

PATIENT and PROFESSIONAL COMMENTS:

--- I'd read your article in the past, and as a nurse of over 20 years, most in critical care, I really appreciate the attention you bring to this issue. I don't know when my field became so incredibly cavalier, but this is not how I was trained. I searched for your article last night after watching my 21yo have IV fluids started with multiple 2 to 3 in long air bubbles. The nurse ignored my request to purge the air and walked out. My daughter's in DKA, she does not need that kind of additional risk.??When they came to start her insulin drip I saw the same problem, had pulled up this article, and insisted they fix it.??Sadly, I was not able to go with her to ICU because of covid; she told me this morning it was even worse in the ICU. I'm sending the link for your article to the patient advocate. It's absolutely unacceptable.?I swore I'd never work in mental health but ended up becoming an advanced practice RN with my focus on caring for patients with autoimmune or other chronic illnesses. Regardless of the area of healthcare, patient concerns are far too frequently dismissed as non-issues with long lasting negative consequences on overall health and patient trust / confidence in our ability to care for them. I appreciate how you address that issue here.

--- One institution, years before I worked there, used bubble counters on their circuits’ arterial line. During normal bypass it would count an occasional bubble. But about 30 seconds after anesthesia would push a drug in an iv the counter would count a cluster of bubbles.

--- My grandmother is in the ICU at the moment for a stroke that she experienced during a varicose vein procedure. She was at a small hospital in Texas and was given Valium prior to beginning the procedure. She closed her eyes and became unresponsive with right sided weakness. She was transported to the nearest hospital in a major city to receive a higher level of care. The procedure was done on her right leg but being that she has a PFO, she experienced a left brain stroke. I have not seen the CT scan or MRI but was told it was a large stroke. Plans are to extubate today; she remains with right sided weakness. No excuse for this! We are very sad that this procedure led her to this.

--- Reading your article while watching a group of bubbles in my IV, the nurses assured me there were no problems, was unsettling ... and also why I called the nurse and told her to take the bubbles out, regardless. The disturbing part is that it took the nurse 15 seconds to fix the problem. Why just not doing a clean job in the first place?

Oh, being hospitalized for a minor stroke, that thanks to a good luck day self-resolved in full recovery within a few hours, I found seeing bubbles in my IV, being told not to worry, a potentially very stupid way to undoing good luck.

I don't want to cause troubles to the young nurses, who probably are just doing as trained. Then again, a different nurse during a previous shift, was confronted with the same problem, after she changed the IV bag. I didn’t need to say anything.?She noticed and cleaned the IV free of bubbles.

Notice, I am at a very modern privately owned Japanese hospital. I experienced health care in the US (lived in California for ~20 years), Switzerland (home country) and now Japan. I consider the Japanese health care system by far the best for quality, state of the art and most of all cost.

So, it's kind of unsettling, this should be basic quality of work attitude, like the first nurse did. I will quote your article on my way out, in the feedback form ... They should give a reward to the guy, who invented feedback forms :-)

--- It always bothered me how nonchalant anesthesia providers and nurses approached IV air. Bravo for bringing this issue forward!

--- I recently had surgery at a large hospital clinic. I was given two meds separately in my IV in preop. I noticed a large amount of air in IV. I expressed concern to anesthesiologist that a lot of air was in the line and did not want a PE! Maybe 1-2 minutes later I developed the most intense pain I have ever experienced in my brain. The pain was so intense that I thought I was having multiple brain aneurysms! I stood up very frightened & my head had to be held by me as my head felt like it was trying to fall off. The two meds run in my IV had been given on several other surgeries in the past. I finally decided to report this to Head of Anesthesia & told it would virtually be impossible for air to enter right heart, go through lungs, then left heart then to brain. There were no other symptoms other than INTENSE brain pain. The pre-op meds were Versed & Fentanyl (low dose).?

Any comments welcomed. (I am in medical field). I reported this not for any purpose other than re-education on air in IV lines to prevent any other patients being potentially harmed. I have zero health conditions & in my late 60’s. Should I see a cardiologist? Great, great article! This article should be in JAMA, etc.! I feel lucky to be alive, and not a vegetable.

--- I've been told exactly that when I challenged the medical team looking after me. Over the last couple of days, I've watched scores of air bubbles enter my bloodstream. I will show them this post tomorrow to see what they have to say.

--- I just sent this to my infusion nurse. At the end of an infusion, at the beginning of which, I said didn’t want any air in my line and insisted he flush over an inch of air out, he insisted on injecting a bunch that was in my IV that he easily and extremely quickly could have removed by pulling on the syringe before flushing. Instead, he said trust me and pushed em in!

--- I encountered an incident where my wife is undergoing treatment for her cancer. She was undergoing treatment when IV monitor alerted that bubbles were forming in the line. The nurse did an adjustment to clear the alarm but there was a bubble that formed in the line past the warning sensor I pointed it out but nurse told me " don't worry this isn't tv and a?little air would not hurt her". But it was enough for me to notice and that troubled me, and it led me to your blog. If chemo is known to attack the blood cells, why would you allow that to occur?

--- I was in the hospital for a knee surgery a while back, and they kept me overnight. During one of my IV changes, I saw a pretty large air bubble (maybe 20 inches of line) go into my hand. I asked the nurse about it, and she was most of the way through telling me that it was nothing when my heart felt like it was jumping out of my chest. The heart monitor I was hooked up to started alarming. She looked worried. I was worried. Then it passed. Someone else came by (guessing a head nurse?) and asked me about what happened. I said I saw some air in my IV, which she said was normal, but didn't seem pleased when I mentioned how much there was. I had a different nurse for the rest of my stay.

--- It needs no discussion; air is a foreign body in the blood circulation and does not belong there. It proves some sloppiness to infuse this.

--- During surgery, when I point out air bubbles traveling through the intravenous line towards a patient’s arm, I am usually met with a shrug from the anesthetist. Although introduction of small amounts of air rarely causes harm, it is still a potential hazard that should be avoided.?

--- I've been told exactly that when I challenged the medical team looking after me. Over the last couple of days, I've watched scores of air bubbles enter my bloodstream. I will show them this post tomorrow to see what they have to say.

--- Thanks for the detailed pathophysiology associated with the adverse events associated with air introduced into the vascular system via IV line. The popular believe is that air less than 50 cc is harmless. This myth has to change in that nurse educators need to help understand their students to understand at a cognitive level the pathophysiology involved. Purging air from an IV line is not a rocket science; it is a simple but critical skill acquired; and is one of the indexes to measure one's competence. Leaders in nursing especially nurse managers should be held accountable to assure nurses working under their supervision are equipped with this critical competence. Today's customers are informed and are not like the customers a few years ago.

--- I do not allow air bubbles in my vein and not accept comments of " not worry about it." Air bubbles in the bloodstream cause serious problems and should be avoided

--- That idea of them stating the bubbles will be absorbed into the lungs is shocking.

--- Thanks for posting this. Too often I see air treated so blasé because of the "lung filtering". Not a 100% guarantee.

--- This is such an important safety concern that it is so often dismissed due to misconceptions of it “being okay because it’s venous.”

--- Across all disciplines. Quality of care improves when we work as a team, not in silos. I wish certain topics like this were covered in interdisciplinary formats in the education programs. It perplexes me that most RNs and some perfusionists are hyper-vigilant and make the effort to be meticulous in their practice (while perhaps not understanding the full impact down to the pathophysiologic level of air interface within the intravascular space) while other disciplines may remain casually nonchalant. Is it a lack of knowledge? Lack of in depth understanding. Lack of consequences? Apathy? Sheer luck that they've gone so far in their career without an adverse patient event that could be directly attributed to their practice? Regardless, in the end, just because others do it and tolerate it, or you haven't seen anything bad happen before, doesn't make it acceptable or the right thing to do.?

JOURNAL of FORENSIC ARTICLE