Response to Air Embolism Good, But Prevention Lacking

Description

A 55-year-old male suffered neurologic deficits secondary to an air embolism during a stent-assisted coiling procedure for a cerebral aneurysm.

Key Lessons

• Quickly recognizing that a problem is not going to resolve with ease, and seeking help from a second physician, is a key aspect of competent crisis management.
• A key consideration in treating air embolism is preparedness and anticipation, including the use of a safety checklist.
• When a patient suffers a preventable complication that leads to harm, the opportunity for the defense to prevail in court is narrow.

Clinical Sequence

A 55-year-old male patient presented to the Emergency Department (ED) with worsening headaches and gait instability. A head CT revealed a large basilar tip artery aneurysm. During a stent-assisted coiling procedure, the patient’s heart rate and blood pressure decreased. When the patient started to experience bradycardia, the neurosurgeon looked at the line and saw that it was empty. Air was discovered in one of the flush line bags connected to the angiography catheter. The flush apparatus was immediately disconnected, and the arterial catheter was aspirated with a syringe. MRI demonstrated bubbles in the aneurysm. The patient was started on 100 percent oxygen, and the surgeon consulted a second neurosurgeon regarding the complication. The procedure was stopped for approximately 15 minutes and the bubble decreased in size. The next angiogram showed that the bubble had reabsorbed. After the patient was stabilized, the decision was made to proceed with stenting and coiling, which was completed without incident. Following the procedure, the family was notified of the intra-procedure air embolism.

During the evening after the procedure, the patient developed a generalized seizure and was treated with Ativan, Dilantin, Decadron, and Propofol. He was comatose for approximately two days. Subsequent neurologic deficits included deterioration in mental status, need for assistance in walking, and difficulty with activities of daily living. The patient was discharged to a rehabilitation facility for six months. He died of lung cancer two years later.

Allegation

The patient’s estate sued the neurosurgeon, two interventional radiologists (an attending and a fellow), two nurses, two technicians, and the institution. Their allegations included an assertion that failure to properly monitor the flush bags led to an air embolus in the basilar artery aneurysm, leaving the patient with neurological deficits.

Disposition

The case was settled in the medium range ($100,000-$499,999) against the institution.

Analysis

1. Halfway through the stenting and coiling procedure, one of the flush line bags ran dry, allowing an air bubble to pass into the patient’s brain and cause an intra-arterial air embolus.
   An air embolism is preventable: the key consideration is preparedness and anticipation, including the use of a safety checklist. Preoperatively, the drip bags are set up before the patient enters the room. Pressure is applied to the bags in different ways through the use of a compression sleeve that “squeezes” the flush bags. Air will always rise to the top of the bag, so ensuring that the top of the bag is visible helps ensure that the air can be detected. The nurses and/or techs de-gas the bags and run the lines to get the air out. If it appears to be problematic, consideration must be given to discarding a flush bag altogether, rather than making multiple attempts to fix it.
2. The neurosurgeon responded immediately to the change in the patient’s vital signs and consulted with another physician, minimizing risk to the patient.
   Recognition and recovery from a complication can lessen the damage and signal to anyone reviewing the care that the clinician did all that could be done. Quickly recognizing that a problem is not going to resolve with ease, and seeking help from a second physician, are key aspects of competent crisis management.
3. An air embolism that causes patient death or serious disability is a National Quality Forum serious reportable event (“never” event) that Medicare will not reimburse...and a difficult case to defend in court.
   When a patient suffers a preventable complication that leads to harm, the opportunity for the defense to prevail in court is narrow. Even a complication noted during the consent process is not defensible if the care is sub-standard. In the presence of clear negligence, strong indications that the adverse event caused the harm will bolster the argument to reach a settlement.