Case 7: Air embolus—a rare and possibly unavoidable complication Obstetrics and Gynaecology CASE SUMMARY A 48-year-old woman who was fit and well underwent a 7 mm cervical dilatation, hysteroscopy and resection of a 3 cm submucosal fibroid or polyp that was distorting the endometrial cavity and causing menorrhagia. Routine general anaesthesia was administered. The patient suffered an intraoperative collapse just after dilatation. On commencing resection she suddenly became bradycardic and hypotensive, with a fall in expired CO2, oxygen saturation and cyanosis. Glycine was used as the irrigating fluid, and by the end of the procedure there was a 200 ml deficit remaining. Surgery was abandoned immediately. The patient was intubated, and cardiopulmonary resuscitation (CPR) commenced for pulseless electrical activity (PEA) arrest. Good resuscitation resulted in return of circulation. Transfer was arranged to hospital A ICU for initial investigations and then to hospital B ICU for ongoing management. Two further PEA arrests occurred; ECMO commenced. With no meaningful neurological improvement after weaning from ECMO and inotropic support, it was decided to withdraw active support due to hypoxic brain injury.
DISCUSSION This case appears to be a rare and unexpected complication with a known high mortality rate. There was no evidence of intraoperative anaphylaxis. Contemporaneous record-keeping was good, with clear documentation of care being taken to ensure no air bubbles in tubing. There are no areas for concern in the management of the patient in either hospital A or B or by the surgeon or anaesthetist involved in the intraoperative care and preoperative planning. Some post-resuscitative complications occurred during ICU management but these did not appear to contribute to the outcome. Autopsy showed diffuse infarction of the brain due to air or fat embolism. There was no probe patency of the foramen ovale but there are demonstrations in the literature that show pressurised patency of the foramen ovale.1 Consideration could be given to cervical preparation in situations where dilatation
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NATIONAL CASE NOTE REVIEW BOOKLET
