Acta Anaesthesiol Scand 2006; 50: 648 Printed in Singapore. All rights reserved
# 2006 The Authors Journal compilation # 2006 Acta Anaesthesiol Scand
ACTA ANAESTHESIOLOGICA SCANDINAVICA
Letter to the Editor Fatal cerebral air embolism after endoscopic retrograde cholangiopancreatography doi: 10.1111/j.1399-6576.2006.00978.x Sir, Air embolism may complicate diagnostic or therapeutic procedures in which the gas, insufflated into a body cavity, enters the vascular system through a traumatic or surgical lesion. Three fatal events have already been reported during endoscopic retrograde cholangiopancreatography (ERCP) following liver biopsy (1) and sphincterotomy (2, 3). We report a case of fatal cerebral embolism during ERCP performed 4 months after percutaneous transhepatic biliary drainage (PTBD). A 65-year-old male was referred because of recurrent episodes of biliary colic and icterus. For a similar episode, 4 months previously, the patient had undergone a PTBD and, 1 week later, an ERCP with sphincterotomy. Because of the presence of a ‘calculus’ in the extrahepatic biliary tree at cholangio-nuclear magnetic resonance, a further ERCP was programmed. During the procedure, sedation was obtained with remifentanil (0.05—0.1 mg/kg/min) and propofol as needed (total amount, 160 mg). Spontaneous breathing was maintained with O2 therapy. Respiratory and haemodynamic parameters remained stable throughout the 45 min of the procedure (SpO2 > 97%; heart rate, 80—100 beats/min; sinus rhythm; systolic blood pressure, 120—160 mmHg). Two minutes after the end of the procedure, a sudden decrease in SpO2 (87%) was observed. A nasogastric tube was positioned to exclude gastric distension. Soon, supraventricular tachycardia (150 beats/min) and hypotension (systolic blood pressure, < 90 mmHg), followed by ventricular fibrillation, ensued. After 10 min of cardiopulmonary resuscitation, a valid circulatory function was resumed. The patient was transferred to the intensive care unit. The Glasgow Coma Score was 3. At echocardiography, cardiac contractility was preserved (ejection fraction, > 60%). A computed tomography scan showed intrahepatic air and massive cerebral air embolism with severe brain swelling. The patient died 3 days later without regaining consciousness. At autopsy, air insufflated into the biliary tree was found to exit from the suprahepatic veins, thus revealing the presence of a biliary-vascular fistula. Although rare, a variety of endoscopic and laparoscopic surgical procedures have been associated with air embolism, and the presence of air in the hepatic veins after endoscopic sphincterotomy is frequently reported. Mohammedi et al. (4) experienced a cardiac air embolism after ERCP in a case of blunt hepatic trauma. Most of these events are self-limited, but three fatal cases following ERCP and sphincterotomy (2, 3) or liver biopsy (1) have been reported. In addition to the rarity of this event, the peculiarity of our report lies in its possible relationship to an invasive procedure,
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PTBD, performed 4 months previously. A posteriori, the recurrent biliary colic that the patient experienced despite sphincterotomy may be ascribed to episodes of haemobilia. At ERCP, the macroscopic appearance of the drained ‘calculus’ may actually support this hypothesis. Moreover, the autopsy showed the presence of a biliary-vascular fistula that could not be related to any procedure performed during the later hospital admission. The presence of air in the central nervous system (paradoxical air embolism), in the absence of a patent foramen ovale, can occur by overwhelming the ability of the pulmonary circulation to filter out gas emboli (particularly in cases of massive or small continuous amounts of gas) (4, 5). As reported by other authors, utmost care must be taken when an ERCP is performed after an invasive procedure on the biliary tract. Moreover, an accurate medical history should be collected as the risks may still be present even months after the procedure. L. Stabile M. Cigada D. Stillittano E. Morandi M. Zaffaroni G. Rossi G. Iapichino
References 1. Siddiqui J, Jaffe PE, Aziz K, et al. Fatal air and bile embolism after percutaneous liver biopsy and ERCP. Gastrointest Endosc 2005; 61: 153—7. 2. Kennedy C, Larvin M, Linsell J. Fatal hepatic air embolism following ERCP. Gastrointest Endosc 1997; 45: 187—8. 3. Nayagam J, Ho KM, Liang J. Fatal systemic air embolism during endoscopic retrograde cholangiopancreatography. Anaesth Intensive Care 2004; 32: 260—4. 4. Mohammedi I, Ber C, Peguet O, Ould-Aoudia T, Duperred S, Petit P. Cardiac air embolism after endoscopic retrograde cholangiopancreatography in a patient with blunt hepatic trauma. J Trauma 2002; 53: 1170—2. 5. Murphy BP, Harford FJ, Cramer FS. Cerebral air embolism resulting from invasive medical procedures. Treatment with hyperbaric oxygen. Ann Surg 1985; 201: 242—5.
Address: Dr Marco Cigada Istituto di Anestesia e Rianimazione Universita` degli Studi di Milano Azienda Ospedaliera San Paolo Via A. di Rudinı` 8 20142 Milan Italy e-mail:
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