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Hemodialysis central venous catheter removal and air embolism.

Sahutoglu, T., Sakaci, T., Hasbal, N.B., Kara, E., Ahbap, E., Sevinc, M. ... Unsal, A. (2017). Air embolism following removal of hemodialysis catheter. Hemodialysis International, 27(1), 29-34. Retrieved from doi/10.1111/hdi.12456/full

The authors of this study in Turkey used the MEDLINE database to identify nine patients and one locally presented case who had experienced air embolism following dialysis central vein catheter (CVC) removal. All catheters were non-tunneled and were placed in either the internal jugular or subclavian vein. There was no discussion about selection of catheter placement sites. The median duration of catheter placement was 75 days, while the range was quite broad, from two to 60 days. The time over which patients experienced symptoms ranged from within seconds up to six hours post-CVC removal.

Signs and symptoms, in descending order, included dyspnea, hypoxemia, cerebral dysfunction, hypotension, and coronary ischemia. None described air suction noise. Air was found, in descending order, in the aorta, pulmonary artery, right ventricle, aorta, cerebral arteries, cerebral venous system, and right atrium. Four patients expired from the emboli, one of whom had a cerebrovascular accident, and none of them had occlusive dressings at the air entry sites. The remaining six had a complete recovery.

Understanding the significance of air embolus is important, and symptoms can range from asymptomatic, mild and transient, organ ischemia, hemodynamic failure, or even death. While the volume of air that is threatening is not clear, 50 mL is considered intolerable, and 100 mL to 500 mL are thought to represent fatal doses. Cough, dyspnea, tachypnea, and hypoxemia signify sudden onset pulmonary symptoms. Cerebral dysfunction/confusion and hemodynamic alterations are other clinical manifestations. Heart auscultation revealing air sucking or mill wheel murmur, a churning and splashing sound, can lead to immediate identification of air embolism.

Emergent intervention is critical to the prospects for survival without adverse sequalae. Blocking the air portal is essential to prevent further air from entering because the respiratory distress can lead to gasping that will only increase the amount of air entering the vasculature. The airway should be secured, and breathing and circulation should be supported. Place the patient in a recumbent, left lateral Trendelenberg position to trap the air in the apex of the right ventricle. This is to prevent/minimize the further travel of air to the cerebral veins and throughout the circulatory bed and organs. If these efforts are inadequate in restoring hemodynamic stability and/or organ dysfunction, more aggressive actions may be necessary, including hyperbaric oxygen therapy and possible removal of air and chest compressions.

Prevention of air embolism at the time of removal of a hemodialysis CVC can be safely accomplished by placing the patient in a Trendelenberg position; have the patient hold his breath as the catheter is withdrawn, and place an occlusive dressing on the site after removal. The patient should be instructed not to remove the dressing.

The authors do not identify the timeframe over which data were collected and is limited by the number of patients for whom data are presented. Because air embolism following CVC removal is likely an infrequent event, larger numbers would be difficult to collect. This is a low-frequency occurrence but clearly a high-risk event of which nurses must be cognizant.

Robbins, K.C. (2017). Journal club: Read it, share it. Nephrology NursingJournal, 44(3), 260-262.

Karen C Robbins, MS, RN, CNN, is the Associate Editor of the Nephrology Nursing Journal, Past-President of ANNA, and member of ANNA's Desert Vista Chapter.

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Author:Robbins, Karen C.
Publication:Nephrology Nursing Journal
Geographic Code:1USA
Date:May 1, 2017
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