15 Mar

Pathogenesis of Cerebral Air Embolism during Neodymium-YAG Laser Photoresection: Course

On the second postoperative day, fiberoptic bronchoscopic study was performed and demonstrated a large, hyperemic endobronchial lesion totally occluding the LLL bronchus. All obtained biopsy specimens were nondiagnostic. A lobectomy was deemed hazardous owing to the recent empyema and risk of developing a stump infection. The patient was therefore transferred to our institution for photoresection and biopsy of the obstructing lesion (presumably an adenoma) to establish patency of the LLL bronchus and to facilitate resolution of the pneumonia. The patient underwent neodymium-YAG laser resection after multiple endobronchial biopsies with frozen sections and Wang needle aspirations of the lesion were obtained. Preoperatively, the patient had received meperidine, hydroxyzine HC1, atropine sulfate, and fentanyl citrate; while anesthesia was maintained with atracurium besylate and isoflurane. Positive-pressure ventilation was maintained using a volume-anesthesia ventilator and a 35 percent fractional inspired Oz. Nd-YAG laser power was used in the range of 40 to 50 W and time exposure of 0.7 to 0.8 second. A total of 1,268 W/s was used to establish patency of the bronchus.

Purulent secretions were noted emanating from the LLL segments. Approximately 40 to 60 ml of hemorrhage occurred during the procedure, which was well controlled with aliquots of 1:20,000 epinephrine and the hemostatic effect of the YAG laser. Near completion of the procedure, ST segment depression was noted on the ECG, followed by an episode of supraventricular tachycardia (SVT) with intermittent wide complexes at a rate of 150 to 200/min and a concomitant decrease in systolic blood pressure from 130 to 95 mm Hg. The SVT was converted with propranolol and lidocaine infusion. Oxygen saturation was 97 percent by oximetry. A “flush” was noted on the patients malar eminence associated with a blanching over the abdomen. Anesthesia was immediately reversed, and an anisocoria (OD = 4 mm; OS = 7 mm) consistent with a Horners syndrome, a left homonymous hemianopsia, left dense hemiparesis, and left ankle clonus were noted. Funduscopic study results were unremarkable.

Categories: Air Embolism
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