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Thomas Arno Albini, Steven Gayer, Andrew Mcclellan, Nidhi Relhan, Jean-Marie A Parel, Harry W Flynn, Ricardo Martinez, Nelson Salas, Howard Palte; In-vivo Porcine Model for Venous and Cardiac Air Embolism from Air Infusion during Vitrectomy. Invest. Ophthalmol. Vis. Sci. 2016;57(12):4448.
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© ARVO (1962-2015); The Authors (2016-present)
Multiple reports document venous air embolism as a possible cause of rare cardiac death during pars plana vitrectomy (PPV). Presumably the mechanism involves inadvertent infusion of air into the suprachoroidal space, shearing of the vortex veins, thereby allowing air to escape into the venous circulation and the heart. In vitro studies have demonstrated passage of air from the suprachoroidal space to the vortex veins. In this study, we attempted to recreate cardiac air embolism and cardiac death in a porcine model following placement of a standard 25 gauge infusion in the suprachoroidal space during PPV.
Approval was obtained from the Institutional Animal Care and Use Committee. This experiment was performed in three eyes of two pigs. The pig was placed under general isoflurane anesthesia. End-tidal CO2, oral transmucosal oxygen saturation, electrocardiogram (ECG) and carotid arterial blood pressure were monitored in real time. Four chamber view transesophageal echocardiography (TEE) was used to monitor for intracardiac air. A 25-gauge three port PPV and lensectomy using the cutter was performed in all eyes.
In two eyes, attempted air infusion into the suprachoroidal space was unsuccessful. In the third eye, the suprachoroidal space was identified, air infusion at a pressure 30 mm Hg initiated and a large quadrantic choroidal detachment developed. The pressure was increased to 60 mm Hg. Within 30 seconds, intracardiac air was observed on TEE. End tidal CO2 dropped first. Blood pressure and ECG changes followed. Oxygen saturation dropped subsequently. Six minutes after increasing the infusion pressure to 60 mm Hg, the pig expired.
This in vivo porcine study of fatal air embolism during air infusion into the suprachoroidal space in standard PPV confirms the potential clinical scenario in humans. Fatal venous/cardiac air embolism can occur with air infusion during standard PPV if the infusion cannula is inadvertently positioned in the suprachoroidal space. Based on this model, it is important for vitreoretinal surgeons to confirm the position of the infusion cannula prior to and during air infusion in standard PPV.
This is an abstract that was submitted for the 2016 ARVO Annual Meeting, held in Seattle, Wash., May 1-5, 2016.
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