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Air Embolism
Risk Prevention in Infusion Therapy
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Air Embolism
Definition
Causes
Definition
Vascular air embolism is the entrainment of
air (or exogenously delivered gas) from the
operative field or other communications with
the environment into the venous or arterial
vasculature, producing systemic effects
[Mirski et al. 2007].
2
Causes
Air embolism principally is caused by the entry of air into the vascular system (Fig. 1). Many different causes are described and most
are of iatrogenic nature [Gabriel 2008, Wittenberg 2006, Josephson
2006, Patel 2000, Booke et al. 1999, Obermayer 1994].
Pathophysiology
The embolism is propelled into the heart, creating an intracardiac air
lock at the pulmonary valve and preventing the ejection of blood
from the right ventricle of the heart. The right side of the heart
overfills with blood because less blood is ejected from the right
ventricle. The force of myocardial contractions increases in an attempt to eject blood past the air lock. The forceful contractions
cause small air bubbles to break loose from the pocket (Fig. 2).
These small bubbles reach the pulmonary circulation system,
creating an obstruction to forward blood flow and tissue hypoxia.
Pulmonary hypoxia leads to vasoconstriction of the lung, which
further increases the workload of the right ventricle and reduces
blood flow out of the right side of the heart [Perdue 2001,
Phillips et al. 1997].
Causes
Fig. 1: Air embolism is principally caused by the entry of air into
the vascular system.

open IV systems

not properly filled and vented infusion lines

parallel infusions

disregard of products’ instructions for use
Fig. 2: Air within the right heart. The air can arrive at the heart
and then cause an intracardiac air lock. The beating heart can also
disintegrate the tropped air into smaller bubbles. These bubbles
bear the risk of impairing blood circulation in smaller vessels.
This is specially critical for the pulmonary circulation system.
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Air Embolism
Causes
Common causes for air embolism include:
 Entering of air through open IV access and infusion systems
(e.g. open stop cock, deconnection, leakage due to product
failure). The amount of air entry is influenced by the position
of the patient and height of the vein with respect to the right
side of the heart [Josephson 2006, Perdue 2001, Muth et al.
2000].
 Not properly filled and completely vented infusion line.
 Parallel infusions, where gravity infusions and infusion pumps
are connected together and interact through the infusion lines
(Fig. 3). Such systems can develop a beading (fluid-air-fluid etc.),
when the gravity infusion runs dry (Fig. 4)
[Obermayer 1994].
 Durring various surgical interventions, especially neurosurgical,
vascular, obstetric, gynecological, or orthopedic procedures
[Mirski et al. 2007, Muth et al. 2000, Natal and Doty 2009,
Wong and Irwin 2005] by the opened vascular system.
 Incorrect execution of procedures for pressure infusion
[Gray et al. 1999].
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Fig. 3: Parallel infusion. Combinations of gravity infusion and pump
driven infusion (blue) in parallel bears the risk of air embolism, when
gravity infusion runs dry.
Fig. 4: Beading (fluid-air-fluid) in parallel infusion.
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Air Embolism
Consequences
Possible symptoms* / Clinical signs
Anxiety [Josephson 2006]
Tachycardia [Mirski et al. 2007, Wittenberg 2006]
Dyspnea [Mirski et al. 2007, Perdue 2001]
Tachypnea [Mirski et al. 2007, Wittenberg 2006]
Chest pain [Mirski et al. 2007, Perdue 2001]
Altered level of consciousness [Wittenberg 2006]
Agitation or disorientation [Wittenberg 2006]
Severe hypotension / shock [Wittenberg 2006]
Shortness of breath [Perdue 2001]
Cardiac “mill wheel” murmur** [Wittenberg 2006]
Cyanotic appearance [Perdue 2001]
Sudden loss of consciousness, circulatory shock or
sudden death [Wittenberg 2006, Josephson 2006]
Symptoms and clinical signs
The symptoms and clinical signs of air embolism are related to the
degree of air entry into the circulation system. They usually develop
immediately after embolization [Mirski et al. 2007, Wittenberg
2006, Josephson 2006, Perdue 2001].
Complications
It is generally accepted that any amount of air that might enter the
patient must be considered critical. The impact is directly correlated with the patient’s condition, the volume of air and the rate of accumulation [Gabriel 2008, Mirski et al. 2007, Josephson 2006, Booke
et al. 1999, Orebaugh et al. 1992].
Clinical complications are diminished cardiac output, shock and
death [Wittenberg 2006, Josephson 2006].
* The symptoms are associated with vascular collapse and can be nonspecific.
** The cardiac “mill wheel” murmur (or cog wheel murmur) is a loud, churning murmur heard over
the apex of the heart, sounding like machinery (a late sign).
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Fig. 5: Estimation of possible additional costs as a consequence of complications caused by air embolism. In order to facilitate the
attribution of each complication to the cost calculation, severity levels were introduced. RICU: Respiratory Intermediate Care Unit
Risk related costs for the healthcare institution
Even non-fatal episodes of venous air embolism lead to extensive
involvement for diagnostic (e.g. blood-gasanalyses, echocardiography, ultrasonography) and therapeutic interventions (e.g. oxygen,
intravascular volume expansion, catecholamines) [Mirski et al.
2007, Muth et al. 2000, Booke et al. 1999].
A cost evaluation of the risk can be done by assigning costs to
their related clinical treatment and resulting extended length of stay.
The cost can be calculated using the average daily cost [Gianino
2007, Bertolini 2005] of the expected clinical treatment. Fig. 5
shows the results of such a calculation for selected examples
of complications.
Conclusion
Preventing the entrance of air into the patient’s circulatory system
can result in tangible budget savings for the healthcare provider.
In the case of severe multiple complications which require full ICU
treatment, a hospital may save up to 56,670 € per single case.
Financial impact
Severe complications may lead to an additional
financial burden of up to 56,670 € per single case
of air embolism.
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Air Embolism
Preventive
strategies
Fig. 6:
Trendelenburg position
for the insertion of
central venous catheter.
Fig. 7:
A siphon (>20 cm)
protects against the
ingress of air in the
infusion set.
Fig. 8:
In parallel infusions, the
three-way valve of the
bypass should be placed
in the ascending siphon
tube. Use a check valve
for gravity infusions.
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Preventive strategies
 For the placement of a peripheral cannula, the risk
of air embolism can be reduced by ensuring that
the selected arm of the patient is kept below the
level of the heart during the insertion or removal
procedure [Gabriel 2008].
 For the central venous catheter, the best position
for its insertion or removal is in the supine or
Trendelenburg position. This minimizes the risk of
air embolism (Fig. 6) [Gabriel 2008, Mirski et al.
2007, Wittenberg 2006, Josephson 2006, Dougherty
2006, Perdue 2001].
 Follow the instructions for use of the IV equipment
and IV containers.
 The incidence of air embolism can also be reduced
by the use of Luer-Lock connections. This minimizes
the potential for the accidental disconnection of
administration sets and syringes from intravenous
catheters [Gabriel 2008, Perdue 2001].
 Leaking infusion tubes should be changed
immediately to eliminate the risk of air being drawn
into the vascular system [Perdue 2001].
 Infusion regimens should always be set up to create
a siphon (>20 cm) in the infusion system, which
protects against the ingress of air (Fig. 7, 8)
[Riemann 2004].
 Modern infusion filters are able to separate 100 %
of air from infusion lines in addition to the removal
of particles and bacteria [Riemann 2004].
 Usage of modern infusion sets featuring an air stop
mechanism [Riemann 2004].
Prevention

correct position of the patient according
to the procedure

follow instructions for use of IV products

create a siphon

use Luer-Lock connections

immediate change of leaking infusion tubes


use infusion systems with air stop
mechanism
use modern infusion filters
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Air Embolism
Riskprevention
Intrafix® SafeSet
The safest and most convenient IV-Set.
A unique airtight 15 μm filter membrane in the drip chamber
(AirStop):
 Acts as a barrier, protecting against air infusion.
 Prevents the infusion line running dry and air
getting through to the patient.
Safeflow / Ultrasite®
Capless valves for safe and convenient access to the
infusion line.
The valve continuously maintains the closed system.
 Closed valve prior to activation.
 Air tight, leak resistant sealing when Luer cone
connects to the valve.
 Closure of the valve when Luer connection is disconnected.
Discofix® C
The unique stopcock for premium safety.
 A special material prevents air embolism by eliminating
stress cracks.
 The unique Discofix® C resists all pharmaceutical agents
even during long-term application.
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Intrapur® and Sterifix® Infusion Filters
A whole range of filters for safe infusion therapy.
 Two hydrophobic polytetrafluorethylene (PTFE)
membranes ensure reliable air venting elimination
of filter position during application.
cross-section
air-elimination
Mandrins / Stylets
Mandrin / Stylet for B. Braun IV catheters allowing
a safe and convenient short-term interruption of
IV administration.
 Secure Luer-Lock connection between mandrin and
catheter prevents air entrance during interruptions
in IV administration.
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Air Embolism
Literature
Literature
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venöse paradoxe Luftembolie. Anaesthesist 1999; 48(4): 236-41
Demaerel P, Gevers AM, De Bruecker Y, Sunaert S and Wilms G.
Gastrointest Endosc. Stroke caused by cerebral air embolism during
endoscopy 2003; 57(1): 134-5
Gabriel J. Infusion therapy. Part two: Prevention and man-
agement of complications. Nurs Stand 2008; 22(32): 41-8
Gray AJ, Glover P. Air emboli with Haemaccel®. Anaesthesia 1999; 54(8): 790-2
Jardin F, Gurdjian F, Desfonds P, Fouilladieu JL and Margairaz A.
Hemodynamic factors influencing arterial hypoxemia in massive
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Josephson DL. Risks, complications, and adverse reactions associated with intravenous infusion therapy. In: Josephson DL.
Intravenous infusion therapy for medical assistants.
The American association of Medical Assistants. Clifton Park:
Thomson Delmar Learning 2006; 56-82
Lamm G, Auer J, Punzengruber C, Ng CK and Eber B. Intracoronary
air embolism in open heart surgery – an uncommon source of
myocardial ischaemia. Int J Cardiol 2006; 112(3): 85-6
Lynch JJ, Schuchard GH, Charles N, Gross and Samuel L. Prevalence of right-to-left atrial shunting in a healthy population:
detection by Valsalva maneuver contrast echocardiography.
Am J Cardiol 1984; 53(10): 1478-80
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Mirski MA, Lele AV, et al. Diagnosis and treatment of
vascular air embolism. Anesthesiology 2007; 106(1): 164-77
Muth CM, Shank ES. Gas embolism. N Engl J Med 2000; 342(7): 476-82
Natal BL and Doty CI. Emedicine, http://emedicine.medscape.com/,
last update: Jul 2009
Obermayer A. Physikalisch-technische Grundlagen der Infusionstechnik – Teil 2. Medizintechnik 1994; 114(5): 185-190
Orebaugh SL. Venous air embolism: clinical and experimental
considerations. Crit Care Med 1992; 20(8): 1169-77
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Perdue MB. Intravenous complications. In: Perucca R. Infusion
therapy equipment: types of infusion therapy equipment.
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Soto-Sarrión C, Poyatos C, Isarria-Vidal S, Faus-Cerdá R and
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H Jr. Nonselective endothelin-receptor antagonism attenuates hemodynamic changes after massive pulmonary air embolism in dogs.
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Tuxen DV, Scheinkestel CD, Salamonson R. Air embolism – a neglected cause of stroke complicating cardiopulmonary bypass (CPB)
surgery. Aust N Z J Med 1994; 24(6): 732-3
Wittenberg AG. Venous Air Embolism. Emedicine, last updated:
May 2006
Wong AY, Irwin MG. Large venous air embolism in the sitting
position despite monitoring with transoesophageal echocardiography. Anaesthesia 2005; 60(8): 811-3
Phillips LD, Kuhn MA. Manual of intravenous medications. Lippincott Williams & Wilkins 1997; 294-95
Riemann T. How many “milliliters” of air will lead to an air embolism? Die Schwester Der Pfleger 2004; 8: 594-595
Sagara M, Haraguchi M, Isowaki S, Yoshimura N and Nakamura K.
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Masui 1996; 45(7): 884-7
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Air Embolism
Notes
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The summarized scientific information in this document has been prepared for healthcare professionals. It is based on an analysis of
public literature and guidelines. The intention is to give an introduction to the risks commonly associated with infusion therapy and to
increase the awareness of healthcare workers to these kinds of problems. Due to its summary nature, this text is limited to an overview
and does not take into account all types of local conditions. B. Braun does not assume responsibility for any consequences that may
result from therapeutical interventions based on this overview.
B. Braun Melsungen AG | Hospital Care | 34209 Melsungen | Germany
Tel. +49 5661 71-0 | www.bbraun.com | www.safeinfusiontherapy.com
Nr. 6069093 Edition: 03/2011