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Fatal Air Embolism During Presacral Insufflation of Air
THE .JOURNAL OF UROLOGY
Vol. 77, No. 1, January 1957
Printed in U.S.A.
FATAL AIR EMBOLISM DURING PRESACRAL INSUFFLATION OF AIR AARON M. LEFKOVITS From the General Jl!Iedicine and Rheumatology Section of the Veterans Administration JV[edical Teaching Group (Kennedy) Hospital, JVfeinphis 15, Tenn.
In 1950 Ruiz Rivas1 described presacral insuffiation of air as a diagnostic procedure to visualize the intra-abdominal organs. Since then this method has been fairly widely employed in clinical medicine as a diagnostic aid in patientE' suspected of having intra-abdominal tumors, especially pheochromocytorn.a. Several authors have reported on the use of this procedure and have emphasized its simplicity, efficacy and safety. Air ern.bolism with fatal outcome as a sequel to presacral air insuffiation has rarely been deRcribed. ,Vilhelm2 reported that one of his patients, an elderly female, developed air embolism after 800 cc of air was injected and died 15 minutes later. At autopsy a large amount of air was found in the right heart chambers and in the larger and smaller veins. Another of his patients had chills, high fever and jaundice within 36 hours after presacral air insuffiation: a "large retroperitoneal" phlegm developed on the right side; "wide surgical drainage and antibiotics" were of no avail and the patient died. Another instance of serious air embolism was reported by Russ et al.3; the patient, a 74-year-old woman, after injection of 600 cc of oxygen, suddenly became cyanotic, the skin was clammy, blood pressure was unobtainable and a loud mill--wheel type of murmur was heard with each heart beat. The patient responded to treatment and gradually recovered. In general, however, presacral insuffiation has not been followed by any significant morbidity or mortality; this is in contrast to the experience with perirenal insuffiation which "has been abandoned in many institutions because of the frequency with which air embolism occurs during the procedure." 4 The follmving brief case report is another instance of fatal air embolism following presacral air insufflation: A 47-year-old Negro was adrn.itted to the hospital on September 21, 1955. He stated that in 1939 or 1940 he was told that he had high blood pressure. While under observation in the hospital, his blood pressure was found to be paroxysmal in character and fluctuated between 216/140 and 150/100. In addition, he was found to have diabetes mellitus and arteriolar nephrosclerosis. An intravenous regitine test was positive for pheochromocytorna; the intravenous benodiane and intramuscular regitine tests, however, were negative. On November 9, 1955, presacral air insuffiation was done and 1300 cc of air injected. Immediately after Accepted for publication July 10, 1956. Ruiz Rivas, M.: Generalized subserous emphysema through a single puncture. Am. J. Roentgenol., 64: 723-734, 1950. 2 Wilhelm, S. F.: Gas insuffiation through the lumbar and presacral routes. Surg ., Gynec. & Obst., 99: 319-323, 1954. 3 Russ, F. N., Glenn, D. L. and Gianturco, C.: Gas embolism during extraperitoneal insuffiation. Recovery in the left decubitus position. Radiology, 61: 637-638, 1953. 4 Steinbach, H. L., Lyon, R. P., Smith, D.R. and :Miller, E. R.: Extraperitoneal pneumography. Radiology, 59: 167-176, 1952. 112 1
FATAL AIR EMBOLISM
113
Fm. 1
moving the patient from the knee-chest to the prone position acute hyperpnea developed; he lost consciousness, stopped breathing and his pulse was unobtainable. He was immediately placed in the left lateral decubitus position and artificial respiration, intubation, oxygen, and intracardiac epinephrin were administered. He did not respond to these measures and died. Roentgen examination of the abdomen after death revealed considerable amount of air in the retroperitoneal space and outlined the kidneys adequately (fig. 1). At postmortem examination air was found retroperitoneally in the region of both kidneys. Slight bulging of the right antrum was noted and air bubbles were present in the coronary vessels. The right ventricle was opened under water and air was seen to escape from it. ]Harked coronary artery sclerosis was found; one large vessel was almost completely occluded by atheromatous material and the small vessels showed marked intimal thickening. The adrenal glands were normal in size, shape and consistency. The renal arteries and arterioles showed concentric thickening and in the glomeruli varying degrees of hyalinization were found. COMMENT
This unfortunate experience led to a review of the literature dealing with presacral air insuffiation. Several reports were found and reviewed. The pertinent data are recorded in table 1. These authors emphasized the following advantages of presacral air insuffiation: The method provides information which is unobtainable by another method; requires no premedication; may be carried out iu 15 minutes; patient walks out of the examining room to resume his normal activities; only one puncture is needed to visualize both kidneys and other abdominal organs; the retrorectal space is easily penetrated by the needle and is easily accessible; it is a vascular and therefore embolism improbable; the only
114
AARON M. LEFKOVITS
TABLE
No. Cases
Blackwood5
15
Duff et al. 6
Not stated
J. Gershon-Cohen
Not stated
et al.7 Lerman et al. 8 Reese and JvlacLean 9
Over 200 20
Renfer 10 Russ et al. 3 Senger et al. 11 Steinbach et al. 4
28 Not stated Over 100 60
Wilhelm 2 Mosca* collected
67 1500
1 Complications
Surgical emphysema of scrotum: 2; shoulder tip pain with sense of constriction in epigastrium: 1. Puncture of rectum: 2; scrotal emphysema: 1; emphysema of abdominal wall: 3; cervical emphysema: 2; mild sub sternal pressure with dyspnea: 2; fullness in loins and epigastrium is common. Patient experiences practically no discomfort and walks out of examining room to resume his normal activities. None stated. Surgical emphysema up to neck: 1; "About half complained of pain in tip of shoulder. Almost all patients complain of a feeling of distention but this soon passes off." None stated. Air embolism: 1; see text. Not stated. "1 patient complained of more than mild discomfort." Air embolism: 1; see text. Infection: 1. See text. "Without fatal accidents."
* Quoted by Russ 3 • contraindication is an inflammatory process in region of anus and presacral space; it is easy to perform, is reliable and extraordinarily safe. At this hospital presacral air insuffiation was performed in approximately 14 patients12 prior to the case which is the subject of this report. The procedure is carried out by the members of the genitourinary staff of the hospital by the following technique: The patient is placed in the knee-chest position. After appropriate sterilization of the skin a small novocain wheal is made in the skin just ventral to the tip of the coccyx. An 18 gauge needle is inserted through the wheal and its point is guided by the gloved left index finger in the rectum so that the point of the needle is just anterior to the sacrum. A short piece of flexible rubber tubing is attached to the hub of the needle to the distal end of which a 50 cc syringe with a two-way stopcock is adapted. The plunger of the syringe is then withdrawn to make certain Blackwood, J.: Presacral perirenal pneumography. Brit. J. Surg., 39: 111-119, 1951-52. Duff, J., Kenyon, H. R and Hyman, R. M.: Pyelography in combination with simultaneous retroperitoneal pneumography. J. Urol., 70: 963-968, 1953. 7 Gershon-Cohen, J., Levins, S. and Hermel, M. B.: Retroperitoneal pneurnography by injection of oxygen into the presacral space. Am. J. Roentgenol., Rad. Ther. & Nuclear Med., 68: 391-394, 1952. 8 Lerman, F., Harper, J. G. l\1., Hertzberg, A. D., Berman, lVI. H. and Lerman, P.H.: Presacral air injection. J. Urol., 70: 312-317, 1953. 9 Reese, L. and MacLean, J. T.: Presacral insuffiation of oxygen for outlining the contents of the retroperitoneal space. Canad. M.A.J., 67: 632-637, 1952. 10 Renfer, H. R.: Pneumoretroperitoneum by presacral insuffiation. Radio!. Clin., 22: 29-43, 1953 (In German). Abstract in Radiology, 61: 857, 1953. 11 Senger, F. L., Horton, G. R., Bottone, J. J., Chin, H. Y. H. and Wilson, M. C.: Perirenal air insuffiation by the paracoccygeal retrorectal route. New York State J. Med., 53: 2823-2826, 1953. 12 Bradley, Wm. S.: Personal communications. 5 6
FATAL AIR EMBOLISM
115
that the needle is not in a blood vessel. If no blood is obtained, 5 cc of sterile saline solution are injected, followed by aspiration as an additional precautionary measure. The air is then injected slowly in 50 cc amounts until 1000-1500 cc are introduced. During the entire procedure, care is taken to keep the needle stationary and aspiration is done frequently to make certain that the needle is not in a blood vessel. Following the injection of air, the patient is placed on the x-ray table and a series of films are taken. The following sequellae have been noted at this hospital following the procedure: Pain over the epigastrium accompanied by "choking" sensation, "gas on stomach", dull aching retrosternal pain, abdominal discomfort, pain over the left upper quadrant of abdomen, pain in the shoulders on deep inspiration, subcutaneous emphysema of abdomen, external genitals, neck, free air under the diaphragm and mediastinal emphysema. All of these were of brief duration and disappeared spontaneously in a few hours to several days. The cause of the air embolism was not definitely determined. The air was injected slowly in 50 cc amounts. During the procedure aspiration was carried out repeatedly to insure that the needle was not in a blood vessel. The presence of the large amount of free air in the retroperitoneal space indicates that only a fraction of the total air injected gained entrance into the vascular system. It is conjectural whether the air was injected into a vein directly or whether the air entered a vessel as it dissected its way through the retroperitoneal tissues. At any rate it is very disconcerting that occasionally a fatal outcome results following, what is commonly believed to be, an innocuous and a useful diagnostic procedure. In an attempt to prevent serious and fatal complications, Wilhelm2 suggested that the following precautionary measures be taken during the performance of presacral air insuffiation: 1) strict aseptic conditions, 2) the use of a blunt canula-like needle with a sharp obdurator, 3) slow injection of gas. 4) Insufllation should be done with the patient in the left lateral position whenever possible, 5) constant observation of patient during entire procedure. 6) A resuscitator and stimulants should be at hand. In addition to these, the following precautionary measures are suggested: Auscultation of the heart during the entire procedure to detect the rnill-wheel13 type of murmur in case it occurs; readiness to manually massage the heart and stimulate it electrically in event of cardiac arrest. SUMMARY
An instance of fatal air embolism following presacral air insufllation is reported. The related literature is briefly reviewed. Certain preventive measures are suggested to eliminate air embolization. The writer expresses his appreciation to Dr. Wm. S. Bradley, chief of the Genito-Urinary Section, Veterans Administration Medical Teaching Group Hospital for supplying the description of the technique of presacral air insufflation, and to the Medical Illustration Laboratory for preparing the photograph. 13 Durant, T. M., Long, J. and Oppenheimer, M. J.: Pulmonary (venous) air embolism. Am. Heart J., 33: 269-281, 1947.
Vol. 77, No. 1, January 1957
Printed in U.S.A.
FATAL AIR EMBOLISM DURING PRESACRAL INSUFFLATION OF AIR AARON M. LEFKOVITS From the General Jl!Iedicine and Rheumatology Section of the Veterans Administration JV[edical Teaching Group (Kennedy) Hospital, JVfeinphis 15, Tenn.
In 1950 Ruiz Rivas1 described presacral insuffiation of air as a diagnostic procedure to visualize the intra-abdominal organs. Since then this method has been fairly widely employed in clinical medicine as a diagnostic aid in patientE' suspected of having intra-abdominal tumors, especially pheochromocytorn.a. Several authors have reported on the use of this procedure and have emphasized its simplicity, efficacy and safety. Air ern.bolism with fatal outcome as a sequel to presacral air insuffiation has rarely been deRcribed. ,Vilhelm2 reported that one of his patients, an elderly female, developed air embolism after 800 cc of air was injected and died 15 minutes later. At autopsy a large amount of air was found in the right heart chambers and in the larger and smaller veins. Another of his patients had chills, high fever and jaundice within 36 hours after presacral air insuffiation: a "large retroperitoneal" phlegm developed on the right side; "wide surgical drainage and antibiotics" were of no avail and the patient died. Another instance of serious air embolism was reported by Russ et al.3; the patient, a 74-year-old woman, after injection of 600 cc of oxygen, suddenly became cyanotic, the skin was clammy, blood pressure was unobtainable and a loud mill--wheel type of murmur was heard with each heart beat. The patient responded to treatment and gradually recovered. In general, however, presacral insuffiation has not been followed by any significant morbidity or mortality; this is in contrast to the experience with perirenal insuffiation which "has been abandoned in many institutions because of the frequency with which air embolism occurs during the procedure." 4 The follmving brief case report is another instance of fatal air embolism following presacral air insufflation: A 47-year-old Negro was adrn.itted to the hospital on September 21, 1955. He stated that in 1939 or 1940 he was told that he had high blood pressure. While under observation in the hospital, his blood pressure was found to be paroxysmal in character and fluctuated between 216/140 and 150/100. In addition, he was found to have diabetes mellitus and arteriolar nephrosclerosis. An intravenous regitine test was positive for pheochromocytorna; the intravenous benodiane and intramuscular regitine tests, however, were negative. On November 9, 1955, presacral air insuffiation was done and 1300 cc of air injected. Immediately after Accepted for publication July 10, 1956. Ruiz Rivas, M.: Generalized subserous emphysema through a single puncture. Am. J. Roentgenol., 64: 723-734, 1950. 2 Wilhelm, S. F.: Gas insuffiation through the lumbar and presacral routes. Surg ., Gynec. & Obst., 99: 319-323, 1954. 3 Russ, F. N., Glenn, D. L. and Gianturco, C.: Gas embolism during extraperitoneal insuffiation. Recovery in the left decubitus position. Radiology, 61: 637-638, 1953. 4 Steinbach, H. L., Lyon, R. P., Smith, D.R. and :Miller, E. R.: Extraperitoneal pneumography. Radiology, 59: 167-176, 1952. 112 1
FATAL AIR EMBOLISM
113
Fm. 1
moving the patient from the knee-chest to the prone position acute hyperpnea developed; he lost consciousness, stopped breathing and his pulse was unobtainable. He was immediately placed in the left lateral decubitus position and artificial respiration, intubation, oxygen, and intracardiac epinephrin were administered. He did not respond to these measures and died. Roentgen examination of the abdomen after death revealed considerable amount of air in the retroperitoneal space and outlined the kidneys adequately (fig. 1). At postmortem examination air was found retroperitoneally in the region of both kidneys. Slight bulging of the right antrum was noted and air bubbles were present in the coronary vessels. The right ventricle was opened under water and air was seen to escape from it. ]Harked coronary artery sclerosis was found; one large vessel was almost completely occluded by atheromatous material and the small vessels showed marked intimal thickening. The adrenal glands were normal in size, shape and consistency. The renal arteries and arterioles showed concentric thickening and in the glomeruli varying degrees of hyalinization were found. COMMENT
This unfortunate experience led to a review of the literature dealing with presacral air insuffiation. Several reports were found and reviewed. The pertinent data are recorded in table 1. These authors emphasized the following advantages of presacral air insuffiation: The method provides information which is unobtainable by another method; requires no premedication; may be carried out iu 15 minutes; patient walks out of the examining room to resume his normal activities; only one puncture is needed to visualize both kidneys and other abdominal organs; the retrorectal space is easily penetrated by the needle and is easily accessible; it is a vascular and therefore embolism improbable; the only
114
AARON M. LEFKOVITS
TABLE
No. Cases
Blackwood5
15
Duff et al. 6
Not stated
J. Gershon-Cohen
Not stated
et al.7 Lerman et al. 8 Reese and JvlacLean 9
Over 200 20
Renfer 10 Russ et al. 3 Senger et al. 11 Steinbach et al. 4
28 Not stated Over 100 60
Wilhelm 2 Mosca* collected
67 1500
1 Complications
Surgical emphysema of scrotum: 2; shoulder tip pain with sense of constriction in epigastrium: 1. Puncture of rectum: 2; scrotal emphysema: 1; emphysema of abdominal wall: 3; cervical emphysema: 2; mild sub sternal pressure with dyspnea: 2; fullness in loins and epigastrium is common. Patient experiences practically no discomfort and walks out of examining room to resume his normal activities. None stated. Surgical emphysema up to neck: 1; "About half complained of pain in tip of shoulder. Almost all patients complain of a feeling of distention but this soon passes off." None stated. Air embolism: 1; see text. Not stated. "1 patient complained of more than mild discomfort." Air embolism: 1; see text. Infection: 1. See text. "Without fatal accidents."
* Quoted by Russ 3 • contraindication is an inflammatory process in region of anus and presacral space; it is easy to perform, is reliable and extraordinarily safe. At this hospital presacral air insuffiation was performed in approximately 14 patients12 prior to the case which is the subject of this report. The procedure is carried out by the members of the genitourinary staff of the hospital by the following technique: The patient is placed in the knee-chest position. After appropriate sterilization of the skin a small novocain wheal is made in the skin just ventral to the tip of the coccyx. An 18 gauge needle is inserted through the wheal and its point is guided by the gloved left index finger in the rectum so that the point of the needle is just anterior to the sacrum. A short piece of flexible rubber tubing is attached to the hub of the needle to the distal end of which a 50 cc syringe with a two-way stopcock is adapted. The plunger of the syringe is then withdrawn to make certain Blackwood, J.: Presacral perirenal pneumography. Brit. J. Surg., 39: 111-119, 1951-52. Duff, J., Kenyon, H. R and Hyman, R. M.: Pyelography in combination with simultaneous retroperitoneal pneumography. J. Urol., 70: 963-968, 1953. 7 Gershon-Cohen, J., Levins, S. and Hermel, M. B.: Retroperitoneal pneurnography by injection of oxygen into the presacral space. Am. J. Roentgenol., Rad. Ther. & Nuclear Med., 68: 391-394, 1952. 8 Lerman, F., Harper, J. G. l\1., Hertzberg, A. D., Berman, lVI. H. and Lerman, P.H.: Presacral air injection. J. Urol., 70: 312-317, 1953. 9 Reese, L. and MacLean, J. T.: Presacral insuffiation of oxygen for outlining the contents of the retroperitoneal space. Canad. M.A.J., 67: 632-637, 1952. 10 Renfer, H. R.: Pneumoretroperitoneum by presacral insuffiation. Radio!. Clin., 22: 29-43, 1953 (In German). Abstract in Radiology, 61: 857, 1953. 11 Senger, F. L., Horton, G. R., Bottone, J. J., Chin, H. Y. H. and Wilson, M. C.: Perirenal air insuffiation by the paracoccygeal retrorectal route. New York State J. Med., 53: 2823-2826, 1953. 12 Bradley, Wm. S.: Personal communications. 5 6
FATAL AIR EMBOLISM
115
that the needle is not in a blood vessel. If no blood is obtained, 5 cc of sterile saline solution are injected, followed by aspiration as an additional precautionary measure. The air is then injected slowly in 50 cc amounts until 1000-1500 cc are introduced. During the entire procedure, care is taken to keep the needle stationary and aspiration is done frequently to make certain that the needle is not in a blood vessel. Following the injection of air, the patient is placed on the x-ray table and a series of films are taken. The following sequellae have been noted at this hospital following the procedure: Pain over the epigastrium accompanied by "choking" sensation, "gas on stomach", dull aching retrosternal pain, abdominal discomfort, pain over the left upper quadrant of abdomen, pain in the shoulders on deep inspiration, subcutaneous emphysema of abdomen, external genitals, neck, free air under the diaphragm and mediastinal emphysema. All of these were of brief duration and disappeared spontaneously in a few hours to several days. The cause of the air embolism was not definitely determined. The air was injected slowly in 50 cc amounts. During the procedure aspiration was carried out repeatedly to insure that the needle was not in a blood vessel. The presence of the large amount of free air in the retroperitoneal space indicates that only a fraction of the total air injected gained entrance into the vascular system. It is conjectural whether the air was injected into a vein directly or whether the air entered a vessel as it dissected its way through the retroperitoneal tissues. At any rate it is very disconcerting that occasionally a fatal outcome results following, what is commonly believed to be, an innocuous and a useful diagnostic procedure. In an attempt to prevent serious and fatal complications, Wilhelm2 suggested that the following precautionary measures be taken during the performance of presacral air insuffiation: 1) strict aseptic conditions, 2) the use of a blunt canula-like needle with a sharp obdurator, 3) slow injection of gas. 4) Insufllation should be done with the patient in the left lateral position whenever possible, 5) constant observation of patient during entire procedure. 6) A resuscitator and stimulants should be at hand. In addition to these, the following precautionary measures are suggested: Auscultation of the heart during the entire procedure to detect the rnill-wheel13 type of murmur in case it occurs; readiness to manually massage the heart and stimulate it electrically in event of cardiac arrest. SUMMARY
An instance of fatal air embolism following presacral air insufllation is reported. The related literature is briefly reviewed. Certain preventive measures are suggested to eliminate air embolization. The writer expresses his appreciation to Dr. Wm. S. Bradley, chief of the Genito-Urinary Section, Veterans Administration Medical Teaching Group Hospital for supplying the description of the technique of presacral air insufflation, and to the Medical Illustration Laboratory for preparing the photograph. 13 Durant, T. M., Long, J. and Oppenheimer, M. J.: Pulmonary (venous) air embolism. Am. Heart J., 33: 269-281, 1947.