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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 3  |  Issue : 3  |  Page : 177-179

Case of fatal air embolism during double-J ureteral stent placement


1 Department of Forensic Medicine, Faculty of Basic Medical Sciences, Chongqing Medical University, Chongqing, China
2 Forensic Medical Examination Center of Beijing Public Security Bureau, Beijing, China
3 Faculty of Medical Technology, Chongqing Medical and Pharmaceutical College, Chongqing, China

Date of Web Publication29-Sep-2017

Correspondence Address:
Shisheng Zhu
Faculty of Medical Technology, Chongqing Medical and Pharmaceutical College, Chongqing 401331
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfsm.jfsm_26_17

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  Abstract 

Air embolism is a severe and fatal complication, but it is very rare during transurethral surgery. This report describes a case of air embolism during double-J ureteral stent placement in a 45-year-old woman. During ureteroscopy, a sudden decrease in oxygen saturation and end-expiratory carbon dioxide pressure and cyanosis of the face were observed. Subsequent echocardiography confirmed an air embolism by detecting bubbles in the heart. Despite resuscitative measures, the patient died rapidly. Detailed autopsy was performed to clarify the cause of death and the route of air entering into the circulatory system. The report presented here reminds urologists and pathologists that air embolism can occur during double-J ureteral stent placement and offers some suggestions regarding identification of air embolism at autopsy.

Keywords: Air embolism, autopsy, double-J ureteral stent placement, forensic science


How to cite this article:
Zhang P, Qing C, Li J, Zhu S. Case of fatal air embolism during double-J ureteral stent placement. J Forensic Sci Med 2017;3:177-9

How to cite this URL:
Zhang P, Qing C, Li J, Zhu S. Case of fatal air embolism during double-J ureteral stent placement. J Forensic Sci Med [serial online] 2017 [cited 2022 May 28];3:177-9. Available from: https://www.jfsmonline.com/text.asp?2017/3/3/177/215809


  Introduction Top


Air embolism is exceedingly rare in transurethral surgery. In this paper, we report a case of air embolism during double-J ureteral stent placement in which malfunction of the perfusion pump led to a large volume of air rapidly entering the retroperitoneal space and circulation.

According to our own PubMed database search for articles reporting air embolisms in endoscopic procedures, this is the first reported case of air embolism during double-J ureteral stent placement. Intraoperative echocardiography and detailed autopsy were performed and confirmed the cause of death and the route of air entering the circulation system. Informed consent was obtained from the family of the patient, and this study was approved by the Ethical Committee of Chongqing Medical University.


  Case Report Top


A 45-year-old female patient with bilateral kidney stones and right ureteral calculi underwent right side ureteroscopic holmium laser lithotripsy and double-J ureteral stent placement for the relief of frequent pain in the right lumbar region. Twenty days later, the patient was readmitted to the hospital to undergo left side double-J ureteral stent placement. All preoperative protocols were performed, including urinalysis, which revealed microscopic hematuria. The operation was initiated under general anesthesia with intubation in the lithotomy position, and the pressure of the perfusion pump was set at 120 mmHg. Three minutes after the surgery commenced, a sudden decrease in oxygen saturation and end-expiratory carbon dioxide pressure and cyanosis of the face were observed by the operating room nurse. The procedure was terminated immediately at the step of ureteroscopy, and there was no ureteral rupture or severe bleeding detected. Then, the ureteroscope was removed, and only a small amount of urine flowed from the urethra. At this time, it was realized that there was no physiological saline drainage from the tube of the perfusion pump during the ureteroscopy procedure. Air embolism was suspected and confirmed on subsequent echocardiography by detecting bubbles in the heart [Figure 1]. Positive measures including resuscitation efforts with cardiopulmonary resuscitation were performed, but her heart rate and blood pressure were soon undetectable, and she was subsequently pronounced dead. While the cause of death was deemed to be an air embolism, the location of air entering into the circulation was still unclear for the treating clinicians. Therefore, an autopsy was performed.
Figure 1: Echocardiography shows a large number of bubbles in the heart

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Autopsy finding

Autopsy revealed a yellowish green area of soft tissue emphysema at the base of the mesentery, exhibiting palpable crepitus and an unclear boundary, measuring 10 cm × 10 cm × 4 cm [Figure 2]a. A bulging bladder filled with air was recognized [Figure 2]b. Focal hemorrhage, which was most likely due to her history of kidneys stones and ureteral calculi, was observed bilaterally on the mucous membrane of the renal pelvis and ureter. No vascular rupture, which could be recognized by the naked eye, was found in the urinary system. When the right atrium was punctured using a 5 ml syringe containing 2 ml water, we identified a large quantity of air bubbles flooding into the syringe. The presence of focal hemorrhage on the bilateral mucous membrane of the renal pelvises and ureters in combination with the high pressure was considered to be the etiology of air entering venous circulation, eventually flowing to the heart and causing death.
Figure 2: Autopsy shows a yellowish green area of tissue emphysema at the base of the mesentery (a) and a bulging bladder filled with air (b)

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  Discussion Top


The clinical effects of air embolism are a consequence of the rate or volume of air entering the circulation exceeded the compensatory mechanisms of the body and can occur with any endoscopic procedure.[1] It is a rare but potentially catastrophic event in clinical practice that can produce serious consequences include systemic cardiovascular collapse and organ ischemia, particularly the brain and heart.[2],[3]

Double-J ureteral stent placement, a minimally invasive technique, is widely used to correct ureteral obstructions of various causes.[4],[5] To the best of our knowledge, this is the first report of air embolism occurring during double-J ureteral stent placement. In the present case, air bubbles detected in the heart confirmed the existence of an air embolism. The cause of air embolism was considered to be the presence of focal hemorrhage on the bilateral mucous membranes of the renal pelvises and ureters and insufflation of air at high pressure, due to malfunction of the perfusion pump.

Emergent treatment in such situation is to terminate all operative procedures immediately, flush the operation field with saline to prevent more air entering the circulation, and keep the patient in the left lateral head-down position to confine the air in the right atrium, which is beneficial for aspirating air from the heart if necessary.[6],[7] To prevent the type of air embolism occurring in the present case, the following measures are necessary before the operation: (i) confirm the absolute air conurbation of the perfusion pump; (ii) open the perfusion pump before the operation to expel air in the perfusion pump and tube; and (iii) check the drainage of the perfusion pump using a cup of physiological saline before the operation.


  Conclusion Top


The cause of air embolism was a malfunction of the perfusion pump. Thus, it is essential to confirm that the perfusion pump works properly before the operation. Air embolism is rarely identified in the practice of forensic medicine. Awareness of the possibility of air embolism and a detailed autopsy examination are important for the identification of the cause of death. The detection of air in the circulation system is the most significant positive finding for the diagnosis of air embolism. Moreover, the discovery of air in the right atrium, right ventricle, and pulmonary artery on chest X-ray or total body computed tomography before autopsy can have not only diagnostic significance for air embolism but can also guide autopsy performance. While detecting air in the circulation system is the most significant positive finding for the diagnosis of air embolism, clarifying the route of air entering into the circulation system is another noteworthy finding for clinicians.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Donepudi S, Chavalitdhamrong D, Pu L, Draganov PV. Air embolism complicating gastrointestinal endoscopy: A systematic review. World J Gastrointest Endosc 2013;5:359-65.  Back to cited text no. 1
[PUBMED]    
2.
Rocca G, Pizzorno E, Tajana L, Osculati A, Ventura F. Sudden death during medical thoracoscopy. J Forensic Leg Med 2014;21:38-41.  Back to cited text no. 2
    
3.
Kato T, Sugimoto M, Matsuoka Y, Sakura Y, Hayashida Y, Hirama H, et al. Case of vascular air embolism during holmium laser enucleation of the prostate. Int J Urol 2015;22:227-9.  Back to cited text no. 3
    
4.
Haleblian G, Kijvikai K, de la Rosette J, Preminger G. Ureteral stenting and urinary stone management: A systematic review. J Urol 2008;179:424-30.  Back to cited text no. 4
    
5.
Nabavizadeh B, Keihani S, Hosseini Sharifi SH, Kajbafzadeh AM. Insertion of a single double-J stent for bilateral open ureteral reimplantation: Introducing a novel technique and assessment of feasibility. Int Urol Nephrol 2016;48:1015-9.  Back to cited text no. 5
    
6.
Muth CM, Shank ES. Gas embolism. N Engl J Med 2000;342:476-82.  Back to cited text no. 6
    
7.
van Hulst RA, Klein J, Lachmann B. Gas embolism: Pathophysiology and treatment. Clin Physiol Funct Imaging 2003;23:237-46.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]


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