Central venous air embolism without a catheter

Venous air embolism is a well-recognized complication of central venous catheterization. Although previous reports have documented venous air embolism occurring in a number of ways, including during initial catheterization, when catheters crack or are disconnected, and after catheter removal, no reports mention the possibility of air embolism occurring when a guide wire without a catheter was in place. A patient is presented who displayed signs and symptoms of venous air embolism (tachypnoea, chest pain, and arterial hypoxaemia) during central venous catheter manipulation while a guide wire alone was in place. Pulse oximetry was used to detect hypoxaemia and suggest an aetiology for the patient's clinical symptoms. It is postulated that a previously described gasp reflex or some sort of sustained negative pressure manoeuvre caused venous air embolism around the guide wire and accounted for the patient's signs and symptoms. During central venous catheter placement, a high index of suspicion for venous air embolism should be maintained, pulse oximetry should be used, the skin entrance site should be kept covered by an occlusive dressing, and the patient should be positioned head-down.