Cerebral air embolism: Process change with unintended consequences.

Area of Science:

• Neuroendovascular procedures
• Medical device safety

Background:

• Cerebrovascular procedures require meticulous air exclusion to prevent cerebral air emboli, which can lead to severe neurological deficits or death.
• A recent process change involving refrigeration of mixed heparin for storage introduced unintentional air, or off-gassing, into the fluid lines.

Purpose of the Study:

• To explain the cause and effect of air formation (off-gassing) in heparinized fluids during neuroendovascular procedures.
• To raise awareness of this phenomenon to prevent patient harm.

Main Methods:

• Observational analysis of an off-gassing phenomenon noted during procedures.
• Investigated potential causes, including fluid preparation and device manufacturing.
• Identified a correlation between refrigerated heparin and off-gassing when fluid flowed through warming devices.

Main Results:

• Off-gassing, leading to potential cerebral air emboli, occurs when cold heparinized fluids are warmed during neuroendovascular procedures.
• Warming fluids prior to use is crucial to prevent this phenomenon.

Conclusions:

• Air formation (off-gassing) is a risk when cold fluids are warmed, particularly in neuroendovascular procedures.
• This unintentional air can cause significant patient morbidity and mortality.
• Recognizing and mitigating this risk through fluid warming is essential for patient safety.