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You have a patient on central Line in ICU who deteriorates suddenly with crashing of BP due to large of amount of air entering right side of the heart. The large air bubbles will crowd and occlude the flow of blood into pulmonary artery. This leads to crashing of BP. What is the first step to be taken in its management? Shift the patient using Durant maneuver as shown in the inset below.

Durant maneuver consists of placing the patient in left lateral decubitus position followed by Head low position in order to prevent venous air bubbles from lodging in lungs. In patients who may have patent fossa ovalis they may enter into left side of heart and go into brain causing features of stroke.

The logic is that air will stay in right heart away from pulmonary conus and will gradually be absorbed. Another rationale for head low position is to prevent arterial air embolism bubbles from travelling to the brain.

Transesophageal echocardiography will help in estimating the amount of air that is causing venous air embolism.

Interventions in air embolism

1. Direct aspiration of air from central venous catheter into the right atrium can be attempted
2. Consider shifting to Hyperbaric oxygen therapy unit if possible
3. Give CPR if patient is pulseless. Giving CPR will break those air bubbles making it easier for dissolution of air.

Bonus point: Venous air embolism can be seen during which surgery? Ans- Neurosurgery during Craniotomy