Indian Journal of Urology
LETTER TO EDITOR
Year
: 2014  |  Volume : 30  |  Issue : 4  |  Page : 456--457

Re: Parikh GP, Sonde SR, Kadam P. Venous air embolism: A complication during percutaneous nephrolithotomy. Indian J Urol 2014;30:348-9


Hakan Ozturk 
 Department of Urology, School of Medicine, Sifa University, Izmir, Turkey

Correspondence Address:
Hakan Ozturk
Basmane Hospital of Sifa University, Fevzipasa Boulevard No: 172/2, 35240, Basmane-Konak-Izmir
Turkey




How to cite this article:
Ozturk H. Re: Parikh GP, Sonde SR, Kadam P. Venous air embolism: A complication during percutaneous nephrolithotomy. Indian J Urol 2014;30:348-9 .Indian J Urol 2014;30:456-457


How to cite this URL:
Ozturk H. Re: Parikh GP, Sonde SR, Kadam P. Venous air embolism: A complication during percutaneous nephrolithotomy. Indian J Urol 2014;30:348-9 . Indian J Urol [serial online] 2014 [cited 2021 Oct 18 ];30:456-457
Available from: https://www.indianjurol.com/text.asp?2014/30/4/456/142081


Full Text

Dear Editor,

With reference to the recent article on venous air embolism during percutaneous nephrolithotomy published in your journal, [1] we would like to reiterate that air embolism is a very rare and important complication that should always be kept in mind by endourologists performing percutaneous nephrolithotomy (PCNL). The position of the air embolism in the Clavien-Dindo classification system is not clear because it can presents a wide spectrum ranging from Grade I complication with spontaneously resolution to Grade V complication that may be fatal. It was first defined by Miller et al. in 1984 [2] While sudden death following air embolism during PCNL was first reported by Hobin et al. in 1985. [3] Air embolism occurring in PCNL has potential consequences involving the respiratory, cardiovascular and central nervous systems such as hypoxia, ST-T depression on the ECG, hypotension and tachycardia. However, if the embolus passes into the arterial system, the complications make become worse and its diagnosis may be possible only with echocardiography. This situation, also called paradoxical air embolism and was first described during PCNL by Seung-Hun Song et al. in 2007. [4] It developed in this case through a patent foramen ovalebut may also be possible through an undiagnosed atrial or ventricular septal defect. Air in the arterial system can cause neurological complications such as altered consciousness, loss of sensation and seizures. The most significant complication is "cryptogenic stroke." [5] Other possible complications include aphasia, coma, paraplegia, hemiplegia and quadriplegia. As discussed in this article, mortality and morbidity of the air embolism is determined by velocity, volume, pressure of the air, position of the patient during the procedure and situation of the heart. It should be known that other medical gases such as nitrogen, nitrogen dioxide, carbon dioxide and helium may also cause air embolism. The complication rate is relatively lower with soluble carbon dioxide. The volume of the collecting system is about 10-12 mL. Usually, 20-50 mL of air is used for pyelography. Most cases of air embolism during PCNL have been described for patients under general anesthesia, in the prone position and who have undergone pyelography with air. In the present case, 40 mL of air was used and the patient underwent the procedure in the prone position under general anesthesia. In 2013, Abbas Basiri et al. evaluated a total of 30,666 patients from 13 centers. In that series of patients, neurological complications were reported in 11 patients. In all cases, room air was used for pyelography with the patients being in the prone position under general anesthesia. Cases with complications were reported even though the amount of air used was close to the physiological volume (17 mL). [5]

In conclusion, air embolism occurring during PCNL may result in serious complications such as death, coma, hypoxic encephalopathy, cryptogenic stroke, paraplegia, hemiplegia and quadriplegia, causing financial and emotional stress in the patients and their relatives. Urologists who prefer using air for pyelography during PCNL operation under general anesthesia should be aware of the potential risk of air embolism. They should especially know this rare complication and should be cautious on potential results in making diagnosis and planning the treatment.

References

1Parikh GP, Sonde SR, Kadam P. Venous air embolism: A complication during percutaneous nephrolithotomy. Indian J Urol 2014;30:348-9
2Miller RA, Kellett MJ, Wickham JE. Air embolism, a new complication of percutaneous nephrolithotomy. What are the implications? J Urol 1984;90:337-9.
3Hobin FP. Air embolism complicating percutaneous ultrasonic lithotripsy. J Forensic Sci 1985;30:1284-6.
4Song SH, Hong B, Park HK, Park T. Paradoxical air embolism during percutaneous nephrolithotomy: A case report. J Korean Med Sci 2007;22:1071-3.
5Basiri A, Soltani MH, Kamranmanesh M, Tabibi A, Mohsen Ziaee SA, Nouralizadeh A, et al. Neurologic complications in percutaneous nephrolithotomy. Korean J Urol 2013;54:172-6.