Iatrogenic cerebral air embolism: importance of an early hyperbaric oxygenation.

OBJECTIVES: To assess the relationship between the time period before hyperbaric oxygenation therapy (HBO) and clinical outcome in patients with iatrogenic cerebral air embolism. DESIGN AND SETTING: Retrospective study in a hyperbaric chamber and medical intensive care unit of a university hospital. PATIENTS: All patients with air embolism from 1980 to 1999. INTERVENTIONS: We retrieved the cases of 86 patients who benefited from an identical HBO and analyzed the relationship between the time period before HBO and clinical outcome. RESULTS: Patients treated with HBO less than 6 h had a better outcome than those treated later. In patients treated within this delay the cause was venous air embolism in 84% and arterial air embolism in only 16% of cases. After this delay the cause was venous air embolism (53%) and arterial air embolism (47%). Patients with venous air embolism and recovery had a shorter delay than patients with sequelae or death (2 h 15 min vs. 4 h). Patients with venous air embolism treated less than 6 h had a better outcome than those treated later. In patients with arterial air embolism the time period before HBO was longer than in venous air embolism (8 h vs. 3 h) and the outcome worse (recovery in 35% vs. 67%). In patients with arterial air embolism no difference in the time period was found between patients with recovery and sequelae or death. CONCLUSIONS: We stress the beneficial effect of an early HBO in air embolism, the importance of an increased awareness of physicians concerned with this severe complication, and the need to develop techniques to detect air emboli in the cerebral circulation.

[Is thiamine supplementation necessary in patient with cardiac insufficiency?]. / Une supplémentation en thiamine est-elle nécessaire chez les insuffisants cardiaques?

Interest has recently risen regarding thiamine deficiency in patients with cardiac deficiency who are receiving long-term diuretic therapy. Thiamine deficiency can lead biventricular myocardial failure (cardiac beriberi), and treatment consists of thiamine administration. Studies have shown that long-term furosemide use may be associated with thiamine deficiency through urinary loss, contributing to cardiac insufficiency in patients with congestive heart failure. Thiamine supplementation could improved left ventricular function. However, the results of those studies are controversial, and none study have till proved the clinical impact of a systematic administration of thiamine in a cohort of patients with cardiac insufficiency. To date, and waiting for available literature, thiamine administration should be consider in patients at risk for thiamine deficiency (elderly, malnourished, alcoholic), and in patients receiving very large doses of diuretics.

[Cardiac beriberi]. / Béribéri cardiaque.

Interest has recently risen regarding thiamine deficiency (beriberi). In industrial countries, not only alcoholics, but also deprived people with malnutrition, elderly patients and patients with AIDS are at risk of thiamine deficiency. Moreover, long-term furosemide use may be associated with thiamine deficiency through urinary loss, contributing to cardiac insufficiency in patients with congestive heart failure. Cardiovascular (wet beriberi) manifestations of thiamine deficiency are characterized by peripheral vasodilatation with increased cardiac output, myocardial lesion, sodium and water retention and biventricular myocardial failure. Treatment consists of thiamine administration with rapid clinical improvement after supplementation.

[Fat embolism after intrapenile injection of sweet almond oil]. / Embolie graisseuse après injection intrapénienne d'huile d'amande douce.

We report a case of fat embolism following self injection of vegetable oil in the penis, to treat an impotence. The patient developed respiratory failure and neurological disorders as confusion. A chest roentgenogram revealed diffuse alveolar infiltrate. Initially, he presented an hemoconcentration, and fat globules in his urine. The outcome was favourable in 72 hours, with oxygen and hydration. The diagnosis of fat embolism was made after neurological improvement: the patient admitted to injection his penis with vegetable oil, in his corpus cavernosum.

[Changes in cardiac function during recreational diving]. / Modifications de la fonction cardiaque en plongée sportive.

Underwater diving is a widely practised leisure activity. As cardiac patients may wish to participate, cardiologists should be aware of potential changes of cardiac function during diving. Multiple factors may affect haemodynamics. Firstly, changes in pressure, secondary to ventilation of a high density gas mixture which increases afterload. Hyperoxia is the principal factor which slows the heart rate, a commonly observed phenomenon. Excitability and conduction speed may be modified by the increase in hydrostatic pressure. During decompression, gaseous pulmonary embolism may increase right heart pressures and cause a paradoxical embolism may increase right heart pressures and cause a paradoxical embolism in patients with a right-to-left shunt. Immersion increases the preload. Exposure to cold also plays a role increasing afterload and slowing the heart rate. These factors may disturb cardiac function and expose cardiac patients to accidents during underwater diving.

[Prognosis in iatrogenic gas embolism]. / La prognosi delle embolie gassose iatrogene.

Prognosis of iatrogenic air embolism is various according to previous studies. The purpose of this study was to determine the risks factors associated with the prognosis of iatrogenic air embolism. We conducted a retrospective analysis of 113 patients treated with HBO therapy in our hyperbaric center from 1979 to 1993. Initial symptomatology consisted in neurological disorders (71% of cases), respiratory disorders (43% of cases) and hemodynamic disorders (33% of cases). When neurological disorders were observed, HBO therapy included immediate compression to 6 atm abs for 10 to 15 mn with air followed by decompression to 2 atm abs where the patients received 100% oxygen during 1 hour. When no neurological disorders was observed, HBO therapy consisted in an oxygenation for 1 h, 2 atm abs, FiO2 = 1. Overall outcome was: recovery: 69 per cent of cases, sequelae: 26 per cent of cases, death: 5 per cent of cases. Prognosis was very different according to etiologies and existence of neurological disorders. Venous emboli had a better improvement than arterial emboli. In conclusion, patterns of air embolism can be divided clinically into two major categories, cerebral and pulmonary air embolism, which should be individualised in clinical studies. The studies must also individualised etiologies.

[Neurologic accident of decompression: a new indication of transesophageal echocardiography]. / Accident neurologique de décompression: une nouvelle indication de l'échocardiographie transoesophagienne.

Decompression sickness in a 33-year-old SCUBA diver led to neurological lesions with brain damage. The existence of a patent foramen ovale detected with a transoesophageal contrast echocardiography suggested paradoxal gas embolism. This observation emphasizes the intest of transoesophageal contrast echocardiography in decompression sickness as discussed in the literature. Its widely utilization would permit a better understanding of the pathophysiology of decompression sickness. It also may help the physician in deciding whether or not to authorize further diving.