20

Anesthesiology
2000; 92:20 3
2000 American Society of Anesthesiologists, Inc.
Lippincott Williams & Wilkins, Inc.

Incidence of Venous Air Embolism during

Craniectomy for Craniosynostosis Repair
Lisa W. Faberowski, M.D.,* Susan Black, M.D., J. Parker Mickle, M.D.

Background: Investigations to determine the incidence of

venous air embolism in children undergoing craniectomy for
craniosynostosis repair have been limited, although venous air
embolism has been suspected as the cause of hemodynamic
instability and sometimes death. A precordial Doppler ultrasonic probe is an accepted method for detection of venous air
embolism and is readily available at most institutions.
Methods: A prospective study was conducted using a precordial Doppler ultrasonic probe in children undergoing craniectomy for craniosynostosis repair. The Doppler signal was continuously monitored intraoperatively for characteristic changes
of venous air embolism. A recording was made of the precordial
Doppler probe pulses, which was later reviewed by a neuroanesthesiologist, blinded to the intraoperative events. This information was correlated with the intraoperative events and episodes of venous air embolism were graded.
Results: Twenty-three patients were enrolled in the study
during the 2-yr study period. Nineteen patients (82.6%) demonstrated 64 episodes of venous air embolism; six patients (31.6%)
had hypotension associated with venous air embolism. Thirtytwo episodes of hypotension were demonstrated in eight patients (34.7%). None of the patients developed cardiovascular
collapse.
Conclusion: The incidence of venous air embolism in our
study of 23 children undergoing craniectomy for craniosynostosis was 82.6%. Though most episodes of venous air embolism
during craniosynostosis repair are without hemodynamic con-

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sequences, the preemptive placement of a precordial Doppler

ultrasonic probe is a noninvasive, economic, and safe method
for the detection of venous air embolism. Prompt recognition
may allow for the early initiation of therapy, thereby decreasing
morbidity and mortality rates related to venous air embolism.
(Key words: Children; hypotension; intervention; precordial
Doppler ultrasonic probe.)

INVESTIGATIONS to determine the incidence of venous

air embolism (VAE) in children undergoing craniectomy
for craniosynostosis repair have been limited. A few case
reports have suggested VAE as the cause of hemodynamic instability and sometimes death in these surgical
patients.1 4 Recent advances in the surgical management
of craniosynostosis and the potential for greater blood
loss with the more involved surgical procedures may
further predispose these children to VAE.5,6 The anatomic and physiologic characteristics of younger surgical
patients may make VAE more likely and the consequences even more devastating.79
A precordial Doppler ultrasonic probe is an accepted
method for the detection of VAE and is readily available
at most institutions.10,11 The routine placement of a
precordial Doppler probe in patients undergoing craniectomy allows continuous monitoring for characteristic
changes that suggest VAE. Identification of VAE in children undergoing craniectomy for craniosynostosis allows better perioperative care in this subset of surgical
patients.

* Fellow, Department of Anesthesiology.

Associate Professor, Department of Anesthesiology.

Methods

Professor, Department of Neurosurgery.

Received from the Departments of Anesthesiology and Neurosurgery, University of Florida College of Medicine, Gainesville, Florida.
Submitted for publication March 18, 1999. Accepted for publication
July 19, 1999. Supported by the I. Heermann Anesthesia Foundation,
Gainesville, Florida. Presented in part at the annual meeting of the
Society for Pediatric Anesthesia, Las Vegas, Nevada, February 18 21,
1999.
Address reprint requests to Dr. Black: Department of Anesthesiology, PO Box 100254, Gainesville, Florida 32610-0254. Address electronic mail to: black@anest2.anest.ufl.edu

After institutional review board approval and parental

consent, 23 children undergoing surgical repair for craniosynostosis from August 1, 1996, through October 1,
1998, were enrolled in this prospective study. After
induction of anesthesia, routine monitors and a precordial Doppler ultrasonic probe were placed. Anesthesia
was maintained with isoflurane or halothane in oxygen
and air. End-tidal carbon dioxide and nitrogen concentrations were monitored. However, because all patients

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VENOUS AIR EMBOLISM DURING CRANIOSYNOSTOSIS REPAIR

Table 1. Percentage of Patients Undergoing Different Surgical

Procedures for Craniosynostosis
Suture

Sagittal
Bicornal
Metopic
Coronal
Lambdoidal

% of Patients (n)

47.8 (11)
26 (6)
13 (3)
8.6 (2)
4.3 (1)

received a mixture of oxygen and air, end-tidal nitrogen

was not considered to be a sensitive monitor for VAE and
was not recorded. Placement of an arterial catheter, a
central venous line, or both was at the discretion of the
attending anesthesiologist. The patients were positioned
supine, prone, or modified prone as determined by the
surgical procedure (table 1). After final operative positioning, the Doppler probe was secured with a clear
adhesive, and correct placement was verified by rapid
intravenous injection of 510 ml of agitated saline peripherally and the subsequent observation of characteristic Doppler tones. The precordial Doppler tones were
monitored continuously during the operative procedure.
Injection of fluids, blood products, or medications was
designated on the audio recording by the verbal communication of the anesthesiologist. Episodes of VAE were
diagnosed by characteristic changes in Doppler tones
and with continuous audio recording.
The audio recording of the Doppler tones was later
reviewed by an experienced neuroanesthesiologist
blinded to the intraoperative events. The timing of the
episode of VAE relative to the operative course was
noted and correlated with data regarding blood pressure
and end-tidal carbon dioxide concentration. The severity
of VAE was graded according to the following scale:
grade I, Doppler tone changes only; grade II, Doppler
tone changes plus decreases in end-tidal carbon dioxide
concentration greater than 2 mmHg; and grade III,
Doppler tone changes plus a 20% decrease from baseline
(preoperative) systolic arterial pressure, with or without
a change in end-tidal carbon dioxide concentration. Neither anesthetic or surgical plans were altered because of
a patients inclusion in this study.
Several therapeutic maneuvers were used simultaneously intraoperatively with the detection of hemodynamically significant air. The maneuvers used to treat
VAE were administration of fluid, often packed erythrocytes; application of bone wax; and flooding the surgical
field. Procedures such as lowering the surgical field and
the aspiration of air from a right atrial catheter were not
performed.

Statistical Analysis
Episodes of hypotension, VAE, or both are designated
as median values with a measure of variance (2575%
percentiles).

Results
Evidence of VAE was demonstrated in 19 patients
(82.6%), of whom 6 (31.5%) developed hypotension
associated with VAE. There were 64 total episodes of
VAE, with hypotension occurring in 10 (15.6%) of the
episodes (fig. 1). Hypotension was demonstrated in eight
(34.7%) patients, with a total of 32 episodes (fig. 2). Ten
episodes of hypotension (31%) were associated with
VAE. None of the patients developed cardiovascular collapse. The median number of VAE episodes per surgical
procedure was 2.0 (range 0 8), and the median number
of hypotension episodes per surgical procedure was 0.0
(range 0.0 1.7).

Discussion
The incidence of VAE in our study (82.6%) was greater
than previously reported (66%)3,12 and greater than that
reported with suboccipital craniotomy in children
(33%).13 Intraoperative hypotension in our study associated with VAE (31.5%; 6/19 patients with VAE) was less
frequent than previously reported in children (69%) but
similar in frequency to adult patients (36%).1,13 Interestingly, only one third of the total episodes of intraoperative hypotension were associated with VAE. Clinical factors predisposing children to VAE such as age, weight,

Fig. 1. Number of venous air embolism (VAE) episodes detected

by precordial Doppler for all craniosynostosis repairs. There
were 31 (48.4%) episodes of Doppler only detected VAE (grade
I), 23 (36%) episodes of grade II VAE (carbon dioxide changes),
and 10 (15.6%) episodes of grade III VAE (hypotension: 20%
decrease from baseline systolic blood pressure).

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FABEROWSKI ET AL.

Fig. 2. Number of hypotension and venous

air embolism (VAE) episodes according to
cranial suture involved in surgical repair
(mean 6 SEM). The cranial suture involved
in surgical repair is designated on the xaxis. Proceeding from left to right for each
cranial suture is the median number of
episodes of VAE per hour, total number
(median) of VAE episodes, the median
grade of VAE, the median number of hypotension episodes (with or without VAE) per
hour, and the total number of hypotension
episodes (with or without VAE).

estimated blood loss, and suture involvement could not

be determined from this study. However, large blood
losses are inevitable with the surgical repair of craniosynostosis and are the likely cause for most episodes of
hypotension.
Venous air embolism may occur during any operative
procedure in which the operative site is above the level
of the heart and noncollapsible veins are exposed to air.
With the operative site above the level of the heart, a
pressure gradient may develop that favors air entry
rather than bleeding if a vein is opened. A 5-cm gradient
is sufficient to entrain air in a patient undergoing a
neurosurgical procedure.13 VAE occurs in approximately
10 17% of craniotomies performed in the prone position and is a more common complication in the sitting
position (42%).11,13,14
Children undergoing craniectomy in the supine position may be more predisposed to VAE compared with
adults for several reasons. When infants are supine, their
larger heads relative to their weights unintentionally may
be positioned above the heart. Because of the highly
vascular nature of the infant scalp, rapid hemorrhage is
not unusual.7,8 Rapid blood loss can lead to a decrease in
central venous pressure and the development of a pressure gradient between the right atrium and the surgical
site favoring entrainment of air. Thus, hypotension associated with blood loss may precede VAE. Hypotension
with VAE may be more pronounced in children because
the volume of entrained air is greater in comparison to
their cardiac volume. The persistence of a patent foramen ovale in 50% of children younger than 5 yr of age

may increase the potential for paradoxic air embolism.9,15

Several monitors have been used to detect VAE: transesophageal echocardiography, precordial Doppler probe
monitoring, end-tidal nitrogen concentration, end-tidal
carbon dioxide concentration, transcutaneous oxygen
saturation, central venous pressure monitoring, and
esophageal stethoscope monitoring. The most sensitive
monitors are the transesophageal echocardiogram and
the precordial Doppler probe.10,11,14,16 Precordial Doppler monitoring is inexpensive, noninvasive, and very
sensitive, but not specific, in the detection of VAE. Continued experience in using the precordial Doppler probe
and increased familiarity with the changes in Doppler
tones has allowed early detection of VAE.
Routine use of the precordial Doppler probe in procedures such as posterior fossa craniotomy in the sitting
position resulted in an increased incidence of VAE detection.14 Also, a dramatic reduction in the morbidity
rate related to VAE and near elimination of deaths resulting from VAE resulted from the routine use of a precordial Doppler probe in these patients. Before routine use
of precordial Doppler probes during sitting posterior
fossa craniotomy, the incidence of VAE was reported as
115%, with a mortality rate of 0 73% and major morbidity rate of 25%.16 With the routine use of a precordial
Doppler probe, VAE is detected in 43 45% of patients,
with major morbidity and mortality rates reported as
0 1%.14 It is likely that the same is true with craniosynostosis repair. Routine use of a precordial Doppler probe
could be expected to result in a significant increase in

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VENOUS AIR EMBOLISM DURING CRANIOSYNOSTOSIS REPAIR

diagnosis of VAE, allowing for prompt treatment before

the development of clinical signs of VAE. This would in
turn be expected to result in the reduction of morbidity
and mortality rates related to VAE.
Venous air embolism might have been the cause of
fewer than one third of the hypotensive episodes in our
study. Craniosynostosis is associated with a large blood
loss and frequent hypotensive episodes. Consequently,
VAE might be overlooked as a possible cause of intraoperative hypotension in these patients if precordial Doppler monitoring is not utilized. Volume replacement for
suspected hypovolemia is only one of the appropriate
treatments if VAE is occurring; elimination of air entrainment by the surgeon is crucial. Without precordial
Doppler monitoring, VAE might not be recognized.
Venous air embolism is common in the surgical repair
of craniosynostosis. VAEs can be quickly detected with
the preemptive placement of a precordial Doppler
probe. Early detection of VAE can expedite therapeutic
maneuvers, such as elimination of the source of VAE and
replacement of intravascular volume. Interventions such
as these potentially attenuate the incidence of hemodynamic instability in this subset of surgical patients.

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