399

Air Embolism Diagnosed by Doppler Ultrasound

JOSEPH C. MAROON, M.D.
MAURICE S. ALBIN, M.D.
Pittsburgh, Pennsylvania*

Doppler cardiac auscultation appears to be the most sensitive method for detecting air emboli
before pathophysiologic alterations occur in the cardiorespiratory system. I n more than 200
patients in our series monitored with this technic, the incidence approaches 26 percent for those
undergoing operations in the sitting position. A Doppler fetal ultrasonic unit, modified to cut off
in the presence of annoying radiofrequency interference generated by electrocautery units, cur-
rently in use, provides an acceptable method for monitoring, but still further refinements are
under study.

L ABORATORYand clinical observations have

confirmed that cardiac auscultation with
Doppler ultrasound is the most sensitive
diagnostic method for detecting air embo-
lism-a common phenomenon in patients
operated upon in the upright position.l-G
Furthermore, it is presently the only method
that permits diagnosis before pathophysi-
ologic changes occur in the heart rate, arte-
rial or venous blood pressure, electrocardio-
gram, or expired gases.'.;' Thus, preventive
measures can be instituted before the onset
of catastrophic cardiorespiratory collapse.
Until recently, the technical problems of
correct placement and fixation of the trans-
ducer over the right heart and an intolerable
level of interference generated by concurrent
use of electrocautery units have limited
widespread application of this method. Now,
a Doppler ultrasonic instrument, the Feta-
sondeTMt, has been modified to provide a
more acceptable method for neurosurgical FIG.1. Battery-powered Fetasonde Doppler unit,
monitoring. The principles, application, and with chest strap and grooved transducer head. The
results of Doppler cardiac auscultation are raised top reveals cable for recharging and storage
area for strap, transducer, and acoustic gel when
presented. not in use.

MATERIALS AND METHODS moving red blood cells and cardiac struc-
The Fetasonde 2000 'fig. transducer tures. This reflected signal is electronically
generates a continuous 2.5 mHz Doppler converted to a readily discernible audible
ultrasonic signal which is reflected from When air. an acoustical re-
-
t h h e Medical Electronics, Cranbury, New Jersey. flector, passes thkugh the ultrasonic field, a

*Department of Neurological Surgery and Department of Anesthesiology, University of Pittsburgh School

of Medicine, Pittsburgh, Pennsylvania 15213.
Paper received: 8/9/73
Accepted for publication: 9/10/73
400 ANESTHESIA
AND ANALGESIA . .
. Current Researches VOL. 53, N O . 3, MAY-JUNE,
1974

FIG.2. Transducer correctly placed over right atrium and secured with circumferential strap. Insert:
simplified schematic of Doppler cardiac auscultation.

high-pitched, “scratchy,” “chirping,” or thumping sound produced by heart wall and

“roaring” noise is heard, characteristic of an
air embolus.
To detect air before it enters the pulmo-
nary circulation, the transducer must be cor-
rectly positioned over the right atrium or
right ventricle. Since in normal patients the
right heart underlies the sternum and the
parasternal area between the 3rd and 6th
interspaces, we initially place the transducer
with a small amount of acoustic gel just to
the right of the sternum and a few inches
above the xyphoid process (fig. 2). By
angling and/or sliding the transducer ceph-
alad or caudad, the characteristic high-
pitched swishing sounds of intracardiac
blood flow superimposed on the “heavy”
valvular motion are heard.
Sometimes it is necessary to place the
transducer directly over or slightly to the
left of the sternum, but in all patients the
correct position can usually be found and
the transducer fixed in position in less than
a minute. There is usually some variation
in the intensity of the Doppler sounds with
the respiratory cycle, presumably due to
movement of the cardiac structures away
from the anterior chest wall during inspira-
tion, but this is of little consequence.
Once the correct site is located, a circum-
ferential rubber strap previously passed be-
hind the patient’s back is threaded through

* DR.JOSEPHC. MAROON received his M.D. degree from

Indiana University School of Medicine, Indianapolis in
1965. After completing his internship at the Indiana
University Medical Center in 1966, Dr. Maroon held a
one-year Residency in Neurosurgery at Georgetown Uni-
versity Hospital, Washington, D.C., returning to Indiana
University Medical Center in 1967 where he completed
his Residency in Neurosurgery in 1971. Currently, Dr.
Maroon is Assistant Professor of Neurological Surgery,
Department of Neurological Surgery, at the University of Pittsburgh, School
of Medicine, Pittsburgh, Pennsylvania.
Air Embolism . . . Maroon and Albin 401

the specially constructed grooves of the plies pressure to the internal jugular veins
transducer head and fastened into place. It bilaterally to increase cerebral venous pres-
is essential that no movement of the trans- sure, discontinues the flow of nitrous oxide,
ducer occur after fixation, since a slight de- if being used, applies continuous positive
gree of angulation may result in loss of the pressure ventilation, and aspirates the right
signal. Initially, we tried various adhesives atrial catheter.’ The surgeon immediately
and tape for fixation, but the circumferen- floods the wound with saline solution, oc-
tial rubber strap has proved the most advan- cludes any open venous channels, and makes
tageous. certain that all bone edges are appropriately
covered with bone wax. In none of our
To further confirm correct transducer cases1.4’sor in those reported by Michen-
placement, we may inject 0.25 to 0.5 ml. of felder and associates6 were any further
carbon dioxide or air into the right atrial measures necessary. However, appropriate
catheter, which we always have in place for chemotherapy for cardiac arrhythmias must
patients undergoing operations in the up- be readily available, and one must also be
right position. The characteristic “chirping” ready to lower the table to the recumbent
should be heard; otherwise, transducer
placement may be incorrect and a slight
adjustment necessary. RESULTS
The most disconcerting feature of all The described instrument has been found
Doppler ultrasonic units used during neuro- quite practical for neurosurgical monitoring.
surgical procedures has been the radiofre- In dogs and baboons we have demonstrated
that less than 0.5 ml. of air entering the right
quency “noise” signals generated by electro-
atrium is immediately detected. Tests with
cautery units. These signals are picked up
various electrocautery units, including the
by the ultrasonic transducer and heard as
bipolar type, have shown that radiofrequen-
loud, harsh static that completely obliterates
cy interference is effectively eliminated.
cardiac signals. If the surgeon depresses the
cautery foot pedal while one is listening to Clinical application in more than 200 pa-
heart sounds with earphones, various ex- tients confirms the ease with which the right
pletives are also invariably emitted! This atrium is located and proper and prolonged
problem has been eliminated by construct- fixation to the chest obtained.
ing a cutoff circuit as an integral part of the We have also found that after a brief ex-
audio portion of the instrument. planation and demonstration with tape re-
cordings, anesthesiologists and residents un-
Radiated interference noise produced by familiar with ultrasonic equipment have no
electrocautery units is squelched in the Feta- difficulty in correctly using the instrument
sonde 2000 by a detector that responds to and recognizing the sounds of air emboli.
the energy contact in a selected frequency No complications from prolonged ultrasonic
band of the output of various electrocautery monitoring have occurred and none are an-
units. The frequency band ranges from 3000 ticipated, because of the low intensity of the
Hz to 300 kHz, which is below the 2.5 mHz ultrasound. l 2
transmitted by the Fetasonde 2000. The de-
tected radiation is used to switch off the
Fetasonde only during actual use of a cau- DISCUSSION
tery for cutting or coagulation. The Doppler Before the use of Doppler cardiac auscul-
unit is deactivated within 10 m c . after the tation, the incidence of air embolism during
cautery operation is initiated, and reacti- neurosurgery, estimated at from 0.5 to 8 per-
vated in approximately 200 msec. Because cent, was virtually impossible to assess ac-
of the brevity of these periods of interrup- curately, since criteria for diagnosis by ne-
tion, there is only a slight chance that a cessity included a pathologic alteration in
significant air embolus will be missed. It is the patient’s vital signs and, not infrequent-
emphasized, however, that a unit totally free ly, cardiorespiratory With the
of cautery interference would be optimal. Doppler method, presymptomatic emboli
We are presently working with engineers can now be detected, thus permitting insti-
toward this end. tution of prophylactic measures before sig-
nificant pathophysiologic alterations occur.
In any patient in whom abnormal Doppler
sounds consistent with an air embolus are In approximately 292 patients now moni-
heard, immediate therapeutic measures are tored with this technic in three different in-
taken. The anesthesiologist immediately ap- stitutions, the incidence of air embolism has
402 . . . Current Researches VOL. 53, NO.3, MAY-JUNE,
AND ANALGESIA
ANESTHESIA
ranged from 21 to 39 percent, with an aver-
age close to 29 p e r ~ e n t . ~As
- ~ long
~ ~ ~sus-
* designed primarily for obstetric use, which
pected by many neurosurgeons, air does,
indeed, enter the vascular system fre-
quently during procedures performed with
the patient upright. Not to be overlooked
is the fact emphasized by Shenkin and
Goldfedder"; that air emboli can also occur
in the prone position, as illustrated by their
patient who had a massive and fatal air em-
bolus during a posterior fossa exposure for
an arteriovenous malformation. Fortunately,
however. most air emboli are small and are
satisfactorily tolerated. In the 200 patients
in our series only 7, or 3.5 percent, had con-
current changes in the electrocardiogram,
blood pressure, respiratory pattern, or steth-
oscopic heart sounds. In all, preventive
measures were immediately instituted and
no serious or fatal complications occurred. It
is, of course, impossible to predict whether
any major problems would have developed
had prophylactic measures not been imme-
diately taken.
A frequent criticism of this method has
been that it is overly sensitive, not quanti-
tative, and that the majority of episodes of
air emboli would probably never be clini-
cally significant. It is well recognized, how-
ever, that the most important factor in the
treatment of air embolism is early diagnosis
before ciirdiorespiratory collapse occurs. The
Doppler technic appears to be the most sen-
sitive diagnostic method for this purpose. As
explained by Michenfelder and associates,e
objection to relatively innocuous "unneces-
sary'' therapeutic measures does not appear
valid.
In our clinical and laboratory experience
with this instrument as well as other ultra-
sonic units, the first diagnosis of an air em-
bolism has always been made with the Dop-
pler technic. Michenfelder and associates,e
however, diagnosed 29 episodes of air emboli
in 69 patients, and in 2 of these, a cardiac
systolic murmur was heard through a stetho-
scope at a time when no changes were noted
in the Doppler heart sounds. Although this
was probably due to inaccurate transducer
placement, an esophageal stethoscope as an
added diagnostic safety measure is still indi-
cated.
We have evaluated in the laboratory as
well as clinically most of the commercially
available Doppler ultrasonic units. There is
little difference in the sensitivity of these
1974
instruments for detecting air emboli. Any
have a deeper focusing point than those de-
signed for peripheral vascular uses, should
be adequate for neurosurgical monitoring,
provided modifications for proper transducer
fixation and elimination of electrocautery
static are made.
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1969
2. Edmonds-Seal J , Prys-Roberts C, Adams AP:
Transcutaneous Doppler ultrasonic flow detectors
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3. Malis L: Personal communication
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Evaluation of an ultrasonic device (Doppler) for
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