Be on the alert again for the risk of pulmonary air embolisation in paediatric patients during the insertion of a central venous catheter under general anaesthesia with spontaneous respiration

Dear Editor,
Air embolism is a very rare but well- known and potentially fatal complication of central venous catheter insertion [1, 2]. We experienced a paediatric case of suspected pulmonary air embolisation during insertion of a Hickman catheter with a peel-off sheath system (Medicon Inc., Osaka, Japan).
A tunnelled double-lumen Hickman catheter was inserted in a two-year-old patient (height 86 cm; body mass 13 kg) for planned chemotherapy due to yolk sac tumour with multiple metastases. Because the anaesthesio­logists considered it to be a minimally invasive procedure, perioperative anaes­thetic management was performed under general anaesthesia with a laryngeal mask using pressure support ventilation to maintain spontaneous respiration of the patient via sevoflurane and intermittent bolus administration of fentanyl. Paediatric surgeons scanned the bilateral subclavian veins of the patient in the Trendelenburg position, and the right subclavian vein was chosen for the puncture site of the 7.5 Fr Hickman catheter insertion. The puncture needle was successfully inserted into the right subclavian vein in the Trendelenburg position using real-time ultrasound-guidance [3–5]. The guide wire was inserted through the puncture needle in the direction of the superior vena cava using a portable X-ray machine. The peel-off sheath and dilator were inserted together over the guide wire. Then, the dilator was drawn out, leaving the peel-off sheath with a free opening at the distal end. Next, the Hickman catheter was inserted into the sheath, and then the sheath was peeled off gradually. During the procedure, the operator put his thumb on the free opening at the distal end of sheath at his own discretion, and the anaesthesiologist attempted the Valsalva manoeuvre with 30 cm H₂O (3 kPa) positive pressure intermittently to maintain positive intrathoracic pressure under close communication with the operator regarding the timing of it, to prevent air from entering the vein.
However, the anaesthesiologist felt through the anaesthesia reservoir bag in his hand that the patient unexpectedly breathed in very deeply during the procedure when a Valsalva manoeuvre was released. Directly after that, SpO2, heart rate, and noninvasive systolic blood pressure declined to 70%, 120 min-1, and 70 mm Hg, from 100%, 140 min-1, and 85 mm Hg before the episode, respectively. The anaesthesiologist suspected that air had entered the vein; therefore, 1 mg kg-1...


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