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• W2395107746 abstract "Editor'I have read with great interest the study of Eckle and colleagues,1Eckle VS Neumann B Greiner TO Wendel HP Grasshoff C Intrajugular balloon catheter reduces air embolism in vitro and in vivo.Br J Anaesth. 2015; 114: 973-978Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar who provide new experimental evidence that intrajugular balloon catheterization may reduce the risk of air bubbles passing through a blood-filled vessel. They extrapolate their findings to venous air embolisms (VAE), which are mostly seen in neurosurgical patients in the sitting position. Irrespective of the complex in vitro and in vivo settings and the well-conducted experiments, I would like to comment on a few aspects. As the authors stated, the range of VAE incidence is still controversial throughout the literature, and values as high as 76% seem questionable. In patients with a patent foramen ovale, paradoxical embolism after VAE may cause severe complications. In contrast, rescue treatments after VAE without patent foramen ovale (i.e. jugular compression or aspiration of blood from the right atrium), attempting to reduce further advancement of air into the pulmonary circulation, are not associated with any substantial change in perioperative morbidity or mortality2Black S Ockert DB Oliver Jr, WC Cucchiara RF Outcome following posterior fossa craniectomy in patients in the sitting or horizontal positions.Anesthesiology. 1988; 69: 49-56Crossref PubMed Scopus (158) Google Scholar nor can they significantly reduce the need for haemodynamic support. As high central venous pressure may reduce the risk of VAE considerably, the question remains, whether more central venous lines, with the possibility of occluding the vessel, can really decrease the progress of VAE and thus reduce complications of VAE, which has no implication on the patients’ outcome. Do the authors suggest that the commonly used ‘long’ central line, placed in the right atrium, should be removed and replaced by two central lines on either side of the neck in both jugular veins? Or do they want to place two additional central lines? In fact, two lines would be needed, because we do not know whether VAE finds its way via the right or the left jugular vein. This implies that an additional central catheterization3Eckle VS Grasshoff C Intrajugular balloon catheter for prevention of air embolism.J Neurosurg Anesthesiol. 2012; 24: 81-82Crossref PubMed Scopus (3) Google Scholar would have to be performed, with all the additional risks, such as accidental arterial cannulation, nerve injury, or even pneumothorax. This should be weighed carefully, because the correct placement does not necessarily mean that VAE is avoided or attenuated. Two central venous lines would have to be placed for temporary internal compression (or inflation) after VAE was detected. Permanent compression of both veins would cause severe damage to the intimal layer of the vessel and thus is not feasible. As Ganslandt and colleagues4Ganslandt O Merkel A Schmitt H et al.The sitting position in neurosurgery: indications, complications and results. A single institution experience of 600 cases.Acta Neurochir (Wien). 2013; 155: 1887-1893Crossref PubMed Scopus (3) Google Scholar demonstrated (reviewing their neurosurgical patients in the sitting position), in three out of 600 patients VAE led to changes in the surgical procedure. In these patients, positioning was changed for the operation but was not associated with any consequence regarding morbidity or even mortality. In conclusion, the authors suggest an additional tool, which will not prevent VAE but may cause extra risks for the patients, while the number needed to treat is 200 (according to Ganslandt and colleagues),4Ganslandt O Merkel A Schmitt H et al.The sitting position in neurosurgery: indications, complications and results. A single institution experience of 600 cases.Acta Neurochir (Wien). 2013; 155: 1887-1893Crossref PubMed Scopus (3) Google Scholar with a complication rate of 6.3–9.4%.5Troianos CA Hartman GS Glas KE et al.Special articles: guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists.Anesth Analg. 2012; 114: 46-72Crossref PubMed Scopus (229) Google Scholar None declared." @default.
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• W2395107746 title "Intrajugular ballon catheter will not abolish venous air embolism or its consequences" @default.
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