Patient Safety Alert: Air Embolism During Cardiac Ablation

Authors

Abstract

During a cardiac ablation procedure, the catheter irrigation fluid bag emptied and was replaced by staff. While priming the tubing, air was noted in the tube, and the catheter was immediately removed from the patient. The patient experienced a decrease of heart rate and blood pressure requiring a code response.

Radiofrequency cardiac ablation requires the use of heparinized irrigation fluid to cool and anticoagulate the ablation site. If the procedure requires more fluid than originally hung, it requires the bag to be replaced. This introduces an opportunity for air to enter the irrigation tubing. Air emboli can then be infused into the patient, causing cardiac arrhythmia, myocardial infarction, respiratory symptoms, and/or neurologic symptoms, and, potentially, total cardiovascular collapse.

Solutions

  • During cardiac ablation procedures, air should be removed from any bagsand the pump (or any other pressurized delivery device) tubing should be primed before being connected to a patient.
  • Do not bypass alarms that detect air in the pump or tubing systems.
  • Do not prime the irrigation line without first disconnecting the tubing setfrom the patient, regardless of whether a stopcock is in use.
  • Review the manufacturer’s instructions for how to change fluid bags to ensure safe operations.
  • Be aware of potential access points for air to enter the system and mitigate the risk.

Author Biographies

Michelle Bell, BSN, RN, Patient Safety Authority

Michelle Bell (michbell@pa.gov) is the director of Outreach and Education with the Patient Safety Authority (PSA). Bell began working with the PSA in 2010 as a patient safety liaison for the Southeast region. She joined the PSA after completing a yearlong fellowship with the Institute for Safe Medication Practices, a world-renowned expert organization on medication safety.

Bruce C. Hansel, PhD, ECRI

Bruce Hansel joined ECRI in 1984 as a project engineer, bringing extensive experience in science and engineering. His career with ECRI has been focused on managing and investigating accidents involving medical technology of all descriptions—including numerous gas embolism incidents—as well as lecturing on investigative methodology and patient safety.

Image of heart, next to title.

Published

2022-12-16

How to Cite

Bell, M., & Hansel, B. C. (2022). Patient Safety Alert: Air Embolism During Cardiac Ablation. Patient Safety, 4(4), 6–7. Retrieved from https://patientsafetyj.com/index.php/patientsaf/article/view/air-embolism
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