Management of a Large Air Embolus in the Right Ventricle

Initial Management

The European Society of Cardiology recommends positioning the patient in the left lateral decubitus head-down position to prevent air from migrating to the pulmonary artery and to trap air in the apex of the right ventricle 1
If a central venous catheter or pulmonary artery catheter is in place, attempt to aspirate the air from the right heart 1
Provide hemodynamic support with vasopressors and inotropes as needed to maintain adequate cardiac output 2

For right ventricular failure due to outflow tract obstruction, initiate inotropic support with dobutamine to improve right ventricular contractility 3
Consider milrinone as an alternative inotrope with additional pulmonary vasodilatory effects 3
Use vasopressors such as norepinephrine or vasopressin to maintain coronary perfusion pressure if hypotension is present 3
Avoid excessive fluid administration as this may worsen right ventricular distention and compromise left ventricular filling 3

Continuously monitor heart rate, blood pressure, and oxygen saturation 2
Consider bedside echocardiography to assess right ventricular function and confirm resolution of the air embolus 3
For patients with significant right ventricular dysfunction, consider pulmonary vasodilators such as inhaled nitric oxide or sildenafil 3, 2

During central line insertion or removal, place patients in Trendelenburg position to increase central venous pressure and reduce the risk of air entrainment 4
Use meticulous technique during vascular procedures, which are the most common cause of iatrogenic air embolism 4