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Incidence of Venous Air Embolism During Endoscopic Retrograde Cholangiopancreatography

Afreen, Lubana K., BS*; Bryant, Ayesha S., MSPH, MD*; Nakayama, Tetsuzo, MD*; Ness, Timothy J., MD, PhD*; Jones, Keith A., MD*; Morgan, Charity J., PhD; Wilcox, Charles M., MD; Phillips, Mark C., MD*

doi: 10.1213/ANE.0000000000003566
Patient Safety: Original Clinical Research Report

BACKGROUND: Known complications of endoscopic retrograde cholangiopancreatography (ERCP) include pancreatitis, bleeding, duodenal perforation, and venous air embolism (VAE). The aim of this study was to determine the incidence of VAE during ERCP and be able to differentiate high-risk versus low-risk ERCP procedures.

METHODS: This is a prospective cohort study consisting of patients who underwent ERCP and were monitored with a precordial Doppler ultrasound (PDU) for VAE. PDU monitoring was digitally recorded and analyzed to confirm the suspected VAE. Demographic and clinical data related to the anesthetic care, endoscopic procedure, and intraoperative hemodynamics were analyzed.

RESULTS: A total of 843 ERCP procedures were performed over a 15-month period. The incidence of VAE was 2.4% (20 patients). All VAE’s occurred during procedures in which stent placement, sphincterotomy, biopsy, duct dilation, gallstone retrieval, cholangioscopy, or necrosectomy occurred. Ten of 20 (50%) of VAEs were associated with hemodynamic alterations. None occurred if the procedure was only diagnostic or for stent removal. Subanalysis for the type of procedure showed that VAE was statistically more frequent when stents were removed and then replaced or if a cholangioscopy was performed.

CONCLUSIONS: The high incidence of VAE highlights the need for practitioners to be aware of this potentially serious event. Use of PDU can aid in the detection of VAE during ERCP and should be considered especially during high-risk therapeutic procedures. Detection may allow appropriate interventions before serious adverse events such as cardiovascular collapse occur.

From the Departments of *Anesthesiology and Perioperative Medicine


Gastroenterology, University of Alabama at Birmingham, Birmingham, Alabama.

Accepted for publication January 19, 2018.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Ayesha S. Bryant, MSPH, MD, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 625 19th St S, JT 880A, Birmingham, AL 35249. Address e-mail to

© 2018 International Anesthesia Research Society
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