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Canadian Journal of Anesthesia 49:96-99
(2002)
© Canadian Anesthesiologists' Society,
2002
Neuroanesthesia and Intensive Care
[Embolie gazeuse de l'artère cérébrale suivant
une bronchoscopie diagnostique : traitement différé avec l'oxygène
hyperbare] Chris G. Wherrett, MD FRCPC*, Reza J. Mehran, MD FRCSC
and Marc-Andre Beaulieu, MD FRCPC
* From the Departments of Anesthesiology
Surgery, Surgery, and Medicine, The Ottawa Hospital Hyperbaric Unit
Ottawa Ontario Canada.
Address correspondence to: Dr. Chris Wherrett,
Department of Anesthesiology, The Ottawa Hospital, General Campus,
501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada. Phone:
613-737-8187; Fax: 613-737-8189; E-mail: wherrett@magma.ca
Purpose: To describe a clinical scenario consistent with the
diagnosis of cerebral arterial gas embolism (CAGE) acquired during
an outpatient bronchoscopy. Our discussion explores the mechanisms
and diagnosis of CAGE and the role of hyperbaric oxygen therapy.
Clinical features: A diagnostic bronchoscopy
was performed on a 70-yr-old man who had had a lobectomy for
bronchogenic carcinoma three months earlier. During the direct
insufflation of oxygen into the right middle lobe bronchus, the
patient became unresponsive and developed subcutaneous emphysema.
Immediately, an endotracheal tube and bilateral chest tubes were
placed with resultant improvement in his oxygen saturation. However,
he remained unresponsive with extensor and flexor responses to pain.
Later, in the intensive care unit, he exhibited seizure activity
requiring anticonvulsant therapy. Sedation was utilized only briefly
to facilitate controlled ventilation. Investigations revealed a
negative computerized tomography (CT) scan of the head, a normal
cerebral spinal fluid examination, a CT chest that showed evidence
of barotrauma, and an abnormal electroencephalogram. Fifty-two hours
after the event, he was treated for presumed CAGE with hyperbaric
oxygen using a modified United States Navy Table 6. Twelve hours
later he had regained consciousness and was extubated. He underwent
two more hyperbaric treatments and was discharged from hospital one
week after the event, fully recovered.
Conclusion: A patient with presumed CAGE made a
complete recovery following treatment with hyperbaric oxygen therapy
even though it was initiated after a significant time
delay
Cerebral
arterial gas embolism following diagnostic bronchoscopy: delayed
treatment with hyperbaric oxygen
Canadian Journal of Anesthesia 49:96-99 (2002)
©
Canadian Anesthesiologists' Society, 2002
Neuroanesthesia and
Intensive Care
[Embolie gazeuse de l'artère cérébrale suivant
une bronchoscopie diagnostique : traitement différé avec l'oxygène
hyperbare] Chris G. Wherrett, MD FRCPC*, Reza J. Mehran, MD FRCSC
and Marc-Andre Beaulieu, MD FRCPC
* From the Departments of
Anesthesiology Surgery, Surgery, and Medicine, The Ottawa Hospital
Hyperbaric Unit Ottawa Ontario Canada.
Address correspondence to: Dr. Chris
Wherrett, Department of Anesthesiology, The Ottawa
Hospital, General Campus, 501 Smyth Road, Ottawa, Ontario, K1H 8L6,
Canada. Phone: 613-737-8187; Fax: 613-737-8189; E-mail:
wherrett@magma.ca
Purpose:
To describe a clinical scenario consistent with
the diagnosis of cerebral arterial gas embolism (CAGE) acquired
during an outpatient bronchoscopy. Our discussion explores the
mechanisms and diagnosis of CAGE and the role of hyperbaric oxygen
therapy.
Clinical
features:
A diagnostic bronchoscopy was performed on a
70-yr-old man who had had a lobectomy for bronchogenic carcinoma
three months earlier. During the direct insufflation of oxygen into
the right middle lobe bronchus, the patient became unresponsive and
developed subcutaneous emphysema. Immediately, an endotracheal tube
and bilateral chest tubes were placed with resultant improvement in
his oxygen saturation. However, he remained unresponsive with
extensor and flexor responses to pain. Later, in the intensive care
unit, he exhibited seizure activity requiring anticonvulsant
therapy. Sedation was utilized only briefly to facilitate controlled
ventilation. Investigations revealed a negative computerized
tomography (CT) scan of the head, a normal cerebral spinal fluid
examination, a CT chest that showed evidence of barotrauma, and an
abnormal electroencephalogram. Fifty-two hours after the event, he
was treated for presumed CAGE with hyperbaric oxygen using a
modified United States Navy Table 6. Twelve hours later he had
regained consciousness and was extubated. He underwent two more
hyperbaric treatments and was discharged from hospital one week
after the event, fully recovered.
Conclusion:
A patient with presumed CAGE made a complete
recovery following treatment with hyperbaric oxygen therapy even
though it was initiated after a significant time delay
New Hope for the Neurologic Damaged Child,
Cerebral Palsy, Anoxic Ishemic Encephalopathy and Traumatic Brain
Injury.
A new era of therapy is now advancing for the
treatment of neurologically disabled children at the Ocean
Hyperbaric Center. In the United Kingdom there is a charity for CP
(cerebral palsy) and the TBI (traumatic brain injury) child
utilizing HBO (hyperbaric oxygen). We understand that a new trial
for the same is beginning at McGill University in Montreal.
CP a catchall term describes brain injuries
either in utero, at the time of delivery, or in the post partum
period. These injuries cause a type of damage to the brain by trauma
or by cutting cerebral circulation producing an AIE (anoxic ischemic
encephalopathy).
The reason for not giving oxygen (normobaric)
to the hypoxic (low oxygen) neonate or premature baby is that
surface oxygen may cause a type of blindness called retrolental
fibroplasia. The use of hyperbaric oxygen however, does not produce
this same effect.
Many children hypoxic at birth are not given
HBO to correct the condition with the exception of South America and
Russia. The incidence of CP is dramatically less in those areas than
in the United States. (Again HBO does not produce the complication
of blindness).
Thousands of children have a near drowning
episode each year. This leads to a permanent neurologic damaged
state ranging from a persistent vegetative coma to being unable to
return to society.
TBI may occur at birth, from the shaken baby
syndrome, to the battered child, or due to the automobile accidents,
etc. Such episodes produce an internal type of brain injury, which
again results in many years of care and lack of normal life.
New techniques with brain imaging, especially
SPECT (single-photon emission- computed tomography) clearly show the
functional status of the brain at a point and time. HBO, that is
100% oxygen at greater than surface pressure, which is administered
to children in small sequential doses of 1.5 ATA (about 18 feet
below sea level), one hour each, one to two times a day for multiple
treatments, depending upon the response. Sequential SPECT scan not
only measures blood flow, but also metabolism. Such data has been
useful in determining the dose* of HBO. As the SPECT scans improve,
frequently, so do the children. There is about a 90% correlation.
All modalities of Speech, OT, PT, biofeedback
and herbal remedies depending on the age are also utilized as a
multi disciplinary brain repair regime.
More recent innovations include the use of
human growth hormone and alphalearning, which is a composite of
biofeedback, audio-visual, and EEG brain balancing technique.
A summary of the effects of HBO both in acute
and semi-acute and long-term neurologic conditions are as follow:
HBOT reduces any pressure within the brain
caused by swelling, restoring the functions of the blood brain
barrier and cell membrane. It neutralizes toxic products in the
brain, and over a period of time, enhances growth of new blood
vessels. It also acts as a scavenger of free radicals and promotes
internal cleaning of debris. HBO also reduces the stickiness of
blood products (white blood cells and platelets), and makes oxygen
available for use without energy transfer (when the hemoglobin
carries oxygen, it requires energy to deliver to the tissue spaces).
With HBO the free oxygen is available immediately for metabolic use.
Theoretically the use of HBOT in CP, TBI and in the very young
will actually give the brain a jump-start. It also produces an ideal
internal environment for the growth of new brain tissue.
There are however many other problems in the
neo or perinatal which may be amenable to HBOT. A) Microbial origin
(German measles, syphilis, herpes, hepatitis, meningitis,
cytomegaly, listeriosis and toxoplasmosis), B) toxicity
(thalidomide, purimotamine, psychotropic, carbon monoxide, alcohol
abuse and smoking), C) metabolic disturbances (diabetes,
malnutrition, hypotension, hemorrhages and eclampsis).
It is hoped that this new innovative approach
with scientific documentation will become more available and such
children will be treated at the time of injury, rather than waiting
for permanent devastating changes to occur.
The following cases represent several of the
many cases treated to date at the HBO center. Several hundred cases,
with encouraging results, are now under treatment in the UK
sponsored by the Hyperbaric Oxygen Trust, (a charity that is
dedicated to the treatment of CP in the brain-injured child).
*(i.e. depth of pressure, length of treatment,
frequency and total amount of treatments)
JAIN KK. Textbook of
Hyperbaric Medicine. 2nd revised edition USA, Hogrefe & Huber,
1996.
Neubauer RA, Walker M. Hyperbaric oxygen therapy. USA,
Avery, 1998.
Machado JJ. Reduction of spasticity, clinically
observed in patients with neurological diseases, submitted to
hyperbaric oxygen-therapy specially children with cerebral palsies.
Presented at: New Horizons in Hyperbaric Medicine, Orlando, Florida,
April 26-30, 1989.
Zerbini, Solonay. Personal communication.
(city), 1998.
Cases:
DW (Figs 1A & 1B): 3 year old white male
suffered perinatal hypoxic ischemic encephalopathy with renal
failure consisting of acute tubular necrosis, thrombocytopenia,
sepsis, respiratory insufficiency, hypovolemia and apnea related to
seizure disorder. The CT scan showed progressive cortical atrophy.
It is remarkable that this patient survived
with the multiple illnesses. The patient received 21 treatments of
HBO and is now able to sit up, hold a cup for the first time in his
life and is more attentive. He is much more alert, makes new vocal
sounds, is more aware of his surroundings and is beginning to grab
at everything. These changes parallel SPECT scan imprint. It is
hoped that future HBO treatments will be available with all types of
supportive therapy.
DS (Figs 2A & 2B): 4 year old white male
was seen with a severe traumatic birth, which caused a left mid
cerebral rupture and then further developed Lennox-Gastaut syndrome
(severe seizure disorder). He was seen four years later and had been
continuously receiving PT, OT, and SP three days per week.
He had done well on a ketogenic diet and
developed the ability to chew. On the daily scale of infant
development, mental status, he was less than 50 (normal = 90-110)
basically with about an eight month level. He was seen with a
spastic paraplegia, barely able to ambulate with assistance. The
patient received 92 HBO treatments and improved dramatically. The
patient has become very much more active, following more commands,
beginning to use his right hand to hold things, responds to his name
and now able to run, but still with a slight limp.
TB (Figs 3A & 3B): 8 year old girl in motor
vehicle accident, closed head trauma and 3 mo coma, total occlusion
of the R mid-cerebral artery and spastic hemiparesis on the left.
She wore a brace, had severe limp, speech deficits and was slow
mentally, although attempting to go to school. SPECT scan showed an
extensive deficit or complete infarct with the R middle cerebral
artery distribution. She was seen 11 months post incident. SPECT
scan before and after HBO showed substantial improvement. She was
only able to stay for 24 treatments, but with HBO along with
therapy, she was able to remove the brace. She became sharp mentally
and was able to almost enter into full activities with other
children. She was most pleased to become more socially accepted by
her peers.
From: Neubauer RA, Uszler JM, James PB.
Hyperbaric oxygenation: The recoverable brain in certain pediatric
patients. (conference)
Case
EC:
A 2 1/2 year old boy was seen 1 1/2 months
after a near-drowning episode. The child hit his head and fell into
the swimming pool. It is not known how long he was submerged. The
family was told that the child was blind and he presented in a
persistent vegetative state with severe spasticity on the left side
and hypomobility of the right leg. He was fed by PEG tube. Initial
SPECT imaging showed extensive and symmetrical deficit throughout
frontal, temporal, parietal and occipital lobes. After three
treatments with hyperbaric oxygen therapy the patient began moving
more, trying to speak, and "acting up" when angry. The patient began
crying with tears for the first time after 16 treatments. After 26
treatments the patient was smiling, much more alert, laughing,
crying, sleeping much better and laughing while dreaming. Following
34 treatments the patient was more aware, developing much more eye
contact and was clearly not blind. To-date the patient has received
199 treatments and now sees clearly, is speaking bi-lingually,
standing and taking a few steps. He is now able to eat and drink
normally. He was given back a life.
From: Neubauer RA, James PB. Cerebral
oxygenation and the recoverable brain. Neuro Res: 20 (Suppl 1)
S33-S36, 1998.
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