AIR EMBOLIZATION DURING PERCUTANEOUS SWAN-GANZ CATHETER PLACEMENT

It is demonstrated that air can enter the heart during percutaneous placement of the Swan Ganz catheter, and that the catheter introducer will accept potentially fatal air flow rates at clinically attainable pressures. It has been shown that a flow of 1 ml/kg/sec is sufficient to cause fatal air embolism. Hence, a 4-torr gradient would be sufficient to induce a fatal air embolus in an adult patient. There was no obvious cause of the air embolus detected in the patient described. She had been tilted head down (20 degrees) and did not appear to attempt to breathe while the introducer hub was open.