FATAL AIR-EMBOLISM DUE TO PERIOPERATIVE BLOOD RECOVERY

This study was initiated to investigate the incidence of acute mortali ty from air embolism associated with perioperative blood recovery and the causative factors and common characteristics of such fatalities. A ll facilities providing transfusion services in New York State are req uired to report severe adverse reactions to, and the total number of, transfusion and blood recovery procedures performed. Relevant data for the period from January 1990 to June 1995 were tabulated. During this time, 127,586 perioperative blood recovery procedures were performed, and 8,955,619 conventional blood components were transfused. The freq uency of fatal air embolism after readministration of recovered blood was approximately 1:30,000-1:38,000; none followed conventional transf usion. Characteristics common to the fatalities (including an addition al case reported before the study interval) were examined; all involve d reinfusion of recovered blood under pressure. In the population stud ied, the incidence of fatal air embolism af ter the perioperative read ministration of recovered blood was significantly higher than that aft er conventional transfusion. A model of such a system demonstrated tha t as much as 200 mL of air could enter the circulation in as little as 4 s, rendering visual detection and intervention extremely difficult. Education and guidelines to reduce the risk and mortality associated with this procedure are recommended.