title: Intraoperative visible bubbling of air may be the first sign of venous air embolism during posterior surgery for scoliosis.
abstract: METHODS
  Case report of two children sustaining venous air embolism (VAE) during posterior surgery for scoliosis.
  
  
  OBJECTIVE
  To report 2 cases where visible bubbling at the operative site was the first clinical indication of VAE-induced cardiovascular collapse and to raise the level of consciousness that VAE in the prone position can occur, often with serious consequences.
  
  
  BACKGROUND
  Twenty-two cases of VAE during surgery for scoliosis in the prone position have been reported. Ten were fatal and ten were in children. Visible bubbling at the operative site was noted in two published cases.
  
  
  METHODS
  Retrospective study of 2 cases of VAE at one institution. Clinical, anesthetic, and radiographic features are presented. Details of previously published cases are reviewed and discussed.
  
  
  RESULTS
  Both patients were girls with adolescent scoliosis who underwent prone positioned posterior spinal fusion with instrumentation. Visible bubbling of air at the thoracic aspect of the surgical site was noted near the completion of instrumentation and was the first indication of VAE. In both cases, this was clinically recognized and promptly treated. One patient survived normally and the other died.
  
  
  CONCLUSIONS
  Visible air bubbling at the operative site may herald the onset of massive VAE during multilevel posterior spinal fusion and instrumentation. A prospective multicenter study using precordial Doppler, central venous catheter, and end-tidal CO2 is recommended to determine the true incidence of VAE in spinal deformity surgery and to evaluate monitoring and treatment methods.
authors.affiliation: Department of Anesthesia, University of New Mexico, Albuquerque, NM, USA.
authors.forename: John
authors.initials: J
authors.lastname: Wills
authors.forename: Richard M
authors.initials: RM
authors.lastname: Schwend
authors.forename: Andrew
authors.initials: A
authors.lastname: Paterson
authors.forename: Maurice S
authors.initials: MS
authors.lastname: Albin
mesh_terms: D000293:Adolescent; D004618:Embolism, Air / Q000175:diagnosis* / Q000209:etiology*; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D016268:Internal Fixators / Q000009:adverse effects; D007431:Intraoperative Complications; D019637:Orthopedic Procedures / Q000009:adverse effects* / Q000379:methods; D011859:Radiography; D012189:Retrospective Studies; D012600:Scoliosis / Q000000981:diagnostic imaging / Q000601:surgery*; D013123:Spinal Fusion; D014680:Veins