title: Delayed hyperbaric oxygen therapy for air emboli after open heart surgery: case report and review of a success story.
abstract: BACKGROUND
  The current case describes a rare diagnosis of iatrogenic air emboli after elective cardiopulmonary bypass that was successfully treated with delayed hyperbaric oxygen therapy, with good clinical evolution in spite of rare complications.
  
  
  METHODS
  A 35 years old male was admitted to the intensive care unit (ICU) for post-operative management after being placed on cardiopulmonary bypass (CPB) for an elective ventricular septal defect closure and aortic valvuloplasty. The patient initially presented with pathologically late awakening and was extubated 17 h after admission. Neurologic clinical status after extubation showed global aphasia, mental slowness and spatio-temporal disorientation. The injected cerebral CT scan was normal; the EEG was inconclusive (it showed metabolic encephalopathy without epileptic activity); and the cerebral MRI done 48 h after surgery showed multiple small subcortical acute ischemic lesions, mainly on the left fronto- parieto- temporo-occipital lobes. He was taken for hyperbaric oxygen therapy (HOT) over 54 h after cardiac surgery. The first session ended abruptly after 20 min when the patient suffered a generalised tonico-clonic seizure, necessitating a moderately rapid decompression, airway management, and antiepileptic treatment. In total, the patient received 7 HOT sessions over 6 days. He demonstrated full neurological recovery at 4 weeks and GOS (Glasgow Outcome Scale) of 5 out of 5 even after a long delay in initial management. Convulsions are a rare complication of HOT either due to reperfusion syndrome or hyperoxic toxicity and can be managed. Prior imaging by MRI or tympanic paracentesis (myringotomy) should not add further delay of treatment.
  
  
  CONCLUSIONS
  HOT should be initiated upon late awakening and/or neurologic symptoms after CPB heart surgery, after exclusion of formal counter-indications, even if the delay exceeds 48 h.
authors.affiliation: Division of Emergency Medecine, County Hospital, University of Geneva, Geneva, Switzerland. Eva.Niyibizi@hcuge.ch.|Emergency Medicine Division, Hopitaux Universitaires de Genève, Rue Gabrielle-Perret.Gentil 4, 1205, Geneva, Switzerland. Eva.Niyibizi@hcuge.ch.
authors.forename: Eva
authors.identifier: http://orcid.org/0000-0002-6724-3539
authors.initials: E
authors.lastname: Niyibizi
authors.affiliation: Department of Anesthesiology Pharmacology and Intensive Care, County Hospital, University of Geneva, Geneva, Switzerland.
authors.forename: Guillaume Elyes
authors.initials: GE
authors.lastname: Kembi
authors.affiliation: Department of Emergency and Primary Care Medecine, County Hospital, Hyperbaric Center, University of Geneva, Geneva, Switzerland.
authors.forename: Claude
authors.initials: C
authors.lastname: Lae
authors.affiliation: Department of Emergency and Primary Care Medicine, County Hospital, Hyperbaric Center, University of Geneva, Geneva, Switzerland.
authors.forename: Rodrigue
authors.initials: R
authors.lastname: Pignel
authors.affiliation: Division of Cardiac Surgery, County Hospital, University of Geneva, Geneva, Switzerland.
authors.forename: Tornike
authors.initials: T
authors.lastname: Sologashvili
mesh_terms: D000328:Adult; D006348:Cardiac Surgical Procedures / Q000009:adverse effects; D002315:Cardiopulmonary Bypass / Q000009:adverse effects*; D017558:Elective Surgical Procedures; D004618:Embolism, Air / Q000209:etiology / Q000628:therapy*; D006331:Heart Diseases / Q000601:surgery*; D006801:Humans; D006931:Hyperbaric Oxygenation; D008297:Male
keywords: Cardiac surgery; Cardiopulmonary bypass (CPB); Hyperbaric oxygen therapy (HOT); Iatrogenic cerebral air emboli; Neurologic deficit