Prevention

British Hyperbaric Association – Safety and Governance Guidance

The true incidence of iatrogenic cerebral or systemic gas embolism (CGE/SGE) is unknown. Although reported rates are extremely low in most countries, underrecognition and underreporting are widely acknowledged. Every confirmed or suspected case should undergo formal review by clinical risk managers, including a structured Root Cause Analysis (RCA).

The British Hyperbaric Association encourages clinicians and organisations to share learning from RCAs. Insights published on institutional websites or in peer-reviewed literature can help prevent recurrence of this rare but catastrophic complication.

The following recommendations are based on analysis of real cases and near-miss events. They are not yet scientifically validated, but they are practical, low-cost, and high-impact measures that can reduce morbidity, mortality, organisational distress, reputational harm, and financial loss.

1. Avoid Excessive Insufflation Pressures

When insufflating any body cavity with gas — laparoscopy, thoracoscopy, gastrointestinal endoscopy — avoid unnecessarily high pressures.

Surgeons should reduce insufflation pressure once adequate visualisation is achieved.
For laparoscopy, 15 mmHg should be the upper limit, and only for short periods.
Lower pressures reduce the risk of gas entering damaged or exposed vasculature.

2. Use Carbon Dioxide Rather Than Air for GI Endoscopy

CO₂ is rapidly absorbed and significantly reduces the risk of embolism compared

with air.

Before connecting insufflation tubing to the patient, prime the system with CO₂.
Some insufflation systems have a dead space of ~100 mL; this must be expelled to avoid delivering a mixture of air and CO₂ into the GI tract.
CO₂ insufflation is now standard in many centres and should be adopted universally.

3. Add Colour to Contrast Media

In dimmed procedural lighting, it is difficult to confirm that all air has been expelled from contrast syringes and injection systems.

Adding a coloured dye to contrast material improves visualisation.
This simple measure reduces the risk of inadvertently injecting air bubbles.

4. Secure Closure of Large-Bore Line Tracts

Removal of large central venous lines—particularly dialysis catheters—can leave a tract that does not close promptly, especially in older patients with reduced tissue elasticity.

Consider tissue glue and/or a pursestring suture to close the tract.
This approach may be appropriate for all central lines, not only dialysis catheters.
Occlusive dressings alone are often unreliable due to sweating or friction from clothing or bedding.

5. Mandatory Flushing of Syringes and Infusion Sets

Before administering any intravenous drug or infusion:

The person administering the injection must flush and prime the syringe or infusion set.
Do not assume that a previously prepared or labelled syringe has been correctly primed.
This prevents inadvertent injection of residual air.

6. Two-Person Check for Arterial Pressure Transducer Systems

Air bubbles introduced under pressure into the arterial system are extremely dangerous.

When setting up invasive arterial pressure monitoring systems, two staff members should confirm that the entire system is fully primed and free of air.
This mirrors the twoperson check used for medication administration and adds safety without significant additional workload.

7. Vigilance in Neurosurgery Performed in the Sitting Position

Neurosurgical procedures in the sitting position carry a recognised risk of venous air entrainment.

Continuous vigilance and meticulous monitoring are essential.
An experienced neuroanaesthetist should be present throughout the procedure.
Early detection and rapid response are critical to preventing catastrophic outcomes.

8. Flushing the opened thoracic cavity with CO2

Flushing the opened thoracic cavity with CO2 during open heart surgery. This eliminates to a large extent air embolism, as CO2 is a lot more soluble and less likely to cause damage if ejected into the cerebral circulation.

Conclusion

Gas embolism is rare but devastating. These preventive measures are simple, inexpensive, and grounded in realworld experience. Adoption across surgical, endoscopic, anaesthetic, and interventional practice can significantly enhance patient safety and reduce the likelihood of iatrogenic Gas Embolism.

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