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    1. P. A. Bothma and C. J. Schlimp.  Retrograde cerebral venous gas embolism: are we missing too many cases?  Br. J. Anaesth. (2014) 112 (3): 401-404 doi:10.1093/bja/aet433 

    2. Beevor, H. and G. Frawley (2016). "Iatrogenic cerebral gas embolism: analysis of the presentation, management and outcomes of patients referred to The Alfred Hospital Hyperbaric Unit." Diving Hyperb Med 46(1): 15-21.

    3. Fakkert, R. A., et al. (2023). "Early hyperbaric oxygen therapy is associated with favorable outcome in patients with iatrogenic cerebral arterial gas embolism: systematic review and individual patient data meta-analysis of observational studies." Crit Care 27(1): 282.

Abstract

BACKGROUND: Iatrogenic cerebral arterial gas embolism (CAGE) caused by invasive medical procedures may be treated with hyperbaric oxygen therapy (HBOT). Previous studies suggested that initiation of HBOT within 6-8 h is associated with higher probability of favorable outcome, when compared to time-to- HBOT beyond 8 h. We performed a group level and individual patient level meta- analysis of observational studies, to evaluate the relationship between time-to-HBOT and outcome after iatrogenic CAGE.

METHODS: We systematically searched for studies reporting on time-to-HBOT and outcome in patients with iatrogenic CAGE. On group level, we meta-analyzed the differences between median time-to-HBOT in patients with favorable versus unfavorable outcome. On individual patient level, we analyzed the relationship between time-to-HBOT and probability of favorable outcome in a generalized linear mixed effects model.

RESULTS: Group level meta- analysis (ten studies, 263 patients) shows that patients with favorable outcome were treated with HBOT 2.4 h (95% CI 0.6-9.7) earlier than patients with unfavorable outcome. The generalized linear mixed effects model (eight studies, 126 patients) shows a significant relationship between time-to-HBOT and probability of favorable outcome (p = 0.013) that remains significant after correcting for severity of manifestations (p = 0.041). Probability of favorable outcome decreases from approximately 65% when HBOT is started immediately, to 30% when HBOT is delayed for 15 h. 

CONCLUSIONS: Increased time-to-HBOT is associated with decreased probability of favorable outcome in iatrogenic CAGE. This suggests that early initiation of HBOT in iatrogenic CAGE is of vital importance.

Laboratory Research:

Gorman, D., et al. (1987). "Redistribution of cerebral arterial gas emboli: A comparison of treatment regimens." 9th International Symposium on Underwater and Hyperbaric Physiology Undersea and Hyperbaric Medical Sociaety, Bethesda, MD: 1031-1050.              

Helps, S. C. and D. F. Gorman (1991). "Air embolism of the brain in rabbits pretreated with mechlorethamine." Stroke 22(3): 351-354.

Helps, S., et al. (1990). "The effect of gas emboli on rabbit cerebral blood flow." Stroke 21(1): 94-99.

Helps, S., et al. (1990). "Increasing doses of intracarotid air and cerebral blood flow in rabbits." Stroke 21(9): 1340-1345.

Weenink, R. P., et al. (2012). "Animal models of cerebral arterial gas embolism." J Neurosci Methods 205(2): 233-245.