Microemboli induced by air bubbles may be deposited in organs as a consequence of contamination during medical care

Ulf Forsberg, Per Jonsson, Bernd Stegmayr, Ulf Forsberg, Per Jonsson, Bernd Stegmayr

Abstract

Background: Larger volumes of accidental air infused during medical care may end up as emboli while microbubbles of air are supposed to be absorbed and cause no harm. The aim of this autopsy study was to investigate if microbubbles of air accidently entering the bloodline may be detected as microemboli (ME) in tissue such as lungs, brain and heart. If so, do differences in prevalence exist between haemodialysis (HD) and amyotrophic lateral sclerosis (ALS) patients.

Methods: Included were data from 44 patients treated by medical healthcare before death. Twenty-five cases had been treated with chronic HD and 19 cases died from ALS. Since air in the bloodline activates coagulation, ME could appear. To discriminate between microbubbles caused by artificial contamination during autopsy versus microbubbles deposited in vivo, tissues were stained with a polyclonal fluorescent antibody against fibrinogen, fibrin and fragments E and D. Fluorescence staining was used to visualize ME counted within 25 microscopic fields (600×) of a tissue preparation. One tissue preparation was used if available from the lung, heart and frontal lobe of the brain and in five cases also the cerebellum.

Results: Microbubbles can be verified at autopsy as ME in the lung, heart and brain in tissue from patients exposed to more extensive medical care. There were significantly more ME in the lungs versus the heart or brain. Women had fewer ME than men. The HD group had a higher median of ME per section than the ALS group (lung: 6 versus 3, P = .007; heart: 2.5 versus 1, P = .013; brain: 7.5 versus 2, P = .001) and had more sections with ME findings than the ALS group (P = .002). A correlation existed between the time on HD (months) and ME in the lungs.

Conclusions: More ME were present in HD patients compared with those who suffered from ALS. Minimizing air contamination from syringes, infusions and bloodlines will decrease ME and subsequent tissue injury.

Keywords: amyotrophic lateral sclerosis; dialysis; haemodialysis; microbubbles; microemboli.

© The Author(s) 2022. Published by Oxford University Press on behalf of the ERA.

Figures

Figure 1:
Figure 1:
Tissue section of the myocardium stained with haematoxylin and eosin. Within the vessel, an air emboli is visible.
Figure 2:
Figure 2:
ME with microbubbles of air (open space) in a vessel of brain tissue from one HD patient (visualized by polyclonal fluorescent antibody against fibrinogen and fibrin). The shape of the emboli shows a tail (marking a thrombus area) that indicates the direction of the prior blood flow in the vessel.
Figure 3:
Figure 3:
Correlation comparison of all patients between the extent of ME findings in the lung versus the heart.
Figure 4:
Figure 4:
Correlation comparison of all patients between the extent of ME findings in the heart versus the brain.
Figure 5:
Figure 5:
Correlation comparison in HD patients only between the extent of ME findings in lung tissue and the time on HD (months).

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