A real-time two-dimensional echocardiogram was used to detect the presence of an
air embolism in patients undergoing
neurosurgical procedures in the sitting position. The technique could with good sensitivity detect the appearance of a single air bubble intraoperatively, thus allowing early intervention to prevent development of further air emboli. Two types of
air embolism could be differentiated; the single-bubble type and the "stormy-bubble" type. The single-bubble type was observed during skin and muscle incisions,
craniotomy, and brain lesion excision. Further
embolism development was prevented by
electrocoagulation and application of
bone wax. The stormy-bubble type occurred during dura and muscle incisions and was prevented by
electrocoagulation, reflection of the dura, or suturing the affected muscle. The routine use of a Swan-Ganz
catheter for removal of
air embolism by suction proved effective for the treatment of the stormy-bubble type of
air embolism. Masking the operative field with saline-soaked cotton strips was of moderate benefit in the stabilization of the single-bubble type of air influx, but proved to be of little value in controlling the entrance of the stormy-bubble type.