CASE REPORT
Fatal venous air embolism in a cat
undergoing dental extractions
A five-year-old domestic shorthair cat underwent general
anaesthesia and tooth extractions. Immediately after use of a high-
speed, air-driven, water-cooled dental drill, the cat suffered cardiac
arrest and attempted resuscitation was unsuccessful. Post-mortem
radiographs showed air in the vena cava, right atrium, right auricle
and right ventricle, hepatic and renal veins. These findings were
confirmed at post-mortem examination. The cause of death was
massive air embolism. There are reports of fatal venous air embolism
in the human literature from the use of high-speed, air-driven, water-
cooled dental drills. In this case, we believe that the air jet from the
cooling system provided an enormous pressure gradient allowing air
entry through an alveolar bone fracture or the inflamed gingival
tissues. This is the first report of fatal venous air embolism
associated with the use of a high-speed dental drill in the veterinary
literature.
M. GUNEW, R. MARSHALL, INTRODUCTION
M. LUI AND C. ASTLEY
Venous air embolism (VAE) is the entrain-
Journal of Small Animal Practice (2008)
49, 601–604 ment of air into the venous circulation,
DOI: 10.1111/j.1748-5827.2008.00606.x which can lead to a wide range of outcomes
including death. There is potential for VAE
to occur whenever air pressure exceeds
venous pressure and there is a communica-
tion between the air and the venous system.
VAE is rarely reported in the veterinary
literature. VAE has been reported follow-
ing pneumocystography in three cats
(Zontine and Andrews 1978, Thayer and
others 1980) and more recently during
endoscopic examination of a retropharyng-
eal diverticulum (Ober and others 2006).
In dogs, VAE has been reported to be asso-
ciated with pneumocystography and pneu-
mourethrography (Ackerman and others
1972), oral cryosurgery (Harvey 1978),
laparoscopy (Lettow 1972, Gilroy and
Anson 1987) and inadvertent injection
of air into a venous catheter (Walsh and
others 2005). All reported clinical cases
in cats and dogs have been fatal. Recently,
a case of non-fatal VAE causing pulmonary
oedema has been reported in the horse
The Cat Clinic, 189 Creek Road, Mt Gravatt, (Holbrook and others 2007) following dis-
Brisbane, QLD 4122, Australia lodgement of a jugular venous catheter cap.
Journal of Small Animal Practice
Vol 49
November 2008
Ó 2008 British Small Animal Veterinary Association
In human beings, VAE is most com-
monly associated with cranial surgery per-
formed in the sitting position but has been
reported with other patient positions
(Palmon and others 1997). Fatal VAE
has been reported in association with den-
tal procedures in human beings (Rickles
and Joshi 1963, Davies and Campbell
1990).
CASE STUDY
A five-year-old female, neutered, domestic
shorthair cat (weighing 3
6 kg) was pre-
sented for management of dental disease.
The cat had lived at a welfare shelter for
the past 12 months, and the owner had
noticed halitosis and gingival inflamma-
tion. There was a history of two isolated
seizures in the past 12 months with the
most recent being two weeks before presen-
tation. Physical examination was unre-
markable except for severe periodontal
disease affecting multiple cheek teeth.
Neurological examination was also unre-
markable. Testing for FeLV (feline leuk-
aemia virus) antigen and FIV (feline
immunodeficiency virus) antibody was
negative, and no other preanaesthetic clin-
ical pathology tests were performed.
Premedication consisted of 0
2 mg/kg
methadone (Methone; Parnell Laboratories)
and 0
25 mg/kg midazolam (Midazolam
Sandoz; Sandoz) subcutaneously, and anaes-
thesia was induced intravenously with 2 mg/
kg alfaxalone (Alfaxan-CD RTU; Jurox).
The cat was intubated and maintained on
isoflurane (Attane; Bomac) and oxygen
delivered through T piece. Intravenous
Hartmann’s solution was given at 10 ml/
kg/hour starting at induction.
The teeth were scaled using an ultrasonic
scaler, and hand instruments and extrac-
tion of multiple teeth was planned because
of advanced periodontal disease; the right
upper molar, second, third and fourth pre-
molar, right lower molar and left upper
molar and fourth premolar. Extraction of
the right side teeth was uneventful. During
extraction of the left upper fourth premo-
lar, the apical tip of the mesiopalatal root
was fractured and retained. A high-speed,
601
 M. Gunew and others

air-driven water-cooled drill (GS Deluxe;

iM3) was used to remove a portion of radic-
ular bone to help in the use of a root eleva-
tor to effect extraction of the retained root.
Immediately following use of the high-
speed drill, the oxygen saturation, heart rate
and blood pressure declined precipitously
and the cat suffered cardiopulmonary
arrest. Cardiopulmonary resuscitation was
commenced immediately but was unsuc-
cessful. External chest compression and
positive pressure ventilation were used
and two doses of adrenaline (Adrenaline;
AstraZeneca) (0
5 ml of 1:1000 solution)
were given intravenously and one dose
through the endotracheal tube. There was
no response to resuscitation efforts, the
pupils remained fixed and dilated and
no femoral pulses were palpable. Resuscita- FIG 1. Post-mortem lateral thoracic radiograph showing air in the right heart (white arrows), hepatic
tion attempts were discontinued after 15 and renal veins (black arrowheads) and the cranial and caudal vena cava (black arrows)
minutes.
Immediately following cessation of fourth premolar. The brain was grossly a potentially fatal complication that can
resuscitation efforts, the intravenous fluid normal. The mild pneumothorax, liver lac- occur during a wide range of procedures. In
system was examined and thoracic radio- eration and haemoabdomen likely resulted the veterinary literature, these procedures
graphs were obtained as there was a clinical from the resuscitation efforts. The cause of include diagnostic imaging (Ackerman
suspicion of VAE because of the use of death was massive VAE. and others 1972, Zontine and Andrews
a high-pressure air source and the absence 1978, Thayer and others 1980), cryosur-
of other common causes of anaesthetic gery (Harvey 1978), laparoscopic/endo-
death. There were no abnormalities found DISCUSSION scopic procedures (Lettow 1972, Gilroy
in the fluid administration system and no and Anson 1987, Ober and others 2006)
air in the lines. Radiographs showed retrac- This case shows the potential for fatal and intravenous catheter complications
tion of the lung lobes from the thoracic VAE to occur during dental procedures (Walsh and others 2005, Holbrook and
wall, associated with free gas in the pleural when using a high-speed, air-driven, others 2007).
space. The changes were most obvious on water-cooled dental drill. The entrainment In human medicine, a wide range of
the left side. There was a mediastinal shift of air into the venous vascular system is surgical, imaging and catheterisation
with the cardiac silhouette displaced to the
right. Air was present in the right atrium,
auricle and ventricle (Fig 1). The cranial
and caudal vena cava, hepatic veins (pre-
dominately involving the left liver lobes)
and left renal interlobar veins also con-
tained air.
A post-mortem examination was carried
out 15 minutes after resuscitation finished.
There was a mild haemorrhagic abdominal
effusion and a 3 mm laceration in the right
lateral lobe of the liver. Examination of the
vascular system showed large numbers of
air bubbles in the cranial and caudal vena
cava, hepatic veins and renal veins (Figs 2
and 3). Aspiration from the right ventricle
using an 18 G needle and syringe produced
a mixture of air bubbles and blood. Exam-
ination of the oral cavity revealed a fracture
of the alveolar bone between the mesiobuc-
cal and mesiopalatal roots of the left upper FIG 2. Air within the cranial vena cava (black arrow)

602 Journal of Small Animal Practice
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FIG 3. Air within the renal vein (black arrow) and caudal vena cava (black arrowheads)
procedures have been associated with VAE
(Muth and Shank 2000). Twelve cases of
VAE have been reported during dental
implant surgery in human beings (Davies
and Campbell 1990) and root canal ther-
apy (Rickles and Joshi 1963) in which four
were fatal. Three fatal cases occurred dur-
ing dental implant procedures and the VAE
was believed to be because of intraosseous
irrigation with coolant air and water and
from high-pressure air flushing in the root
canal case.
Entry of air into the venous system can
occur if several factors are present; a source
of air, a communication between the air
source and the venous system and a pressure
gradient from the air source to the venous
system. In this case, the source of air was the
air component of the cooling system of the
high-speed drill. The communication was
most likely through high-pressure air
entering either the maxillary medullary
cavity exposed by alveolar bone fracture
or the blood vessels associated with the
inflamed alveolar sockets and surrounding
gingival tissues. The pressure gradient was
provided by the high-speed drill in which
the coolant system is powered by a 35
pounds per square inch air source, which
equates to approximately 1800 mmHg.
Despite not knowing exactly what pressure
is delivered at the drill tip, it is believed that
this pressure is far in excess of normal cen-
tral venous pressure of 0 to 7 mmHg, pro-
viding an enormous pressure gradient. This
Journal of Small Animal Practice
Vol 49
November 2008
Ó 2008 British Small Animal Veterinary Association
Fatal venous air embolism in a cat
gradient may have been exacerbated when
the burr was introduced into the alveolar
socket as the air nozzle was closer to the tis-
sues. During cryosurgery, fatal VAE has
occurred in dogs following the application
of liquid nitrogen at pressures up to 30
pounds per square inch into alveolar sock-
ets and the maxillary medullary cavity
(Harvey 1978).
The consequences of VAE depend on
the rate and volume of air entrained and
the patient position (Palmon and others
1997). With rapid entrainment, volumes
as low as 2
5 ml/kg of air may be fatal in
dogs (Geissler and others 1997). Large vol-
ume rapid entrainment of air into the
venous system will cause an air lock in
the right ventricular outflow tract, which
leads to cardiac arrest (Durant and others
1947). It is likely that an air lock of the right
ventricle and atrium was the cause of car-
diac arrest in our patient. This is in contrast
to slow entrainment in which 1400 ml of
air can be tolerated by dogs if given over
several hours (Hybels 1980). Slow entrain-
ment of air leads to accumulation of air
emboli within the pulmonary vasculature
causing reduced cardiac output through
increased pulmonary artery pressures, pul-
monary oedema and decreased venous
return to the left heart (Durant and others
1947, Muth and Shank 2000). Injection of
0
5 ml/kg of air into cat’s pulmonary veins
is fatal (Moore and Braselton 1940); how-
ever, this is a different situation to air enter-
ing the systemic veins as the air will be
trapped in the microcirculation in the
lungs. Oppenheimer and others (1953)
found that left recumbency gave the high-
est survival rate, followed by sternal recum-
bency. The highest mortality was in right
recumbency which was the position our
patient was in when arrest occurred and un-
fortunately also while cardiopulmonary
resuscitation (CPR) was attempted.
The antemortem diagnosis of VAE can
be challenging. The most sensitive meth-
ods in human medicine are trans-oeso-
phageal echocardiography and precordial
Doppler ultrasound (Palmon and others
1997). These methods are difficult to apply
to veterinary medicine because of equip-
ment cost, training, time and the rarity
of VAE. A drop in end tidal CO2 is a con-
sistent but a non-specific finding. Drum
like and ‘‘mill wheel’’ murmurs may also
be heard on auscultation (Palmon and
others 1997).
Resuscitation after massive VAE is often
unsuccessful. There are no reports of suc-
cessful resuscitation in clinical veterinary
cases. Resuscitation has been successful
in many experimental studies in dogs with
varying success rates (Durant and others
1947, Oppenheimer and others 1953,
Colley and Artru 1987). Placing animals
in left lateral recumbency as soon as possi-
ble after VAE significantly improves sur-
vival (Oppenheimer and others 1953).
Survival is also improved with catheter
aspiration of air from the right atrium using
a multi-orifice catheter (Colley and Artru
1987). Increasing central venous pressure
with intravenous fluids will reduce or stop
the entrainment of air into the venous sys-
tem in many circumstances (Palmon and
others 1997, Muth and Shank 2000). In
the presence of a high-pressure air source
as in this case, increasing central venous
pressure is unlikely to be beneficial. The
use of positive inotropes to improve cardiac
function has been suggested and nitrous
oxide should be discontinued if used as
an anaesthetic agent (Palmon and others
1997, Muth and Shank 2000). External
cardiac compression can also be effective
in resolving the air lock and was shown
to be equally as effective as intracardiac
aspiration using a single orifice catheter
or left lateral recumbency (Alvaran and
others 1978).
603

This is the first reported case of fatal
VAE associated with the use of a
high-speed, air-driven dental drill in the
veterinary literature and illustrates the
potential for VAE to occur during routine
dental, surgical and imaging procedures.
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