Beyond bubble resolution: neurological recovery after iatrogenic gas embolism–induced cardiac arrest treated with hyperbaric oxygen — a case report

Iatrogenic venous gas embolism (VGE) during central venous catheter (CVC) manipulation is a rare but potentially fatal complication of routine intensive-care procedures, with mortality approaching 30%. Sitting position during catheter removal generates a subatmospheric venous pressure that allows atmospheric air entrainment. Post-resuscitation imaging is frequently negative because 100% oxygen — the correct first-line treatment — accelerates bubble dissolution and erases the imaging substrate. A 66-year-old woman, recovering on the ward from severe community-acquired triple-pathogen pneumonia (influenza A, pneumococcus, methicillin-susceptible Staphylococcus aureus), sustained witnessed cardiac arrest immediately after jugular CVC removal performed in the sitting position. The arrest was witnessed with immediate bystander CPR, yielding zero no-flow time; pulseless electrical activity was the initial rhythm. Return of spontaneous circulation (ROSC) was obtained after 6 min of standard cardiopulmonary resuscitation and a single 1 mg dose of intravenous epinephrine. Post-ROSC computed tomography showed no acute cerebral lesion and no intravascular gas, but new bibasilar consolidations consistent with aspiration pneumonia. Despite imaging-negative status, the diagnosis of VGE was retained on the basis of high clinical probability and the patient was transferred for emergency hyperbaric oxygen therapy (HBOT). A US Navy Treatment Schedule 6 A protocol (90 min at 2.8 atmospheres absolute) was initiated within 8 h of the arrest. The patient was extubated on day 3 post-arrest and discharged from the intensive care unit on day 6, fully conscious and oriented (Glasgow Coma Scale 15/15) with only mild residual memory complaints. Complete neurological recovery at ICU discharge — consistent with a beneficial role of early empirical HBOT within a synergistic recovery pathway rather than an isolated HBOT effect — is achievable when three conditions align: (i) procedural prevention through strict supine positioning; (ii) standard advanced cardiac life support (ACLS) without modification; and (iii) early empirical HBOT (≤ 6–8 h) initiated on high clinical probability rather than confirmatory imaging. We propose a four-step decision framework requiring prospective validation before formal guideline adoption.