RT Journal
A1 Levinsky WJ
T1 FAtal air embolism during insertion of cvp monitoring apparatus
JF JAMA
JO JAMA
YR 1969
FD September 15
VO 209
IS 11
SP 1721
OP 1722
DO 10.1001/jama.1969.03160240077031
UL http://dx.doi.org/10.1001/jama.1969.03160240077031
AB To the Editor:— 
    The central venous pressure (CVP) technique is a valuable method of patient monitoring.Although venous air embolism in this procedure has been mentioned as a theoretical hazard,1,3 a search of the literature revealed that this is believed to be the first recorded instance of such a fatal complication.Report of a Case:— 
    This 80-year-old woman had arteriosclerotic heart disease, atrial fibrillation, and advanced congestive failure.By the percutaneous method and with the patient in a high Fowler's position, a house officer inserted a CVP catheter into the right subclavian vein. While the physician's back was turned, and prior to connecting the V-connection adapter, a distinct sucking sound was heard. Shortly the CVP monitoring setup was made intact. A cardiac arrest ensued moments later. Resuscitative measures were ineffective.At autopsy considerable air was noted in opening the submerged heart chambers on the right side and an organized