CARDIAC ARREST ASSOCIATED WITH AIR EMBOLISM DURING ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY

Air embolism is an uncommon but potentially fatal complication of therapeutic endoscopic retrograde cholangiopancreatography (ERCP). We report the case of a 78-year-old woman with arterial hypertension who underwent ERCP for suspected choledocholithiasis under general anesthesia with tracheal intubation and air insufflation. Preprocedural magnetic resonance cholangiopancreatography showed cholelithiasis with dilatation of the common bile duct. Approximately 20 minutes after anesthetic induction, during attempted sphincterotomy, she developed abrupt hemodynamic collapse with an end-tidal carbon dioxide (ETCO₂) decrease to approximately 15 mmHg, followed by asystolic cardiac arrest. Cardiopulmonary resuscitation included chest compressions, intravenous epinephrine, ventilatory adjustment, central venous access, and norepinephrine. Intra-arrest transesophageal echocardiography was interpreted by the treating team as demonstrating intracardiac air, supporting the diagnosis of air embolism. Return of spontaneous circulation was achieved after approximately 40 minutes. After initial stabilization and extubation, the patient developed massive upper gastrointestinal bleeding with refractory hemorrhagic shock and died. This case highlights the importance of considering air embolism when sudden hypotension and a marked ETCO₂ decrease occur during therapeutic ERCP, and illustrates the diagnostic value and reporting limitations of intra-arrest echocardiography.