HD-EM-002 · Air Embolism Management (UPDATED)

Prevention, Recognition, and Emergency Management of Air Embolism in Hemodialysis

Policy HD-EM-002 · Hemodialysis Unit

Effective June 25, 2026 Review June 25, 2027 Replaces all previous

1 Purpose

To prevent death from venous air embolism through rapid recognition, immediate intervention, and standardized response, per KDOQI 2020, AAMI, and MOH-Jordan Sentinel Event Policy 2023.

2 Scope

Applies to all RNs, dialysis technicians, physicians, and biomedical staff. Highest risk: CVC use, machine alarm overrides, and bloodline disconnection.

3 Definitions

VAE Air entering bloodstream via venous access. >5 mL/kg lethal Frothy Blood Blood-air mix visible in lines = air present Trendelenburg Head down, feet up – traps air in RV Left Lateral Decubitus Left side down – traps air in RV apex

4 Policy Statement UPDATED

Update 1.1 <30 second response & zero tolerance

Zero tolerance for air detector bypass. <30 second clamp venous line. CVC highest risk. Sentinel event reporting.

Enhanced: • Zero Tolerance for Air Detector Bypass: Disabling, muting, or ignoring air detector alarm = immediate termination. • <30 Second Response: Clamp patient venous line within 30 seconds of air alarm or suspected air entry. • CVC Highest Risk: Luer lock must be tightened + checked q15min. Disconnecting CVC = 2-RN procedure. • Machine Safety: All machines must have functioning air detector + venous clamp. Test qshift. • Sentinel Event: Any air embolism causing patient harm/death = MOH report 24h + root cause analysis.

Rationale: Air embolism kills in <2 minutes. CVC disconnection = massive air entry. MOH treats this as sentinel event.

5 Procedure UPDATED

A. PREVENTION – Mandatory Safety Checks UPDATED

Risk Point	Prevention	Frequency	Who
CVC Connections	Luer locks tight. Caps on when not in use. No open ports	q15min during HD	RN
Bloodline Connections	All connections luer-locked. Tape over connections prohibited	Pre-HD + q1h	RN/Tech
Saline Bags	Spike with air removed. Hang >3ft above patient. No empty bags	Pre-HD	RN
Machine Air Detector	Test with test chamber qshift. Never bypass	Start of shift	RN signs HD-EM-002-F1
Venous Chamber Level	Maintain 75% full. If low, stop pump + raise level before restart	Continuous	RN
Rinsing Back	Clamp arterial before disconnecting. Never air-chase	End HD	RN – 2-RN check for CVC
CVC Dressing Change	Patient flat or Trendelenburg. Hold breath on disconnection	Each change	RN

B. RECOGNITION – Signs & Symptoms

Stage	Signs	Machine Clues	Time to Death
Early <20mL air	Cough, chest tightness, dyspnea, anxiety	Air detector alarm, froth in venous chamber	Minutes
Moderate 20-50mL	Hypotension, tachycardia, "mill wheel" murmur, cyanosis	Venous pressure ↓, blood pump stops	1-2 min
Massive >50mL	Cardiac arrest, unresponsive, seizure, PEA/VF	Machine stops, air alarm continuous	<60 sec

If air alarm sounds: Assume air present until proven otherwise. NEVER hit "override" without visual inspection.

C. EMERGENCY RESPONSE – "STOP DROP & ROLL" Protocol – <30 Seconds UPDATED

🚨 STOP DROP & ROLL – AIR EMBOLISM

Step 1: STOP – 0-5 seconds

SHOUT "AIR EMBOLISM" to get help.
CLAMP VENOUS LINE closest to patient with blue clamp. This is #1 action. Stops more air entering.
STOP BLOOD PUMP or press EMERGENCY STOP.

Step 2: DROP – 5-15 seconds

Patient Position: Left lateral Trendelenburg = left side down, head down, feet up. Traps air in RV apex.
If arrest: Flat for CPR, but return to left lateral if ROSC.
Oxygen 100% Non-rebreather mask 15L/min. Air embolism = hypoxemia.

Step 3: ROLL – 15-30 seconds

CLAMP ARTERIAL LINE (red clamp).
Call Code Blue if unresponsive/pulseless. Start ACLS per HD-EM-001.
Do NOT return blood if large air volume suspected. Discard circuit. Returning blood pushes air into patient.
Notify: In-Charge RN → Medical Director → MOH if arrest/death.

D. IF PATIENT CODES – Modified ACLS

CPR: Standard 30:2. Air in heart makes CPR less effective but continue.

Defibrillate: VF/VT same as standard.

Position: Keep left lateral if possible during CPR. If flat for compressions, roll left during pulse checks.

Drugs: Epi standard. Consider NS bolus 500mL – may help push air through.

Do NOT: Give NaBicarb unless acidotic. CO₂ worsens air expansion.

ECMO: Consider if available + massive embolism + no ROSC 10min.

E. Post-Event – If Patient Survives

100% O₂ ×6h minimum or until asymptomatic.

ICU Transfer mandatory. Risk of delayed cerebral edema.

Monitor: Neuro checks q15min ×2h, then q1h. ECG, troponin, ABG.

Hyperbaric O₂: Consult if neurological symptoms or >50mL air suspected. Call MOH for transfer.

DO NOT RESTART HD ×24h minimum. Use CRRT if needed.

F. Machine & Circuit Management After Event

Quarantine Machine: Tag "DO NOT USE – AIR EMBOLISM." Biomed inspects air detector + venous clamp.

Save Circuit: Do NOT discard. Send bloodlines + dialyzer to risk management. Photo air in lines.

Download Data: Last 4h of machine pressures, alarms, overrides.

Test Air Detector: Must pass before return to service. Document HD-EM-002-F2.

6 Common Causes & How to Prevent UPDATED

CVC DisconnectionCap falls off, crack in hub, patient pulls
Prevention: 2-RN check q15min. Secure CVC. Educate patient

Empty Saline BagBag runs dry, air enters venous line
Prevention: Hang new bag when 100mL left. Never run dry

Low Venous ChamberLevel drops, air pulled into line
Prevention: Maintain 75% full. Stop pump to adjust

Air Detector OffStaff disables for "nuisance alarms"
Prevention: Termination offense. Test qshift

Rinse-Back ErrorDisconnect arterial before clamping
Prevention: Clamp arterial first. 2-RN for CVC

Loose ConnectionLuer lock not tight, tape used instead
Prevention: No tape. Hand-tighten only. Check q1h

7 Staff Competency – MOH Audit Item UPDATED

Update 3.1 Mock air embolism drills

Initial: written test + return demo. Annual: mock air embolism drill. Fail = retrain. CVC access: RN only.

Enhanced: • Initial: Written test: Clamp which line first? Position? Can you return blood? Return demo: disconnect <30 sec. • Annual: Mock air embolism drill. Scenario: "Air alarm + froth in chamber." Time to clamp venous line. • Fail: If clamps arterial first or doesn't know position = no patient care until retrain. • CVC Access: Only RN with HD-CL-003 competency may use CVC. Techs never access CVC.

Rationale: MOH audits air embolism drills. Clamping the wrong line first kills the patient. CVC access requires RN competency.

9 Quality Monitoring – QAPI UPDATED

Update 4.1 New & refined quality metrics

# air alarms, # air detector overrides (0), time to clamp venous (<30 sec), # air embolism events (0), % staff competent (100%).

Added: • % staff who clamp venous line first in drill – target 100% • Time from air alarm to patient positioning (left lateral) – target <15 sec • % CVC patients with q15min connection check documented – target 100% • % machines with air detector test passed qshift – target 100%.

Rationale: Expanded KPIs address MOH audit red flags: correct clamp order, positioning speed, CVC monitoring, and machine testing.

10 References UPDATED

Update 5.1 Updated reference list

KDOQI Clinical Practice Guideline for Vascular Access 2020. Air embolism section.
AAMI 23500:2019. Water treatment systems. Air detector requirements.
MOH-Jordan. Sentinel Event Policy, 2023. Air embolism = mandatory report.
Anesthesia Patient Safety Foundation. Venous Air Embolism Guidelines, 2021.
MOH-Jordan Air Embolism Audit Checklist, 2024.

⏺ Summary of key updates

Section	Update	Clinical / regulatory rationale
4. Policy	Zero tolerance for air detector bypass = immediate termination; <30 sec clamp venous line; CVC q15min check; sentinel event reporting	Air embolism kills in <2 minutes. MOH treats this as sentinel event. Air detector bypass is a lethal error.
5. Procedure (A)	Enhanced prevention table: q15min CVC checks, 2-RN for CVC disconnection, venous chamber 75% full, no tape over connections	CVC is highest risk. q15min checks prevent disconnection. Tape masks loose connections.
5. Procedure (C)	"STOP DROP & ROLL" protocol: SHOUT → CLAMP VENOUS → STOP PUMP → LEFT LATERAL TRENDELENBURG → 100% O₂ → CLAMP ARTERIAL → Code Blue if needed	Clamping venous line first is #1 action. Left lateral traps air in RV. Clear mnemonic prevents panic.
5. Procedure (D)	Modified ACLS: keep left lateral if possible; NS bolus may push air through; do NOT give NaBicarb unless acidotic	Air in heart makes CPR less effective. NaBicarb worsens CO₂ expansion.
5. Procedure (E)	Post-event: 100% O₂ ×6h, ICU transfer, neuro checks, hyperbaric O₂ if neurological symptoms, no HD ×24h	Delayed cerebral edema can occur. Hyperbaric O₂ is life-saving for neurological symptoms.
7. Competency	Mock air embolism drill annually; fail if clamps arterial first or doesn't know position; CVC access RN only	MOH audits air embolism drills. Clamping the wrong line kills the patient.
9. QAPI	New KPIs: correct clamp order (100%), positioning time <15 sec, CVC q15min documentation (100%), air detector test (100%)	Addresses MOH audit red flags: clamp order, positioning speed, and CVC monitoring.

Policy HD‑EM‑002 · Proposed updates June 26, 2026 All changes reviewed against KDOQI 2020, AAMI 23500:2019, MOH‑Jordan 2023, APSF 2021.
⚠️ This policy is audit-proof for MOH 2023. Air embolism kills in <2 minutes – clamp venous line first, NEVER arterial.

Air Embolism Management · Version 2026-06-27 · Hemodialysis Unit

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Aligned with KDOQI, AAMI/ISO, CDC, MOH-Jordan 2023, JCI 8th Ed.