Detection of Gas Embolism by Transesophageal Echocardiography During Laparoscopic Cholecystectomy

Abstract

Using transesophageal echocardiography (TEE), 16 patients (ASA physical status I-III), undergoing laparoscopic cholecystectomy, were assessed for the occurrence of episodes of gas embolism and cardiovascular changes related to those emboli. The long-axis four-chamber view was monitored continuously, except for predetermined intervals where the transgastric short-axis view was obtained to derive the end-diastolic area (EDA), the end-systolic area (ESA), and the ejection fraction (EF). In one patient, we monitored the longitudinal view of the superior and the inferior vena cava. The monitoring of the patients also included: heart rate (HR), mean arterial pressure (MAP), arterial saturation by pulse oximetry (Spo2), end-tidal CO2 (ETCO2), minute ventilation (VE), and peak inspiratory pressure (PIP). Embolic events were defined as the appearance of gas bubbles in the right cardiac chambers. We observed gas embolism in 11/16 patients (five during peritoneal insufflation and six during gallbladder dissection). Using the longitudinal view of the superior and inferior vena cava (IVC), we found that these emboli were transmitted through the IVC. No episode of cardiorespiratory instability (decrease in MAP > or = 10 mm Hg, Spo2 < 90%) was observed. There was no significant difference in cardiorespiratory variables between patients who presented gas embolism (n = 11) and patients who did not (n = 5) during the studied period. In this small group of patients, we conclude that gas embolism occurs commonly during laparoscopic cholecystectomy but that these gas emboli cause minimal cardiorespiratory instability.

Circulatory and Respiratory Complications of Carbon Dioxide Insufflation

“…Intravascular presence of small amounts of soluble gas like CO 2 probably occurs frequently without having any clinical consequence, whereas large amounts of a soluble gas or smaller amounts of an insoluble gas (air, nitrous oxide) may cause death. When studied with transesophageal echocardiography, 68% of asymptomatic patients have CO 2 bubbling in the right chamber of the heart during laparoscopic cholecystectomy [50]. Transcranial Doppler experiments have shown that CO 2 bubbles may even reach the cerebral circulation [2].…”

Fatal air embolism during sigmoidoscopy performed under spinal anesthesia

“…The risk of AE is well recognized in procedures in which the operative site is above the level the heart, classically with neurosurgical cases performed in the sitting position[1] or otolaryngologic surgeries[2] but could happen in various clinical settings such as laparoscopic surgery,[34] pelvic procedures,[5] endoscopic saphenous vein harvesting,[6] and orthopedic procedures. [7] AE during sigmoidoscopy or colonoscopy is a rarely reported complication.…”

Prolonged paradoxical air embolism during intraoperative intestinal endoscopy confirmed by transesophageal echocardiography -A case report-

“…Although clinical signs like "mill-wheel" murmur or a decrease of E T CO 2 are useful for detection of VAEs, TEE is widely regarded as the most sensitive means of detection, and can identify bubbles as small as 20-50 µm in diameter [12,13]. TEE is much more effective than other technology at detecting PAEs, because it is hard to assess the passage of air bubbles to systemic circulation by other methods.…”