Severe carbon dioxide embolism during laparoscopic kidney resection

Abstract

Sir,A 72-year-old man without a significant abnormal past medical history underwent an elective laparoscopic right kidney resection. After successful endotracheal intubation, mechanical ventilation was adjusted to maintain P ET CO 2 between 33 and 38 mmHg. Arterial blood gas (ABG) indicated pH 7.44, PaO 2 517 mmHg and PaCO 2 38 mmHg.The patient was then placed in a left lateral decubitus with the head-down (Durant's) position. Pneumoperitoneum was established with CO 2 insufflation to maintain the intra-abdominal pressure (IAP) at 15 mmHg. Unfortunately, the inferior vena cava was incised during dissection and the blood loss was only about 30 ml without any specific surgical interventions. However, central venous pressure (CVP) gradually increased from 7 to 21 mmHg in the following 10 min, whereas BP, HR, SpO 2 and P ET CO 2 remained relatively stable. Precordial auscultation revealed a specific splashing millwheel murmur. Embolism of CO 2 was highly suspected; thus, gas was subsequently aspirated via the central venous catheter. A total volume of 80 ml of gas was obtained after several aspirations; therefore, CO 2 embolism was confirmed. A synchronous ABG indicated pH 7.13, PaCO 2 88 mmHg and PaO 2 305 mmHg. Another 15 ml of gas was aspired after advancing the central venous catheter towards the right atrium; simultaneously, the incision of the inferior vena cava was clipped. Then pneumoperitoneum was terminated and the surgery was suspended. Twenty minutes later, the murmur disappeared and CVP returned to 9 mmHg with stable BP, HR, SpO 2 and P ET CO 2 . Another repeated ABG revealed pH 7.34, PaCO 2 46 mmHg and PaO 2 470 mmHg. Based on these rapid recoveries laparoscopic surgery proceeded smoothly with an IAP 10-12 mmHg. The patient recovered uneventfully without any sequelae.The incidence of clinically significant CO 2 embolism during laparoscopy is rare and its severity depends on the rate and volume of gas entry. 1,2 Durant's position allowed the gas bubble to migrate toward the apex of the heart and away from the pulmonary artery, 2,3 which contributed to the discrepancy of severe CO 2 embolism with few significant signs in this patient. This case report also suggested that BP, HR, SpO 2 and P ET CO 2 are not sensitive surrogates in detecting CO 2 embolism in some cases.

Prolonged inspiratory time produces better gas exchange in patients undergoing laparoscopic surgery: A randomised trial

“…It may be difficult to improve the gas exchange simply by changing the respiratory rate or tidal volume (V T ), as the high airway pressure may not allow a further increase in V T , and adjusting the respiratory rate sometimes fails to correct hypercapnea. Thus, CO 2 retention that occurs with a high airway pressure may make the anaesthetic management challenging, especially for patients with morbid obesity …”

Venous Gas Embolism During Radical Robotic Prostatectomy: A Case Report and Evidence-Based Management Algorithm

“…For prostatectomies, the vascular-rich envelopment of the prostate increases the level of risk even with the minimally invasive RARP approach [16] with one study reporting 100% of subclinical embolic events during RARP occurring during transection of the deep dorsal venous complex [12]. The most commonly reported risk factor, gas insufflation, was mentioned in 73% of the case reports reviewed [6,7,9,[17][18][19][20][21][22][23][24][25][26][27][28][29][30]. The schematic in Figure 1 highlights several of these risks.…”

“…Auscultation of a "mill-wheel" murmurs over the precordium rules in VAE [18]. Even with these options, these technologies used as a tool for VAE detection were referenced in 47% of case reports [9,14,[23][24][25][26][27][28][29][30][31].…”

Embolia de dióxido de carbono

“…Se desconoce la incidencia en niños [2]. La gravedad del cuadro clínico, depende de la velocidad y el volumen de la entrada de gas [6]. Aunque a menudo sin secuelas adversas, estos émbolos son potencialmente fatales [2].…”

“…Esto es primordial, sobre todo si el cambio de EtCO 2 es durante la insuflación en la cirugía laparoscópica[1]. En relación a la clínica, se han descrito los siguientes síntomas: caída en saturación de oxígeno, bradicardia, pCO 2 elevada, compromiso hemodinámico (hipotensión), disnea, cianosis, arritmias, midriasis súbita bilateral[16], soplo en rueda de molino a la auscultación (patognomónico), aumento repentino inicial en la concentración de CO 2 al final de la espiración, que disminuye más tarde debido al colapso cardiovascular, aumento de presión venosa central, aspiración de burbujas en cateterismo venoso, en ETE se ha visto burbujas en carótida, cavidades cardiacas derechas e izquierdas (embolia paradójica), TAC con múltiples émbolos en arterias y venas cerebrales y cardíacas; además, paro cardiorrespiratorio, con resultado fatal[3],[11],[17],[4],[6],[18]. Los cambios en el ECG no son lo suficientemente específicos ni lo suficientemente sensibles como para ser útiles en la detección del embolismo venoso de CO 2 temprano.…”