Paradoxical carbon dioxide embolism during endoscopic thyroidectomy confirmed by transesophageal echocardiography

Carbon dioxide (CO₂) embolism is a rare but potentially life-threatening complication of laparoscopic procedures. Although endoscopic thyroidectomy using CO₂ gas insufflation appears to be superior to conventional open thyroidectomy in terms of cosmetic results, it may cause venous or fatal paradoxical CO₂ embolism. We report a case of paradoxical CO₂ embolism during CO₂ gas insufflation in an endoscopic thyroidectomy that was confirmed by transesophageal echocardiography (TEE). Paradoxical embolization via transpulmonary right-to-left shunting of venous CO₂ gas emboli was revealed by TEE examination. The patient recovered without complications. In conclusion, although endoscopic thyroidectomy is a promising approach that is gaining popularity and offers excellent cosmetic results compared with conventional open thyroidectomy, this case report emphasizes the importance of anticipating and being vigilant for potential CO₂ embolism.     

Arterial air emboli on computed tomography (CT) autopsy

ObjectiveTo describe radiological appearances of systemic air emboli versus intravascular air from putrefaction.Materials and methodsThe hospital trauma database was searched for patients who underwent computed tomography (CT) autopsy. The studies were reviewed and evaluated for intravascular gas. The appearances and location of intravascular air were characterised.ResultsFour cases of intravascular gas were identified out of 15 cases of CT autopsy performed from March 2004 to December 2006. In three cases, intravascular air was predominantly in the arterial system, coupled with severe pulmonary injury. In one case, the air was predominantly in the venous system with a large amount of gas in portal veins.ConclusionWe propose to consider pulmonary alveoli–venous fistula as a possible cause of systemic air emboli, as identified on CT autopsy by large amounts of gas in the arterial circulation, coupled with severe pulmonary injury.     

Large venous air embolism in the sitting position despite monitoring with transoesophageal echocardiography

A 49-year-old male with neurofibromatosis type II was scheduled for posterior fossa craniotomy and excision of a right acoustic neuroma and placement of an auditory brainstem implant in the sitting position. Intra-operatively, the patient was monitored with transoesophageal echocardiography which detected two major episodes of venous air embolism. Despite immediate treatment the patient's gas exchange progressively worsened during surgery and a chest X-ray showed extensive bilateral pulmonary infiltrates. The patient developed acute respiratory distress syndrome and required inotropic support in the intensive care unit. Although transoesophageal echocardiography allowed rapid detection of venous air embolism, there was no evidence of therapeutic benefit.     

Embolie gazeuse massive lors d'une insufflation pulmonaire en vue d'une tomodensitométrie thoracique chez un polytraumatisé atteint de contusions pulmonaires

We report a case of gas embolism into both right and left circulation in a polytrauma patient with lung contusions, revealed by thoracic CT scan showing the heart and aorta filled with gas. It followed a lung inflation with a O₂/N₂O mixture for about 30 seconds at a pressure of at least 40 cmH₂O in order to obtain apnoea for CT scan and to recruit atelectatic territories. The presumed mechanism was the passage of the O₂/N₂O mixture during the lung inflation manoeuvre out of disrupted airways into torn pulmonary blood vessels and pushed back into the heart chambers. The patient recovered fully. Lung inflation manoeuvre to obtain a prolonged apnoea during CT scan examinations of thorax is contraindicated in case of thorax trauma, as it carries a risk of gas embolism.     

Transient portal venous gas associated with reversible non-occlusive mesenteric ischemia: A case report

ObjectivesTo report the utility of abdominal ultrasonography (US) to identify the presence of portal venous gas (PVG) during non-occlusive mesenteric ischemia (NOMI), and to follow the disappearance of portal venous gas after resolution of the NOMI.Data sourcesThis was a clinical observation of a patient, with images of abdominal computed tomography (CT), and a video of portal venous gas identified by ultrasonography.Data synthesisWe describe the case of an adult patient admitted to our ICU for NOMI developing 48 h after cardiac surgery. Medical intensive care associated with jejunal resection and vacuum-assisted closure led to rapid recovery. Three weeks later, the patient presented acute pulmonary edema, and developed a new episode of NOMI that was suspected by identification of PVG on US, and then confirmed on abdominal CT. The patient rapidly improved after orotracheal intubation and treatment of pulmonary edema. A second US performed 9 h later showed disappearance of PVG. The laparotomy performed 10 h after the first US did not find evidence of small bowel or colon ischemia. The postoperative period was uneventful.ConclusionsUS is a useful tool for the detection of PVG in critically ill patients, prompting suspicion of AMI. PVG can be observed at the early phase of AMI, even before irreversible transmural gut ischemia; transient PVG that disappears rapidly (within several hours) may suggest resolution of the NOMI.     

Management of pulmonary embolism during acrylic vertebroplasty

A 55-year-old man diagnosed with osteogenesis imperfecta had multiple pulmonary embolism from acrylic cement during vertebroplasty. The patient immediately developed respiratory distress, renal failure, and right cardiac failure. A computed tomographic scan showed the presence of cement in the right and left pulmonary arteries, and in both lungs. Cardiac and respiratory functions did not improve with medical treatment, therefore the patient underwent pulmonary artery embolectomy. Cement was easily removed from both pulmonary arteries. The patient quickly recovered from respiratory and cardiac failure. We believe pulmonary embolectomy is a reliable and effective procedure to treat this rare and dreadful complication of acrylic vertebroplasty.     

Oxygen venous embolism after the use of hydrogen peroxide during lumbar discectomy

Purpose

The knee-prone position is commonly used for patients undergoing spinal surgery. Venous air embolism m such a position may be produced by the negative venous pressure gradient between the ambient air and the venous plexuses of the spinous process. When hydrogen peroxide is used to deanse the wound, oxygen is produced. We report a case of suspected oxygen venous embolism during lumbar discectomy in the knee-prone position after use of H₂O₂.

Clinical Features

Immediately after irngation of a discectomy wound with H₂O₂. a dramatic decrease of the P_ETCO₂, blood pressure and oxygen saturation coincident with ST segment elevation occurred suggesting a coronary gas embolism. Symptomatic treatment was initiated immediately and the patient recovered without any sequelae.

Conclusion

Although hydrogen peroxide has an innocuous reputation, cases of accidental ingestion or massive gas embolism after wound irngation leading to death have been reported. A review of the literature suggests that many of the clinical and physiopathological features of air and oxygen emboli are similar. For both, measures of prevention and treatment of complications are similar. We argue that the use of hydrogen peroxide should be avoided during procedures where the position of the patient (sitting, knee-prone) increases the risk of gas embolism and that hydrogen peroxide is a potentially dangerous solution.     

Generalisierte Gasbrandinfektion mit Rhabdomyolyse nach Cholezystektomie

We report a rare case of spontaneously developing generalised gas gangrene with massive rhabdomyolysis after a cholecystectomy and drainage of a hepatic abscess. On preoperative physical examination the patient appeared severely ill and was icteric and oliguric. Laboratory evaluation showed signs of systemic inflammation, elevated lactate levels, evidence of disseminated intravascular coagulation (DIC), and increased levels of serum creatine kinase (CK) activity. Abdominal ultrasound and endoscopic retrograde cholangiography showed a gallbladder perforation and a hepatic abscess. Cholecystectomy and drainage of the abscess was performed immediately and without technical problems. After postoperative admission to the intensive care unit, the patient showed evidence of generalised myonecrosis with subcutaneous gas formation and acute renal failure. Initially, there were few other signs of systemic toxicity; the patient was not hypotensive and the pulmonary gas exchange was normal. Within hours diffuse swelling of his right leg developed with cutaneous gangrene and a compartment syndrome. After fasciectomy and extensive surgical debridement, uncontrollable bleeding due to DIC developed from the fasciectomy site, which finally required exarticulation of the leg at the hip joint. At this point, multiple organ failure including severe adult respiratory distress syndrome was present. Two days after cholecystectomy, the patient died from hypoxic cardiocirculatory failure. Clostridium perfringens was repeatedly isolated from the wounds. Besides gas gangrene, the differential diagnosis of such infections includes localised clostridial cellulitis, nonclostridial anaerobic cellulitis caused by mixed aerobes and anaerobes, and type I or type II necrotising fasciitis. Patients with systemic necrotising infections should be treated with broad-spectrum antimicrobial regimens (penicillin G, 3rd generation cephalosporins, clindamycin, and aminoglycosides). An otherwise unexplained elevation of serum CK activity in the presence of acute cholecystitis may suggest haematologic spread of an aggressive myolytic agent and the beginning of myonecrosis. This should prompt immediate surgical exploration after establishing broad-spectrum antibiotic coverage. The role of hyperbaric oxygen treatment in this situation remains to be established. If hyperbaric oxygen is to be employed, it should neither delay surgical exploration nor jeopardise the patient with the hazards of an interhospital transport.     

Conservative approach to Hepatic Portal Venous Gas: A case report

IntroductionHepatic Portal Venous Gas (HPVG), a rare condition in which gas accumulates in the portal venous circulation, is often associated with a significant underlying pathology, such as Crohn’s disease, ulcerative colitis, diverticulitis, pancreatitis, sepsis, intra-abdominal abscess, endoscopic procedures, mesenteric ischemia, abdominal trauma.Presentation of caseHere we report a case of HPVG in an 82-year-old patient who underwent a left colectomy for stenosing tumor of the descending colon. The patient was treated conservatively, and his symptoms resolved. Follow-up computed tomography (CT) scan showed complete resolution of HPVG.DiscussionThe mechanism underlying the passage of the gas from the intestine into the mesenteric, then portal, venous system is not fully understood. Historically, this condition has been related to acute intestinal ischemia, as a consequence of a bacterial translocation through a wall defect.ConclusionThis case underscores the role of conservative management, highlighting how the severity of the prognosis of HPVG should be related to the underlying pathology, and not influenced by the presence of HPVG itself.     

Successful usage of extracorporeal membrane oxygenation as a bridge therapy for acute pulmonary embolism between hospitals

A 50-year-old man presented to a nearby hospital with loss of consciousness. Investigation revealed thrombus formation at the tricuspid valve. Due to suspected pulmonary embolism, the patient underwent contrast-enhanced computed tomography during which he went into a shock with sudden drop in functional oxygen saturation (SpO₂). Extracorporeal membrane oxygenation (ECMO) was introduced for cardiovascular and respiratory support, and he was transferred to our hospital for further treatment. The patient was treated by surgical thromboembolectomy and was dismissed from the hospital without major complications. We have experienced a case where ECMO was successfully used for cardiovascular and respiratory support, serving as a bridge therapy between hospitals.     

Cardiopulmonary responses to experimental venous carbon dioxide embolism

Background: Although the low-flow CO₂ insufflation rate used to initiate pneumoperitoneum may reduce the severity of potential venous embolism, its safety is not established. Methods: Anesthetized pigs were ventilated with room air at a fixed minute ventilation. After 1 h of baseline, they were intravenously infused with CO₂ at the rate of 0.3, 0.75, or 1.2 ml/kg/min for 2 h (n = 5 for each group), followed by 1 h of recovery. Results: All animals experienced pulmonary hypertension, depressed stroke volume, hypoxemia, hypercarbia, and acidemia during intravenous CO₂ infusion. They had systemic hypertension at the low rate and hypotension at the highest rate of infusion. End-tidal CO₂ levels briefly decreased, then increased in all cases. In the highest rate group, three of the five animals (60%) died at 50, 65, and 100 min of infusion. These three animals had severe hypotension and hypoxemia, with visible coronary gas embolism. There was no patent foramen ovale at necropsy in any animals. Conclusions: The low-flow insufflation rate exceeds the fatal rate of continuous intravenous CO₂ infusion. End-tidal CO₂ levels were increased in venous CO₂ embolism, not decreased as seen in venous air embolism. Severe hypoxemia and hypotension are predictors of potentially fatal cases.     

Cardiopulmonary responses to intravenous infusion of soluble and relatively insoluble gases

Background: Carbon dioxide is the current gas of choice for pneumoperitoneum, but hemodynamic and acid–base effects secondary to its systemic absorption have been reported. Various studies have suggested inert gases as alternatives. Methods: We studied the cardiopulmonary responses to intravenous infusion of carbon dioxide, nitrous oxide, argon, helium, and nitrogen in anesthetized swine. The gas was infused into the femoral vein at a rate of 0.1 ml · kg^?1· min^?1 for 30 min. The changes in end-tidal CO₂, mean arterial pressure, hemodynamics, and arterial blood gases were compared to baseline values. Results: No animals died during infusion of the soluble gases (CO₂ and N₂O). Three of the five pigs infused with nitrogen died suddenly at 20 and 30 min of infusion. The animals in the insoluble gas groups (Ar, He, N₂) experienced clinical pulmonary gas embolism and severe acidemia, hypercapnea and tachycardia. Conclusions: Venous gas embolism is poorly tolerated when the gas is relatively insoluble. Insoluble gases should not be used for pneumoperitoneum when there is any risk of venous gas embolism.     

Pulmonary embolism of cement during vertebroplasty

A 62-year-old woman with severe osteoporosis experienced pulmonary embolism by polymethylmethacrylate after percutaneous vertebroplasty. The patient immediately developed respiratory and cardiac distress, and a computed tomographic scan revealed the presence of cement in the pulmonary circulation. Proper techniques can minimize the risk of pulmonary embolism during percutaneous vertebroplasty: adequate preparation of cement and fluoroscopy during the procedure are recommended.     

Severe hyperglycemic shock associated with hepatic portal venous gas

We report a case of hyperglycemic shock associated with hepatic portal venous gas. A 79-year-old woman with post-stroke depression developed severe tachycardiac atrial fibrillation and hypotension due to hypovolemia caused by severe hyperglycemia, as well as showing disseminated intravascular coagulation (DIC). Continuous intravenous infusion of insulin and volume loading with normal saline gradually achieved normalization of the serum glucose level and hemodynamic stability. However, the DIC did not resolve, and abdominal computed tomography (CT) revealed hepatic portal venous gas (HPVG) in the left lobe of the liver. Surgery was thus considered mandatory. However, because severe hemodynamic lability occurred again immediately after the CT examination, and persisted, surgery could not be performed, and the patient died of septic shock due to bowel perforation. It was concluded that the underlying causes of DIC should be sought promptly, without delay.     

Persistent portal venous gas

This case report describes a patient diagnosed with ongoing portal venous gas, initiated by a rather common Campylobacter enterocolitis and maintained by septic thrombophlebitis and possibly by chronic cholecystitis. Cholecystectomy attenuated the patient’s septic condition. The etiology of portal venous gas determines both the patient’s prognosis and the choice for either conservative or surgical treatment. This report describes persistence of portal venous gas for a long period and a possible role for chronic cholecystitis as a cause.     

Pulmonary artery bullet embolism—Case report and review

INTRODUCTIONBullet embolism, an uncommon but serious complication of penetrating vascular trauma, poses a unique clinical challenge for the trauma physician. Migration of bullets can lead to infection, thrombosis, ischemia, hemorrhage and death.PRESENTATION OF CASEWe report a patient in whom a bullet embolized from the left femoral vein to the right pulmonary artery, a situation ultimately managed by observation alone.DISCUSSIONBullet embolism should be suspected when the number of penetrating entry wounds exceeds the number of exit wounds. Patients with radiographic studies showing a bullet outside the established trajectory require further evaluation. Most bullet emboli are arterial, and are generally symptomatic presenting with early signs of ischemia. Venous emboli are less common, and they are generally asymptomatic. Most venous bullet emboli travel in the direction of the blood flow and may lodge in the pulmonary arterial tree causing serious complications. Management of bullet emboli in the pulmonary arterial tree remains controversial and specific guidelines have not been clearly established. However, the available data in the literature suggest that pulmonary artery embolism can be observed in the asymptomatic patient.CONCLUSIONSymptomatic pulmonary bullet emboli should be managed with endovascular retrieval when available or operative therapy. Asymptomatic intravascular bullet emboli may be managed conservatively as seen in our patient.     

Retroperitoneal abscess with concomitant hepatic portal venous gas and rectal perforation: a rare triad of complications of acute appendicitis. A case report

Background  

While retroperitoneal abscess is a known complication, hepatic portal venous gas and rectal perforation have not been reported as a concomitant sequelae of acute appendicitis. Here we report a case of a patient with a perforated appendicitis that was associated with these triad of complications.     

Detection of arterial gas embolism by increased end-tidal nitrogen in dogs

Increased end-tidal (ET) nitrogen in a patient being ventilated with a nitrogen-free gas mixture through a leak-free circuit has been considered a specific sign of venous air embolism. We hypothesized that increased ETN2 would occur after arterial air emboli, just as following venous air emboli, and that clinically relevant arterial air emboli could be detected with respiratory gas monitoring by mass spectrometry. After approval from the institutional Animal Utilization Committee, eight mongrel dogs were studied. All were anesthetized with pentobarbital and ventilated with room air by a volume ventilator. Each animal was monitored by a femoral artery and a pulmonary artery catheter for systemic and pulmonary blood pressures, respectively, an electrocardiograph, pulse oximetry, and inspired and expired respiratory gas measurements by mass spectrometry. Arterial blood gas analysis was undertaken after one series of air emboli. Air boluses (containing the nonradioactive nitrogen isotope N2) of 50, 100, 200, and 500 mul/kg were injected slowly into the distal aorta through a second arterial catheter advanced 35 cm above the inguinal ligament. All emboli >/=100 mul/kg and 60% of the 50 mul/kg emboli were detected by increased ETN2 within 30 s, reaching peak levels in <2.75 min. The washout time for the N2 was longer for larger emboli, ranging from 2.9 +/- 2.8 min for 50 mul/kg emboli to 17.3 +/- 3.2 min for the 500 mug/kg emboli. There were no significant changes in end-tidal carbon dioxide, pulmonary or systemic blood pressures, or arterial blood gases. Increased ETN2 can no longer be considered pathognomonic for venous air embolism; arterial air embolism may have occurred.     

Gastrobronchial fistula after toothbrush ingestion

Gastrobronchial fistulous communications are uncommon complications of disease processes with only 36 previously reported cases. Described as complication of a number of conditions, such as previous gastroesophageal surgery, subphrenic abscess, and gastric ulcers (Jha P, Deiraniya A, Keeling-Robert C, et al. Gastrobronchial fistula—a recent series. Interact Cardiovasc Thorac Sur 2003;2:6-8), we report a case of fistulization caused by ingestion of a foreign body.A patient with mental retardation, admitted for the treatment of osteomyelitis, presented during hospitalization symptoms of high fever, vomiting, and respiratory distress. Endoscopy showed the presence of a gastrobronchial fistula, which developed after ingestion of a toothbrush. The toothbrush was extracted endoscopically, and the fistula was subsequently closed by surgery. The patient recovered completely.We report the first case of a gastrobronchial fistula as a complication of foreign body ingestion.     

Massive Air Embolism after the Repair of Obstructed Total Anomalous Pulmonary Venous Drainage: An Unusual Complication

Abstract We report a case of obstructed total anomalous pulmonary venous drainage that was repaired using the sutureless repair with the in situ pericardium. In the immediate postoperative period, the patient developed massive air embolism that was managed by mechanical support. The patient recovered without any significant clinical sequelae. (J Card Surg 2010;25:582‐583)