Intra-operative and post-operative hypercapnia leading to delayed respiratory failure associated with transanal endoscopic microsurgery under general anaesthesia

We present an unusual case of hypercapnia and surgical emphysemaduring transanal endoscopic microsurgery, which led to delayedpost-operative ventilatory failure. The hypercapnia and surgicalemphysema were secondary to rectal insufflation with carbondioxide used to facilitate visualization and resection of arectal tumour. Despite a return to wakefulness after surgery,the patient’s level of consciousness deteriorated in therecovery area as a result of hypercapnia. The Pa_CO2 rose to16.8 kPa because of absorption of carbon dioxide from the surgicalemphysema. On close examination, surgical emphysema was identifiedin unusual areas, including the anterior abdominal wall, bothloins, both groins and the left thigh. Reventilation was requireduntil these unusual carbon dioxide stores had dissipated. Wediscuss the need for prolonged post-operative vigilance in patientswith surgical emphysema secondary to carbon dioxide insufflation,and the risk of delayed ventilatory failure. Br J Anaesth 2001: 86; 586–9