Delayed recovery following laparoscopic partial hepatectomy

We present a 42-year-old woman with unexpected coma after laparoscopic partial hepatectomy. MRI demonstrated ischaemic cerebral lesions. Further investigation revealed a patent foramen ovale. Cryptogenic stroke arising from a paradoxical carbon dioxide embolism was diagnosed. After 5 days of intensive care, she made a near complete recovery. Perioperative stroke, paradoxical emboli during surgery, patent foramen ovale, carbon dioxide cerebral embolism and therapeutic strategies are discussed.     

Carbon dioxide embolism in a 3-week-old neonate during laparoscopic pyloromyotomy: a case report

Laparoscopic pyloromyotomy has gained popularity in the treatment of hypertrophic pyloric stenosis. This is the first case report of carbon dioxide embolism during laparoscopic pyloromyotomy. We describe a case of carbon dioxide embolism in a 3-week-old neonate during laparoscopic pyloromyotomy by injection of carbon dioxide into a patent umbilical vein. The diagnosis of carbon dioxide embolism was made on the basis of the abrupt decrease in end-tidal CO₂, sudden decreased Spo₂, hypotension, and cyanosis. Portable x-ray with the clinical presentation was sufficient for a diagnosis of carbon dioxide embolism. Treatment included termination of CO₂ insufflation, placing the patient in Durant's position, and adequate resuscitation as necessary. Despite the fact that the insufflation pressure was in the recommended range, a carbon dioxide embolism was thought to be caused by injection of carbon dioxide into a patent umbilical vein. Although laparoscopic pyloromyotomy has demonstrated to be a safe and effective procedure, this is a serious and rare complication causing prolonged length of stay and skewed hospital charges.     

Transcutaneous O2 and CO2 monitoring of neurosurgical patients: detection of air embolism

Transcutaneous oxygen tension (PtcO2) and transcutaneous carbon dioxide tension (PtcCO2) were monitored in 60 patients undergoing neurosurgical procedures. Twenty-six patients were in the sitting position and underwent routine monitoring for air embolism. Seventeen episodes of air embolism were diagnosed by precordial Doppler ultrasound or transesophageal echocardiography, and the PtcO2 decreased early during the course of each episode. The mean PtcO2 decrease was 48 +/- 35 mmHg. During ten episodes the end-tidal carbon dioxide tension (PETCO2) decreased but only after the PtcO2 had already begun to decrease. PtcCO2 increased during air embolism but PETCO2 changes preceded the change in PtcCO2 by 1-2 min. Transcutaneous values during air embolism were verified with simultaneous arterial blood gas values during six air embolism episodes. A strong positive correlation was found between transcutaneous and arterial oxygen and carbon dioxide tensions. Correcting the PtcCO2 by the patient's baseline PtcCO2/PaCO2 ratio, PtcCO2 monitoring correctly reflected hypocarbia, normocarbia, and hypercarbia in 92% of the cases. PtcO2 monitoring was useful in detecting venous air embolism and may respond sooner than PETCO2. PtcCO2 monitoring was not useful as an early detector of air embolism.     

Carbon dioxide embolism during laparoscopic cholecystectomy due to a patent paraumbilical vein

Carbon dioxide embolism is a rare but potentially fatal complication of laparoscopic surgery. The most common cause is inadvertent injection of carbon dioxide into a large vein or solid organ during initial peritoneal insufflation. We describe a case of carbon dioxide embolism in a 13-year-old boy during an elective laparoscopic cholecystectomy, caused by injection of carbon dioxide into a large paraumbilical vein. The clinical manifestations of carbon dioxide embolism were hypotension, bradycardia, and an abrupt drop in end-tidal CO₂. He subsequently did well and had no sequelae. Carbon dioxide embolism is a recognized complication of laparoscopic surgery, although the risk to the patient may be minimized by the surgical team's awareness of the problem, continuous intraoperative monitoring of end-tidal CO₂, and using an open technique for initial access to the peritoneum.     

PaCO2-EtCO2差值：腹腔镜术中二氧化碳气体栓塞的监测指标？

［摘要］ 目的 探讨PaCO2-EtCO2差值可否作为腹腔镜术中二氧化碳气体栓塞的监测指标，用于二氧化碳气体栓塞的诊断和疗效评估。方法 回顾分析了2例腹腔镜肝切除术中的二氧化碳气体栓塞并查阅相关文献。结果 2例气体栓塞的患者主要表现为SpO2的轻度下降和呼末二氧化碳（EtCO2）短暂升高，其中1例患者心前区均可闻及“磨轮音”。2例患者的动脉血气分析均提示氧合指数下降的同时二氧化碳分压升高，PaCO2-EtCO2差值增大。经处理后，2例患者的氧合改善，PaCO2-EtCO2差值基本下降至基础水平。结论 麻醉医师围术期应警惕二氧化碳气体栓塞的发生。动脉血气分析不仅可以用于评估患者的内环境情况，还可以得出PaCO2-EtCO2差值，后者可用于二氧化碳气体栓塞的诊断和疗效评估。     

腔镜甲状腺手术CO_2气腹对颈内静脉压力及中心静脉压的影响

目的:探讨腔镜下胸乳入路甲状腺手术CO_2气腹对颈内静脉压力及中心静脉压的影响。方法:30例患者经胸乳入路行腔镜下甲状腺手术,分别于CO_2充气前,充气后10 min、20 min、40 min,关闭充气后5 min、20 min测量颈内静脉压力、中心静脉压,比较不同时点颈内静脉压力、中心静脉压的变化。结果:与充气前相比,充气后各时点的颈内静脉压力、中心静脉压显著上升(P0.05);解除充气后,逐渐下降,与充气前相比差异无统计学意义(P0.05);充气后三个时间点的颈内静脉压力均大于8 mmHg(P0.05),中心静脉压均小于8 mmHg(P0.05)。结论:经胸乳入路腔镜甲状腺手术中CO_2气腹会导致颈内静脉压力、中心静脉压显著升高,切除甲状腺中上部时无发生气体栓塞的可能,但切除甲状腺下部时有发生气体栓塞的可能。     

Carbon dioxide embolism during laparoscopy: effect of insufflation pressure in pigs.

Carbon dioxide embolism is a rare but potentially devastating complication of laparoscopy. To determine the effects of insufflation pressure on the mortality from carbon dioxide embolism, six swine had intravascular insufflation with carbon dioxide for 30 seconds using a Karl Storz insufflator at a flow rate of 35 mL/kg/min. The initial insufflation pressure was 15 mm Hg. Following recovery from the first embolism, intravascular insufflation using a pressure of 20 mm Hg at the same flow rate was performed in the surviving animals. Significantly less carbon dioxide (8.3 +/- 2.7 versus 16.7 +/- 3.9 mL/kg; p < 0.02) was insufflated intravascularly at 15 mm Hg than at 20 mm Hg pressure. All of the pigs insufflated at 15 mm Hg pressure with a flow rate of 35 mL/kg/min survived. In contrast, 4 of the 5 pigs insufflated at 20 mm Hg pressure died. The surviving pig died when insufflated with 25 mm Hg pressure following an embolism of 15.7 mL/kg. Intravascular injection was often associated with an initial rise in end-tidal carbon dioxide tension, followed by a rapid fall in all cases where the embolism proved fatal. Insufflation should be begun with a low pressure and a slow flow rate to limit the volume of gas embolized in the event of inadvertent venous cannulation. Insufflation should immediately be stopped if a sudden change in end-tidal carbon dioxide tension occurs.     

Successful resuscitation after catastrophic carbon dioxide embolism during laparoscopic cholecystectomy

A 92-year-old female was scheduled for laparoscopic cholecystectomy. Following intraperitoneal carbon dioxide insufflation and removal of her gallbladder, the patient developed serious haemodynamic deterioration associated with a decrease of both end-tidal carbon dioxide concentration (ETCO2) and chest compliance. Carbon dioxide embolism was suspected and the diagnosis was confirmed by aspiration of 20 mL of foamy blood from the central venous line. The patient was successfully resuscitated after discontinuation of carbon dioxide insufflation and ventilation of the lungs with 100% oxygen. Carbon dioxide embolization must always be suspected during laparoscopic surgery whenever sudden haemodynamic deterioration associated with a decrease in ETCO2 and chest compliance occur.     

Faut-il réévaluer le risque d'une embolie gazeuse compliquant une intervention avec insufflation de gaz carbonique ?

Due to the characteristics of the carbon dioxide, gas embolism occurring during coelioscopy using this gas is usually considered as non critical. We report three observations of gas embolism which have occurred during laparoscopic surgery, one mild and two having led to death in spite of hyperbaric oxygen therapy. These observations prompted us to reevaluate the role of carbon dioxide in the severity of gas embolism.     

CO2– Gasembolie nach akzidenteller Gefäßpunktion bei laparoskopischer Cholezystektomie

We report a case of carbon dioxide (CO(2)) embolism in a 52-year-old man during a laparoscopic cholecystectomy, which caused an accidental CO(2)-insufflation in a vessel despite exact control of the Verres needle. The first manifestations were two drops of the partial pressure of endtidal carbon dioxide (Petco(2)) from 34 mmHg to 13 mmHg and again from 37 mmHg to 11 mmHg, followed by pulseless ventricular tachycardia. It was possible to achieve resuscitation and a recompensation of the right heart failure with drug therapy. After successful resuscitation and restoration of a stable hemodynamic situation, an abrupt increase in the Petco(2) from 11 mmHg to 52 mmHg was noted. This increase of Petco(2) could be interpreted as the reinstallation of circulation and the amount of CO(2) in the organism after carbon dioxide embolism.     

Lethal air embolism after spray of tissue adhesive-fibrinogen and factor XIII aerosol during laparoscopic partial nephrectomy

We report a case of lethal air embolism just after spray of adhesive-fibrinogen and factor XIII aerosol during laparoscopic surgery. A 76-year-old man underwent laparoscopic partial nephrectomy for the left renal cancer. After partial nephrectomy, adhesive-fibrinogen and factor XIII aerosol were sprayed to a bleeding region of the kidney. The blood pressure and the end-tidal carbon dioxide concentration suddenly decreased, followed by cardiac arrest. Trans-esophageal echocardiography and computed tomography after cardiopulmonary resuscitation confirmed multiple air embolism. The use of a spray aerosol during laparoscopic surgery may be associated with the risk of lethal air embolism.     

The capnograph, a reliable non-invasive monitor for the detection of pulmonary embolism of various origin

The wash-out curve in the capnogram is known to be a sign of pulmonary air embolism. This characteristic pattern is also seen in the case of pulmonary embolism of other nature. Capnographic recordings were studied retrospectively and 22 wash-out curves were found. The quantitative change in end-tidal carbon dioxide concentration was compared with the change in other, circulatory parameters known to change in the case of pulmonary air embolism. There proved to be a quantitative correlation between the decrease in end-tidal carbon dioxide concentration and the change in pulmonary artery pressure, central venous pressure and mean arterial pressure. The capnograph showed to be a reliable monitor for the detection of pulmonary embolism of various origin just like pulmonary artery pressure monitoring is. In cases with concomitant Doppler ultrasound detection, the capnograph showed to be a more reliable monitor for the detection of pulmonary air embolism as is the Doppler ultrasound device.     

Air embolism during anaesthesia for shoulder arthroscopy

We report a case of venous air embolism during an elective shoulderarthroscopy in which air was used as a joint distending agent.Venous air embolism was diagnosed by the sudden decrease inthe end-tidal carbon dioxide concentration. The patient sufferedno serious complications of venous air embolism and made a fullrecovery. We present this case to make surgeons and anaesthetistsaware of the possibility of gas/air embolism during electivearthroscopy, when gas/air is used to distend the joint. Thiscase also illustrates that the end-tidal carbon dioxide monitor,which is part of the standard anaesthetic monitoring system,is very sensitive in detecting venous air embolism. Br J Anaesth 2000; 85: 925–7     

Effects of carbon dioxide embolism with nitrous oxide in the inspired gas in piglets

We have compared cardiorespiratory variables in anaesthetized piglets whose lungs were ventilated with oxygen in nitrous oxide (N2O group) or nitrogen (N group) after right ventricular carbon dioxide boluses (0.5 or 1 ml kg-1; n = 12) or slow graded injections (n = 6). Boluses affected all variables studied significantly (P < 0.05) except mean systolic arterial pressure. Significant changes in PE'CO2 (P = 0.012) and PaO2 (P = 0.048) values were observed in the N2O group. Changes in PaCO2 were related to volumes of injected carbon dioxide (P = 0.044). Boluses of 1.0 ml kg-1 induced severe circulatory collapse in two piglets in the N2O group. Slow embolization altered respiratory variables significantly (P < 0.001)). PaO2 decreased significantly in the N2O group (P < 0.0001). Mean pulmonary arterial pressure increased significantly over time (P = 0.001) and lasted longer in the N2O group (P < 0.05). Volumes and time required to induce a 50% increase in mean pulmonary arterial pressure differed significantly between groups (P < 0.05). We conclude that nitrous oxide worsened the effects of rapid and slow carbon dioxide emboli on cardiopulmonary variables. Rapid carbon dioxide embolism altered respiratory and haemodynamic variables, while slow carbon dioxide embolism changed only respiratory variables.      

Gas embolism during laparoscopic cholecystectomy

Advancements in laparoscopic surgery have resulted in decreased length of hospitalization, reduced postoperative pain, and better cosmesis following general surgical procedures. Carbon dioxide gas embolism is a rare occurrence that can be fatal. We report the case of a patient with a venous gas embolism during laparoscopic cholecystectomy. A 63-year-old woman presented with intermittent right upper quadrant pain, and her abdominal ultrasound showed a possible gallbladder polyp. A laparoscopic cholecystectomy was planned. A Veress needle was placed in the right upper quadrant to initiate abdominal access. Shortly after carbon dioxide insufflation, the patient's hemodynamic status deteriorated, her oxygen saturation dropped, and her end-tidal CO2 decreased. Gas insufflation was immediately stopped, and the patient was resuscitated. She stabilized quickly, and the procedure was performed without further event. She did well postoperatively and was discharged home the next day. Carbon dioxide embolism during laparoscopy, albeit rare, can be a fatal complication of the procedure. Whenever sudden changes in hemodynamic stability occur, venous gas embolism should be considered. As laparoscopic techniques and applications are expanded, the general surgeon must be aware of this entity.     

Venous air embolism during radical perineal prostatectomy

An abrupt decrease in end-tidal carbon dioxide (CO₂) occurred in an anesthetized male who was placed in the head down position during radical perineal prostatectomy. The end-tidal CO₂ was restored after insertion of a wet pack into the operative site, which strongly indicated venous air embolism as the cause. Predisposing factors, detection, and treatment of venous air embolism in this setting are discussed.     

Capnography in the early diagnosis of carbon dioxide embolism during laparoscopy

Venous embolism of carbon dioxide occurred during elective diagnostic laparoscopy in a healthy adult female. The diagnosis of gas embolism was made on the basis of the sudden abrupt onset of systolic and diastolic murmurs. The continuously recorded end-tidal carbon dioxide concentration (FETCO2) increased abruptly from 3.8 to 4.2 per cent and then slowly decreased to 4.0 per cent over the subsequent 30 seconds. CO2 insufflation was terminated immediately following the establishment of the diagnosis. The patient recovered uneventfully. A transient but rapid rise in FETCO2 is suggested as a useful early sign of venous CO2 embolism during laparoscopy.     

Transesophageal echocardiographic diagnosis of carbon dioxide embolism during minimally invasive saphenous vein harvesting and treatment with inhaled epoprostenol

IMPLICATIONS: We describe a patient scheduled for coronary artery bypass who developed carbon dioxide (CO2) embolism with acute pulmonary hypertension during endoscopic saphenectomy. Transesophageal echocardiography was useful in the diagnosis of CO2 embolism and to assess response to inhaled epoprostenol.     

Carbon dioxide embolism treated with hyperbaric oxygen

We report a case of suspected carbon dioxide embolism occurring during laparoscopy. Among the sequelae was neurological dysfunction felt to be secondary to paradoxical embolization. The patient was treated with hyperbaric oxygen therapy. Hyperbaric oxygen should be considered when confronted with a clinically important gas embolism.     

Gas embolism during laparoscopy

The use of laparoscopic surgery has grown considerably, and the occurrence of some accidents, albeit rare, is now reported. Among them, gas embolism can induce a bad postoperative outcome. We report seven cases of carbon dioxide embolism (CO₂) during laparoscopic surgery. In the seven cases gas embolism occurred during insufflation or a few minutes later. All the patients had a previous abdominal or pelvic surgical history. Five patients presented cardiac bradycardia or arrhythmia. Cardiovascular collapse or cyanosis was the first manifestation in three cases. Sudden bilateral mydriasis was the earliest neurologic sign, present in five cases. Finally, the gas embolism complication was lethal in two cases. In summary, this study strongly stresses the need for precise rules of prevention of gas embolism, and close monitoring of cardiac rhythm during insufflation of carbon dioxide. The patients who had previous surgery should be considered as a risk population.