Carbon dioxide embolism during laparoscopy and hysteroscopy

Venous carbon dioxide embolism is a rare but potentially lethal complication of laparoscopy. The risk is increased when it is associated with hysteroscopy. A case is presented of a young women undergoing laparoscopy and hysteroscopy for infertility. Cardiovascular collapse and cardiac arrest, associated with a mill-wheel murmur, occurred during hysteroscopy at the time of a change of position. The patient had irreversible brain damage and died a week later. Early diagnosis and prevention of this serious complication are discussed.     

The detection of carbon dioxide embolism during laparoscopy in pigs: a comparison of transesophageal Doppler and end-tidal carbon dioxide monitoring

Background: The aim of the study was to compare the value of transesophageal Doppler and end-tidal carbon dioxide monitoring to detect venous carbon dioxide embolism in pigs during laparoscopic cholecystectomy.
Method: Ten pigs were anesthetized under constant ventilation, and instrumented for laparoscopic cholecystectomy. CO₂ pneumoperitoneum was performed at 15 mmHg and then, successive increased intravenous gas boluses of 0.1 to 4 ml/ kg injectedthrough the femoral vein using a 55-mm long catheter. The responses indicative of embolism were defined as: 1) a change in Doppler tone placed facing the junction of the right atrium and inferior vena cava; 2)
Results: Doppler was more sensitive in detecting 0.1, 0.2 and 0.4 ml/mg of CO₂ embolism than end-tidal CO₂ ( P <0.05). Over 0.4 ml/mg no differences in sensitivity were found but the Doppler signal modifications occurred earlier than the changes in end-tidal CO₂. Moreover, these changes always consisted of a reduction of the value.
Conclusions: During laparoscopic cholecystectomy in pigs, transesophageal Doppler was a highly sensitive monitor which provided an earlier detection of CO₂ embolism and at lower doses than end-tidal CO₂ monitoring.     

Increased carbon dioxide absorption during retroperitoneal laparoscopy

Background. Retroperitoneoscopy for renal surgery is now a commonprocedure. We compared carbon dioxide absorption in patientsundergoing retroperitoneoscopy for adrenal or renal surgerywith that of patients undergoing laparoscopic cholecystectomy. Methods. We measured carbon dioxide elimination with a metabolicmonitor in 30 anaesthetized patients with controlled ventilation,undergoing retroperitoneoscopy (n=10), laparoscopy (n=10) ororthopaedic surgery (n=10). Results. Carbon dioxide production increased by 38, 46 and 63%at 30, 60 and 90 min after insufflation (P<0.01) in patientshaving retroperitoneoscopy. Carbon dioxide production (mean(SD)) increased from 92 (21) to 150 (43) ml min^–1 m^–260–90 min after insufflation and remained increased afterthe end of insufflation. During laparoscopy, V^·_CO2 increasedless (by 15%) (P<0.05 compared with retroperitoneoscopy)and remained steady throughout the procedure. Conclusion. Retroperitoneal carbon dioxide insufflation causesmore carbon dioxide absorption than intraperitoneal insufflation,and controlled ventilation should be increased if hypercapniashould be avoided. Br J Anaesth 2003; 91: 793–6     

Detection of aerosolized cells during carbon dioxide laparoscopy

Laparoscopic surgery for malignancy has been complicated by port-site recurrences. The exact mechanism has yet to be defined. In vitro studies suggest that carbon dioxide-induced tumor cell aerosolization may play a role. We have attempted to document this in a human model. Patients scheduled for elective laparoscopy underwent port placement and abdominal insufflation with carbon dioxide. A suction trap was then filled with 40 cc of normal saline solution and attached to an insufflation site on the port. The carbon dioxide effluent was directed through the sahne. The specimen was concentrated, resuspended, and transferred to a slide. A Papanicolaou stain was used. Thirty-five specimens were obtained. Fifteen patients (37%) had malignant disease, which was metastatic in eight. Five patients had carcinomatosis. In two of those with carcinomatosis, staining revealed a large number of malignant cells. Malignant cells were not found in any other patients. In two patients, however, aerosolized mesothelial cells were identified. Follow-up ranged from 2 to 7 months. One patient who displayed cellular aerosolization developed a port-site recurrence. We conclude that malignant cells are aerosolized but only during laparoscopy in the presence of carcinomatosis. It is unlikely that tumor cell aerosolization contributes significantly to port-site metastasis. Supported in part by a grant from United States Surgical Corporation. Presented at the Thirty’-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14,1997.     

Arterial to end-tidal carbon dioxide difference during laparoscopy]

Arterial as well as end-tidal PCO2 (PaCO2, PetCO2), and arterial to end-tidal PCO2 difference (P(a-ET)CO2) were studied in 16 ASA-I patients anesthetized for laparoscopy under controlled ventilation. Using constant ventilation throughout the procedure, PaCO2 and PetCO2 increased significantly (P less than 0.01) to the maximum level (about 10 mmHg above the control level) within 22 min after CO2 insufflation, along with significant increase in mean arterial pressure and heart rate. There was a statistically significant correlation between PaCO2 and PetCO2 at the time of control (before surgery), at the time of maximum PetCO2 and 30 to 60 min after CO2 insufflation (P less than 0.01). Although mean P(a-ET)CO2 remained relatively constant during the procedure, a statistically significant correlation between PaCO2 and P(a-ET)CO2 was found at the time of maximum PetCO2 after CO2 insufflation (r = 0.71, P less than 0.01). These results suggest that when PvCO2 is increasing by CO2 insufflation, P(a-ET)CO2 depend on relative ventilation efficacy.     

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.     

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.     

新生儿腹腔镜麻醉中呼吸循环功能的变化

目的：观察新生儿腹腔镜中，CO2气腹对呼吸循环系统功能的影响。方法：50例腹腔镜幽门环肌切开术的新生儿均行硬膜外麻醉辅以浅全麻，术中VT10ml/kg，调整呼吸频率使PETCO2在30－40mmHg范围内，注气前、气腹中、注气毕记录各时点的呼吸循环动力学指标。结果：气腹后，心率、MAP、PETCO2、最大吸气压（PIP）、PaCO2与注气前基础值相比均明显增高，pH值明显下降，SaO2值没有显著性变化。PETCO2在术毕10分钟内转为基础值。结论：新生儿气腹可引起呼吸循环功能的改变，使用硬膜外麻醉行腹腔镜幽门环肌切开术安全可行。     

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.     

Arterial carbon dioxide markedly increases during diagnostic laparoscopy in portal hypertensive children

Several factors are responsible for hypercarbia during laparoscopic procedures. This study was undertaken because we observed a sudden increase in PaCO(2) in children with portal hypertension (PHT), which was unusual in healthy children undergoing laparoscopic procedures. Fifty-seven children underwent laparoscopic procedures under general anesthesia and were mechanically ventilated. Arterial blood samples were obtained 5 min after intubation (T(0)), 15 min and 30 min after CO(2) pneumoperitoneum (T(15) and T(30)), 5 min after desufflation (T(end)), and 10 min after extubation (T(ext)) for blood gas analysis. The changes in PaCO(2), pH, and ETCO(2) were statistically significant during the study periods in both groups (P < 0.05). The percentage of PaCO(2) increase between T(0) and T(15) was 11.5% and 20.1%, respectively, in the control group and the PHT group (P < 0.05). This increase reached 36.8% at T(30) in the PHT group, whereas the control group had a 17.2% increase (P < 0.05). ETCO(2) presented similar changes. The variability in base excess, bicarbonate, PaO(2), arterial oxygen saturation, and SpO(2) was not significant in either group (P > 0.05). The PaCO(2) increased remarkably in children with PHT undergoing laparoscopy, with no difference in intrahepatic or extrahepatic origin. Limiting the duration of CO(2) pneumoperitoneum and intraabdominal pressure and adjusting ventilatory variables to accommodate hypercarbia are of the utmost importance for such cases. IMPLICATIONS: We compared children with portal hypertension with systemically healthy children during laparoscopy. The increase in arterial and end-tidal CO(2) was remarkable in children with portal hypertension, regardless of bicarbonate changes. Managing ventilation to accommodate hypercarbia is of the utmost importance for such cases.     

Fatal carbon dioxide embolism and severe haemorrhage during laparoscopic salpingectomy

We report a case of fatal carbon dioxide embolism and severehaemorrhage during laparoscopic salpingectomy. A sudden decreasein end-tidal carbon dioxide concentration occurred after 1 hof operating time which, together with the clinical signs, suggestedcarbon dioxide embolism. Haemorrhage after pelvic venous injurywas first noted after deflation of the pneumoperitoneum andresulted in potentiation of the adverse haemodynamic effectsof massive gas embolism. Minimally invasive surgery involvesmore extensive tissue trauma and an increased duration of pneumoperitoneumcompared with diagnostic laparoscopy and may increase the riskof serious complications.     

Difference between arterial and end-tidal carbon dioxide pressures during laparoscopy in paediatric patients

Purpose

To assess the effect of pneumoperitoneuim on P_(a-ET)CO₂ gradient in children.

Methods

Sixty one ASA I and II children (10.7 ± 3.0 yr, 38.4 ± 14.2 kg, mean ± SD), scheduled for visceral or urological laparoscopic procedures, were studied. They were anaesthetized, intubated, paralysed and their lungs ventilated with constant ventilator settings to obtain P_ETCO₂ values between 4.3 and 4.8 kPa. Intra-abdominal pressure was maintained between 8 and 14 mmHg. The following measurements were performed at steady state, before the pneumoperitoneum (T₁) and 15 min later (T₂): heart rate, systolic and diastolic arterial pressure; peak airway and intra-abdominal pressure; P_aCO₂ corrected for the patient’s temperature; P_ETCO₂ drawn between the micropore filter and the ventilator tubes, corrected for BTPS conditions; P_a-ETCO₂. Values between -1.0 and + 1.0 mmHg were considered nil; patient position (horizontal or head-down tilt): all patients were horizontal at T₁.

Results

Arterial pressure, heart rate and peak airway pressure increased at T₂: P_aCO₂ and P_ETCO₂ increased by 14%. The incidence of negative gradients increased from 54 to 67% although mean P_(a-ET)CO₂ remained clinically unchanged. No difference was found in P_(a-ET)CO₂ gradient, whatever the position and intra-abdominal pressure. The 95% confidence intervals for P_(a-ET)CO₂ were [-5.6; +3.2] at T₁ and [-8.8; +4.8] at T₂.

Conclusion

P_ETCO₂ often overestimates P_aCO₂ during laparoscopy in children, by up to 8.8 mmHg. Arterial blood gas analysis should be performed during long procedures to avoid hyperventilation.