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.     

Cardiac catheters for diagnosis and treatment of venous air embolism: a prospective study in man

One hundred consecutive patients undergoing neurosurgical procedures in the seated position were monitored for venous air embolism with a Swan-Ganz pulmonary artery (PA) catheter, precordial Doppler ultrasound device, and continuous end-tidal CO2 (FETCO2) analysis. Simultaneous determinations of right atrial and pulmonary capillary wedge pressures were also performed during each operation. Although 80 episodes of air embolism were detected by changes in Doppler sounds, only 36 were associated with increased PA pressure, and only 30 developed a decrease in FETCO2. Changes in PA pressure and FETCO2 agreed closely (r = 0.86), and only marked changes were associated with systemic hypotension. Air was recovered from the right atrium and PA only in small amounts (2 to 20 ml) during air embolism, although it was possible to aspirate large quantities of blood. Twenty-nine patients were found to have right atrial pressures that were higher than pulmonary capillary wedge pressures. Paradoxical air embolism from a probe-patent foramen ovale was possible in these patients, and one developed signs and symptoms of systemic air embolism postoperatively. We conclude that noninvasive monitoring with the combination of a precordial Doppler device and end-tidal CO2 analysis is satisfactory for rapid detection of clinically significant venous air embolism. The unique advantage of Swan-Ganz monitoring, however, is that it permits identification of patients who may sustain paradoxical air embolism, and that it differentiates the hemodynamic effects of brain-stem manipulation from those caused by air embolism.     

Experimental study of effect of embolism of different laparoscopy insufflation gases

BACKGROUND AND PURPOSE: Whilst carbon dioxide is the gas generally used for insufflation during laparoscopy, several studies have reported adverse effects specifically associated with its use. These effects may be attributable to chemical, metabolic, or immunologic effects specific to CO2. Because helium is chemically, physiologically, and pharmacologically inert, it has been suggested as a possible substitute insufflation gas. However, there has been concern about the potential implications of venous gas embolism during helium insufflation. The aim of this study was to examine the physiological effect of the intravenous injection of He and CO2 in an experimental model. MATERIALS AND METHODS: Eleven domestic white pigs were randomly allocated to receive multiple intravenous injections of increasing volumes of either CO2 or He gas. Cardiorespiratory function was measured, and the intravenous volumes of gas that resulted in cardiac arrest were determined. RESULT: Cardiorespiratory functional measures returned to normal quicker after CO2 than after He injection. Helium injection quickly overwhelmed the animal's ability to compensate and resulted in death at a lower volume than did CO2 injection. CONCLUSIONS: Gas embolism during He insufflation is more likely to be lethal than is CO2 embolism. This scenario is most likely following Veress needle insertion into a large vein. Therefore, if He is to be used for insufflation during clinical laparoscopy, the possibility of venous injection should be minimized by avoiding Veress needle use. Further investigation of the safety of He insufflation is warranted before a role during clinical laparoscopy can be recommended.     

Peritoneal response to pneumoperitoneum and laparoscopic surgery

BACKGROUND: It is generally believed that laparoscopic surgery inflicts less trauma to the peritoneum than open surgery. Local peritoneal fibrinolysis is a critical factor in adhesion development. The objective was to investigate fibrinolytic changes in the peritoneum during laparoscopic and open surgery. METHODS: At laparotomy (n = 10) peritoneal biopsies were taken at opening of the abdomen and just before closure. At laparoscopy (n = 12) opening peritoneal biopsies were taken after carbon dioxide insufflation, and closure biopsies just before exsufflation. Tissue concentrations of tissue-type plasminogen activator (tPA), plasminogen activator inhibitor type 1 (PAI-1) and the resulting tPA activity were assayed. RESULTS: Concentrations of tPA in peritoneal tissue declined during operation in both groups, but significantly so only in the laparotomy group (- 53 per cent; P = 0.01). PAI-1 levels were higher in opening biopsies from the laparoscopy group (P = 0.004). There was an increase in PAI-1 concentration during laparotomy, but not during laparoscopy. At the end of the operation, there was no difference between the groups. The resulting tPA activity did not differ between groups at opening or closure. In both groups there was a significant decline during operation (laparotomy: - 59 per cent, P = 0.02; laparoscopy: - 63 per cent, P = 0.01). CONCLUSION: These findings indicate that the peritoneal response to open and laparoscopic surgery is similar. The initial rise in peritoneal PAI-1 concentration during laparoscopy suggests an adverse effect of carbon dioxide insufflation, which might affect peritoneal repair.     

Fresh gas flow in the Bain circuit during laparoscopy

Twenty-two women were studied during laparoscopy with abdominal insufflation of carbon dioxide. A bain anaesthetic breathing circuit was used with a fresh gas flow (VFG) of 110 ml.min-1.kg-1, and controlled ventilation was applied with a minute ventilation (VE) of 175 ml.min-1.kg-1. Arterial blood gases were analysed at the end of the operation. Nineteen of the women (86 per cent) were found to have a PaCO2 within the range for normocapnia (i.e., 4.7-5.9 kPa (35-45 mmHg), two were hypocapnic with a PaCO2 of 4.4 and 4.5 kPa (33 and 34 mmHg) respectively and one was found to have a PaCO2 of 6.2 kPa (46.5 mmHg). It was concluded that the carbon dioxide absorbed from the abdomen during laparoscopy demands fresh gas flows that are higher than normally used in the Bain circuit if a PaCO2 within the normal range is to be obtained. A simultaneous increase in VFG and VE of about 45 per cent is sufficient to achieve normocapnia.     

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.     

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.     

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。     

Impact of laparoscopy with carbon dioxide versus helium on local and systemic inflammation in an animal model of peritonitis.

Increased intraperitoneal pressure and insufflation of carbon dioxide during laparoscopy may cause sepsis by promoting systemic inflammation in patients with intra-abdominal inflammatory diseases. The influence of carbon dioxide and helium during laparoscopy on bacteremia, endotoxemia, the plasma concentration of tumor necrosis factor-alpha (TNF-alpha), TNF-alpha secretion ex vivo by peripheral blood mononuclear cells (PBMCs), and intraperitoneal abscess formation was investigated in an animal model. A standardized fecal inoculum was injected intraperitoneally, and rats underwent laparoscopy with either carbon dioxide (N = 20) or helium (N = 20) or no further manipulation (control group; N = 20). Bacteremia was significantly more common 1 hour after laparoscopy with CO2 than in animals receiving helium or the control group. Furthermore, helium use led to a significant decrease of bacteremia 1 week after intervention. Fecal inoculation caused significant leukocytopenia in all groups within 1 hour after intervention, with complete recovery only in the helium-treated group (p < 0.05). The TNF-alpha plasma concentration was significantly lower in the helium-treated group, and suppression of ex vivo production recovered only in the animals undergoing laparoscopy with helium (p < 0.05). The number of intraperitoneal abscesses was significantly lower after laparoscopy with helium (2+/-1.5) than after CO2 laparoscopy (6.3+/-5.1) or in the control group (5.2+/-4.8). Laparoscopy with CO2 increased systemic inflammation only slightly, while helium use was associated with a significant lower incidence of bacteremia and local and systemic inflammation compared with the control group.     

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.     

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.     

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.     

Circulatory collapse during laparoscopy

This case report details the intraoperative course of a patient, in her early pregnancy, who had a cardiac arrest during transvaginal insufflation of carbon dioxide (CO2) for laparoscopic tubal ligation. Modern monitoring methods and their ability to detect gas embolism and aid in the diagnosis and treatment of this rare but life-threatening complication are discussed.     

A normal appendix found during diagnostic laparoscopy should not be removed

BACKGROUND: Diagnostic laparoscopy has been introduced as a new diagnostic tool for suspected appendicitis. While the normal appendix used to be removed routinely, laparoscopy allows us to leave a normal looking appendix in place. This latter strategy is, however, not generally accepted. The long-term results of not removing a normal looking appendix were evaluated. METHODS: This was a prospective evaluation of 109 diagnostic laparoscopies for suspected appendicitis in which a normal looking appendix was left in place. After a median follow-up of 4.4 years a telephone questionnaire was performed. RESULTS: There were no false-negative laparoscopies. In 65 patients (60 per cent) another diagnosis was obtained (group 1). In 44 patients (40 per cent) no diagnosis was obtained (group 2). After a median interval of 8 months, 15 patients presented to the emergency department for symptoms possibly involving the appendix, during the median follow-up of 4.4 years. This resulted in readmission of nine patients, of whom eight were reoperated. In only one patient (1 per cent) was a histologically proven appendicitis found and the appendix removed. Some 105 patients were eligible for follow-up. Of the 100 patients interviewed (95 per cent), nine patients (9 per cent) (six in group 1 and three in group 2) still had recurrent pain in the right lower abdominal quadrant. There were no differences between patients with or without another diagnosis obtained during preceding laparoscopy. CONCLUSION: It is safe to leave a normal looking appendix in place when a diagnostic laparoscopy for suspected appendicitis is performed, even if another diagnosis cannot be found at laparoscopy.     

Carbon dioxide embolism during endoscopic vein harvesting

Endoscopic vein harvesting (EVH) is becoming common for the patients undergoing coronary artery bypass grafting. Using carbon dioxide insufflations during the vein harvest can produce rare but catastrophic CO(2) embolism. We report a case of massive right atrial CO(2) embolism due to femoral vein injury which occurred during the performance of a routine EVH procedure.     

Arterial to end-tidal carbon dioxide tensio difference during laparoscopy Magnitude and effect of anaesthetic technique

The relationship between arterial carbon dioxide tension and end-tidal carbon dioxide tension was studied in 25 patients during laparoscopy. Thirteen patients received general anaesthesia and 12 epidural anaesthesia. The overall mean difference between arterial and end-tidal carbon dioxide tensions was 0.44 kPa (95% confidence intervals 0.28-0.60 kPa) which was significantly less than that reported in studies during other procedures. The reasons for this difference are probably associated with the physiological changes induced by CO2 pneumoperitoneum and steep Trendelenburg positioning. The choice of anaesthetic technique did not affect the arterial to end-tidal carbon dioxide tension difference significantly (p greater than 0.9).     

The effects of carbon dioxide on pulmonary mechanics in hyperventilating, normal volunteers.

Transpulmonary pressure, air flow, and end-tidal carbon dioxide levels were measured in normal human volunteers during hypocapnic, eucapnic, and hypercapnic hyperventilation. Respiratory rate and tidal volumes were well matched at a minute ventilation of 52 L. on three inspired gas mixtures: 21 per cent oxygen and 79 per cent nitrogen; 5 per cent carbon dioxide, 21 per cent oxygen and 74 per cent nitrogen; and 12 per cent carbon dioxide, 21 per cent oxygen and 67 per cent nitrogen. Respiratory rate, tidal volume, lung compliance, resistance, and resistive work per liter were calculated with a digital computer. In 13 experiments in 7 normal volunteers, no net bronchoconstriction or bronchodilatation was observed when eucapnic hyperventilation was compared to hypocapnic or hypercapnic hyperventilation. During hyperventilation of this degree, a change in bronchomotor tone owing to alteration in arterial or alveolar PCO2 either does not occur or else is masked by other reflexes or mechanical factors acting on the bronchi.     

Effects of caudal block with mepivacaine on resting ventilation and ventilatory response to carbon dioxide in sedated children

We examined the effects of caudal anaesthesia using 10 mg.kg-1 of one or two per cent mepivacaine without epinephrine on resting ventilation, arterial blood gas tensions and the ventilatory response to carbon dioxide in 27 sedated children. Expired minute volume and respiratory frequency decreased significantly after the caudal blocks in both groups. PaO2 and PaCO2 remained unchanged in both groups. The slope of the CO2 response curve increased significantly in both groups. The mean plasma mepivacaine levels were 4.6 +/- 1.6 (SD) and 4.6 +/- 1.0 micrograms.ml-1 20 minutes after the caudal blocks with one and two per cent mepivacaine, respectively. These results demonstrate that resting ventilation is impaired but the ventilatory response to carbon dioxide is improved similarly by caudal block with one or two per cent mepivacaine.     

Comparative examination of female urethral pressure profiles measured by CO2 and H2O infusion techniques

The urethral closure pressure profile (UCPP) was recorded in 100 consecutive patients using both the water infusion and the carbon dioxide infusion methods. Ninety-one per cent of the patients complained of discomfort during CO2 infusion. Thirty-two of the CO2 profiles were distorted due to patient discomfort or shortcomings in the design of the measuring system, and in these no quantitative comparisons could be made. In 68 cases the profile measurements were compared: average maximum closure pressures and functional urethral lengths were slightly less with the CO2 but some individual variations were substantial. We concluded that unreliability and patient reaction make CO2 infusion less suitable than H2O for measuring UCPP.     

THE VENTILATORY RESPONSE TO CARBON DIOXIDE DURING PARTIAL PARALYSIS WITH TUBOCURARINE

The ventilatory response to carbon dioxide of five normal subjectswas measured at two levels of partial paralysis of the respiratoryand peripheral muscles with tubocurarine. During mild paralysisthe mean reduction of vital capacity was 14 per cent, maximumpleural pressure 19 per cent and grip strength 55 per cent ofmeasurements before curarization. With moderate paralysis, meanreduction of vital capacity was 34 per cent, maximum pleuralpressure 28 per cent and grip strength 94 per cent of controlmeasurements. There was no change in the ventilatory responseto carbon dioxide during mild or moderate paralysis.