Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.55 no.1 Campinas Jan./Feb. 2005
Carbon dioxide embolism during laparoscopic surgery. Case report*
Embolia gaseosa por dióxido de carbono durante cirugía laparoscópica. Relato de caso
Tania Berger; Renata Veloso Silva, TSA, M.D.; Anderson Sampaio Marui, TSA, M.D.; Domingos Dias Cicarelli, TSA, M.D.
Anestesiologista do Hospital Universitário da USP
BACKGROUND AND OBJECTIVES: Carbon dioxide
gas embolism is an uncommon but potentially lethal complication of laparoscopic
surgery. Our report aimed at describing a case of pulmonary carbon dioxide embolism
with favorable evolution.
CASE REPORT: Hypertensive patient was submitted to laparoscopic surgery under general anesthesia due to cholelithiasis. After 150 minutes of pneumoperitoneum, patient developed tachycardia with severe hemodynamic deterioration, despite the use of vasopressor drugs. Arterial blood-gas revealed major difference between PaCO2 and PETCO2. Carbon dioxide embolism was suspected and pneumoperitoneum was immediately deflated. Surgery was converted to a conventional technique. Patient has evolved with hemodynamic improvement and was extubated at surgery completion, being referred to post-anesthetic care unit (PACU).
CONCLUSIONS: Early diagnosis and immediate treatment resulted in positive outcome in this case.
Key words: COMPLICATIONS: gas embolism; SURGERY, Abdominal: laparoscopic
JUSTIFICATIVA Y OBJETIVOS: La embolia
venosa por CO2 durante cirugías laparoscópicas es una complicación
rara, sin embargo fatal en la mayoría de los casos. El objetivo de este
relato es describir un caso no fatal de embolia venosa por CO2 durante
RELATO DEL CASO: Paciente hipertensa fue sometida a la anestesia general para laparoscopia y para exploración del colédoco. Después de 150 minutos de pneumoperitoneo, la paciente evolucionó con taquicardia e hipotensión refractaria al uso de vasopresor. La gasometría arterial reveló grande diferencia entre la pCO2 y la PETCO2. De frente a la hipótesis de embolia gaseosa, fue desinsuflado el pneumoperitoneo, y la cirugía terminada por la técnica convencional. La paciente evolucionó con mejoría del cuadro hemodinámico, siendo extubada al término de la cirugía y encaminada para la sala de recuperación pos-anestésica (SRPA).
CONCLUSIONES: El diagnóstico precoz y el tratamiento inmediato fueron fundamentales para una buena evolución del caso descrito.
Laparoscopy is becoming an increasingly popular surgical technique in our country, in an attempt to decrease surgical aggression and its related complications. For this reason, benefits as well as complications of this technique have been exhaustively studied in recent years 1.
An uncommon, however major complication, due to the severity of its effects, is gas embolism 1,2. Gas embolism during laparoscopic procedures is caused by the gas used to inflate pneumoperitoneum, which most of the times is CO2 (carbon dioxide). Although being a very severe complication, there is no report in the national literature on gas embolism and few cases are reported by the international literature, most of them with lethal outcomes.
Caucasian female patient, 74 years old, 67 kg, diagnosed with choledocholitiasis after cholecystectomy, was admitted for laparoscopic procedure. Patient referred systemic hypertension being treated with captopril (25 mg.day-1). Preoperative tests were normal. Anesthesia was induced with intravenous fentanyl (250 µg), propofol (180 mg) and cisatracurium (7 mg). Patient was easily intubated and placed in mechanical ventilation with the following parameters: TV = 650 mL, HR = 12 rpm, Ri:e = 1:2, PEEP = 5 cmH2O. Anesthesia was maintained with 1.5% isoflurane. After 150 minutes of surgery with pneumoperitoneum, patient presented 120 bpm tachycardia and 70 x 40 mmHg hypotension. Hypotension was refractory to 10 mg bolus ephedrine. Surgeon was informed and has referred no change in surgical field. Pulse oximetry and capnography were normal (PETCO2 = 44 mmHg). Dopamine infusion (5 µg.kg-1.min-1) was started and was increased to 14 µg.kg-1.min-1 with no pressure response. Blood gases analysis has revealed: pH = 7,05; PaO2 = 169 mmHg; PaCO2 = 86 mmHg; bicarbonate = 22 mmol.L-1; SaO2 = 99%. As a consequence of the diagnostic hypothesis of CO2 embolism, surgical team has deflated pneumoperitoneum and converted the technique. Immediately after conversion, the anesthetic team was informed by the surgeon of the presence of a bleeding hepatic vein, which had not been noticed during pneumoperitoneum. Patient's pressure levels and heart rate have improved. Thirty minutes after pneumoperitoneum completion patient presented BP = 100 x 60 mmHg (with 3 µg.kg-1.min-1 dopamine), HR = 100 bpm and PETCO2 = 30 mmHg. A new arterial blood gases analysis was performed with pH = 7,21; PaO2= 178 mmHg; PaCO2 = 60 mmHg; bicarbonate = 24 mmol.L-1 and SaO2= 99%. Three hours after pneumoperitoneum, with surgery completion and normal blood gases, patient was extubated in the operating room and referred to the post-anesthetic care unit (PACU). Patient was discharged from PACU two hours later with Aldrete-Kroulik index of 10.
The incidence of gas embolism during laparoscopic surgeries may vary from 0.01% (when clinical signs are evaluated) to 69% with transesophageal echocardiography 3. CO2 absorption may trigger from hypercabia with respiratory acidosis 3, to lethal embolism with bubbles inside right atrium or ventricle, impairing right heart filling and with possibility of paradoxal embolism in patients with patent oval foramen (20% of population), of pulmonary embolism with hypoxia and cardiac arrest2. Symptoms severity is a direct function of CO2 absorption rate 2. Most reported sequence of symptoms is decreased blood pressure associated to decreased PETCO2 and pulmonary compliance, and hypoxia.
In our case, absorption was slow enough not to change pulmonary compliance and cause hypoxia, however fast enough to lead to the difference between PETCO2 and PaCO2, even with CO2, which is a rapidly diffused gas. Transesophageal echocardiography and precordial Doppler are the most sensitive methods to detect small emboli 2. In one case, diagnosis was done when 20 mL of gas were aspired from patient's central catheter 4. Other reported cases describe embolism at gallbladder dissection 5 and at blind introduction of Verres needle which may catheterize some vein 6,7. In our country, the blind introduction of Verres needle was replaced by a small incision and dissection until the peritoneum with needle introduction under direct view.
The treatment of CO2 embolism consists in pneumoperitoneum deflation and positioning the patient in left lateral and head down position. This way, the amount of gas going from right heart to pulmonary circulation is lower. Nitrous oxide should be discontinued and, if these measures are not effective, a central catheter may be positioned for gas aspiration 2,8. In our case, pneumoperitoneum deflation alone was enough for complete patient's recovery.
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Submitted for publication June 17, 2004
Accepted for publication October 8, 2004
* Received from Serviço de Anestesiologia do Hospital Universitário da Universidade da USP, (HU-USP), São Paulo, SP