Near-fatal paradoxical gas embolism during gynecological laparoscopy

Abstract

Laparoscopy is an established procedure of minimally invasive surgery. Although risks and complications during laparoscopy are rare, complications arise from hemorrhage or intestinal perforation, and hemodynamic compromise may result from extensive pneumoperitoneum. Massive gas embolism is a potentially life threatening complication (1-5). We report an incident of severe paradoxical CO 2 embolism verified by an intraoperative transesophageal echocardiogram. Case reportA twenty-three-year-old woman (59 kg, 158 cm) was submitted to gynecologic laparoscopy because of a suspected tubalovarian abscess. She presented with normal hemodynamics, chest X-ray and electrocardiogram. Physical examination revealed no pathological findings except pain on pressure in the lower abdomen. Serum levels of white blood cells were increased to 18500 G/L. Except for a nickel allergy and nicotine abuse (20 cigarettes per day) the patient had no notable previous diseases, and previous surgeries (tonsillectomy and appendectomy) had been uneventful. The patient was submitted to total intravenous anesthesia (midazolam, fentanyl, propofol, vercuronium) and was monitored by ECG, non-invasive blood pressure monitoring, capnometry (i.e. measuring the CO 2 concentration of expired air) and pulse oximetry. Mechanical ventilation using 35% oxygen in air resulted in an oxygen saturation of 98%. In the anti-Trendelenburg's position the patient remained stable until gas was insufflated into the peritoneal cavity through a Veress' needle. Suddenly, end-expiratory CO 2 and peripheral oxygen saturation level dropped below 30 mmHg and 85%, respectively, with the lips turning cyanotic. Blood pressure was no longer measureable non-invasively, peripheral pulses were no longer perceivable. An inital increase in heart rate was followed by bradycardia and ST-segment elevation. Gas insufflation was terminated immediately, and 100% oxygen combined with a high positive end-expiratory pressure (PEEP) was administered. Pharmacological resuscitation had to be performed with repeated doses of epinephrine. Transesophageal C Acta Obstet Gynecol Scand 79 (2000) echocardiography revealed severe gas embolism, but gas bubbles were also detected in the left atrium and ventricle (Fig. 1). After stabilization of the patient's hemodynamics, laparotomy was performed, but no injured large blood vessels nor bleeding could be detected. The ovarian abscess was removed surgically, and the patient was transferred to the ICU.At the ICU the patient's oxygenation returned to normal. A CT examination of the head and chest was performed, but showed no evidence of thromboembolism or any gas-related incident. Finally, extubation was performed successfully twelve hours after the initial event. A left-sided hemiparesis was observed and a second cerebral CT scan was performed. It did not show signs of local ischemia, but the ventricular system appeared slightly narrowed and a diffuse brain edema was diagnosed. The patient received 10% mannitol and the neurological symptoms resolved completely ...

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“…CO 2 embolism is a recognized risk during laparoscopic procedures [2][3][4]. A necessary condition for the development of gas embolism is the presence of an open vein with a lower pressure in the vein than the surrounding pressure [2].…”

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