Paradoxical carbon dioxide embolism during laparoscopic surgery without intracardiac right-to-left shunt: two case reports and a brief review of the literature

Hou, Weimin; Zhong, Jing; Pan, Bo; Huang, Jiapeng; Wang, Biyu; Sun, Zhirong; Miao, Changhong

doi:10.1177/0300060520933816

Cited by 14 publications

(9 citation statements)

References 35 publications

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“…However, in this case, no intracardiac shunt was found on preoperative or intraoperative echocardiographic examinations. Similar to our case, several reports have described paradoxical air embolism that occurred during laparoscopic surgery even though the patients did not have an intracardiac shunt[ 4 , 17 - 19 ]. In these reports, the authors described three possible mechanisms.…”

Section: Discussionsupporting

confidence: 88%

Paradoxical carbon dioxide embolism during laparoscopic hepatectomy without intracardiac shunt: A case report

Jeon¹,

Hong²,

Lee³

et al. 2022

WJCC

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BACKGROUND Laparoscopic hepatectomy has recently become popular because it results in less bleeding than open hepatectomy. However, CO 2 embolism occurs more frequently. Most CO 2 embolisms during laparoscopic surgery are self-resolving and non-symptomatic; however, severe CO 2 embolism may cause hypotension, cyanosis, arrhythmia, and cardiovascular collapse. In particular, paradoxical CO 2 embolisms are highly likely to cause neurological deficits. We report a case of paradoxical CO 2 embolism found on transesophageal echocardiography (TEE) during laparoscopic hepatectomy, although the patient had no intracardiac shunt. CASE SUMMARY A 71-year-old man was admitted for laparoscopic left hemihepatectomy. During left hepatic vein ligation, the inferior vena cava was accidentally torn. We observed a sudden drop in oxygen saturation to 85%, decrease in systolic blood pressure (SBP) below 90 mmHg, and reduction in end-tidal CO 2 to 24 mmHg. A “mill-wheel” murmur was auscultated over the precordium. The fraction of inspired oxygen was increased to 100% with 5 cmH 2 O of positive end-expiratory pressure (PEEP) and hyperventilation was maintained. Norepinephrine infusion was increased to maintain SBP above 90 mmHg. A TEE probe was inserted, revealing gas bubbles in the right side of the heart, left atrium, left ventricle, and ascending aorta. The surgeon reduced the pneumoperitoneum pressure from 17 to 14 mmHg and repaired the damaged vessel laparoscopically. Thereafter, the patient’s hemodynamic status stabilized. The patient was transferred to the intensive care unit, recovering well without complications. CONCLUSION TEE monitoring is important to quickly determine the presence and extent of embolism in patients undergoing laparoscopic hepatectomy.

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Section: Discussionsupporting

confidence: 88%

Paradoxical carbon dioxide embolism during laparoscopic hepatectomy without intracardiac shunt: A case report

Jeon¹,

Hong²,

Lee³

et al. 2022

WJCC

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“…The treatment in the paper of Hou W et al. is as follows: pneumoperitoneus is stopped, Trendelenburg position that facilitates the flow of gas into the apex of the right ventricle and prevents it from entering the pulmonary artery ( 36 ) is adjusted, and air bubbles are released from the central line ( 37 ).In view of the serious consequences that CO2 gas embolism can cause, we believe that the possibility of CO2 gas embolism should be considered in patients with no significant hemorrhage during surgery but accompanied by sudden hemodynamic changes, or a decrease in EtCO2, or spO2. Among above, the early warning consciousness of the surgeon, the roving nurse and the anesthesiologist is the key to early detection of severe CO2 gas embolism.…”

Section: Discussionmentioning

confidence: 99%

“…Among above, the early warning consciousness of the surgeon, the roving nurse and the anesthesiologist is the key to early detection of severe CO2 gas embolism. Second, TEE can quickly help diagnose embolism and determine the extent and location of embolism ( 37 ).…”

Section: Discussionmentioning

confidence: 99%

Treatment of hepatic venous system hemorrhage and carbon dioxide gas embolization during laparoscopic hepatectomy via hepatic vein approach

Feng

et al. 2023

Front. Oncol.

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With the improvement of laparoscopic surgery, the feasibility and safety of laparoscopic hepatectomy have been affirmed, but intraoperative hepatic venous system hemorrhage and carbon dioxide gas embolism are the difficulties in laparoscopic hepatectomy. The incidence of preoperative hemorrhage and carbon dioxide gas embolism could be reduced through preoperative imaging evaluation, reasonable liver blood flow blocking method, appropriate liver-breaking device, controlled low-center venous pressure technology, and fine-precision precision operation. In the case of blood vessel rupture bleeding in the liver vein system, after controlling and reducing bleeding, confirm the type and severity of vascular damage in the liver and venous system, take appropriate measures to stop the bleeding quickly and effectively, and, if necessary, transfer the abdominal treatment in time. In addition, to strengthen the understanding, prevention and emergency treatment of severe CO2 gas embolism in laparoscopic hepatectomy is also the key to the success of surgery. This study aims to investigate the methods to deal with hepatic venous system hemorrhage and carbon dioxide gas embolization based on author’s institutional experience and relevant literature. We retrospectively analyzed the data of 60 patients who received laparoscopic anatomical hepatectomy of hepatic vein approach for HCC. For patients with intraoperative complications, corresponding treatments were given to cope with different complications. After the operation, combined with clinical experience and literature, we summarized and discussed the good treatment methods in the face of such situations so that minimize the harm to patients as much as possible.

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“…History of abdominal surgery, 26 preoperative anticipation of possible intraoperative venous injury, 22 and liver cirrhosis 27 have been reported to affect the occurrence of gas embolism during LLR; hence, these 3 factors were stratified and included in the prespecified subgroup analyses. In addition, the risk of gas embolism may increase during the surgical transection of lesions proximal to major vessels.…”

Section: Discussionmentioning

confidence: 99%

“…A compensatory increase in HR may decrease cardiac output and increase the risk of cardiac events; 34 however, no cardiorespiratory instability has been reported in studies related to laparoscopic cholecystectomy 39,40 or laparoscopic radical prostatectomy 4 . Nonetheless, tachycardia, decreased SpO 2 and systolic arterial pressure, and even postoperative epileptiform seizures 22 or cardiac arrest 13 have been reported in LLR. Another porcine study found that LLR was associated with a 57% rate of gas embolism accompanied by cardiac arrhythmias 8 .…”

Section: Discussionmentioning

confidence: 99%

Low Pneumoperitoneum Pressure Reduces Gas Embolism During Laparoscopic Liver Resection

Luo,

Jin,

Huang

et al. 2023

Annals of Surgery

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Objective: To compare the effect of low and standard pneumoperitoneal pressure (PP) on the occurrence of gas embolism during laparoscopic liver resection (LLR). Background: LLR has an increased risk of gas embolism. Although animal studies have shown that low PP reduces the occurrence of gas embolism, clinical evidence is lacking. Methods: This parallel, dual-arm, double-blind, randomized controlled trial included 141 patients undergoing elective LLR. Patients were randomized into standard (“S,” 15 mm Hg; n = 70) or low (“L,” 10 mm Hg; n = 71) PP groups. Severe gas embolism (≥ grade 3, based on the Schmandra microbubble method) was detected using transesophageal echocardiography and recorded as the primary outcome. Intraoperative vital signs and postoperative recovery profiles were also evaluated. Results: Fewer severe gas embolism cases (n = 29, 40.8% vs n = 47, 67.1%, P = 0.003), fewer abrupt decreases in end-tidal carbon dioxide partial pressure, shorter severe gas embolism duration, less peripheral oxygen saturation reduction, and fewer increases in heart rate and lactate during gas embolization episodes was found in group L than in group S. Moreover, a higher arterial partial pressure of oxygen and peripheral oxygen saturation were observed, and fewer fluids and vasoactive drugs were administered in group L than in group S. In both groups, the distensibility index of the inferior vena cava negatively correlated with central venous pressure throughout LLR, and a comparable quality of recovery was observed. Conclusions: Low PP reduced the incidence and duration of severe gas embolism and achieved steadier hemodynamics and vital signs during LLR. Therefore, a low PP strategy can be considered a valuable choice for the future LLR.

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Paradoxical carbon dioxide embolism during laparoscopic surgery without intracardiac right-to-left shunt: two case reports and a brief review of the literature

Cited by 14 publications

References 35 publications

Paradoxical carbon dioxide embolism during laparoscopic hepatectomy without intracardiac shunt: A case report

Paradoxical carbon dioxide embolism during laparoscopic hepatectomy without intracardiac shunt: A case report

Treatment of hepatic venous system hemorrhage and carbon dioxide gas embolization during laparoscopic hepatectomy via hepatic vein approach

Low Pneumoperitoneum Pressure Reduces Gas Embolism During Laparoscopic Liver Resection

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