Paradoxical carbon dioxide embolism during endoscopic thyroidectomy confirmed by transesophageal echocardiography

Abstract

Carbon dioxide (CO₂) embolism is a rare but potentially life-threatening complication of laparoscopic procedures. Although endoscopic thyroidectomy using CO₂ gas insufflation appears to be superior to conventional open thyroidectomy in terms of cosmetic results, it may cause venous or fatal paradoxical CO₂ embolism. We report a case of paradoxical CO₂ embolism during CO₂ gas insufflation in an endoscopic thyroidectomy that was confirmed by transesophageal echocardiography (TEE). Paradoxical embolization via transpulmonary right-to-left shunting of venous CO₂ gas emboli was revealed by TEE examination. The patient recovered without complications. In conclusion, although endoscopic thyroidectomy is a promising approach that is gaining popularity and offers excellent cosmetic results compared with conventional open thyroidectomy, this case report emphasizes the importance of anticipating and being vigilant for potential CO₂ embolism.

Carbon dioxide embolism during transoral robotic thyroidectomy: A case report

“…12,13 There are also 2 case reports of CO 2 embolism in endoscopic thyroidectomy using the bilateral-axillo-breast approach, although there was no cardiac arrest, unlike in our case. 13,14 In 1 case, the event occurred after dissection of the thyroid gland; end-tidal CO 2 suddenly dropped from 34 to 8 mm Hg, and oxygen saturation to 60%, with hypotension and bradycardia. After administration of glycopyrrolate, ephedrine, and 100% oxygen, vital signs returned to normal.…”

“…A CO 2 embolism has been reported in several laparoscopic procedures, including laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic liver resection, and gynecological laparoscopy . There are also 2 case reports of CO 2 embolism in endoscopic thyroidectomy using the bilateral‐axillo‐breast approach, although there was no cardiac arrest, unlike in our case . In 1 case, the event occurred after dissection of the thyroid gland; end‐tidal CO 2 suddenly dropped from 34 to 8 mm Hg, and oxygen saturation to 60%, with hypotension and bradycardia.…”

“…The operation was then converted to a conventional open thyroidectomy. Numerous gas bubbles were seen in the heart by transesophageal ECG …”

Anesthetic course and complications that were encountered during endoscopic thyroidectomy -A case report-

“…In the case of pneumoperitoneum, CO 2 can be eliminated quickly and helps minimize the patient's postoperative discomfort. Its many advantages notwithstanding, CO 2 , when absorbed into the blood, can cause hypercapnia, subcutaneous emphysema, pneumothorax, and embolism [3,4]. …”

Carbon Dioxide Embolism during Laparoscopic Surgery

“…There have been reports of carbon dioxide emboli occurring in various procedures including laparoscopic appendectomy,3 laparoscopic cholecystectomy,4-7 endoscopy,8 hysteroscopy,9 and other gynecological laparoscopic surgeries 10-13. Recently, carbon dioxide emboli have also been reported to occur during laparoscopic nephrectomy,14 laparoscopic hepatectomy,15 endoscopic vein harvesting,16,17 endoscopic thyroidectomy,18 and laparoscopic radical prostatectomy 19…”