Transient asystole related to carbon dioxide embolism during transoral endoscopic parathyroidectomy vestibular approach

Abstract

Background: Rarely, during the endoscopic thyroidectomy, carbon dioxide (CO 2 ) embolism may occur.Methods: Case 1: A 65-year-old female who was seen with prolonged fatigue and generalized bone pain was diagnosed primary hyperparathyroidism (PHPT) based on her preoperative biochemical profile. Transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) was planned. Case 2: A 52-year-old male patient was seen with weakness and hepatosteatosis and was diagnosed PHPT based on the laboratory workup. TOEPVA was planned. Results: After subplatysmal dissection with vascular tunnel probe, both of the patients developed severe bradycardia and hypotension leading to asystole during the CO 2 insufflation. The possibility of CO 2 embolism was considered and insufflation was terminated. After a successful cardiac massage, sinus rhythm returned. Conclusion:TOEPVA may develop CO 2 embolism leading to asystole during the CO 2 insufflation.

Carbon dioxide embolism during transoral endoscopic thyroidectomy: A case report and literature review

“…If asystole develops, immediate chest compressions should be initiated. [1][2][3][4][5]7,8 Injured blood vessel(s) can be controlled by initially applying lateral neck compression and using advanced bipolar/ultrasonic devices (if vital signs permit). Although aspiration of a gas embolus can be performed via a central venous catheter, this was not necessary in the reported cases.…”

“…3 Most authors report that patients recover well without any significant neurologic or cardiac sequelae and were discharged home typically within 4 days after surgery. [3][4][5][6][7][8][9] CO 2 embolism may be prevented by compressing the external neck for 1-3 min before CO 2 insufflation, using low initial CO 2 pressure (6-8 mmHg, which we have now applied in our succeeding cases), careful and gentle dissection of the surgical space, and swift control of an injured vessel. Lastly, surgeons should have an in-depth knowledge of anatomy in performing TOETVA, particularly the relation of the anterior jugular vein and other small vessels during dissection.…”

“…CO 2 embolism occurs when CO 2 enters the injured vessel upon insufflation 2 . Although considered a rare occurrence, CO 2 embolism can result in hemodynamic instability and cardiac arrest 2–5 . We aim to report another case of CO 2 embolism during TOETVA and present a literature review on its clinical presentation, management, and prevention.…”

Working Space Creation in Transoral Thyroidectomy: Pearls and Pitfalls

“…Usually, bleeding at this stage is self-limited or can be managed endoscopically after trocar insertion and CO 2 insufflation. However, two cases of CO 2 embolism that occur immediately after gas insufflation have been reported in the literature [ 42 , 55 ]. Both patients developed hypotension and asystole and received cardiopulmonary resuscitation.…”

“…Unable to identify the bleeder or at least temporarily stop the bleeding may pose the risk of letting CO 2 enter the lacerated vein and subsequently lead to fatal CO 2 embolism. Hypotension and even asystole have been reported in patients who develop CO 2 embolism during transoral thyroidectomy and parathyroidectomy [ 55 , 61 ]. In such cases, CO 2 insufflation should be terminated and 100% oxygen should be provided.…”