Treatment of CO2 embolism in laparoscopic hepatectomy / 中华肝胆外科杂志

Objective To study the diagnosis and treatment of CO2 embolism in laparoscopic hepatectomy (LH).Methods A retrospective study was conducted on 80 patients who underwent various types of LH from June 2016 to November 2017.The clinical data of 4 patients who suffered from severe CO2 embolism were analyzed.Results The operation time of 80 patients varied from 65 min to 345 min (average 170 min).Tbe amount of blood loss ranged from 50 ml to 2 500 ml (average 450 ml).28 patients (35％) required blood transfusion.Two patients were converted to open operation because of uncontrollable bleeding.Four patients suffered from severe CO2 embolism with significant changes in circulation and respiration.After active and effective treatment,none required open conversion and all recovered well.Conclusions Any sudden respiratory and circulatory changes during LH should lead us to think of severe CO2 embolism.Timely and effective treatment could convert a dangerous situation to become safe.

Re-insufflation after deflation of a pneumoperitoneum is a risk factor for CO2 embolism during laparoscopic prostatectomy: A case report / 대한마취과학회지

Although symptomatic carbon dioxide (CO2) embolism is rare, it recognized as a potentially fatal complication of laparoscopic surgery. Sudden hemodynamic instability could be a CO2 embolism especially during insufflation. A 65-year-old man received laparoscopic prostatectomy for 5 hours under CO2 pneumoperitoneum without any problem. After resection of prostate, it was stopped following deflation. Thirty minutes later, peumoperitoneum was re-induced to continue the operation. Shortly after re-insufflation, the patient revealed hemodynamic instability suggested a CO2 embolism; severe hypotension, tachyarrythmia, hypoxemia, increased CVP, and changed end-tidal CO2. Gas insufflation was stopped. He was managed with Durant's position, fluid and cardiotonics for 20 minutes. The residual was completed by open laparotomy. Re-insufflation, inducing gas entry through the injured vessels, might be a risk factor for CO2 embolism in this case. The risk to the patient may be minimized by the surgical team's awareness of CO2 embolism and continuous intra-operative monitoring of end-tidal CO2.

Detection of Carbon Dioxide Embolism Using Transesophageal Echocardiography during Thoracoscopic Sympathicotomy / 대한마취과학회지

BACKGROUND: Thoracoscopic Sympathicotomy (TS) is widely accepted as an effective method for the treatment of palmar hyperhidrosis. Single lumen endotracheal tube using CO2 insufflation is a simple and safe method for thoracoscopic surgery. However, there are chances of CO2 embolism during CO2 insufflation and nerve dissection. The object of this study were to assess the incidence of embolic events using transesophageal echocardiography (TEE) and to evaluate the related cardiorespiratory consequence during TS. METHODS: Thirty-two patients undergoing TS were studied. The long axis four chamber view was obtained continuously, except for predetermined intervals (after induction, CO2 insufflation in left thoracic cavity, left sympathicotomy, CO2 insufflation in right thoracic cavity, and right sympathicotomy) where the transgastric short axis view was obtained to derive ejection fraction (EF). Heart rate, mean arterial pressure (MAP), O2 saturation, and end tidal CO2 were monitored. Statistical analysis was performed using multivariated ANOVA and unpaired Student's t-test. P < 0.05 was considered significant. RESULTS: We observed CO2 embolism in 28/32 patients during CO2 insufflation (left or right) and in 32/32 patients during nerve dissection (left or right). There was no significant difference in cardiorespiratory variables between patients who presented embolism and who did not, during four distinct periods of events. Meanwhile, MAP decrease (P = 0.002) and EF increased significantly (P = 0.007) after sympathicotomy. This can be explained by decrease in systemic vascular resistance (SVR) by sympathicotomy. CONCLUSIONS: Embolic events commonly occur during CO2 insufflation and nerve dissection without cardiorespiratory instability during TS. However, we should pay attention when administrating N2O.

Transesophageal Echocardiographic Assessment of Venous Carbondioxide Embolism during Laparoscopic Cholecystectomy / 대한마취과학회지

BACKGROUND: Although major CO2 gas embolism has occurred rarely during laparoscopic cholecystectomy (LC), the incidence of less severe episodes of CO2 embolism is unknown. It is also possible that such gas embolism, if present, could affect to cardiorespiratory variables. This study was designed to assess the incidence of subclinical embolic events using transesophageal echocardiography (TEE) and to evaluate the related hemodynamic consequence during LC. METHODS: With IRB approval, 20 patients undergoing LC were studied. The long axis four chamber view was obtained continuously, except for predetermined intervals where the transgastric short axis view was obtained to derive ejection fraction (EF). Heart rate, mean arterial pressure, O2 saturation, and end-tidal CO2 were monitored. Statistical analysis was performed using multivariated ANOVA and unpaired Student's t-test. P<0.05 was considered significant. RESULTS: We observed gas embolism in 4/20 patients during CO2 insufflation and 20/20 patients during gallbladder (GB) dissection. There was no significant difference in cardiorespiratory variables between embolic and nonembolic patients during insufflation. Also there was no significant difference in cardiorespiratory variation in all patients with embolism between before and after GB dissection. EF decreased significantly after insufflation (P = 0.002) and was recovered after exsufflation (P = 0.001). This can be explained by increase in systemic vascular resistance (SVR). CONCLUSIONS: Embolic events commonly occur during CO2 insufflation and GB dissection without cardiorespiratory instability. Although embolic event itself didn't affect the hemodynamic variables, peritoneal insufflation increased SVR and decreased EF. We should pay attention to patients undergoing LC who have decreased cardiac function and also prepare for serious CO2 embolic event.