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Arterial to end-tidal CO₂ gradient reversal during laparoscopic pheochromocytoma resection

[Le renversement du gradient du CO₂ artériel/télé-expiratoire pendant la résection laparoscopique d’un phéochromocytome]

From the Department of Anesthesia, Tufts-New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA.

Address correspondence to: Dr. Jana Hudcova, Department of Anesthesia, Tufts-New England Medical Center, Box 298, 750 Washington St., Boston, Massachusetts 02111, USA. Phone: 617-636-6044; Fax: 617-636-8384; E-mail: jhudcova{at}tufts-nemc.org

Purpose: We report the development of severe intraoperative hypercarbia and a pronounced arterial to end-tidal gradient reversal during laparoscopic pheochromocytoma resection. Although complex physiologic mechanisms may be responsible for this finding, anatomic alterations such as a direct communication between a capnoperitoneum and/or capnothorax and the airways resulting from prior pathology and the type of procedure should also be considered.

Clinical features: During anesthesia for laparoscopic pheochromocytoma removal we noticed an abrupt, extensive increase of the end-tidal CO₂ accompanied by a change of the capnographic CO₂ tracing and reversal of the normal arterial-to-end-tidal gradient. These changes consistently disappeared by intermittent deflation of the abdomen and at the end of surgery. A chest x-ray revealed a right-sided loculated pneumothorax with pleural thickening. Peritoneo-thoracic CO₂ tracking and pleural scaring with pulmonary adhesions resulting in a unidirectional communication between the pleural space and airways may best explain the chest x-ray and clinical findings.

Conclusion: Severe intraoperative hypercarbia and arterial to end-tidal CO₂ gradient reversal represents an intraoperative challenge. The possibility of a direct communication between the pleural space and the bronchial tree should be considered when other etiologies have been excluded. Simple maneuvers such as abdominal de- and re-inflation and analysis of the end-tidal capnographic tracing might aid in the differential diagnosis and management.