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Canadian Journal of Anesthesia 48:319-320 (2001)
© Canadian Anesthesiologists' Society, 2001

Correspondence

Pulmonary carbon dioxide embolism during laparoscopic cholecystectomy

Tadahiko Ishiyama, MD, Kazuyuki Hanagata, MD, Satoshi Kashimoto, MD and Teruo Kumazawa, MD

Yamanashi, Japan

To the Editor:

We wish to report an unusual1 pulmonary carbon dioxide (CO2) embolism which occurred after intrahepatic CO2 insufflation following inadvertent puncture of the liver by a Verres needle.

A 77-yr-old man underwent laparoscopic cholecystectomy under general anesthesia. A Verres needle was inserted at the right subcostal area. Shortly after the onset of CO2 insufflation, end-tidal CO2 (PETCO2) suddenly decreased from 35 to 12 mmHg. Then, oxygen saturation (Spo2), blood pressure and heart rate decreased. Electrocardiogram revealed transient complete right bundle branch block. Insufflation was stopped, and ephedrine and 100% oxygen were administered. Blood pressure, heart rate and Spo2 returned to normal, and PETCO2 increased to 22 mmHg over five minutes. Arterial blood-gas revealed pH 7.32, PaCO2 49.3 mmHg, PaO2 270.5 mmHg. Thirty minutes later, insufflation was restarted. Laparoscopic inspection showed a tear in the liver surface. When the gallbladder was dissected via the laparoscope, PETCO2 decreased from 38 to 26 mmHg, whereas PaCO2 was 46.1 mmHg. After the surgery, the patient complained of chest pain and dyspnea. He was fully recovered following one day of mechanical ventilation.

Since decrease in PETCO2 was noted soon after the initiation of insufflation, and laparoscopic inspection indicated the inadvertent puncture of the liver by the Verres needle, intrahepatic insufflation of CO2 should be responsible for the cardiovascular collapse. It has been shown that a 37% incidence of CO2 embolism during gallbladder dissection.2 Because PETCO2 decreased during gallbladder dissection, CO2 pulmonary embolism may have recurred. Anesthesiologists should be aware of occurrence of pulmonary embolism during peritoneal insufflation and gallbladder dissection.

References

1 Wahba RW, Tessler MJ, Kleiman SJ. Acute ventilatory complications during laparoscopic upper abdominal surgery. Can J Anaesth 1996; 43: 77–83.[Abstract/Free Full Text]

2 Derouin M, Couture P, Boudreault D, Girard D, Gravel D. Detection of gas embolism by transesophageal echocardiography during laparoscopic cholecystectomy. Anesth Analg 1996; 82: 119–24.[Abstract]





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