This Article Full Text (PDF) Submit a scholarly reply Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Councilman-Gonzales, L. M. Articles by McAllister, R. K. Search for Related Content PubMed PubMed Citation Articles by Councilman-Gonzales, L. M. Articles by McAllister, R. K.

A probable CO₂ embolus during laparoscopic cholecystectomy

Temple, Texas

To the Editor:

We witnessed a case of a probable carbon dioxide (CO₂) embolus during an otherwise routine laparoscopic cholecystectomy. The patient was a 32-yr-old, 82 kg, ASA Class II woman with a past medical history significant only for cholelithiasis and iron-deficiency anemia. Surgery proceeded uneventfully until dissection of the gallbladder from the liver bed. There was a sudden fall in arterial oxygen saturation (SaO₂) to 68% and an abrupt drop in the end-tidal carbon dioxide (ETCO₂) was noted. A switch to manual ventilation revealed a marked decrease in pulmonary compliance. The blood pressure (BP) dropped to 70/40 mmHg and the heart rate (HR) rose to 120 beats•min^-1. At that time, we were advised of brisk bleeding in the surgical field, which the surgeons were trying to control. The surgeon was notified of a probable CO₂ embolus and the peritoneum was immediately decompressed. Volume replacement was accomplished with lactated Ringer’s solution and a synthetic colloid intravenously. Ephedrine, in divided doses, was used for blood pressure support. A laparotomy was performed to control the bleeding, which was due to a transected bridging vein between the liver and gallbladder. The patient rapidly recovered with a return of ETCO₂ to 34 and normalization of airway pressure, SaO₂, BP, and HR. The elapsed time from onset of symptoms to normalization of vital signs was only minutes. The patient did have a total blood loss of 2500 mL. The surgery was completed without any other untoward events and the postoperative course was uneventful.

Because of the symptoms and the sudden onset and resolution of the symptoms, we believe this patient experienced a CO₂ embolus. The mechanism of entrainment of CO₂ was through the tear in the bridging vein during gallbladder dissection. Since we didn’t have a precordial Doppler or transesophageal stethoscope in place and no arterial blood gas was drawn, we have no confirmatory proof of an embolus, however, we believe that is the most likely explanation for this scenario. Another possible explanation is hypovolemic shock compounded by the increased intra-abdominal pressures during ip insufflation, leading to a dramatic decrease in venous return to the heart. Unfortunately, we will not be able to definitively diagnose the inciting event of this case, but it was truly an educational experience, reminding us that there are life-threatening complications around every "routine" corner.

This article has been cited by other articles:

				C. D. McClain, F. X. McGowan, and P. G. Kovatsis Laparoscopic Surgery in a Patient with Fontan Physiology Anesth. Analg., October 1, 2006; 103(4): 856 - 858. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Submit a scholarly reply Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Councilman-Gonzales, L. M. Articles by McAllister, R. K. Search for Related Content PubMed PubMed Citation Articles by Councilman-Gonzales, L. M. Articles by McAllister, R. K.