Circulatory Collapse Laparoscopy
during
Pontus L. btman, MD,* Fried1 H. Pantle-Fisher, MD,? Eveline A. Faure, MD,* Beth Glosten, MD* Department of Anesthesia Chicago, IL.
This case report details the intraoperative course of a patient, in her early pregnancy, who had a cardiac arrest during transvaginal insufflation of carbon dioxide (CO,) for laparoscopic tubal ligation. Modern monitoring methods and their ability to detect gas embolism and aid in the diagnosis and treatment of this rare but life-threateniqg complication are discussed. Keywords: Laparoscopy, cardiac arrest; carbon dioxide; anesthesia.
embolism,
and Critical
Care,
University
of Chicago,
sudden cardiovascular collapse during laparoscopy exist in the anesthesia literature to remind us of the potential morbidity and mortality associated with this procedure.“-6 With modern monitoring equipment such as the mass spectrometer and pulse oximeter, however, the diagnosis and treatment of such catastrophic events can be improved. The following case report describes the intraoperative course of a patient who was 8 weeks pregnant and suffered a cardiac arrest, most likely secondary to CO, embolism during transvaginal insufflation for laparoscopic tubal ligation.
Introduction Laparoscopic tubal ligation is recognized as a safe and effective method of female sterilization. Although it is considered a minor ambulatory surgical procedure, it is associated with complications.‘J Case reports about
*Assistant Professor of Anesthesia and Critical Care tResident
in Anesthesiology
Address reprint requests to Dr. &.tman at the Department thesia, University of Iowa Hospitals and Clinics, Iowa 52242, USA. Received accepted
for publication for publication
0 1990 Butterworth
September November
Publishers
26, 1989; revised 22, 1989.
of AnesCity, IA
manuscript
Case Report A 41-year-old, 72-kg, 162-cm female, gravida II, para I, was admitted for elective dilatation and suction curettage of an 8-week intrauterine pregnancy and sterilization by tubal ligation. Her medical history was remarkable for hepatitis (197 l), depressive disorder, and cholecystectomy. Blood pressure (BP) was 1101 70 mmHg, and pulse was 80 beats/minute and regular. Physical examination and laboratory testing were normal. The patient received no premeditation. Intravascular access was with an 18-gauge cannula in a vein on the dorsum of the hand. In the operating room, the following monitors were used: electrocardiogram (EKG) (lead II), automatic BP monitor (Dinamap VSM 1846, Criticon, Tampa, FL), pulse oximeter (Biox J. Clin.
Anesth.,
vol. 2, March/April
1990
129
3700, Ohmeda, Louisville, CO), mass spectrotneter (Model 6000 Multigas Monitor, Ohmeda, Anglewood, CO), esophageal stethoscope, and peripheral nerve stimulator. Prior to induction of anesthesia, midazolam hydrochloride 0.5 mg, d-tubocurarine chlorine 3 mg, and fentanyl citrate 100 kg were given intravenously (IV). Anesthesia was induced with 200 mg thiamylal sodium, and oral tracheal intubation was aided with 80 mg of succinylcholine IV. Anesthesia was maintained with 1% enflurane in nitrous oxide 2 L/min and oxygen 1 Limin. Additional muscle relaxation was provided with vecuronium chloride. Respiration was controlled mechanically. After pelvic examination in the lithotomy position, dilatation and suction curettage were completed. Ergonovine maleate 0.2 mg was given intramuscularly (IM) to facilitate uterine contraction. The patient was then placed in the Trendelenburg position. BP was 120170 mmHg, and HR was 86 beats/ minute. Oxygen saturation was lOO%, and end-tidal CO, concentration was 32 mmHg. CO, insufflation was started via a Verres cannula placed transvaginall) into the fossa Douglas to produce pneumoperitoneum. Insufflating pressures were between 10 and 20 mmHg. When approximately 1.5 liters of CO, had and been injected, HR decreased to 65 beats/minute. a murmur was heard from the esophageal stethoscope. This murmur was accompanied by premature ventricular complexes and widening of the QRS cwllplex. Ventricular tachycardia was seen on the EKG monitor. BP was unobtainable. ‘The pulse wave on the pulse oximeter disappeared, and the end-tidal (10, waveform reading on the mass spectrometer became flat at 0 mmHg. The patient appeared cyanotic. Insufflation was stopped immediately, and the pneumoperitoneum was released. All the anesthetics were discontinued, and the patient was ventilated with 100% oxygen. Cardiopulmonary resuscitation was initiated with manual closed-chest cardiac compressions. Resuscitative medications included IV ephedrine, epinephrine, calcium chloride, and sodium bicarbonate. After approximately 2 minutes, EK(G showed suprawhich converted spontaventricular tachycardia, neously to sinus rhythm. BP was now 1401100 mmHg, HR was 115 beats/minute, oxygen saturation was lOO%, and end-tidal CO, concentration was 28 mmHg. ‘l‘he neuromuscular blockade was reversed with neostigmine and atropine, and the patient resumed spontaneous ventilation. The endotracheal tube was removed when the patient was awake and cooperative and the vital signs were stable. In the recovery room, a 12-lead EKG showed no]‘ma1 sinus rhythm with left axis deviation. ST-T wave changes were consistent with anterolateral ischernia. 130
J. Clin. Anesth.,
vol. 2, March/April
1990
Neurologic examination was normal. EKG later the same day and the following morning were normal. IsoenLymes (creatine phosphokinase and lactate dehydrogenase) obtained the day of surgery and 24 hours later were within normal limits. ‘rhe patient was discharged the following day. She was admitted 1 week later and underwent tubal ligation via rninilaparotonl) under epidural anesthesia without complication. On laparotomy, it was found that the uterus was retroverted and the cul-de-sac was obliterated by adhesions.
Discussion The mortality associated with laparoscopy is approximately 4 per 100,000. Other serious complications occur in approximately 2% of the procedures.‘-’ (Complications caused by the use of the Verres needle with injury to vascular 01 or trocar can be traumatic, visceral structures. Insufflation of gas can be complicated bv the creation of false routes or the LM ot excessi\,e amounts ot gas to create pneumoperiloneui11. ‘l‘his pneuriioperitoneuni may cause cardiovascular depression, vasovagal reflexes and tlysrhythmias, increased blood CD, partial pressure. and ,gas embolism. H I0 I ntra-abdominal hemorrhage. puhnonary thromboembolisn~. arid pneumothorax also are recognized as potential complications. (X),, air, or nitrous oxide can he used to induct ~,ilcumo~,eritorle~ln~. (X>, is chosen f’or its high soubility in blood and rapid excretion through the lungs. This solubility allows for rapid absorption and elimination of the gas postoperatively. Rapid elimination also increases the margin of safety if the gas is injected via IV.” ‘l‘hc literature indicates that gas embolism during laparoscopy is a rare complication, I.? but criteria tar diagnosis of gas embolism vary, aild the data ma\
not
be
accurate.
In the patient in this report, a “mill-wheel” murmurwas noted concomitantly with cardiovascular collapse and the disappearance of a normal end-tidal CO, waveform on the mass spectrometer. Theoretically, a brief’ increase in end-tidal CO, should have been seen prior to cardiovascular collapse. ‘I’his increase ma) have gone unnoticed, or the initial ernbolus could have been large enough to cause a severe fall in cardiac output. In addition, EKG changes (wide QRS or ventricular tachycardia), such as those described by I)urant rl nl..’ I were seen. We speculate that the prompt initiation of external chest compressions may ha\ta broken down the right-sided (atrial/ventricular) obstructive gas bubble into smaller ones, and because CO, is highly soluble in blood, the smaller bubbles
Carbon dioxide embolism: &man et al.
were quickly absorbed into the bloodstream, enabling rapid restoration of circulation. The patient most likely suffered cardiovascular collapse due to the intravascular injection of CO,. The cardiac arrest occurred shortly after the initiation of transvaginal CO, insufflation into the fossa Douglas. Minilaparotomy performed 1 week later showed the uterus to be retroverted and the cul-de-sac obliterated by adhesions. Perhaps the CO, was initially insufflated intravascularly, although myometrial placement cannot be ruled out. This patient may have been at higher risk for this complication due to the transvaginal insufflation and her pregnant state, resulting in pelvic vein dilatation. Previously, gas embolism during laparoscopy has been reported to occur during the latter part of insufflation.“,” However, this patient was more extensively monitored than patients in earlier CO, embolism reports. The monitors (mass spectrometer and pulse oximeter) greatly expedited early diagnosis and thera case in which peritoneal apy. Yacoub et ~1.~ reported gas disappeared during diagnostic laparoscopy, and as insufflation was started again, the patient suffered A mill-wheel murmur was cardiovascular collapse. heard, and foamy blood was aspirated through a central venous catheter. Similarly, Clark et al.:’ heard a mill-wheel murmur just prior to cardiovascular collapse. Their patient was successfully resuscitated, and a subsequent laparotomy showed an omental hematoma. CO, embolization can obstruct the pulmonary outflow tract and cause cessation of effective pulmonary circulation and gas exchange, eliciting an immediate decrease in end-tidal CO, concentration. Marked dilatation of the right side of the heart will follow. The increasing right ventricular and atria1 pressure will interfere with the myocardial blood supply, and right ventricular failure is imminent.’ i The acute right-sided hypertension may open the foramen ovale and allow arterial embolization of the gas. A moderate increase in physiologic dead space occurs during air embolism.‘” Hypoxemia may occur secondary to an increase in lung units with low ventilation-perfusion ratios. Because of its high blood solubility, CO, embolism causes similar but less marked effects than those produced by air embolism. CO, embolism does not produce bronchoconstriction or the changes in the pulmonary compliance that accompany air embolism.‘:’ In addition to general resuscitative measures, treatment of gas embolism includes placing the patient in a steep left lateral Trendelenburg position to minimize right ventricular outflow obstruction, stopping further embolization and gas insufflation, and aspirating the obstructing embolus through a central venous cath-
eter.‘4,‘5 Early detection is most important for the prevention of serious sequelae due to CO, embolization. The diagnosis of gas embolism depends on the detection of emboli in the right side of the heart or recognition of the physiologic changes associated with the sensitivity of gas emboli. Glenski et ~1.‘~ compared available monitoring methods. They evaluated transesophageal echocardiography, Doppler ultrasound, trdnscutaneous oxygen tension, transcutaneous CO, tension, end-tidal CO, tension (PET,;,,,), and pulmonary artery pressure (PAP) to determine their ability to reflect the volume of air infused in dogs. Transesophageal echocardiography and Doppler ultrasound were very sensitive in detecting small quantities of air prior to physiologic changes. Transcutaneous oxygen tension, PAP, and PET,:,, reflected the quantity of air infused equally well, but the response time was longer and air requirement for detection was much larger than that with transesophageal echocardiography and Doppler ultrasound. It is difficult to show that monitoring with these devices would improve outcome in laparoscopic procedures. Wadhwa et al.” monitored 100 patients undergoing laparoscopic procedures with a Doppler ultrasonic instrument and found no incidence of gas embolism (the estimated sensitivity of their method was 0.1 ml of gas). ‘l-he pulse oximeter, precordial stethoscope, EKG, and, particularly, mass spectrometer with end-tidal CO, monitoring were valuable in allowing early recognition of the problem and prompt initiation of therapy. End-tidal CO, monitoring was valuable for determining the cessation and subsequent restoration of effective circulation. The anesthesiologist should look for the presen$ of blood on aspiration from the Verres needle, observe possible pulsations of the flowmeter pressure gauge (which are the same frequency as the patient’s HR), and note the absence of abdominal distention when a sufficient volume of gas has been infused. Any of these conditions may be early signs of a misplaced Verres needle. Adequate monitoring and clinical alertness in early recognition and treatment of CO, embolus cannot be overemphasized in these minor but potentially hazardous surgical procedures.
References 1. Peterson HB, DeStefano F, Rubin (;L, Greenspan JR, Lee NC, Ory HW: Deaths attributable to tubal sterilization in the United States, 1977 to 1981. AmJ Obstet Gynecol 1983; 146: 13 1-6. 2. Phillips J, Keith D, Hulka J, Hulka
R, Keith L: Gyne-
J. Clin. Anesth., vol. 2, March/April
1990
131
Case Reports
3.
4. 5.
6.
7.
8.
9.
132
cologic laparoscopy in 1975. J Reprod Med 1976;3: 10517. Clark CC, Weeks DB, Gusdon JP: Venous carbon dioxide embolism during laparoscopy. A,ne.cth Analg 1977; 56:650-2. Lee CM: Acute hypotension during laparoscopy: a case report. An&h Analg 1975;54:142-3. Root B, Levy MN, Pollack S, Lubert M, Pathak K: Gas embolism death after laparoscopy delayed by “trapAnesth Analg 1978;57:232ping” in portal circulation. 7. Yacoub OF, Cardona I, Coveler LA, Dodson MG: Carbon dioxide embolism during laparoscopy. Ane.rthesiology 1982;57:533-5. DeStefano F, Greenspan JR, Dicker RC, Peterson HB, Straus LT, Rubin GL: Complications of interval lap”roscopic tubal sterilization. Ob.ftet Gynecol 1983;6 1: 1538. Ivankovich AD, Miletich DJ, Albrecht RF, Heyman H,], Bonnet RF: Cardiovascular effects of intraperitoneal insufflation with carbon dioxide and nitrous oxide in the dog. Anesthesiology 1975;42:281-7. Graff TD, Arbegast NR, Phillips OC, Harris LC, FraLiel TM: Gas embolism: a comparative study of air and carbon dioxide as embolic agents in the systemic venous system. Am J Obstet Gynecol 1959;78:259-65.
J. Clin. Anesth.,
vol. 2, March/April
1990
10. Hodgson C, McClelland KM, Newron.jR: Some et’fects OF the peritoneal insufflation of carbon dioxide at laparoscopy. Anaesthesia 1970;25:382-90. 11. Durant TM, Long J, Oppenheimer MJ: Pulmonary (venous) air embolism. Am Heart J 1947;-33:269-Xl. 12. English JB, Westenskow D, Hodges MR, Stanley TH: Comparison of venous air embolism monitoring in su pine dog. AnesthesioloCq 1978;48:425-9. 13. Khan MA, Alkalay I, Suetsugu S, Stein M: Acute changes in lung tnechanics following pulmonary emboli of various gases in dogs. J Appl Physiol 1972;33:774-7. 14. Michenfelder .JD, Martin J’I‘, Alterburg BM, RehdelK: Air ernbolism during neurosurgery. An evaluation of right-atria1 catheters for diagnosis and treatment. ,/A&f/i 1969;208: 13X-8. 1.5. Gottlieb ,JD, Erickson JA, Sweet KH: Venous air enholism: a review. An&h Analg 1965;44:773-9. 16. (ilrnski ,JA. Cut-chiara RF, Michenfelder ,JD: ‘1‘1~an>esophageal echocardiography and transcutaneous 0. and COi monitoring for detection of venous air embolism. nl~atlh~siolo93’ 1986;64:542-5. 17. Wadhwa RK, McKenzie R, Wadhwa SK, Katz DL, Byers J I;: Gas embolism during laparoscopy. Anc~.s/horolo~q 1078:48:74-6.
during
Pontus L. btman, MD,* Fried1 H. Pantle-Fisher, MD,? Eveline A. Faure, MD,* Beth Glosten, MD* Department of Anesthesia Chicago, IL.
This case report details the intraoperative course of a patient, in her early pregnancy, who had a cardiac arrest during transvaginal insufflation of carbon dioxide (CO,) for laparoscopic tubal ligation. Modern monitoring methods and their ability to detect gas embolism and aid in the diagnosis and treatment of this rare but life-threateniqg complication are discussed. Keywords: Laparoscopy, cardiac arrest; carbon dioxide; anesthesia.
embolism,
and Critical
Care,
University
of Chicago,
sudden cardiovascular collapse during laparoscopy exist in the anesthesia literature to remind us of the potential morbidity and mortality associated with this procedure.“-6 With modern monitoring equipment such as the mass spectrometer and pulse oximeter, however, the diagnosis and treatment of such catastrophic events can be improved. The following case report describes the intraoperative course of a patient who was 8 weeks pregnant and suffered a cardiac arrest, most likely secondary to CO, embolism during transvaginal insufflation for laparoscopic tubal ligation.
Introduction Laparoscopic tubal ligation is recognized as a safe and effective method of female sterilization. Although it is considered a minor ambulatory surgical procedure, it is associated with complications.‘J Case reports about
*Assistant Professor of Anesthesia and Critical Care tResident
in Anesthesiology
Address reprint requests to Dr. &.tman at the Department thesia, University of Iowa Hospitals and Clinics, Iowa 52242, USA. Received accepted
for publication for publication
0 1990 Butterworth
September November
Publishers
26, 1989; revised 22, 1989.
of AnesCity, IA
manuscript
Case Report A 41-year-old, 72-kg, 162-cm female, gravida II, para I, was admitted for elective dilatation and suction curettage of an 8-week intrauterine pregnancy and sterilization by tubal ligation. Her medical history was remarkable for hepatitis (197 l), depressive disorder, and cholecystectomy. Blood pressure (BP) was 1101 70 mmHg, and pulse was 80 beats/minute and regular. Physical examination and laboratory testing were normal. The patient received no premeditation. Intravascular access was with an 18-gauge cannula in a vein on the dorsum of the hand. In the operating room, the following monitors were used: electrocardiogram (EKG) (lead II), automatic BP monitor (Dinamap VSM 1846, Criticon, Tampa, FL), pulse oximeter (Biox J. Clin.
Anesth.,
vol. 2, March/April
1990
129
3700, Ohmeda, Louisville, CO), mass spectrotneter (Model 6000 Multigas Monitor, Ohmeda, Anglewood, CO), esophageal stethoscope, and peripheral nerve stimulator. Prior to induction of anesthesia, midazolam hydrochloride 0.5 mg, d-tubocurarine chlorine 3 mg, and fentanyl citrate 100 kg were given intravenously (IV). Anesthesia was induced with 200 mg thiamylal sodium, and oral tracheal intubation was aided with 80 mg of succinylcholine IV. Anesthesia was maintained with 1% enflurane in nitrous oxide 2 L/min and oxygen 1 Limin. Additional muscle relaxation was provided with vecuronium chloride. Respiration was controlled mechanically. After pelvic examination in the lithotomy position, dilatation and suction curettage were completed. Ergonovine maleate 0.2 mg was given intramuscularly (IM) to facilitate uterine contraction. The patient was then placed in the Trendelenburg position. BP was 120170 mmHg, and HR was 86 beats/ minute. Oxygen saturation was lOO%, and end-tidal CO, concentration was 32 mmHg. CO, insufflation was started via a Verres cannula placed transvaginall) into the fossa Douglas to produce pneumoperitoneum. Insufflating pressures were between 10 and 20 mmHg. When approximately 1.5 liters of CO, had and been injected, HR decreased to 65 beats/minute. a murmur was heard from the esophageal stethoscope. This murmur was accompanied by premature ventricular complexes and widening of the QRS cwllplex. Ventricular tachycardia was seen on the EKG monitor. BP was unobtainable. ‘The pulse wave on the pulse oximeter disappeared, and the end-tidal (10, waveform reading on the mass spectrometer became flat at 0 mmHg. The patient appeared cyanotic. Insufflation was stopped immediately, and the pneumoperitoneum was released. All the anesthetics were discontinued, and the patient was ventilated with 100% oxygen. Cardiopulmonary resuscitation was initiated with manual closed-chest cardiac compressions. Resuscitative medications included IV ephedrine, epinephrine, calcium chloride, and sodium bicarbonate. After approximately 2 minutes, EK(G showed suprawhich converted spontaventricular tachycardia, neously to sinus rhythm. BP was now 1401100 mmHg, HR was 115 beats/minute, oxygen saturation was lOO%, and end-tidal CO, concentration was 28 mmHg. ‘l‘he neuromuscular blockade was reversed with neostigmine and atropine, and the patient resumed spontaneous ventilation. The endotracheal tube was removed when the patient was awake and cooperative and the vital signs were stable. In the recovery room, a 12-lead EKG showed no]‘ma1 sinus rhythm with left axis deviation. ST-T wave changes were consistent with anterolateral ischernia. 130
J. Clin. Anesth.,
vol. 2, March/April
1990
Neurologic examination was normal. EKG later the same day and the following morning were normal. IsoenLymes (creatine phosphokinase and lactate dehydrogenase) obtained the day of surgery and 24 hours later were within normal limits. ‘rhe patient was discharged the following day. She was admitted 1 week later and underwent tubal ligation via rninilaparotonl) under epidural anesthesia without complication. On laparotomy, it was found that the uterus was retroverted and the cul-de-sac was obliterated by adhesions.
Discussion The mortality associated with laparoscopy is approximately 4 per 100,000. Other serious complications occur in approximately 2% of the procedures.‘-’ (Complications caused by the use of the Verres needle with injury to vascular 01 or trocar can be traumatic, visceral structures. Insufflation of gas can be complicated bv the creation of false routes or the LM ot excessi\,e amounts ot gas to create pneumoperiloneui11. ‘l‘his pneuriioperitoneuni may cause cardiovascular depression, vasovagal reflexes and tlysrhythmias, increased blood CD, partial pressure. and ,gas embolism. H I0 I ntra-abdominal hemorrhage. puhnonary thromboembolisn~. arid pneumothorax also are recognized as potential complications. (X),, air, or nitrous oxide can he used to induct ~,ilcumo~,eritorle~ln~. (X>, is chosen f’or its high soubility in blood and rapid excretion through the lungs. This solubility allows for rapid absorption and elimination of the gas postoperatively. Rapid elimination also increases the margin of safety if the gas is injected via IV.” ‘l‘hc literature indicates that gas embolism during laparoscopy is a rare complication, I.? but criteria tar diagnosis of gas embolism vary, aild the data ma\
not
be
accurate.
In the patient in this report, a “mill-wheel” murmurwas noted concomitantly with cardiovascular collapse and the disappearance of a normal end-tidal CO, waveform on the mass spectrometer. Theoretically, a brief’ increase in end-tidal CO, should have been seen prior to cardiovascular collapse. ‘I’his increase ma) have gone unnoticed, or the initial ernbolus could have been large enough to cause a severe fall in cardiac output. In addition, EKG changes (wide QRS or ventricular tachycardia), such as those described by I)urant rl nl..’ I were seen. We speculate that the prompt initiation of external chest compressions may ha\ta broken down the right-sided (atrial/ventricular) obstructive gas bubble into smaller ones, and because CO, is highly soluble in blood, the smaller bubbles
Carbon dioxide embolism: &man et al.
were quickly absorbed into the bloodstream, enabling rapid restoration of circulation. The patient most likely suffered cardiovascular collapse due to the intravascular injection of CO,. The cardiac arrest occurred shortly after the initiation of transvaginal CO, insufflation into the fossa Douglas. Minilaparotomy performed 1 week later showed the uterus to be retroverted and the cul-de-sac obliterated by adhesions. Perhaps the CO, was initially insufflated intravascularly, although myometrial placement cannot be ruled out. This patient may have been at higher risk for this complication due to the transvaginal insufflation and her pregnant state, resulting in pelvic vein dilatation. Previously, gas embolism during laparoscopy has been reported to occur during the latter part of insufflation.“,” However, this patient was more extensively monitored than patients in earlier CO, embolism reports. The monitors (mass spectrometer and pulse oximeter) greatly expedited early diagnosis and thera case in which peritoneal apy. Yacoub et ~1.~ reported gas disappeared during diagnostic laparoscopy, and as insufflation was started again, the patient suffered A mill-wheel murmur was cardiovascular collapse. heard, and foamy blood was aspirated through a central venous catheter. Similarly, Clark et al.:’ heard a mill-wheel murmur just prior to cardiovascular collapse. Their patient was successfully resuscitated, and a subsequent laparotomy showed an omental hematoma. CO, embolization can obstruct the pulmonary outflow tract and cause cessation of effective pulmonary circulation and gas exchange, eliciting an immediate decrease in end-tidal CO, concentration. Marked dilatation of the right side of the heart will follow. The increasing right ventricular and atria1 pressure will interfere with the myocardial blood supply, and right ventricular failure is imminent.’ i The acute right-sided hypertension may open the foramen ovale and allow arterial embolization of the gas. A moderate increase in physiologic dead space occurs during air embolism.‘” Hypoxemia may occur secondary to an increase in lung units with low ventilation-perfusion ratios. Because of its high blood solubility, CO, embolism causes similar but less marked effects than those produced by air embolism. CO, embolism does not produce bronchoconstriction or the changes in the pulmonary compliance that accompany air embolism.‘:’ In addition to general resuscitative measures, treatment of gas embolism includes placing the patient in a steep left lateral Trendelenburg position to minimize right ventricular outflow obstruction, stopping further embolization and gas insufflation, and aspirating the obstructing embolus through a central venous cath-
eter.‘4,‘5 Early detection is most important for the prevention of serious sequelae due to CO, embolization. The diagnosis of gas embolism depends on the detection of emboli in the right side of the heart or recognition of the physiologic changes associated with the sensitivity of gas emboli. Glenski et ~1.‘~ compared available monitoring methods. They evaluated transesophageal echocardiography, Doppler ultrasound, trdnscutaneous oxygen tension, transcutaneous CO, tension, end-tidal CO, tension (PET,;,,,), and pulmonary artery pressure (PAP) to determine their ability to reflect the volume of air infused in dogs. Transesophageal echocardiography and Doppler ultrasound were very sensitive in detecting small quantities of air prior to physiologic changes. Transcutaneous oxygen tension, PAP, and PET,:,, reflected the quantity of air infused equally well, but the response time was longer and air requirement for detection was much larger than that with transesophageal echocardiography and Doppler ultrasound. It is difficult to show that monitoring with these devices would improve outcome in laparoscopic procedures. Wadhwa et al.” monitored 100 patients undergoing laparoscopic procedures with a Doppler ultrasonic instrument and found no incidence of gas embolism (the estimated sensitivity of their method was 0.1 ml of gas). ‘l-he pulse oximeter, precordial stethoscope, EKG, and, particularly, mass spectrometer with end-tidal CO, monitoring were valuable in allowing early recognition of the problem and prompt initiation of therapy. End-tidal CO, monitoring was valuable for determining the cessation and subsequent restoration of effective circulation. The anesthesiologist should look for the presen$ of blood on aspiration from the Verres needle, observe possible pulsations of the flowmeter pressure gauge (which are the same frequency as the patient’s HR), and note the absence of abdominal distention when a sufficient volume of gas has been infused. Any of these conditions may be early signs of a misplaced Verres needle. Adequate monitoring and clinical alertness in early recognition and treatment of CO, embolus cannot be overemphasized in these minor but potentially hazardous surgical procedures.
References 1. Peterson HB, DeStefano F, Rubin (;L, Greenspan JR, Lee NC, Ory HW: Deaths attributable to tubal sterilization in the United States, 1977 to 1981. AmJ Obstet Gynecol 1983; 146: 13 1-6. 2. Phillips J, Keith D, Hulka J, Hulka
R, Keith L: Gyne-
J. Clin. Anesth., vol. 2, March/April
1990
131
Case Reports
3.
4. 5.
6.
7.
8.
9.
132
cologic laparoscopy in 1975. J Reprod Med 1976;3: 10517. Clark CC, Weeks DB, Gusdon JP: Venous carbon dioxide embolism during laparoscopy. A,ne.cth Analg 1977; 56:650-2. Lee CM: Acute hypotension during laparoscopy: a case report. An&h Analg 1975;54:142-3. Root B, Levy MN, Pollack S, Lubert M, Pathak K: Gas embolism death after laparoscopy delayed by “trapAnesth Analg 1978;57:232ping” in portal circulation. 7. Yacoub OF, Cardona I, Coveler LA, Dodson MG: Carbon dioxide embolism during laparoscopy. Ane.rthesiology 1982;57:533-5. DeStefano F, Greenspan JR, Dicker RC, Peterson HB, Straus LT, Rubin GL: Complications of interval lap”roscopic tubal sterilization. Ob.ftet Gynecol 1983;6 1: 1538. Ivankovich AD, Miletich DJ, Albrecht RF, Heyman H,], Bonnet RF: Cardiovascular effects of intraperitoneal insufflation with carbon dioxide and nitrous oxide in the dog. Anesthesiology 1975;42:281-7. Graff TD, Arbegast NR, Phillips OC, Harris LC, FraLiel TM: Gas embolism: a comparative study of air and carbon dioxide as embolic agents in the systemic venous system. Am J Obstet Gynecol 1959;78:259-65.
J. Clin. Anesth.,
vol. 2, March/April
1990
10. Hodgson C, McClelland KM, Newron.jR: Some et’fects OF the peritoneal insufflation of carbon dioxide at laparoscopy. Anaesthesia 1970;25:382-90. 11. Durant TM, Long J, Oppenheimer MJ: Pulmonary (venous) air embolism. Am Heart J 1947;-33:269-Xl. 12. English JB, Westenskow D, Hodges MR, Stanley TH: Comparison of venous air embolism monitoring in su pine dog. AnesthesioloCq 1978;48:425-9. 13. Khan MA, Alkalay I, Suetsugu S, Stein M: Acute changes in lung tnechanics following pulmonary emboli of various gases in dogs. J Appl Physiol 1972;33:774-7. 14. Michenfelder .JD, Martin J’I‘, Alterburg BM, RehdelK: Air ernbolism during neurosurgery. An evaluation of right-atria1 catheters for diagnosis and treatment. ,/A&f/i 1969;208: 13X-8. 1.5. Gottlieb ,JD, Erickson JA, Sweet KH: Venous air enholism: a review. An&h Analg 1965;44:773-9. 16. (ilrnski ,JA. Cut-chiara RF, Michenfelder ,JD: ‘1‘1~an>esophageal echocardiography and transcutaneous 0. and COi monitoring for detection of venous air embolism. nl~atlh~siolo93’ 1986;64:542-5. 17. Wadhwa RK, McKenzie R, Wadhwa SK, Katz DL, Byers J I;: Gas embolism during laparoscopy. Anc~.s/horolo~q 1078:48:74-6.
