Successful management of a large air embolus during an extended right hepatectomy with an emergency cardiopulmonary bypass

Decompression illness: a comprehensive overview

Decompression illness is a collective term for two maladies (decompression sickness [DCS] and arterial gas embolism [AGE]) that may arise during or after surfacing from compressed gas diving. Bubbles are the presumed primary vector of injury in both disorders, but the respective sources of bubbles are distinct. In DCS bubbles form primarily from inert gas that becomes dissolved in tissues over the course of a compressed gas dive. During and after ascent ('decompression'), if the pressure of this dissolved gas exceeds ambient pressure small bubbles may form in the extravascular space or in tissue blood vessels, thereafter passing into the venous circulation. In AGE, if compressed gas is trapped in the lungs during ascent, pulmonary barotrauma may introduce bubbles directly into the pulmonary veins and thence to the systemic arterial circulation. In both settings, bubbles may provoke ischaemic, inflammatory, and mechanical injury to tissues and their associated microcirculation. While AGE typically presents with stroke-like manifestations referrable to cerebral involvement, DCS can affect many organs including the brain, spinal cord, inner ear, musculoskeletal tissue, cardiopulmonary system and skin, and potential symptoms are protean in both nature and severity. This comprehensive overview addresses the pathophysiology, manifestations, prevention and treatment of both disorders.

Paradoxical carbon dioxide embolism during laparoscopic surgery without intracardiac right-to-left shunt: two case reports and a brief review of the literature

We herein report two cases of paradoxical carbon dioxide (CO₂) embolism during laparoscopic nephrectomy and hepatic left lateral lobectomy without evidence of a right-to-left shunt or obvious rupture of blood vessels. Transesophageal echocardiography detected paradoxical CO₂ embolism before the end-tidal CO₂ partial pressure (P_ETCO₂) dropped from baseline. The pneumoperitoneum was reduced or stopped immediately after detection of the embolism. One patient developed a postoperative epileptiform seizure. In the other patient, many gas bubbles were drawn out from the central venous line. We speculate that rapid introduction of pneumoperitoneum pushed a large amount of CO₂ into the abdominal blood vessels, exceeding the gas exchange capacity of the lung and causing CO₂ bubble formation in the left-side cardiac system. These two cases indicate that intraoperative transesophageal echocardiography can reduce the influence of CO₂ embolism during laparoscopic tumor surgery by early diagnosis of the embolism and provide helpful information to establish a list of differential diagnoses of postoperative complications.

Cerebral infarction detected after laparoscopic partial hepatectomy: case report

Background

Bleeding and carbon dioxide (CO₂) gas embolism have been reported as serious complications associated with laparoscopic surgery. We present a case of cerebral infarction presumably caused by CO₂ gas embolism during laparoscopic hepatectomy.

Case presentation

During liver resection, the end-tidal CO₂ suddenly dropped from 40 to 21 mmHg. Simultaneously, ST elevation in lead II and ST depression in lead V5 of the electrocardiogram were observed. After improvement of these electrocardiographic changes, surgery was continued. Postoperatively, incomplete paralysis was present in the right arm and leg. Magnetic resonance imaging revealed cerebral infarction in the broad area of the left cerebral cortex. These complications might have been caused by paradoxical embolism.

Conclusion

We should always keep in mind the risk of cerebral infarction with neurological deficits in the case of laparoscopic surgery. Careful monitoring and appropriate treatment for gas embolism are necessary during laparoscopic surgery.

Cerebral Infarction by Paradoxical Gas Embolism During Laparoscopic Liver Resection with Injury of the Hepatic Vessels in a Patient without a Right-to-Left Systemic Shunt

Patient: Male, 60

Final Diagnosis: Hepatocellular carcinoma

Symptoms: None

Medication: —

Clinical Procedure: Hepatectomy

Specialty: Surgery

Recognising air embolism as a complication of vascular access

The insertion and maintenance of advanced vascular access devices is increasingly becoming the remit of advanced nurses. Understanding the potential for air embolism as a complication of this procedure, recognising and managing the signs and symptoms, and being able to apply preventative measures, are imperative to enhance patient safety. A range of outcomes can present from air embolism depending on the rate and volume of air entrained, from sub-clinical to death, so the application of expert knowledge and vigilance is essential to minimise risk. According the the available literature, supplemental oxygen administration appears to be the most effective treatment.