Transesophageal Echocardiographic Detection of Gas Embolism and Cardiac Valvular Dysfunction During Laparoscopic Nephrectomy

Stroke Secondary to Air Embolism Following Laparoscopic Nissen Fundoplication

An air embolism is characterized by the entry of gas bubbles into the circulatory system, which can lead to the possible occlusion of blood vessels, posing a potentially life-threatening risk. While commonly associated with lung trauma or decompression sickness, it can also result from medical procedures such as central venous catheter insertion or, in our case, gas insufflation for laparoscopic surgery. We present the case of a 65-year-old female who suffered from a stroke secondary to an air embolism after undergoing a laparoscopic Nissen fundoplication in which carbon dioxide insufflation of the abdominal cavity was utilized. We also will discuss the elusive etiology of this complication as well as diagnosis, treatment, and proposed preventative measures.  A 65-year-old female with gastroesophageal reflux disease and a hiatal hernia elected to undergo a laparoscopic Nissen fundoplication for hernia repair. After a successful surgery, the patient was found with significant neurological deficits, including left-sided hemiplegia, numbness in the left hand, hemianopsia, dysarthria, and a National Institutes of Health Stroke Scale score of 20. CT head imaging revealed several low-density foci in the right frontal lobe, while CT neck and chest imaging revealed subcutaneous emphysema and pneumomediastinum. Subsequent labs were significant for an elevated lactate at 7.6 mmol/L. MRI of the brain depicted evidence of an acute infarct in the right frontal lobe with diffusion-weighted imaging (DWI) sequences. The imaging results were correlated with the patient's clinical presentation to establish the diagnosis of a nondominant hemisphere stroke, localized to an anterior branch of the right middle cerebral artery (MCA). After intubation and supportive treatment for three days, the patient was extubated and able to follow commands but had left facial weakness and diminished strength in the left upper and lower extremities. At the two-month follow-up visit, the patient no longer had any focal neurological deficits. Air emboli, though very rare, can occur as a complication in laparoscopic surgeries that utilize CO2 for body cavity insufflation. Patients may be asymptomatic with small, self-limiting emboli, while others may exhibit pulmonary symptoms, cardiac arrest, or focal neurologic changes, depending on the emoji's size and location. Given the wide range of patient presentations, the elevated mortality of laparoscopic procedures complicated by air emboli, and the rare occurrence of focal neurological symptoms as depicted in this case, rapid diagnosis and close postoperative observation and treatment are vital for both short-term and long-term patient outcomes.

Rates of Air Embolism in Pediatric Patients Undergoing Surgical Procedures of the Peritoneum

Background: Air embolism during laparoscopic surgery is a rare but feared complication in the pediatric population. The objective of this study was to identify rates of air embolus in pediatric patients during hospitalization for laparoscopic or open surgical procedures of the peritoneal cavity. Materials and Methods: Patients 0-18 years old within the Pediatric Health Information System who underwent a predefined, common inpatient laparoscopic or open surgical procedure involving the peritoneal cavity from 2015 to 2020 were studied. International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for air embolism were then searched among patients during the same admission. Firth logistic regression was used to compare rates of air embolism in open and laparoscopic cohorts and in patients >1 and ≤1 year. Results: Unadjusted rates of air embolism were higher in patients undergoing open compared with laparoscopic surgery (open: 9/45,080; 20.0/100,000 patients versus laparoscopic: 3/101,892; 2.9/100,000 patients). In patients ≤1 year (45,726), 2 patients undergoing open surgery (2/1,031; 9.5/100,000 patients) and all 3 patients undergoing laparoscopic surgery had an air embolism diagnosis (3/22,329; 13.4/100,000 patients). For laparoscopic surgery, a suggested lower relative risk (RR) of air embolism was demonstrated for children >1 year compared with children ≤1 year (RR: 0.05, P = .05). Conclusion: Air embolism associated with common pediatric surgical procedures of the peritoneum is rare and patients undergoing laparoscopic and open surgery have similar risks for air embolism. Although rare, the risk should be considered during surgical planning and abdominal access, especially in children ≤1 year old.

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.

Carbon dioxide gas endoscopy of the deep gluteal space

The treatment of hip and pelvic pain associated with abnormalities of the deep gluteal space has evolved and increasingly involves endoscopic techniques with a saline expansion medium. This investigation presents a surgical technique utilizing carbon dioxide as the insufflation medium for deep gluteal space endoscopy in 17 cadaveric hips. This technique was successful in 94% (16/17) of the hips, allowing for visualization of the sciatic nerve, posterior femoral cutaneous nerve, pudendal nerve, branch of the inferior gluteal artery crossing the sciatic nerve, piriformis muscle, hamstring tendon origin, and lesser trochanter. Our experience suggests that gas expansion presents several advantages over fluid expansion.

Carbon Dioxide Embolism Associated With Transanal Total Mesorectal Excision Surgery: A Report From the International Registries

BACKGROUND

Carbon dioxide embolus has been reported as a rare but clinically important risk associated with transanal total mesorectal excision surgery. To date, there exists limited data describing the incidence, risk factors, and management of carbon dioxide embolus in transanal total mesorectal excision.

OBJECTIVE

This study aimed to obtain data from the transanal total mesorectal excision registries to identify trends and potential risk factors for carbon dioxide embolus specific to this surgical technique.

DESIGN

Contributors to both the LOREC and OSTRiCh transanal total mesorectal excision registries were invited to report their incidence of carbon dioxide embolus. Case report forms were collected detailing the patient-specific and technical factors of each event.

SETTINGS

The study was conducted at the collaborating centers from the international transanal total mesorectal excision registries.

MAIN OUTCOME MEASURES

Characteristics and outcomes of patients with carbon dioxide embolus associated with transanal mesorectal excision were measured.

RESULTS

Twenty-five cases were reported. The incidence of carbon dioxide embolus during transanal total mesorectal excision is estimated to be ≈0.4% (25/6375 cases). A fall in end tidal carbon dioxide was noted as the initial feature in 22 cases, with 13 (52%) developing signs of hemodynamic compromise. All of the events occurred in the transanal component of dissection, with mean (range) insufflation pressures of 15 mm Hg (12-20 mm Hg). Patients were predominantly (68%) in a Trendelenburg position, between 30° and 45°. Venous bleeding was reported in 20 cases at the time of carbon dioxide embolus, with periprostatic veins documented as the most common site (40%). After carbon dioxide embolus, 84% of cases were completed after hemodynamic stabilization. Two patients required cardiopulmonary resuscitation because of cardiovascular collapse. There were no deaths.

LIMITATIONS

This is a retrospective study surveying reported outcomes by surgeons and anesthetists.

CONCLUSIONS

Surgeons undertaking transanal total mesorectal excision must be aware of the possibility of carbon dioxide embolus and its potential risk factors, including venous bleeding (wrong plane surgery), high insufflation pressures, and patient positioning. Prompt recognition and management can limit the clinical impact of such events. See Video Abstract at http://links.lww.com/DCR/A961.

Cardiovascular and Ventilatory Consequences of Laparoscopic Surgery

Although laparoscopic surgery accounts for >2 million surgical procedures every year, the current preoperative risk scores and guidelines do not adequately assess the risks of laparoscopy. In general, laparoscopic procedures have a lower risk of morbidity and mortality compared with operations requiring a midline laparotomy. During laparoscopic surgery, carbon dioxide insufflation may produce significant hemodynamic and ventilatory consequences such as increased intraabdominal pressure and hypercarbia. Hemodynamic insults secondary to increased intraabdominal pressure include increased afterload and preload and decreased cardiac output, whereas ventilatory consequences include increased airway pressures, hypercarbia, and decreased pulmonary compliance. Hemodynamic effects are accentuated in patients with cardiovascular disease such as congestive heart failure, ischemic heart disease, valvular heart disease, pulmonary hypertension, and congenital heart disease. Prevention of cardiovascular complications may be accomplished through a sound understanding of the hemodynamic and physiological consequences of laparoscopic surgery as well as a defined operative plan generated by a multidisciplinary team involving the preoperative consultant, anesthesiologist, and surgeon.

[Perioperative transesophageal echocardiography in non-cardiac surgery. Update]

AIM

The aim of this article is to impart knowledge concerning focused transesophageal echocardiographic examination (TEE) for non-cardiac surgery which is an essential part of perioperative monitoring. It allows a rapid echocardiographic examination without interference with the surgical field or under limited transthoracic examination conditions. New recommendations for a comprehensive perioperative TEE examination with expanded standard views and the recently published consensus statement for a shortened baseline examination were crucial for this study.

MATERIAL AND METHODS

The background is the peer-reviewed literature from PubMed.

RESULTS

Apart from cardiac surgery TEE has two main applications: firstly, the evaluation of patients developing acute life-threatening hemodynamic instability in the operating room, in the emergency room or in the intensive care unit (ICU). Secondly, TEE is used as planned intraoperative monitoring when severe hemodynamic, pulmonary or neurological complications are expected because of the type of surgery or due to the cardiopulmonary medical history of the patient. In 2013 a total of 11 relevant standard views were defined for the basic perioperative TEE examination in non-cardiac surgery. These 11 views should be performed for each patient. Appropriate extension to a comprehensive examination may be necessary if complex pathology is obvious.

DISCUSSION

Even in non-cardiac surgery TEE is an important tool allowing clarification of a life-threatening perioperative hemodynamic instability within a few minutes. Furthermore, the hemodynamic management of high-risk patients can be facilitated. Appropriate qualification and continuous training are necessary in order to assure the competence of the examiner.

Carbon dioxide embolism during laparoscopic surgery

Clinically significant carbon dioxide embolism is a rare but potentially fatal complication of anesthesia administered during laparoscopic surgery. Its most common cause is inadvertent injection of carbon dioxide into a large vein, artery or solid organ. This error usually occurs during or shortly after insufflation of carbon dioxide into the body cavity, but may result from direct intravascular insufflation of carbon dioxide during surgery. Clinical presentation of carbon dioxide embolism ranges from asymptomatic to neurologic injury, cardiovascular collapse or even death, which is dependent on the rate and volume of carbon dioxide entrapment and the patient's condition. We reviewed extensive literature regarding carbon dioxide embolism in detail and set out to describe the complication from background to treatment. We hope that the present work will improve our understanding of carbon dioxide embolism during laparoscopic surgery.

Venous air embolism and intracardiac thrombus after pressurized fibrin glue during liver surgery

After segmental liver resection, a fibrin glue aerosol was used to stop diffuse bleeding from the liver resection site. Immediately after pressurized administration, severe hypotension and bradycardia occurred, requiring cardiopulmonary resuscitation and inotropic support. Transoesophageal echocardiography demonstrated air in both ventricles deriving from the inferior vena cava; contractility of both ventricles was markedly reduced. In addition, a 3 cm floating thrombus was detected in the right ventricle. This case demonstrates that sprayed fibrin glue can cause life-threatening air embolism and intracardiac thrombus formation in liver surgery.

The effect of CO2 pneumovesicum on upper urinary tract

OBJECTIVE

Pneumovesicum allows minimal invasive intravesical surgeries. The possible deleterious effect of intravesical CO(2) pressure is not known. We assessed the effect of CO(2) pneumovesicum on the urinary tract and renal function.

METHODS

Pneumovesicum was established and maintained with CO(2) at 10 mm Hg in 10 sows. Cohen cross-trigonal reimplantation was carried out on the left ureter by a vesicoscopic approach. The right ureter was cannulated and served as control. CO(2) pneumovesicum was maintained for 2 hours. Color Doppler measurements of the upper urinary tract and blood sampling were carried out 30 minutes before and 2 hours after establishing pneumovesicum, and 30 minutes after releasing the pneumovesicum.

RESULTS

Compared with the preoperative values, the bilateral anteroposterior diameters of the renal pelves increased significantly after 2 hours of the pneumovesicum (P < .05). Thirty minutes after release of the pneumovesicum, the anteroposterior diameters decreased and showed no statistically significant difference compared with the preoperative values. No air embolus was detected in the ureters, renal pelves, renal veins, or renal arteries on either side 2 hours after establishing the pneumovesicum. There was no statistically significant change in arterial or venous blood flow. There was no significant change in the urea and creatinine levels 2 hours after establishing the pneumovesicum.

CONCLUSION

CO(2) pneumovesicum at a pressure of 10 mm Hg for 2 hours did not result in any demonstrable deleterious effect.

Detection of subclinical CO2 embolism by transesophageal echocardiography during laparoscopic radical prostatectomy

OBJECTIVES

To document incidences of subclinical embolism in laparoscopic radical prostatectomy with continuous monitoring using transesophageal echocardiography (TEE).

METHODS

A total of 43 patients scheduled for elective robotic-assisted laparoscopic radical prostatectomy under general anesthesia were enrolled in this study. A 4-chamber view of 5.0-MHz multiplane TEE was continuously monitored to detect any intracardiac bubbles as an embolism. An independent TEE specialist reviewed the tapes for interpretation, and emboli were classified as 1 of 5 stages. Cardiorespiratory instability during gas emboli entry was defined as an appearance of cardiac arrhythmias, sudden decrease in mean arterial blood pressure >20 mm Hg, or an episode of pulse oximetric saturation <90%.

RESULTS

Gas embolisms were observed in 7 of 41 (17.1%) patients during transection of the deep dorsal venous complex. Of them, 1, 3, 1, and 2 showed stage I, II, III, and IV, respectively. However, there were no signs of cardiorespiratory instability associated with emboli. The 95% confidence interval for gas embolism was 0.204%-0.138%. No correlation was observed between episodes of gas embolism and blood gas variables or end-tidal CO(2) partial pressure.

CONCLUSIONS

Subclinical gas embolisms occur in 17.1% of laparoscopic radical prostatectomies. We should consider that this procedure has a potential for serious gas embolism, especially with the increasing popularity of laparoscopic prostatectomy using robot-assisted techniques.

Laparoscopic surgery: pitfalls due to anesthesia, positioning, and pneumoperitoneum

BACKGROUND

Laparoscopic procedures are increasing in number and extensiveness. Many patients undergoing laparoscopic surgery have coexisting disease. Especially in patients with cardiopulmonary comorbidity, pneumoperitoneum and positioning can be deleterious. This article reviews possible pitfalls related to the combination of anesthesia, positioning of the patient, and the influence of pneumoperitoneum in the course of laparoscopic interventions.

METHODS

A literature search using Medline's MESH terms was used to identify recent key articles. Cross-references from these articles were used as well.

RESULTS

Patient positioning and pneumoperitoneum can induce hemodynamic, pulmonary, renal, splanchnic, and endocrine pathophysiological changes, which will affect the entire perioperative period of patients undergoing laparoscopic procedures.

CONCLUSION

Perioperative management for the estimation and reduction of risk of morbidity and mortality due to surgery and anesthesia in laparoscopic procedures must be based on knowledge of the pathophysiological disturbances induced by the combination of general anesthesia, pneumoperitoneum, and positioning of the patient.

Unexpected surgical difficulties leading to hemorrhage and gas embolus during laparoscopic donor nephrectomy: a case report

PURPOSE

To report the case of a laparoscopic donor nephrectomy in which the preoperative evaluation of the patient gave no indication of the surgical difficulties that were encountered intraoperatively, resulting in substantial bleeding, a suspected gas embolism, and emergency conversion of the procedure from laparoscopic to open donor nephrectomy.

CLINICAL FEATURES

A 59-yr-old man - height: 175 cm, weight: 85.5 kg, American Society of Anesthesiologists physical status I - presented as kidney donor for laparoscopic donor nephrectomy. He was healthy, on no medication, and had no previous abdominal surgery or diseases of the urinary tract. The preoperative computed tomography (CT) scan evaluation of his kidneys confirmed this by reporting a normal bilateral renal and renal vascular anatomy. In contradiction to the preoperative CT scan findings, the surgeon discovered abnormalities in the operative field. This included extensive scarring surrounding the left kidney, adenopathy near the right hilum, and a large branch lumbar vein entering the renal vein. The large branch lumbar vein was clipped but the clips dislodged, causing significant blood loss, and a suspected gas embolus. The procedure was converted to an emergency open donor nephrectomy. Postoperatively the patient made a full recovery.

CONCLUSION

Laparoscopic donor nephrectomies, though usually performed on healthy individuals, have their pitfalls, and complications during this procedure can be sudden and serious. As shown in this case, although CT scan results are regarded as reliable, they can be misleading. As an anesthetic precaution for possible gas emboli during laparoscopic procedures, nitrous oxide should be avoided and the patient be ventilated with 100% oxygen.

Survey of observer variation in transesophageal echocardiography: comparison of anesthesiology and cardiology literature

OBJECTIVE

Transesophageal echocardiographic examination tends to be somewhat observer and experience dependent, and observer bias can arise easily when data are calculated and interpreted by unskilled, nonblinded, or single observers. The study plan was to see whether authors have adequately described how observer bias is minimized in their studies. Thus, a study was conducted systematically reviewing methods reported in transesophageal echocardio graphy articles in peer-reviewed anesthesiology journals versus those reported in peer-reviewed cardiology journals.

INTERVENTIONS

After MEDLINE searches of the literature published from 1997 through 1999, the authors investigated 56 anesthesiology reports and 56 randomly selected, year-matched cardiology reports. An 8-item questionnaire was developed that examined several factors: the number of observers and their experience levels, whether observers were blind to clinical data, whether low-quality images were excluded, the use of on-line or off-line analysis, and observer variability.

MAIN RESULTS

The analysis revealed inadequacies in reporting of important information that relates to bias and quality in 91.1% of anesthesiology and 98.2% of cardiology articles. Observer variability was not reported in 50.0% of the anesthesiology reports and 67.9% of the cardiology reports; however, difference between the 2 bodies of literature was not significant. The journal impact factor was significantly higher for the cardiology literature than for the anesthesiology literature (2.42 [0.386-10.893] v 1.07 [0.664-3.439]; median [range], p < 0.001).

CONCLUSION

Articles reviewed had at least some inadequacies in reporting the methods to minimize observer bias in both the anesthesiology and cardiology literature. Reporting methodology standards in TEE examinations remain to be established.

[Gas embolism during radical nephrectomy by retroperitoneal laparoscopy]

A case of CO2 gas embolism occurring during retroperitoneal laparoscopic right radical nephrectomy in a 70-year-old-woman is reported. Patient's outcome was excellent after venous clamping, fluid loading and application of a positive and expiratory pressure. Gas embolism is a well documented complication of laparoscopic surgery, but has been rarely described in retroperitoneal laparoscopy for urologic procedure. The retroperitoneal surgical site, the major surgical procedure with vessel manipulation and the left lateral position seem to be the risk factors for gas embolism in this case.

The safety and efficacy of laparoscopic live donor nephrectomy: a systematic review

BACKGROUND

The aim of this systematic review was to compare the safety and efficacy of laparoscopic live donor nephrectomy with the "gold" standard of open live donor nephrectomy.

METHODS

SEARCH STRATEGY

Three search strategies were devised to enable literature retrieval from the Medline, Current Contents, Embase, and Cochrane Library databases up until, and including, February 2000.

STUDY SELECTION

Inclusion of a report was determined on the basis of a predetermined protocol, independent assessment by two reviewers, and a final consensus decision. English language reports were selected and acceptable study designs included randomized-controlled trials, controlled clinical trials, case series, or case reports. Each report was required to provide information on at least one of several safety and efficacy outcomes as detailed in the protocol.

DATA COLLECTION AND ANALYSIS

Twenty-five reports met the inclusion criteria. They were tabulated and critically appraised in terms of the methodology and design, sample size, outcomes, and the possible influence of bias, confounding, and chance.

RESULTS

High level evidence comparing the safety and efficacy of laparoscopic live donor nephrectomy with open donor nephrectomy was not available at the time of this review. Limited low level evidence suggested that the laparoscopic approach might be advantageous regarding the donor's hospital stay, convalescence, pain, and resumption of employment.

CONCLUSIONS

The ASERNIP-S Review Group concluded that the evidence-base for laparoscopic live donor nephrectomy was inadequate to make a safety and efficacy recommendation. Clinical and research recommendations were developed regarding the introduction and current practice of this procedure in Australia.

Anesthesia for radical prostatectomy, cystectomy, nephrectomy, pheochromocytoma, and laparoscopic procedures

This article presents some of the more salient aspects of the anesthetic management of the common major renal surgical procedures and discusses the physiology and anesthetic implications of minimally invasive laparoscopic urologic surgery.