Anesth Pain Med.  2022 Oct;17(4):397-403. 10.17085/apm.22170.

Detection of paradoxical carbon dioxide gas embolism with opening of patent foramen ovale by perioperative transesophageal echocardiography during laparoscopic hepatectomy - A case report -

• Kim H
• Lee J
• Lee SG
• Shim KS

• KMID: 2535338
• DOI: http://doi.org/10.17085/apm.22170

Abstract

Background
Due to its various advantages, laparoscopic surgery is preferred over laparotomy in patients who require hepatic resection. Carbon dioxide embolism —which occurs approximately ten times more often in laparoscopic hepatectomy than in general laparoscopic surgery—presents with insignificant symptoms and may be overlooked. Case: A 70-year-old male with hepatic cell carcinoma underwent laparoscopic hepatectomy. Though his vital signs were stable during the initiation of surgery, they became unstable during the procedure. The surgeon detected portal vein rupture, and transesophageal echocardiography was subsequently performed. A large amount of gas in the heart chamber and paradoxical embolism through a patent foramen ovale due to a right-to-left shunt were observed. We treated the symptoms, and the surgery was completed without any further issues.
Conclusions
Active use of transesophageal echocardiography to identify and monitor heart functions during a suspected carbon dioxide embolism can significantly reduce morbidity and mortality associated with that embolism.

Keyword

Gas embolism; Hepatectomy; Laparoscopy; Paradoxical embolism; Patent foramen ovale; Transesophageal echocardiography

Figure

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  Fig. 1. Mid-esophageal bicaval view of the transesophageal echocardiogram. (A) The septum between the right and left atria is observed to be closed, and (B) the septum between the right and left atria is observed to be open. LA: left atrium, IVC: inferior vena cava, SVC: superior vena cava, RA: right atrium.

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  Fig. 2. Mid-esophageal aortic valve short-axis view of the transesophageal echocardiogram with color Doppler shows blood flow (right-to-left shunt) between the right and left atrial septa. LA: left atrium, AV: aortic valve, RA: right atrium, RVOT: right ventricular outflow tract.

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  Fig. 3. Mid-esophageal four-chamber view of the transesophageal echocardiogram. (A) During the left ventricle systolic period, the mitral valve is closed, and air bubbles are observed in the left atrium. (B) During the left ventricle diastolic period, the mitral valve is opened, and a large number of air bubbles are observed in the left ventricle. LA: left atrium, RA: right atrium, MV: mitral valve, RV: right ventricle, LV: left ventricle.

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  Fig. 4. Mid-esophageal long axis view of the transesophageal echocardiogram shows the gas in the left ventricle passing through the aorta. LA: left atrium, AV: aortic valve, LV: left ventricle.

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  Fig. 5. Timeline of the occurrence of CO2 embolism. MAP: mean arterial pressure, EtCO2: end-tidal carbon dioxide, SpO2: saturation of percutaneous oxygen, STE: ST elevation, ECG: electrocardiography, FiO2: fraction of inspired oxygen, IV: intravenous, NE: norepinephrine, NTG: nitroglycerin, TEE: transesophageal echocardiography, ICU: intensive care unit. *In a post-surgery discussion with the surgeon, he informs us that there was a portal vein rupture approximately 5 min prior to the occurrence of the first symptom.

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