Successful resuscitation after suspected carbon dioxide embolism during laparoscopic ureteric reconstructive surgery
A 35-years-old female, weighing 42 kg was posted for transperitoneal laparoscopic Boari's ureteric reimplantation. She had undergone. cesarean section 6 months back. Her, physical examination and routine investigations were unremarkable.\nWith routine monitoring, balanced general anesthesia was given. Patient was positioned supine with 20° trendelenberg tilt. CO2 Pneumoperitoneum was created uneventfully using open insufflation technique and sustained with pressure of 14 mm Hg. Patient was hemodynamically stable. After 2 h, when the surgeon was dissecting the ureters, there was a sudden drop in ETCO2 (8 mm Hg), tachycardia (130/min) followed by multiple ventricular premature beats (VPBs) with blood pressure (BP) 110/72 mm of Hg and SaO2-98%. Surgical bleeding and endotracheal tube blockage were ruled out, and gas embolism was suspected. No drug was being administered intravenously. Infusion tubing was patent. Pneumoperitoneum was terminated immediately and the patient was placed in 45° trendelenberg position. Injection lignocaine 80 mg intravenously was given for VPBs, and the regular rhythm was restored with the heart rate of 42/min. Injection atropine 0.6 mg intravenously was given. At this point, the SaO2 decreased from 98% to 77% while the breath sounds were normal with no adventitious sounds. Also, the patient was cyanosed with non-recordable BP and heart sounds. ECG monitor suggested complete heart block with pulseless electrical activity. One liter of crystalloid was infused. We could not appreciate a “mill wheel” murmur on auscultation. Patient was manually ventilated with 100% O2. Injection atropine, totally 1.8 mg intravenously was given. Cardiopulmonary resusicitation was commenced and injection adrenaline 1 mg intravenously was given. Since there was no response to these measures, injection dopamine 20 ug/kg/min and nor-adrenaline 0.36 ug/kg/min were infused. Multiorifice central venous catheter with its tip at the superior vena cava -right atrium (SVC-RA) junction was inserted via right internal jugular vein but air could not be aspirated. The central venous pressure (CVP) was 15 mm of Hg. After 20 min, resuscitative efforts were successful, patient had pulse rate of 120/min, BP 100/54 mm/Hg, SaO2 100%, ETCO2 30 mm/Hg and ECG showed sinus rhythm with right ventricular strain pattern.At this time the CVP was found to be 10 mm of Hg. ABG analysis was normal. Surgery was abandoned. After ½ h, adrenaline was stopped. Two-dimension echocardiography (2-D Echo) showed no patent ductus arteriosus or any other congenital defects. She was shifted to intensive care unit with dopamine 5 ug/kg/min. which was tapered and stopped after ½ h. The patient did not receive hyperbaric oxygen as we did not have the facility. She regained consciousness after 2 h without neurological deficit and was extubated.