Learning objectives

To describe a case of gas embolism and iatrogenic aortic injury during elective hernia repair and emphasize the importance of continuous capnography intraoperatively 

Case Description

A 77-year-old male with a history of COPD (active smoker), idiopathic pulmonary fibrosis, coronary artery disease, asthma, heavy alcohol use, multiple prior CVAs, and recurrent vertebral fractures presented for elective robotic inguinal hernia repair. He was classified as ASA Physical Status III. The plan included IV induction of general anesthesia with endotracheal intubation.

Approximately 30 minutes after induction, the patient developed a sudden drop in end-tidal CO₂, hypotension, hypoxia, and ST-segment changes on telemetry. Point-of-care ultrasound revealed multiple air bubbles in the cardiac chambers, raising concern for venous air embolism. Emergent surgical exploration revealed approximately one liter of intra-abdominal blood.

He underwent two rounds of CPR, receiving high-dose epinephrine, four units of packed red blood cells, and one unit of fresh frozen plasma. With resuscitation and vasopressor support, ST changes improved, and the patient was stabilized for transfer to the main campus for definitive surgical management.

 Discussion

 The widespread adoption of minimally invasive laparoscopic and robotic techniques in surgery offers substantial advantages such as smaller incisions, shorter hospital stays, and faster recovery. However, alongside benefits, potential complications like conversion to open surgery, organ/vascular damage, and rare but life-threatening cardiopulmonary complications. 

Intraperitoneal CO2 insufflation, essential for creating pneumoperitoneum in minimally invasive surgery, is associated with several respiratory complications such as subcutaneous emphysema, pneumothorax, endobronchial intubation, or gas embolism. ^[1] The case presented illustrates how gas embolism can lead to cardiovascular collapse, often resulting from the direct entry of gas into a vessel or through insufflation into a damaged abdominal organ. Rapid gas entrainment, as observed, can create large emboli that obstruct central vessels, leading to obstruction of the right cardiac chamber and pulmonary artery with subsequent ventilation/perfusion mismatch. 

Early detection of gas embolism is paramount, and capnography serves as a sensitive indicator, with a drop in end-tidal CO2 (ETCO2) correlating to the volume of gas entrained. ^[2] This emphasizes the critical role of continuous ETCO2 monitoring, particularly in at-risk patients or during procedures with potential for vascular injury. The presented case underscores the necessity of prompt recognition and collaborative management between surgical and anesthesia teams to improve outcomes in such critical situations.

 

References

1. Bao, M., Cai, W., Zhu, S., & Kang, X. (2021). Carbon dioxide embolism with severe hypotension as an initial symptom during laparoscopy: a case report. Journal of International Medical Research, 49(4). https://doi.org/10.1177/03000605211004765
2. Kalenda Z. (1975). Capnography: a sensitive method of early detection of air embolism. Acta anaesthesiolgica Belgica, 23 Suppl, 78–85.
3. Park EY, Kwon JY, Kim KJ. Carbon dioxide embolism during laparoscopic surgery. Yonsei Med J. 2012 May;53(3):459-66. doi: 10.3349/ymj.2012.53.3.459. PMID: 22476987; PMCID: PMC3343430.