Paradoxical carbon dioxide embolism during laparoscopic hepatectomy without intracardiac shunt: A case report

Figure 1 Case report timeline. The vital signs, administered drugs, and laboratory findings during the operation. I: Propofol (70 mg) and atracurium (25 mg) i.v., start of phenylephrine infusion; II: Hydrocortisone (100 mg) i.v.; III: End of phenylephrine infusion and start of norepinephrine infusion; IV: 1^st ABGA (pH, 7.300; PCO₂, 48.2 mmHg; PO₂, 100.7 mmHg; Hb, 13.9 g/dL; Na⁺, 140 mmol/L; K⁺, 4.3 mmol/L; lactic acid, 1.43 mmol/L); V: 2^nd ABGA (pH, 7.161; PCO₂, 70.9 mmHg; PO₂, 121.8 mmHg; Hb, 13.1 g/dL; Na⁺, 142 mmol/L; K⁺, 4.2 mmol/L; lactic acid, 2.23 mmol/L); VI: “Mill-wheel” murmur auscultated over the precordium; 3^rd ABGA (pH, 7.112; PCO₂, 78.8 mmHg; PO₂, 73.3 mmHg; Hb, 12.7 g/dL; Na⁺, 142 mmol/L; K⁺, 4.2 mmol/L; lactic acid, 2.47 mmol/L]; TEE: gas bubble scattered in right and left heart, and ascending aorta; VII: Start of transfusion of 1 unit packed red blood cells; VIII: 4^th ABGA (pH, 7.282; PCO₂, 50.5 mmHg; PO₂, 111.1 mmHg; Hb, 13.1 g/dL; Na⁺, 141 mmol/L; K⁺, 4.6 mmol/L; lactic acid, 2.31 mmol/L); TEE: CO₂ gas bubble reduced; IX: The patient was transferred to a surgical intensive care unit. IVC: Inferior vena cava, MBP: Mean blood pressure, SpO₂: Pulse oximetry, HR: Heart rate, BIS: Bispectral index, RR: Respiratory rate, TOF: Train of four, CVP: Central venous pressure, PVI: Pleth variability index, EtCO₂: End-tidal CO₂, Ce: Effect-site concentration, iv: Intravenous, ABGA: Arterial blood gas analysis, PCO₂: Arterial carbon dioxide partial pressure, PO₂: Arterial oxygen partial pressure, TEE: Transesophageal echocardiography.

Figure 2 Intraoperative transesophageal echocardiography. A: On the descending aortic short axis view, transesophageal echocardiography (TEE) shows gas bubbles in the aorta. B: On the mid-esophageal aortic valve short axis view, TEE shows gas bubbles in both the atrium and aortic valve.

Figure 3 Intraoperative transesophageal echocardiography after 30 minutes. A: On the descending aortic short axis view, gas bubbles are not seen. B: On the mid-esophageal aortic valve short axis view, gas bubbles are not seen.