Is It the pH That Matters? Challenging the Pathophysiology of Acidemia in a Case of Severe Hypercapnia Secondary to Intraoperative CO(2) Insufflation

BACKGROUND: Acidemia has been long thought to lead to hemodynamic compromise. While some literature to date challenges this idea, there is no consensus on this topic. CASE SUMMARY: To our knowledge, this is the most severe case of hypercapnia and acidosis due to carbon dioxide (CO(2)) insufflation during laparoscopy reported in the literature. Remarkably, this patient remained hemodynamically normal despite having a blood pH below 6.81. This prompts a wider discussion about the effects of blood pH on human physiology. Most patients who present acidotic are critically ill and have confounding underlying metabolic or respiratory pathophysiology driving their illness. In this case, the patient experienced no respiratory insult leading to an increase in blood CO(2) but rather had CO(2) iatrogenically introduced into the circulatory system, effectively detaching the deleterious effects of CO(2) from the respiratory pathologies that so often cause its accumulation. CONCLUSION: This raises the question, in patients with severe acidosis and hemodynamic compromise, is acidosis a symptom of the underlying process, or is the acidosis itself causing harm?