An abrupt decrease in arterial blood pressure may predict a high level carbon dioxide embolism in retroperitoneoscopic surgery: case report and a literature review

BACKGROUND: Carbon dioxide (CO(2)) embolism is the primary suspect in most cases of intraoperative “cardiovascular” collapse. However, there are few reports about CO(2) embolism in retroperitoneal laparoscopy. CASE PRESENTATION: An abrupt decrease in arterial blood pressure was noted in time of retroperitoneoscopic adrenalectomy in a 40 years old male patient with adrenal adenoma. The end-tidal carbon dioxide (EtCO(2)) and saturation of oxygen were stable with normal cardiography until anesthesiologists found the change of resistant of peripheral circulation, then they gave us a hint of hemorrhage. However, the blood pressure had no reaction to one bolus of epinephrine administration when trying to improve the circulation. Five minutes later, a sudden fall of blood pressure was noted, and then we stopped the processing of cutting tissue and trying to coagulate any bleeding in the operation field. Further vasopressor support proved to be completely ineffective. With the help of transesophageal echocardiography, we found the bubbles in the right atrium, which confirmed the diagnosis of an intraoperative gas embolism (Grade IV). We stopped the carbon dioxide insufflation and deflated the retroperitoneal cavity. All the bubbles in the right atrium totally disappeared and the blood pressure, resistance of peripheral circulation and cardiac output returned to normal 20 min later. We continued the operation and completed it in 40 min with the 10 mmHg air pressure. CONCLUSION: CO(2) embolism may occour during retroperitoneoscopic adrenalectomy, and an acute decrease in arterial blood pressure should alert both the urologists and anesthesiologists to this rare and fatal complication.