The Science Journal of the American Association for Respiratory Care

1996 OPEN FORUM Abstracts

HYPERCARBIA FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY - A CASE REPORT

David Mayo, RRT, Edwin Kohl, RRT, Charles Durbin, MD, University of Virginia Health Sciences Center, Charlottesville, Virginia

INTRODUCTION: Carbon dioxide is used to insuflate the peritoneal cavity to facilitate laparoscopic surgery because it does not support combustion allowing safe use of the electrocautery and because any residual pneumoperitoneum remaining at the end of the procedure is rapidly absorbed. Occasionally, massive amounts of CO_{2} are absorbed and can precipitate hypercarbic respiratory failure. We report a case of severe hypercarbia secondary to subcutaneous insuflation of CO_{2} during laparoscopic cholecystectomy (LC).

CASE REPORT: A 76 y/o female was admitted for repair of a fractured hip following a fall. Her past medical history was remarkable for coronary artery disease with previous CABG, history of CHF, and bradyarrhythmias requiring permanent cardiac pacing. After repair of her hip fracture, she developed abdominal distention secondary to gallstone pancreatitis. On resolution, prior to discharge, she was scheduled for LC. General anesthesia was induced, she was intubated and the peritoneal cavity entered with a trocar. Moderate difficulty was encountered due to a pervious lower abdominal incision. End-tidal CO_{2} (ETCO_{2}) was 38-40 torr until 2 hours into the procedure when it was noted to rise acutely to 54 torr. Despite doubling minute ventilation the ETCO_{2} remained above 50 torr, indicating continued and rapid absorption of insuflated CO_{2}. Massive subcutaneous emphysema was noted on the patient's face, neck and upper abdomen. At the end of the procedure, the patient had the following ABGs: PaO_{2}=92, pH=7. 12, PaCO_{2}=110. Mechanical ventilation was continued and over the next several hours and the hypercarbia resolved.

DISCUSSION: Believed to be benign, LC can cause significant physiological derangements. Cardiovascular effects of the pneumoperitoneum include: decreased venous return, reduced cardiac output and lower renal blood flow. Hypoxemia from dependent lung segment atelectasis and resulting shunt is common. Less frequently seen is hypercarbia from peritoneal resorption of CO_{2}. After the abdominal cavity is initially distended, continuing gas flow between 1-6 L/min maintains pressure between 10-15 torr. System leaks account for most of this continuing flow, however, at least 200-500 cc/min of CO_{2} are normally absorbed across the peritioneal surface. The massive, persistent hypercarbia seen in this case is due to the larger CO_{2} load and more rapid absorption that occurred with subcutaneous insuflation. Complications of hypercarbia including hypertension, increased cerebral blood flow, increased ICP, and cardiac arrhythmias were not seen in this patient.

Reference: OF-96-054

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