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Gas Embolism in Laparoscopic Liver Surgery
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Laparoscopic liver surgery is complicated due to the structure of this organ with open sinusoids. A serious disadvantage is the risk of gas embolism (GE) due to CO2 pneumoperitoneum. CO2 can enter the vascular system through a wounded vein. A common opinion is that gas fluxes along a pressure gradient, e.g. CVP-intra abdominal pressure (IAP). The occurrence of GE could also be eased by entrainment, a ‘Venturi-like’ effect, due to cyclic differences in thoracic pressure and blood flow caused by mechanical ventilation at normal frequency.

The aims of these studies were to survey, in a porcine model, the influence on respiratory and haemodynamic variables by GE, to determine at what frequency, severity and duration GE occurs during laparoscopic liver resection (LLR) and whether there are methods to influence the occurrence or severity of GE.

Pulmonary and circulatory variables were monitored and measured as well as continuous blood gas monitoring. Transoesophageal echocardiogram was used to identify GE and, according to the amount of bubbles in the right outflow tract of the heart, GE was graded as 0, 1 and 2. Pneumoperitoneum was created by using CO2and IAP was set to 16 mm Hg.

A single bolus dose of CO2 influenced respiratory and haemodynamic variables for at least 4 h. During LLR GE occurred in 65-70% of the animals, of which the more serious caused negative influence on cardiopulmonary variables.

Elevated PEEP (15 cm H2O) increased CVP but GE occurred irrespective if CVP was lower than or exceeded IAP. In two last studies, a hepatic vein was cut and left open for 3 m before it was clipped. Interestingly, no signs of GE were seen despite an open vein and IAP > CVP in 8 of 20 animals. In the last study high frequency jet ventilation was used in order to minimise the risk of entrainment. The duration of GE was shortened.

The occurrence of GE seemed to be influenced by several different factors. The physiological reaction of a GE is impossible to predict for a specific patient, and depends among other factors on comorbidity, and amount, site and entrance rate of GE.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2012. , p. 49
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 758
Keyword [en]
Gas embolism, laparoscopic liver, CVP, PEEP, high frequency jet ventilation, cardiopulmonary physiology, carbon dioxide
National Category
Basic Medicine
Research subject
Anaesthesiology and Intensive Care
Identifiers
URN: urn:nbn:se:uu:diva-171797ISBN: 978-91-554-8325-8 (print)OAI: oai:DiVA.org:uu-171797DiVA, id: diva2:512807
Public defence
2012-05-11, Enghoffsalen, Akademiska Sjukhuset, Uppsala, 09:00 (English)
Opponent
Supervisors
Available from: 2012-04-20 Created: 2012-03-27 Last updated: 2018-01-12Bibliographically approved
List of papers
1. The effects of experimental venous carbon dioxide embolization on hemodynamic and respiratory variables
Open this publication in new window or tab >>The effects of experimental venous carbon dioxide embolization on hemodynamic and respiratory variables
2006 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 50, no 2, p. 156-162Article in journal (Refereed) Published
Abstract [en]

Background:  Laparoscopic liver resection is a relatively new surgical procedure. Carbon dioxide (CO2) pneumoperitoneum and laparoscopic liver dissection are recognized as risk factors for CO2 embolism to the pulmonary circulation. The embolization can be difficult to detect and can theoretically increase peri-operative morbidity. The aim of this study was to evaluate the cardiopulmonary effects in a pig model during a time period of 4 h after an experimental CO2 embolization.

Methods:  Eleven piglets were anesthesized. Nine were embolized with a single intravenous injection of 0.4 ml/kg CO2 and two served as controls. Respiratory and cardiovascular variables, including pulmonary artery pressure and cardiac output, were monitored for 4 h after embolization, and arterial blood gases were monitored on-line.

Results:  The embolized piglets had an increase in ventilatory dead space, pulmonary vascular resistance and pulmonary artery pressure and a decrease in cardiac output that lasted throughout the 4-h observation time. The mean arterial pressure and heart rate were unchanged. An early sign of embolization was a rapid fall in end-tidal CO2 and Pao2 and a rise in Paco2.

Conclusion:  Negative changes in cardiopulmonary physiology persisted for at least 4 h after a single intravenous CO2 injection, in spite of this gas being highly soluble in blood. This is a more prolonged influence of CO2 embolization than previously described. Extensive monitoring for early detection of an embolization may be recommended to limit morbidity in patients undergoing laparoscopic liver surgery.

Keyword
carbon dioxide embolism, cardiopulmonary physiology, laparoscopic liver surgery
National Category
Clinical Medicine
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-75720 (URN)10.1111/j.1399-6576.2006.00933.x (DOI)16430535 (PubMedID)
Available from: 2006-02-15 Created: 2006-02-15 Last updated: 2017-12-14Bibliographically approved
2. Gas embolism during laparoscopic liver resection in a pig model: frequency and severity
Open this publication in new window or tab >>Gas embolism during laparoscopic liver resection in a pig model: frequency and severity
2010 (English)In: British Journal of Anaesthesia, ISSN 0007-0912, E-ISSN 1471-6771, Vol. 105, no 3, p. 282-288Article in journal (Refereed) Published
Abstract [en]

Background. Laparoscopic liver surgery is evolving rapidly. Carbon dioxide embolism is a potential complication. The aim of this work was to study the frequency and severity of gas embolism (GE) during laparoscopic liver lobe resection in a pig model and the resulting cardiovascular and respiratory changes. Methods. Fifteen anaesthetized piglets underwent laparoscopic left liver lobe resection. Haemodynamic and respiratory variables were monitored, including systemic and pulmonary arterial pressures, end-tidal CO2, and pulmonary dead space. Online blood gas monitoring and a transoesophageal echocardiography (TOE) were used. GE was graded semi-quantitatively as grade 0 (none), grade 1 (minor), or grade 2 (major), depending on the TOE results. Results. In 10 of 15 piglets, GE occurred. In total, 33 separate episodes of GE were recorded. All 13 episodes of grade 2 and three of grade 1 were serious enough to cause mainly respiratory, but also haemodynamic effects. Mostly, grade 1 GE caused only minor respiratory or haemodynamic changes. Most variables were affected during grade 2 GE; the most important were Pa-O2, Pa-CO2, end-tidal CO2, Vd/Vt, and mean pulmonary arterial pressure. Conclusions. GE occurred frequently during laparoscopic liver resection in this experimental study. Approximately half of the embolisms were serious enough to cause respiratory or haemodynamic disturbances or both. Pending further human studies, a combination of several monitoring techniques, with narrow limits for the alarm settings, will ensure correct interpretation of the complex physiological response to GE and reveal it early enough to alert the anaesthetist and the surgeon to the ongoing problem.

Keyword
embolism, air, liver, surgery, laparoscopic, swine
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-134889 (URN)10.1093/bja/aeq159 (DOI)000282074300006 ()20621927 (PubMedID)
Available from: 2010-12-02 Created: 2010-12-02 Last updated: 2017-12-12Bibliographically approved
3. Elevated PEEP without effect upon gas embolism frequency or severity in experimental laparoscopic liver resection
Open this publication in new window or tab >>Elevated PEEP without effect upon gas embolism frequency or severity in experimental laparoscopic liver resection
2012 (English)In: British Journal of Anaesthesia, ISSN 0007-0912, E-ISSN 1471-6771, Vol. 109, no 2, p. 272-278Article in journal (Refereed) Published
Abstract [en]

Carbon dioxide (CO2) embolism is a potential complication in laparoscopic liver surgery. Gas embolism (GE) is thought to occur when central venous pressure (CVP) is lower than the intra-abdominal pressure (IAP). This study aimed to investigate whether an increased CVP due to induction of PEEP could influence the frequency and severity of GE during laparoscopic liver resection. Twenty anaesthetized piglets underwent laparoscopic left liver lobe resection and were randomly assigned to either 5 or 15 cm H2O PEEP (n10 per group). During resection, a standardized injury to the left hepatic vein [venous cut (VC)] was created to increase the risk of GE. Haemodynamic and respiratory variables were monitored, and online arterial blood gas monitoring and transoesophageal echocardiography (TOE) were used. The occurrence and severity of embolism was graded as 0 (none), 1 (minor), or 2 (major), depending on the TOE results. No differences were found between the two groups regarding the frequency or severity of GE, during either the VC (P0.65) or the rest of the surgery (P0.24). GE occurred irrespective of the CVPIAP gradient. Mechanisms other than the CVPIAP gradient seemed during laparoscopic liver surgery to contribute to the formation of CO2 embolism. This is of clinical importance to the anaesthetists.

Keyword
CVP gradient, gas embolism, laparoscopic, liver surgery, PEEP
National Category
Clinical Medicine
Identifiers
urn:nbn:se:uu:diva-171302 (URN)10.1093/bja/aes129 (DOI)000306363900022 ()
Available from: 2012-03-29 Created: 2012-03-16 Last updated: 2017-12-07Bibliographically approved
4. High Frequency Jet Ventilation shortened the duration of gas embolisation during experimental laparoscopic liver resection 
Open this publication in new window or tab >>High Frequency Jet Ventilation shortened the duration of gas embolisation during experimental laparoscopic liver resection 
Show others...
(English)Article in journal (Refereed) Submitted
National Category
Clinical Medicine
Identifiers
urn:nbn:se:uu:diva-171303 (URN)
Available from: 2012-04-02 Created: 2012-03-16 Last updated: 2012-08-01Bibliographically approved

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