CO2 embolism during laparoscopic liver resection55-year-old man, 88 kg, for laparoscopic resection of a single colorectal liver metastasis

The patient

The examiner asks

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1. Consider

   What are your concerns for his resection?

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   • A 55-year-old with a liver metastasis, for laparoscopic resection with a low CVP requested. Patient
   • Low CVP cuts bleeding but invites gas into open hepatic veins; I'll agree a compromise. Surgery
   • Gas under pressure plus cut liver veins makes CO2 embolism a real risk here.
   • Arterial line, central line, and TEE in the room if possible.
   • No nitrous oxide: it would enlarge any gas bubble.

2. Crisis

   During transection, ETCO2 drops abruptly from 37 to 17 mmHg; BP 72/40, HR 128, SpO2 88%. Talk me through it.

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   • Sudden ETCO2 fall with low pressure and saturation during transection: gas embolism until proven otherwise. (Crisis)
   • Quick check of other causes: disconnection, a blocked tube, or bleeding.
   • Surgeon stops insufflation and releases the pneumoperitoneum; the field is flooded with saline.
   • FiO2 1.0 and a higher minute ventilation to wash out the CO2.
   • Trendelenburg, tilted with his left side down, so gas stays away from his RV outflow.
   • Aspirate the central line to draw gas from his right heart.
   • Fluid fast, phenylephrine 50–100 mcg boluses, and noradrenaline if it persists.

3. Crisis

   A mill-wheel murmur appears, then no pulse can be felt, though the ECG shows an organised rhythm. Next?

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   • Adult arrest algorithm, non-shockable branch: PEA from a gas lock in his right heart. (Crisis)
   • Turn him supine and level for compressions; CPR can't be done well on his side.
   • Gas embolism changes nothing about standard CPR; full compressions now.
   • Adrenaline 1 mg IV without delay, repeated each 3–5 minutes.
   • Keep aspirating his central line during CPR.
   • TEE shows gas in his right heart and guides the resuscitation.

4. Plan

   He has ROSC. What next?

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   • The surgeon and I decide whether to stop or convert to open. (After surgery)
   • ICU on 100% oxygen; I check his neurology for gas crossing to the arteries.
   • Any neurological signs: hyperbaric oxygen is reasonable for gas embolism.
   • Next time, a less aggressive low CVP for his liver surgery.
   • Debrief on the low-CVP transection, report it, and explain the embolism to him and his family.