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• W2080776746 abstract "Increasingly, laparoscopic surgeries are being performed to treat a number of conditions. The technical aspects of specific laparoscopic procedures can increase the risk of certain complications that, although they are of concern in conventional procedures, may be more likely or may occur with greater severity during laparoscopic procedures. We report the anesthetic course and complications that were encountered during laparoscopic parathyroidectomy, a procedure that to our knowledge, has not previously been performed. Although the surgery was successful, the patient developed signs and symptoms of sustained carbon dioxide (CO2) absorption: supraventricular tachycardia, massive subcutaneous emphysema, hypercarbia, and acidosis. Case Report A 37-yr-old, 74-kg man with primary hyperparathyroidism was admitted to undergo transcervical endoscopic parathyroidectomy. The patient had no history of cardiovascular, pulmonary, or renal disease. Intraoperative monitoring included electrocardiography, noninvasive blood pressure monitoring, and pulse oximetry. His preinduction blood pressure (BP) was 124/66 mm Hg, and the heart rate (HR) was 60 bpm. Anesthesia was induced with fentanyl and thiopental. Succinylcholine was used to facilitate endotracheal intubation. Anesthesia was maintained with a 0.7% end-tidal concentration of isoflurane and 60% nitrous oxide in oxygen; the nitrous oxide was discontinued after CO2 insufflation began. Mechanical ventilation was provided with a tidal volume of 650 mL and respiratory rate of 8 bpm (minute ventilation of 5.2 L/min), which produced a peak inspiratory pressure of 22 cm H2 O. After anesthesia induction, the BP and HR remained stable, the oxyhemoglobin saturation as measured by pulse oximetry (SPO2) was 99%, and the end-tidal CO2 was 25-30 mm Hg. A subplatysmal air pocket was then created by insufflating CO2 at an insufflation pressure of 20 mm Hg. At 10 min after CO2 insufflation began, the end-tidal CO2 pressure increased to 42 mm Hg, and the HR increased from 52 to 125 bpm without changes in BP or SPO2. The surgeon reduced the CO2 insufflation pressure to 15 mm Hg. The tidal volume was then increased to 800 mL and the ventilatory rate to 14 bpm (minute ventilation of 11.2 L/min), but a high end-tidal CO2 pressure (50 mm Hg) and tachycardia (120-125 bpm) persisted. Analysis of arterial blood gases revealed a pHa of 7.19, PaCO2 of 63 mm Hg, PaO (2) of 185 mm Hg, and HCO3 of 24 mEq/L. We increased the minute ventilation to more than 20 L/min (tidal volume 720 mL and respiratory rate 28 bpm), which resulted in a peak inspiratory pressure of 45 cm H2 O. However, the HR rate and the hypercarbia remained unchanged. With a minute ventilation of 20 L/min, the pHa was 7.2, PaCO2 was 63 mm Hg, PaO2 was 162 mm Hg, and HCO3 was 24 mEq/L. Hypercarbia and tachycardia of similar magnitude persisted throughout the 7-h surgery. At the end of surgery, the patient had extensive subcutaneous emphysema of the face, neck, chest, abdomen, and inguinal and scrotal regions. The patient resumed spontaneous respiration, and bilateral breath sounds were present. He had no signs of respiratory distress, and his SPO2 was 100%. Direct laryngoscopy revealed no pharyngeal or laryngeal edema; therefore, we extubated the trachea in the operating room. Nasal oxygen, 5 L/min, was started, and 30 minutes later, the pHa was 7.38, PaCO2 was 36 mm Hg, PaO2 was 73 mm Hg, and HCO3 was 23 mEq/L. A chest radiogram was normal. The patient was transferred to a regular nursing unit. Postoperatively, he had severe scrotal pain for the next 18 h. He was discharged home on the fourth postoperative day, recovered fully, and has had no long-term complications. Discussion The parathyroid glands are located anterolaterally at the mid-portion of the neck, but in about one third of patients, they may be found in the mediastinum or inferior neck or adjacent to the thymus [1,2]. Removing such ectopic glands may require sternotomy, thoracotomy, or video-assisted thoracoscopy [3]. In patients with ectopic parathyroid glands, endoscopic transcervical parathyroidectomy may be an advantageous surgical technique because it permits both cervical and thoracic explorations from the same surgical approach. Our institution is developing a method for endoscopic removal of the parathyroid glands. This report describes the first attempt to perform a parathyroidectomy laparoscopically. During endoscopic surgery, gas (usually CO2), is insufflated into a body cavity at 6 L/min while the insufflation pressure is controlled by an electronic variable-flow insufflator [4]. The occurrence of hypercarbia and its severity depend on the insufflation pressure [4,5]; to avoid significant hypercarbia during laparoscopic procedures, the insufflation pressure should not exceed 16 mm Hg. However, during laparoscopic parathyroidectomy, the surgeon must force CO2 into the subplatysmal space to create a new cavity that is not anatomically defined. We found that this maneuver required insufflation pressures as great as 20 mm Hg. Mullet et al. [6] clearly determined that CO2 is significantly higher during extraperitoneal insufflation than during intraperitoneal insufflation. They observed that neither CO2 elimination nor CO2 tension reached a plateau during extraperitoneal insufflation-findings contrary to those seen during intraperitoneal insufflation. At the same time, oxygen consumption remained unchanged; therefore, hypercarbia was not caused by an increase in the metabolic rate. They postulated that hypercarbia was more severe during extraperitoneal insufflation because the gas resorption area continually increased: extraperitoneal insufflation is performed within no defined body cavity, so the gas can widely diffuse through all extraperitoneal spaces. During intraperitoneal insufflation, the defined cavity allows pressure to build to compress the capillary vessels and close off capillary circulation, which causes CO2 diffusion to decrease. In addition, a higher than usual insufflation pressure and subcutaneous emphysema over a large area could have been the combination of factors that led to the severe hypercarbia in our patient. Wolf et al. [7] demonstrated that subcutaneous emphysema, extraperitoneal laparoscopic approach, and increased duration of insufflation-all present in our patient-were independently associated with a greater increase in CO2 absorption. Treatments to reduce hypercarbia include increasing the minute ventilation and reducing the CO2 insufflation pressure. Tan et al. [8] reported that maintaining systemic normocarbia may require an increase in minute ventilation of 20%-30%. On the other hand, Wittgen et al. [9] found that the patients with chronic obstructive pulmonary disease and prior coronary artery bypass surgery developed uncontrollable hypercarbia during laparoscopic cholecystectomy. The authors concluded that ASA physical status II and III patients were at greater risk of hypercarbia than were ASA I patients [10]. It is not clear why, in our healthy patient, both increasing the minute ventilation by 300% and decreasing the CO2 insufflation pressure from 20 mm Hg to 15 mm Hg did not decrease the end-tidal CO2 or PaCO (2). Hypercarbia can cause tachycardia and hypertension as a result of epinephrine and norepinephrine release [10]. In our patient, the HR markedly increased, but the BP did not change during hypercarbia. Exactly how hypercarbia is related to tachycardia and hypertension is not clear. Although tachycardia commonly occurs with hypercarbia [4,5,10], in cases of pneumoperitoneum, changes in HR are inconsistent [11,12]. Our patient did not experience hypertension despite the fact that BP generally increases as CO2 increases [10]; however, the BP response to hypercarbia varies and cannot always be used as a diagnostic sign [10,11]. During endoscopic surgery, predicting the arterial CO2 concentration from the end-tidal CO2 may be difficult because the arterial to alveolar gradient is not linear at higher PaCO2 levels [13,14]. Kent [13] described a patient with subcutaneous emphysema who had an end-tidal CO2 of 69 mm Hg and PaCO2 of 104 mm Hg. Our patient had a 21-mm Hg difference between the PaCO2 (63 mm Hg) and end-tidal CO2. Such large and unpredictable arterial to alveolar differences stress the need for frequent direct arterial measurement of PaCO2 during endoscopic procedures. The development of subcutaneous emphysema requires immediate attention to determine whether pneumothorax or pneumomediastinum is present, especially when laparoscopic techniques are used in surgery involving the chest. Mediastinal emphysema with bilateral pneumothorax during laparoscopic procedures has been reported [15]. Therefore, in patients undergoing laparoscopic thoracic procedures (even those without cardiopulmonary disease), invasive monitoring might be useful not only to monitor arterial blood gases but also to closely follow hemodynamic variables so as to detect these complications quickly. Normally, invasive monitoring is not necessary for most laparoscopic surgeries. However, we believe that the benefits of a procedure that requires only a small neck incision rather than thoracotomy outweigh the disadvantages of invasive monitoring. Further, closely monitoring changes in peak ventilatory pressures can reveal a developing pneumothorax. If the respiratory distress or lower oxyhemoglobin concentration occurs at the end of surgery, the anesthesiologist should obtain a chest radiograph before endotracheal extubation to exclude pneumothorax or pneumomediastinum. Although clinically our patient did not appear to have pneumothorax or pneumomediastinum, we performed a laryngoscopy under direct vision to confirm the absence of clinically significant laryngeal emphysema. We also checked for gas leaks around the occluded endotracheal tube after the tube cuff was deflated. Finally, at the end of intraperitoneal insufflation, an elevated PaCO2 usually returns to baseline within 10 minutes after cessation of insufflation, but when CO2 is introduced in pelvic tissues to delineate lymph nodes, hypercarbia may persist longer [4]. Therefore, patients in whom massive subcutaneous emphysema develops may require ventilatory support for a longer period than those who do not have this complication. In conclusion, we present a patient who underwent endoscopic transcervical parathyroidectomy and developed complications due to massive intravascular absorption and subcutaneous spread of CO2, the gas used for insufflation. Severe hypercarbia was not amenable to standard treatment with an increase in minute ventilation. The complications in our case suggest that CO2 is not a suitable choice as an expansion agent in the neck. Presently, a member of our surgical team (MG) is testing a more suitable liquid expansion agent (glycine solution) for laparoscopic surgery of the neck. The authors wish to thank Cassandra Talarico, Department of Scientific Publications, The Cleveland Clinic Foundation, for help in preparing this manuscript." @default.
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• W2080776746 title "Massive Subcutaneous Emphysema and Severe Hypercarbia in a Patient During Endoscopic Transcervical Parathyroidectomy Using Carbon Dioxide Insufflation" @default.
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