2019 FSA Posters

P067: TO AIR IS HUMAN: A CASE REPORT OF MINIMALLY INVASIVE SURGERY WITH MAXIMUM COMPLICATIONS
Jason Howard, DO, David M Corda, MD; University of Florida

Introduction: Venous air embolism is a high-stakes, rare and potentially fatal complication of hysteroscopic surgery that is often underestimated by surgeons and anesthesiologists. Previous studies have shown up to one hundred percent occurrence rate of sub-clinical gas emboli that occurs during hysteroscopy (1). This case report highlights a triad of complications (air embolism, thromboembolism and pulmonary edema) that occurred during a minimally invasive hysteroscopy along with early detection and intervention.

Case: A 36 year-old 5’9’’, 85 kg, ASA physical status 1 female presented for hysteroscopic removal of leiomyomata. Hysteroscopy was begun in lithotomy position following induction, uneventful placement of a laryngeal mask airway (LMA) and maintenance of anesthesia with sevoflurane in air/oxygen. Twenty minutes into the case, end tidal carbon dioxide began to drop and the LMA position and seal was confirmed. Subsequent bradycardia unresponsive to atropine led to cardiac arrest, chest compressions and epinephrine administration with return of spontaneous circulation. Following intubation, transesophageal echocardiography was performed and showed normal biventricular function and normovolemia with no air, right ventricular strain, or tricuspid regurgitation. The procedure was aborted despite return of hemodynamic stability. Neuromuscular blockade was reversed with sugammadex and the patient was extubated, alert and awake. The patient soon became short of breath with rales and was reintubated with signs of pulmonary edema. CT scanning revealed an air embolism in the right main pulmonary, small adjacent pulmonary embolism and diffuse ground glass opacities with subpleural sparing consistent with pulmonary edema. She was started on a heparin infusion and remained intubated overnight. The next morning she was extubated without complication. She was discharged home on Apixiban 5 mg BID for management of her PE and recommended to avoid estrogen containing oral contraceptives.

Discussion: Surgical hysteroscopy, especially involving a more invasive resection of uterine fibroids, places patients at risk for air and particulate emboli. Emboli during hysteroscopy form secondary to aggressive dilation of the cervix with entrainment of air from exposed vessels, improper purging of room air from hysteroscope lines, frequent plunging of room air by re-insertion of hysteroscopic instruments, gases from electrosurgical vaporization and entrainment of debris or clots entering uterine venous sinuses. Noncardiogenic pulmonary edema from increased pulmonary capillary permeability can often follow an initial large air embolism. Early diagnosis and intervention are paramount in management of these cases. Recommendations include consideration of general endotracheal tube anesthesia for early detection in EtCO2 changes, very careful purging of air from the hysteroscopic system, avoiding N2O and Trendelenburg’s position.

References:

1. Leibowitz D, Benshalom N, Kaganov Y, Rott D, Hurwitz A, Hamani Y. The incidence and haemodynamic significance of gas emboli during operative hysteroscopy: A prospective echocardiographic study. Eur J Echocardiogr. 2010;11:429–31.

2. Verma A, Singh MP. Venous gas embolism in operative hysteroscopy: A devastating complication in a relatively simple surgery. J Anaesthesiol Clin Pharmacol 2018;34:103-6