2023 FSA Podium and Poster Abstracts

P045: CARBON DIOXIDE EMBOLISM IN ROBOTIC HYSTERECTOMY
Kevin Lukose, MD¹; Tilman Chambers, MD¹; Walter Diaz, MD²; David Schmelzer, DO²; Benjamin Houseman, MD, PhD, FASA²; ¹Memorial Healthcare System; ²Envision Physician Services

Carbon dioxide (CO2) embolization is a rare but potentially lethal intraoperative complication of robot-assisted surgery, with an incidence rate of 0.001% and a mortality rate as high as 28% (1,2). Here we describe the management of a massive CO2 embolism that occurred following abdominal insufflation in an elective robot-assisted hysterectomy. We highlight the importance of point of care ultrasound (POCUS) and anesthesia-specific ACLS protocols in management.

A 45-year-old obese female with a past medical history of uterine fibroids, anemia, and hypertension presented for elective robot-assisted total hysterectomy. Her preoperative vitals were within normal limits. Following uneventful induction of anesthesia and endotracheal intubation, a transabdominal plane block was performed. Shortly after trocar placement and insufflation, the patient became hypoxemic (88%), hypotensive (60/27mmHg) and bradycardic (HR 53bpm). End tidal CO2 dropped to 5 mmHg. Insufflation was stopped, and a bolus of ephedrine 10 mg IV was given. Shortly thereafter, she decompensated into pulseless ventricular tachycardia and ACLS was initiated. Patient was administered CPR as well as 500mcg of epinephrine. ROSC was obtained in two minutes. Initial ABG showed a P02 of 143 on 100% Fi02 and PCO2 of 58. POCUS cardiac scan indicated right heart strain. The surgery was canceled and the patient was transported intubated to the ICU. A repeat ABG 30 minutes later showed improved P02 of 359 and PC02 of 55, further supporting CO2 embolism. The patient was extubated the next day and downgraded two days later. Subsequent right heart catheterization was unremarkable for any long-term sequelae. Patient was discharged and later was able to have the surgery successfully without complications.

The overall risk of CO2 embolism during robot-assisted surgery is influenced by both insufflation technique and insufflation pressure (3,4). In theory, the incidence and mortality associated with CO2 embolization might be reduced by opting for the Hasson over the Veress technique of establishing pneumoperitoneum and reducing insufflation pressures (5). Once embolism occurs, hemodynamic collapse occurs rapidly. Both prompt ACLS and use of epinephrine have been associated with improved survival (2). Here, POCUS was useful because it permitted rapid assessment of cardiac and pulmonary function, supporting the diagnosis of embolism over other causes. Initiation of ACLS in this case was made easier because the event occurred prior to docking of the robot and positioning in Trendelenberg. ACLS and other recommended interventions, such as lateral repositioning or central venous aspiration, are often challenging during robot-assisted procedures due to positioning constraints and the need to undock the robot (3).

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