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Massive Subcutaneous Emphysema and

Severe Hypercarbia in a Patient During
Endoscopic Transcervical Parathyroidectomy
Using Carbon Dioxide Insufflation

Article in Anesthesia & Analgesia · June 1997

DOI: 10.1097/00000539-199705000-00040 · Source: PubMed

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Massive Subcutaneous Emphysema and Severe
Hypercarbia in a Patient During Endoscopic Transcervical
Parathyroidectomy Using Carbon Dioxide Insuff lation
Alexandru Goti lieb, MD*, Juraj Sprung, MD, PhD*, Xiang-Ming Zheng, MD*, and
Michael Gagne: , MDt
Departments of *Ge! era1 Anesthesiology and tGenera1 Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio

I ncreasingly, laparoscopic surgeries are being per- the oxyhemoglobin saturation as measured by pulse oxim-
formed to treat a number of conditions. The tech- etry (SroJ was 99%, and the end-tidal CO, was 25-30 mm
nical aspects of specific laparoscopic procedures %
A subplatysmal air pocket was then created by insufflat-
can increase the risk of certain complications that, ing CO, at an insufflation pressure of 20 mm Hg. At 10 min
although they are of concern in conventional proce- after CO, insufflation began, the end-tidal CO, pressure
dures, may be more likely or may occur with greater increased to 42 mm Hg, and the HR increased from 52 to
severity during laparoscopic procedures. We report 125 bpm without changes in BP or SPOT. The surgeon re-
the anesthetic course and complications that were en- duced the CO, insufflation pressure to 15 mm Hg. The tidal
countered during laparoscopic parathyroidectomy, a volume was then increased to 800 mL and the ventilatory
rate to 14 bpm (minute ventilation of 11.2 L/min), but a high
procedure that to our knowledge, has not previously
end-tidal CO, pressure (50 mm Hg) and tachycardia (120-
been performed. Although the surgery was successful, 125 bpm) persisted. Analysis of arterial blood gases revealed
the patient developed signs and symptoms of sus- a pH, of 7.19, Pace, of 63 mm Hg, Pao, of 185 mm Hg, and
tained carbon dioxide (CO,) absorption: supraventric- HCO, of 24 mEq/L. We increased the minute ventilation to
ular tachycardia, massive subcutaneous emphysema, more than 20 L/min (tidal volume 720 mL and respiratory
hypercarbia, and acidosis. rate 28 bpm), which resulted in a peak inspiratory pressure
of 45 cm H,O. However, the HR rate and the hypercarbia
remained unchanged. With a minute ventilation of 20
L/min, the pH, was 7.2, Pace, was 63 mm Hg, Pao, was
162 mm Hg, and HCO, was 24 mEq/L.
Case Report Hypercarbia and tachycardia of similar magnitude per-
A 37-yr-old, 74-kg man with primary hyperparathyroid- sisted throughout the 7-h surgery. At the end of surgery, the
ism was admitted to undergo transcervical endoscopic par- patient had extensive subcutaneous emphysema of the face,
athyroidectomy. The patient had no history of cardiovascu- neck, chest, abdomen, and inguinal and scrotal regions. The
lar, pulmonary, or renal disease. patient resumed spontaneous respiration, and bilateral
Intraoperative monitoring included electrocardiography, breath sounds were present. He had no signs of respiratory
noninvasive blood pressure monitoring, and pulse oximetry. distress, and his Spo, was 100%. Direct laryngoscopy re-
His preinduction blood pressure (BP) was 124/66 mm Hg, vealed no pharyngeal or laryngeal edema; therefore, we
and the heart rate (HR) was 60 bpm. Anesthesia was in- extubated the trachea in the operating room. Nasal oxygen,
duced with fentanyl and thiopental. Succinylcholine was 5 L/min, was started, and 30 minutes later, the pH, was
used to facilitate endotracheal intubation. Anesthesia was 7.38, Pace, was 36 mm Hg, Pao, was 73 mm Hg, and HCO,
maintained with a 0.7% end-tidal concentration of isoflurane was 23 mEq/L. A chest radiogram was normal. The patient
and 60% nitrous oxide in oxygen; the nitrous oxide was was transferred to a regular nursing unit. Postoperatively,
discontinued after CO, insufflation began. Mechanical ven- he had severe scrotal pain for the next 18 h. He was dis-
tilation was provided with a tidal volume of 650 mL and charged home on the fourth postoperative day, recovered
respiratory rate of 8 bpm (minute ventilation of 5.2 L/min), fully, and has had no long-term complications.
which produced a peak inspiratory pressure of 22 cm H,O.
After anesthesia induction, the BP and HR remained stable,

Accepted for publication February 7, 1997. Discussion

Address correspondence to Juraj Sprung, MD, PhD, Department The parathyroid glands are located anterolaterally at
of General Anesthesiology E-31, The Cleveland Clinic Foundation,
9500 Euclid Avenue, Cleveland, OH 44195. Address e-mail to the mid-portion of the neck, but in about one third of
sprungj@cesmtp.ccf.org. patients, they may be found in the mediastinum or

01997 by the International Anesthesia Research Society

1154 Anesth Analg 1997;84:11546 0003-2999/97/$5.00
ANESTH ANALG CASE REPORTS 1155
1997;84:1154-6

inferior neck or adjacent to the thymus (1,2). Remov- obstructive pulmonary disease and prior coronary ar-
ing such ectopic glands may require sternotomy, tho- tery bypass surgery developed uncontrollable hyper-
racotomy, or video-assisted thoracoscopy (3). In pa- carbia during laparoscopic cholecystectomy. The au-
tients with ectopic parathyroid glands, endoscopic thors concluded that ASA physical status II and III
transcervical parathyroidectomy may be an advanta- patients were at greater risk of hypercarbia than were
geous surgical technique because it permits both cer- ASA I patients (10). It is not clear why, in our healthy
vical and thoracic explorations from the same surgical patient, both increasing the minute ventilation by
approach. Our institution is developing a method for 300% and decreasing the CO, insufflation pressure
endoscopic removal of the parathyroid glands. This from 20 mm Hg to 15 mm Hg did not decrease the
report describes the first attempt to perform a para- end-tidal CO, or Pace,.
thyroidectomy laparoscopically. Hypercarbia can cause tachycardia and hyperten-
During endoscopic surgery, gas (usually C02), is sion as a result of epinephrine and norepinephrine
insufflated into a body cavity at 6 L/mm while the release (10). In our patient, the HR markedly in-
insufflation pressure is controlled by an electronic creased, but the BP did not change during hypercar-
variable-flow insufflator (4). The occurrence of hyper- bia. Exactly how hypercarbia is related to tachycardia
carbia and its severity depend on the insufflation pres- and hypertension is not clear. Although tachycardia
sure (4,5); to avoid significant hypercarbia during commonly occurs with hypercarbia (4,5,10), in cases of
laparoscopic procedures, the insufflation pressure pneumoperitoneum, changes in HR are inconsistent
should not exceed 16 mm Hg. However, during lapa- (11,12). Our patient did not experience hypertension
roscopic parathyroidectomy, the surgeon must force despite the fact that BP generally increases as CO,
CO, into the subplatysmal space to create a new cavity increases (10); however, the BP response to hypercar-
that is not anatomically defined. We found that this bia varies and cannot always be used as a diagnostic
maneuver required insufflation pressures as great as sign (10,ll).
During endoscopic surgery, predicting the arterial
20 mm Hg. Mullet et al. (6) clearly determined that
CO, is significantly higher during extraperitoneal in- CO, concentration from the end-tidal CO, may be
difficult because the arterial to alveolar gradient is not
sufflation than during intraperitoneal insufflation.
linear at higher Pace, levels (13,14). Kent (13) de-
They observed that neither CO, elimination nor CO,
scribed a patient with subcutaneous emphysema who
tension reached a plateau during extraperitoneal in-
had an end-tidal CO, of 69 mm Hg and Pace, of
sufflation-findings contrary to those seen during in-
104 mm Hg. Our patient had a 21-mm Hg difference
traperitoneal insufflation. At the same time, oxygen
between the Pace, (63 mm Hg) and end-tidal CO,.
consumption remained unchanged; therefore, hyper-
Such large and unpredictable arterial to alveolar dif-
carbia was not caused by an increase in the metabolic
ferences stress the need for frequent direct arterial
rate. They postulated that hypercarbia was more se- measurement of Pace, during endoscopic procedures.
vere during extraperitoneal insufflation because the The development of subcutaneous emphysema re-
gas resorption area continually increased: extraperito- quires immediate attention to determine whether
neal insufflation is performed within no defined body pneumothorax or pneumomediastinum is present, es-
cavity, so the gas can widely diffuse through all ex- pecially when laparoscopic techniques are used in
traperitoneal spaces. During intraperitoneal insuffla- surgery involving the chest. Mediastinal emphysema
tion, the defined cavity allows pressure to build to with bilateral pneumothorax during laparoscopic pro-
compress the capillary vessels and close off capillary cedures has been reported (15). Therefore, in patients
circulation, which causes CO, diffusion to decrease. In undergoing laparoscopic thoracic procedures (even
addition, a higher than usual insufflation pressure and those without cardiopulmonary disease), invasive
subcutaneous emphysema over a large area could monitoring might be useful not only to monitor arte-
have been the combination of factors that led to the rial blood gases but also to closely follow hemody-
severe hypercarbia in our patient. Wolf et al. (7) dem- namic variables so as to detect these complications
onstrated that subcutaneous emphysema, extraperito- quickly. Normally, invasive monitoring is not neces-
neal laparoscopic approach, and increased duration of sary for most laparoscopic surgeries. However, we
insufflation-all present in our patient-were inde- believe that the benefits of a procedure that requires
pendently associated with a greater increase in CO, only a small neck incision rather than thoracotomy
absorption. outweigh the disadvantages of invasive monitoring.
Treatments to reduce hypercarbia include increas- Further, closely monitoring changes in peak ventila-
ing the minute ventilation and reducing the COP in- tory pressures can reveal a developing pneumothorax.
sufflation pressure. Tan et al. (8) reported that main- If the respiratory distress or lower oxyhemoglobin
taining systemic normocarbia may require an increase concentration occurs at the end of surgery, the anes-
in minute ventilation of 20%-30%. On the other hand, thesiologist should obtain a chest radiograph before
Wittgen et al. (9) found that the patients with chronic endotracheal extubation to exclude pneumothorax or
1156 CASE REPORTS ANESTH ANALG
1997;84:1154d

pneumomediastinum. Although clinically our patient 2. Wei JP, Tippins RB, Rao RN, et al. Nonadenomatous thymic
unencapsulated parathyroid tissue as a cause of persistent pri-
did not appear to have pneumothorax or pneumome-
mary hyperparathyroidism. South Med J 1994;1264-8.
diastinum, we performed a laryngoscopy under direct 3. Prinz RA, Lonchyna V, Carnaille B, et al. Thoracoscopic excision
vision to confirm the absence of clinically significant of enlarged mediastinal parathyroid glands. Surgery 1994;116:
laryngeal emphysema. We also checked for gas leaks 999-1004.
around the occluded endotracheal tube after the tube 4. Bready LL. Anesthesia for laparoscopic surgery. Curr Rev Clin
Anesth 1995;15:133-44.
cuff was deflated. Finally, at the end of intraperitoneal 5. Holzman M, Sharp K, Richards W. Hypercarbia during carbon
insufflation, an elevated Pace, usually returns to base- dioxide gas insufflation for therapeutic laparoscopy: a note of
line within 10 minutes after cessation of insufflation, caution. Surg Laparosc Endosc 1992;2:11-4.
but when CO, is introduced in pelvic tissues to delin- 6. Mullet CE, Viale JP, Sagnard PE, et al. Pulmonary CO, elimina-
eate lymph nodes, hypercarbia may persist longer (4). tion during surgical procedures using intra- or extraperitoneal
CO, insufflation. Anesth Analg 1993;76:622-6.
Therefore, patients in whom massive subcutaneous 7. Wolf JS Jr, Monk TG, McDougall EM, et al. Carbon dioxide
emphysema develops may require ventilatory support absorption during laparoscopic pelvic operation [review]. J Am
for a longer period than those who do not have this Co11 Surg 1995;180:555-60.
complication. 8. Tan PL, Lee TL, Tweed WA. Carbon dioxide absorption and gas
exchange during pelvic laparoscopy. Can J Anaesth 1992;39:
In conclusion, we present a patient who underwent
677-81.
endoscopic transcervical parathyroidectomy and de- 9. Wittgen CM, Andrus CH, Fitzgerald SD, et al. Analysis of the
veloped complications due to massive intravascular hemodynamic and ventilatory effects of laparoscopic cholecys-
absorption and subcutaneous spread of C02, the gas tectomy. Arch Surg 1991;126:997-1000.
used for insufflation. Severe hypercarbia was not ame- 10. Joris JL. Anesthetic management of laparoscopy. In: Miller RD,
ed. Anesthesia. New York: Churchill-Livingstone, 1994:2011-29.
nable to standard treatment with an increase in
11. Huang SJ, Lee CY, Yeh FC, Chang CL. Hypercarbia is not the
minute ventilation. The complications in our case sug- determinant factor of systemic arterial hypertension during car-
gest that CO, is not a suitable choice as an expansion boperitoneum in laparoscopy. Ma Tsui Hsueh Tsa Chi 1991;29:
agent in the neck. Presently, a member of our surgical 5925.
team (MG) is testing a more suitable liquid expansion 12. Rademaker BM, Bannenberg JJ, Kalkman JC, Meyer DW. Effect
of pneumoperitoneum with helium on hemodynamics and ox-
agent (glycine solution) for laparoscopic surgery of the ygen transport: a comparison with carbon dioxide. J Laparosc
neck. Surg 1995;5:15-20.
13. Kent RB III. Subcutaneous emphysema and hypercarbia follow-
ing laparoscopic cholecystectomy. Arch Surg 1991;126:1154-6.
The authors wish to thank Cassandra Talarico, Department of Sci- 14. Wahl RW, Mamas J. Ventilatory requirements during laparo-
entific Publications, The Cleveland Clinic Foundation, for help in scopic cholecystectomy. Can J Anaesth 1993;40:206-10.
preparing this manuscript. 15. Doctor NH, Hussain Z. Bilateral pneumothorx associated with
laparoscopy: a case report of a rare hazard and review of liter-
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