This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ferrando, A. Articles by Goudsouzian, N. G. Search for Related Content PubMed PubMed Citation Articles by Ferrando, A. Articles by Goudsouzian, N. G.

---

LETTERS TO THE EDITOR

Carbon Dioxide Embolism in an Infant

Department of Anaesthesia Gregorio Marañon General Hospital Madrid 28200, Spain

We would like to comment on the interesting article by Nishanian and Goudsouzian (1), in which a carbon dioxide embolism during a hip arthography in an infant is described.

First, the authors state that the possible CO₂ embolism in the child appeared clinically with hypoxemia, cardiac millwheel murmur, hypotension, and a decrease in ETCO₂, a characteristic onset of pulmonary embolism; when the amount of air is relatively small, a decrease in ETCO₂ can be the only sign (2).

It is true that a CO₂ embolism can be accompanied by a decrease in ETCO₂—as an air or fat embolism—but there are reported cases of CO₂ embolism that manifest a rapid and limited increase in ETCO₂ (3–6), which would be a pathognomonic sign of this kind of embolism and should be taken in account when using CO₂.

Second, when CO₂ is used in the course of diagnostic or surgical procedures (hip arthography, laparoscopic surgery), there is a risk of pulmonary embolism, and we believe that N₂O is therefore an undesirable anesthetic given its tendency to increase the size of air bubbles (4).

Finally, in our institution, whenever CO₂ is used in a child, an echocardiogram is obtained to exclude the existence of a permeable oval foramen, which could be responsible for a paradoxical embolism (7); however, this measure does not exclude the risk in 100% of cases (8).

References

1. Nishanian EV, Goudsouzian NG. Carbon dioxide embolism during hip arthography in an infant. Analg 1998;86:299–300.[Web of Science][Medline]
2. Couture P, Boudreault D, Derouin M. Venous carbon dioxide embolism in pigs an evaluation of end-tidal carbon dioxide, transesophageal echocardiography, pulmonary artery pressure and precordial auscultation as monitoring modalities. Anesth Analg 1994;79:867–73.[Abstract/Free Full Text]
3. Shulman D, Aronson HB. Capnography in the early diagnosis of carbon dioxide embolism during laparoscopy. Can Anaesth Soc J 1984;31:455–9.[Web of Science][Medline]
4. Nyarmaya JB, Pierre S, Mazoit JX. Effect of carbon dioxide embolism with nitrous oxide in the inspired gas of piglets. Br J Anaesth 1996;76:428–34.[Abstract/Free Full Text]
5. Delafosse B, Cottin V, Motin J. Embolie gazeuse en chirurgie coelioscopique: monitorage et prevention. Paris:Editions Techniques, 1994:1–4.
6. Derouin M, Couture P, Boudreault D. Detection of gas embolism by transesophageal echocardiography during laparoscopic cholecystectomy. Anesth Analg 1996;82:119–24.[Abstract]
7. Gronert GA, Messick JM, Cuchiara RF, Michenfelder JD. Paradoxical air embolism from a patient foramen ovale. Anesthesiology 1979;50:548–9.[Web of Science][Medline]
8. Cuchiara RF, Nishimura RA, Black S. Failure of preoperative testing to prevent paradoxical air embolism report of two cases. Anesthesiology 1989;71:604–7.[Web of Science][Medline]

Response

Department of Anesthesia and Critical Care Massachusetts General Hospital Boston, MA 02114-7536.

We appreciate the interesting comments of Ferrando et al. about our article (1). We agree that echocardiography does not exclude the risk of paradoxical embolism and urge caution; the incidence of probe patent foramen may be as high as 34% in the first three decades of life (2). These foramina may only open under high right heart pressures that are accompanied by an embolism and may not be picked up during a routine echocardiogram (3).

In regards to the trend in ETCO₂ during CO₂ embolism, the literature describes both decreases and increases, depending on the quantity of air injected. Volumes of CO₂ as great as 5 mL/kg have decreased ETCO₂ in animals (4), and only when the CO₂ bubble dissolves would one correctly predict an increase in ETCO₂ above baseline. Perhaps minuscule bubbles of CO₂ that can more easily be dissolved in blood before reaching the pulmonary capillaries show as an increase in ETCO₂. Clearly, any change in ETCO₂ that is accompanied by hypoxia should prompt investigation as to the cause.

References

1. Nishanian EV, Goudsouzian N. Carbon dioxide embolism during hip arthrography in an infant. Analg 1998;86:299–300.
2. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first ten decades a necropsy study of 965 normal hearts. Clin Proc 1984;59:17–20.
3. Gronert GA, Messick JM, Cucchiara RF, et al. Paradoxical air embolism from a patent foramen ovale. Anesthesiology 1979;50:548.
4. Couture P, Boudreault D, Derouin M, et al. Venous carbon dioxide embolism in pigs an evaluation of end-tidal carbon dioxide, transesophageal echocardiography, pulmonary artery pressure, and precordial auscultation as monitoring modalities. Anesth Analg 1994;79:867–73.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ferrando, A. Articles by Goudsouzian, N. G. Search for Related Content PubMed PubMed Citation Articles by Ferrando, A. Articles by Goudsouzian, N. G.