Minimally Invasive Therapy. 2009;18:366–368 CASE REPORT Venous air embolism during laparoscopic cholecystectomy YESIM COKAY ABUT 1 , RAMAZAN ERYILMAZ 2 , ISMAIL OKAN 2 , KEREM ERKALP 1 1 Department of Anesthesiology, Vakif Gureba Training Hospital, Istanbul, Turkey, 2 Department of Surgery, Vakif Gureba Training Hospital, Istanbul, Turkey Abstract Vascular air embolism is a rare and potentially life-threatening event. In this study, a case of venous air embolism during laparoscopic cholecystectomy due to an injured inferior vena cava is presented. Anesthesiologists and surgeons must be aware of this dangerous complication. Emphasis is given to the prevention and prompt recognition of this event and to the use of all available tools in the management of cardiovascular complications. Key words: Laparoscopic cholecystectomy, complication, venous air embolism Introduction Vascular air embolism (VAE) is a potentially life- threatening event that is rarely encountered in the operating room. Improvements in monitoring devices and deep understanding of the pathophysiology of vascular air embolism facilitate the management of this complication for both surgeons and anesthesiol- ogists. Although clinically apparent carbon dioxide embolism is a rare event in laparoscopic surgery (0.0014 – 0.6% of laparoscopies) (1,2), it is associated with a high mortality rate of 28% (3). The major cause leading to gas emboli is the misplacement of the Veress needle directly into a vein or a parenchymal organ. However, smaller amounts of gas may also enter the circulation through an opening in any injured vessel, either in the abdominal wall or at the operative site (4). We here describe a case of venous embolism during laparoscopic cholecystectomy due to an injured infe- rior vena cava. Case report A 58-year-old man was admitted to our hospital with the diagnosis of chronic calculous cholecystitis. Medical history and clinical examination revealed no signs of abnormality. The patient was scheduled for laparoscopic cholecystectomy. At the induction of anesthesia 500 mg thiopental and 50 mcg fentanyl were given intravenously, followed by 40 mg rocur- onium to facilitate tracheal intubation, controlled mechanical ventilation was then initiated. Usual mon- itoring was used with continuous electrogram, pulse oximetry, end-tidal carbon dioxide and non-invasive blood pressure measurement. Anesthesia was main- tained with 50% nitrous oxide and sevoflurane in oxygen. End tidal carbondioxide was kept in range between 30-35 mmHg. Installation of pneumoperi- toneum through Veress needle inserted in the umbi- licus was achieved. An intraabdominal pressure of 13 cmH 2 O was established in equilibrium. During cholecystectomy, before the removal of the gall bladder, a sudden decrease in end-tidal carbon dioxide from 32 to 11 mm Hg was noticed. Soon after, both systolic arterial pressure and heart rate decreased dramatically. Arterial blood gas measure- ments showed that pCO 2 was 41 mm Hg at that moment. Surgery and insufflation of gas was stopped, ephedrine 5 mg was given intravenously and ventilation with 100 % O 2 was started. Tren- delenburg position was achieved immediately and 1 mg atropin was injected due to severe bradicardia. Correspondence: Ramazan Eryilmaz, Vatan cad. Emlak Bloklari E-4 Blok/55 Fatih-Istanbul, Turkey 34091, Fax: 0212 621 75 80, E-mail: ramazaneryilmaz@hotmail.com ISSN 1364-5706 print/ISSN 1365-2931 online Ó 2009 Informa UK Ltd DOI: 10.3109/13645700903384443