Asymptomatic carbon dioxide embolism during transoral vestibular thyroidectomy: A case report

Table 1 Intraoperative changes of patient’s vital signs during carbon dioxide embolism

Parameter	12:51	12:52	12:53	12:54	12:55	12:56	12:57	12:58	12:59	13:00	13:01
End-tidal CO2 in mmHg	46	68	84	82	78	73	65	60	55	50	47
Noninvasive systolic blood pressure in mmHg	(-)	99	(-)	(-)	101	(-)	(-)	103	(-)	(-)	101
Noninvasive diastolic blood pressure in mmHg	(-)	57	(-)	(-)	53	(-)	(-)	51	(-)	(-)	57
Heart rate in bpm	68	67	66	66	64	63	64	65	64	64	65
Blood oxygen saturation, %	100	100	100	100	100	100	100	100	100	100	100

Table 2 Characteristics of qualified cases with carbon dioxide embolism in endoscopic thyroidectomy in the last decade

Characteristic	Rajan et al[8], 2016	Kim et al[7], 2018	Kim et al[9], 2010	Fu et al[10], 20181
Age in yr	48	59	59	UN
Weight in kg	68	57	54	UN
Size of thyroid nodules in cm	4.0 × 5.0	1.1 × 0.8 × 1.0	UN	UN
Surgical approach	Bilateral axilla and nipple areola	Transoral robotic	Axillo-bilateral-breast approach	Transoral
Insufflation pressure in mmHg	20	6	6	8
Maintenance of anesthesia	UN	O2–air-sevoflurane	O2–air-sevoflurane	UN
Time of event	3 h after operation	During skin flap elevation	Beginning of CO2 insufflation	Beginning of CO2 insufflation
Possible causes	UN	Anterior jugular vein was lacerated	UN	UN
Clinical manifestations	ETCO2↓, SPO2↓, hypotension, bradycardia	ETCO2↓, SPO2↓, hypotension, bradycardia, premature atrial complexes, asystole	ETCO2↓, SPO2↓, hypotension, tall peaked T-wave	SPO2↓, hypotension, tachycardia, asystole
Diagnosis tools	ETCO2	ETCO2	ETCO2, TEE	Precardial Doppler sonography
Treatment	Reduced insufflation pressure, Trendelenburg position, glycopyrrolate 0.2 mg, ephedrine 6 mg, 100% O2 hyperventilation, aggressive intravenous volume expansion, 6 cmH2O PEEP	Stopped CO2 gas insufflation, Durant’s position, ephedrine 10 mg, atropine 0.5 mg, 100% O2 hyperventilation, chest compression, epinephrine 1 mg	Stopped CO2 gas insufflation, Durant’s position, 100% O2 hyperventilation, ephedrine 5 mg	Stopped CO2 gas insufflation, Left lateral decubitus, dexamethasone, aminophylline, dopamine, high flow O2, chest compression
Prognosis	Good	Good	Good	Good

¹This article included 2 cases. CO₂: Carbon dioxide; ETCO₂: End-tidal carbon dioxide; O₂: Oxygen; PEEP: Positive end-expiratory pressure; SPO₂: Percutaneous oxygen saturation; TEE: Transesophageal echocardiography; UN: Unknown.