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10.5005/jp-journals-10033-1208
CO Inducer, Indicator (EtCO ) and venting it, is the Healer of Subcutaneous Emphysema
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CASE REPORT
CO Inducer, Indicator (EtCO ) and venting it, is the Healer
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of Subcutaneous Emphysema
Suman Gupta, Preeti Agrawal, Arunkumar Arumugam

ABSTRACT demonstrated to have the most important impact on the
rate of CO absorption. 2
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Today, surgeons across the world have realized the benefits of
Laparoscopic approaches in gynecologic procedure are
laparoscopic approach, for short hospital stay, improved 3
postoperative recovery times. Thus, laparoscopic surgeries are being used since 1937. Here, we report a case where
being used with greater frequency in health care system. massive subcutaneous emphysema developed in a patient
However, laparoscopy is not without complications like, subcu- undergoing laparoscopic ovarian cystectomy.
taneous emphysema, pneumopericardium, pneumothorax, gas
embolism, visceral injuries. Since, these complications remain
a cause of concern, we need better trained anesthesiologist CASE REPORT
and laparoscopic surgeons. Regular assessment and
monitoring should be done to recognize the complication A 25-year-old 45 kg woman of American Society of
as early as possible and prompt treatment for positive Anesthesiologist (ASA) physical status II was scheduled to
patient outcome. undergo a laparoscopic ovarian cystectomy. She had no
Subcutaneous emphysema is defined as the presence of
previous illness. Preoperative laboratory investigations were
gas within the tissue, beneath the skin. Here, we describe a
case report where the patient developed massive subcutaneous within normal limits. She was shifted to the operation room
emphysema during laparoscopic ovarian cystectomy. (OR) and all standard monitor were applied [noninvasive
blood pressure (NIBP), pulse oximetry, electrocardiogram].
Keywords: Carbon dioxide, Hyperventilation, Laparoscopy,
Subcutaneous emphysema, Ovarian cystectomy. Anesthesia was induced uneventfully with sodium
thiopentone 5 mg/kg (2.5%), succinylcholine 1.5 mg/kg,
How to cite this article: Gupta S, Agrawal P, Arumugam AK.
fentanyl 2 µg/kg BW intravenously, O :N O 50% each and
CO Inducer, Indicator (EtCO ) and venting it, is the Healer of 2 2
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Subcutaneous Emphysema. World J Lap Surg 2013;6(3): 0.5% halothane. Trachea was intubated with Portex 7.5 mm
173-175. cuffed endotracheal tube and confirmed by bilateral equal
Source of support: Nil breath sounds and capnography showing end tidal carbon
dioxide (EtCO ). Neuromuscular blockade was achieved
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Conflict of interest: None declared
by nondepolarizing muscle relaxant injection atracurium.
Adequate minute ventilation was delivered with tidal volume
INTRODUCTION
of 8 ml/kg BW and respiratory rate of 14/min. A nasogastric
As budding surgeons are using laparoscopic approach for tube was placed after induction of general anesthesia. The
almost all surgeries with greater frequency, providing Veress needle and trocar were inserted into the peritoneal
anesthesia for laparoscopic surgeries has become a new cavity without difficulty. Patient’s hemodynamics was stable
challenge for anesthesiologist. It has its own advantages initially during the procedure with an EtCO of 30 mm Hg.
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and disadvantages. Laparoscopic surgery allows for After 15 minutes of CO insufflation there was a steady
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smaller surgical incisions and minimal invasiveness, while rise of EtCO 2 from 30 to 78 mm Hg, with peak airway
still providing sufficient visualization of peritoneal cavity. pressure rising to 40 mm Hg. The insufflation pressure was
Carbon dioxide (CO ) has proven to be beneficial for reduced from 23 to 12 mm Hg. Hyperventilation was
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insufflations because of its rapid diffusion ability, low cost instituted, even then there was no fall in EtCO . We took
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and decrease flammability compared with alternative gases the patient on manual ventilation and noticed resistance in
(air, helium, argon, and N O). However, insufflations the bag and were unable to ventilate the patient despite
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can cause CO diffusion into subcutaneous tissue to adequate depth of anesthesia. Patient heart rate rose to
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cause subcutaneous emphysema. The incidence of 130/min and NIBP to 160/100 mm Hg. While auscultating
subcutaneous emphysema in laparoscopic surgery is 0.3 for the air entry we undraped the patient, which unveiled
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to 3%. Various risk factors attributing to it are increased swelling of face, edematous eyes and crepitus all over the
age, multiple surgical ports, high insufflations pressures chest, both arms and abdomen as the patient had developed
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and prolonged surgical time. Recently, the influence of subcutaneous emphysema. Complication was notified to the
insufflations pressures and surgical duration has been surgeon and laparoscopic check was made for any rent in
World Journal of Laparoscopic Surgery, September-December 2013;6(3):173-175 173