Pulmonary Edema after CO2 Embolism Fig. 1. Chest PA taken before the surgery shows no evidence of a definite abnormality. was maintained with the laparoscopic machine (CO2-aqua-purator 1611: WISAP: Germany), followed by the lithotomy and a 20 degree Trendelenburg head-down position. The surgery and anesthesia were uneventful for one hour with an arterial blood pressure (BP) of 100 - 120/70 - 100 mmHg, a heart rate of 70 - 102 bpm, ETCO2 of 30 - 40 mmHg, and SpO2 of 100%. During irrigation and bleeding control, the ETCO2 suddenly increased from 40 mmHg to 85 mmHg and then dropped to 13 mmHg. The BP decreased to 55/30 mmHg and a "mill-wheel" precordial murmur was heard on auscultation. A pulmonary CO2 embolism was suspected. In response to these events, the inhalational anesthetics were discontinued, and the FiO2 was changed to 100% while the CO2 insufflation was stopped and the laparoscope was removed. At the same time, a 1 mg bolus of epinephrine was administered intravenously with a continuous infusion of 1 mg epinephrine and 4 mg norepine- phrine in NS 100 mL while the IV fluid rate was increased. Despite these efforts, the BP and ETCO2 were still low. Every 2 - 3 minutes, 1.0 mg of Atropine was administered, but the patient's heart rate decreased further and no beat was observed for approximately 15 to 30 seconds. Immediately, chest compression was initiated. After 2 - 3 Fig. 2. Chest AP taken 40 minutes after the CO2 embolism shows newly developing bilateral extensive consolidations in the lungs, indicating pulmonary edema. minutes of compression, fine ventricular fibrillation was observed on the ECG, and defibrillator cardioversion (DC) at 200 J was delivered to the patient's anterior chest. The heart rate returned to sinus rhythm, but it was immediately converted to ventricular fibrillation. With another applica- tion of 200 J DC and 1% lidocaine 60 mg intra- venously, the beat was converted to sinus tachycardia. However, the BP was still low at 55/28 mmHg. The right subclavian vein was cannulated, and her hemodynamics improved gradually. Approxi- mately 40 minutes after the incident, her BP was 130/80 mmHg, her heart rate was 135 bpm, her ETCO2 was 30 mmHg, her SpO2 was 100%, with her FiO2 of 100%. At that time, chest radiography showed newly developing extensive bilateral consolidations in her lungs, suggesting pulmonary edema (Fig. 2). Twenty milligrams of Furosemide and 125 mg of methyl-prednisolone were admini- stered intravenously, and her central venous pressure was maintained within 5 mmHg. In order to locate the hidden bleeding, the lower abdomen was incised and examined. But the bleeding was negligible. A ventilator was applied to the patient in the intensive care unit, and supportive care was carried out to treat this case of pulmonary edema. Yonsei Med J Vol. 49, No. 4, 2008