Yonsei Med J 49(4):676 - 679, 2008 DOI 10.3349/ymj.2008.49.4.676 Pulmonary Edema after Catastrophic Carbon Dioxide Embolism during Laparoscopic Ovarian Cystectomy Yoonki Lee, Eun Sung Kim, and Hae Jin Lee Department of Anesthesiology, School of Medicine, The Catholic University of Korea, Seoul, Korea. Laparoscopy is a surgical procedure used both for diagnosis and for various treatments. A rare but sometimes fatal complication of laparoscopy is pulmonary embolism with CO2 resulting in pulmonary edema. During laparoscopic gynecolo- gical surgery in a 29-year-old woman who had previously undergone lower abdominal surgery, the end-tidal CO2 suddenly increased from 40 mmHg to 85 mmHg and then decreased to 13 mmHg with hemodynamic deterioration. These events are characteristic of a CO2 embolism. When this occurred, CO2 insufflation was immediately stopped and the patient was resuscitated. The patient's condition gradually improved with aggressive treatment, but the clinical course was complicated by bilateral pulmonary edema. This case of pulmonary edema was soon resolved with supportive manage- ment. The formation of a CO2 embolism during laparoscopy must be suspected whenever there is a sudden change in the end-tidal CO2. In addition, the possibility of pulmonary edema should be considered when a CO2 embolism occurs. Key Words: Carbon dioxide, laparoscopy, pulmonary edema, pulmonary embolism INTRODUCTION Carbon dioxide (CO2) is used as a distention medium during laparoscopy because it is more tolerable to patients than other gases. However, the insufflation of several liters of CO2 along with an extreme Trendelenburg position can cause the following: rapid absorption of a large amount of CO2 into circulation, impeded compensatory ventilation with high intraabdominal pressure, Received February 2, 2007 Accepted March 24, 2007 Reprint address: requests to Dr. Hae Jin Lee, Department of Anesthesiology, School of Medicine, The Catholic University of Korea, St. Mary's Hospital, 62 Yeouido-dong, Yeongdeungpo-gu, Seoul 150-713, Korea. Tel: 82-2-3779-1322 Fax: 82-2-783-0368, E-mail: lehaji@catholic.ac.kr Yonsei Med J Vol. 49, No. 4, 2008 and decreased cardiac index with increased systemic and pulmonary vascular resistance. These occurrences can result in a rare CO2 embolism, a possibly fatal complication of laparoscopy.1 The CO2 embolism usually occurs during the insufflation of CO2 or immediately after the completion of CO2 insufflation,2 but one should also consider the unexpected occurrence of a CO2 gas embolism as late as a few hours after the patient has reached a stable cardiorespiratory status.3,4 Sometimes, an air embolism is accom- panied by pulmonary edema, which further complicates the management of the patient.5,6 It is difficult to predict whether or not pulmonary edema will occur during the clinical course of a CO2 embolism. We report a case of a life-threatening CO2 embolism with concomitant fulminant pulmonary edema that occurred approximately an hour after the completion of CO2 insufflation. CASE REPORT A 29-year-old healthy woman who had previ- ously undergone a cervical cerclage procedure for cervical incompetence was scheduled for laparos- copic gynecological surgery. The preoperative evaluation including chest PA was unremarkable (Fig. 1). Anesthesia was induced smoothly with tracheal intubation and was maintained with 1.5- 2% enflurane, 3 L/min nitrous oxide, and 2 L/min O2. The noninvasive blood pressure, electrocar- diography (ECG), pulse oximetry, end tidal CO2 (ETCO2) and urinary output were monitored. The abdomen was insufflated with CO2, and an intraabdominal pressure between 10 and 12 mmHg