P033: CARDIOVASCULAR COLLAPSE DURING ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: A CASE REPORT.
Enrique Puig, MD; Anesthesia and Associates
Case Report: A 66-year old female with a history of morbid obesity and a previous laparoscopic cholecystectomy was admitted with a one-week history of worsening epigastric pain. the dianosis of obstructive jaundice with ascending cholangitis was made and the decision to proceed with a therapeutic ERCP and stone extraction.
Following physician directed wire guided cannulation of the biliary tree, a cholangiogram was performed revealing a distal CBD stone measuring 10mm. A selective biliary sphincterotomy with ampulloplasty with an 8mm dilating balloon. No bleeding was noted after either intervention. A single balloon sweep was performed and purulent fluid along with a single stone were extracted into the duodenum. Due to her clinical picture consistent with cholangitis, a 10F x 9cm CBD plastic stent was placed into the common bile duct over a wire under fluoroscopy. Following stent placement, minor venous bleeding was noted from the proximal biliary tree. This was then followed by an abrupt drop in the patient’s end tidal CO2 (EtCO2). with hypotension and sinus tacycardia.The procedure was promptly terminated and the patient repositioned in the supine position and ACLS protocol was initiated immediately.
As part of the resuscitative efforts a transthoracic echocardiogram was used to aid in the differential diagnosis of the sudden hemodynamic collapse. Air was grossly identified in the right atrium and right ventricle. At this point, the patient was positioned in the left side down position and a right internal jugular catheter was inserted promptly. Air was aspirated out of the right heart which resulted in prompt return of normal EtCO2 and the return of normal hemodynamics and peripheral perfusion. The patient was stabilized and transferred to ICU overnight. She was discharged home few days later without any neurological sequela
Discussion: Systemic air embolism is a less common but a devastating complication which may be overlooked as a cause of hemodynamic collapse during ERCP or any other endoscopic procedure in the gastrointestinal (GI) suite. Increased awareness of the risk factors such as inflammatory diseases of the GI tract, clinical manifestations, diagnostic tools, and treatment modalities, is paramount to a successful outcome. (1, 2)
In our case capnography monitoring although nonspecific was a crucial element in alerting the care team early to a hemodynamic problem since all our interventional ERCPs are performed under general anesthesia with endotracheal intubation and EtCO2 monitoring.
Moreover the early use of transthoracic echocardiography in this case proved to be an invaluable tool guiding the care team toward the correct diagnosis and the adequate therapeutic steps such as patient repositioning (left lateral decubitus) and air lock aspiration through a central venous catheter along with the routine resuscitative measures allowing the return of a spontaneous and adequate perfusion. Hyperbaric oxygen therapy has been cited as a therapeutic modality however it was not used in our case since the patient made an early recovery without any sequela. (3)