Severe hypercapnia and hemodynamic instability following a sudden elevation in end-tidal CO₂ during thoraco-laparoscopic esophagectomy: a case report and literature review.

BACKGROUND

Establishing thoracoscopic pneumothorax in patients with extensive pleural adhesions often increases the risk of trocar-related lung injury, potentially causing abrupt extreme elevations in end-tidal carbon dioxide (ETCO₂) and precipitating life-threatening hemodynamic instability. Given the rarity of such events and complication in recovery, clearer recommendations for early recognition are needed to inform subsequent perioperative management.

CASE PRESENTATION: A 61-year-old male undergoing elective thoraco-laparoscopic esophagectomy for esophageal cancer who had an abrupt elevation in PETCO₂ of 213 mm Hg, accompanied by severe hemodynamic instability-including hypertensive crisis, tachycardia, and subsequent progressive bradycardia during the establishment of a thoracoscopic pneumothorax. Surgical exploration revealed extensive pleural adhesions and a trocar-related injury of the right lower lung, which allowed a large volume of CO₂ to enter the alveoli and airways, resulting in a dramatic rise in PETCO₂. The excessive CO₂ rapidly diffused into the pulmonary circulation, causing a significant increase in PaCO₂ and precipitating severe hypercapnia with acute hemodynamic instability. Following surgical intervention to the injured lung and after showing visible ventilation improvement, and hemodynamic stabilization, the procedure was successfully completed without any complications during recovery.

CONCLUSIONS

Patients with extensive pleural adhesions are at increased risk of trocar-related lung injury during the establishment of CO₂ pneumothorax. Continuous intraoperative ETCO₂ monitoring can facilitate early detection with cases of this type. Prompt recognition, effective hemodynamic management, and appropriate use of ventilatory support are essential to prevent potentially life-threatening complications.