To the Editor:—
Bispectral index (BIS) and entropy measure electroencephalographic voltage between electrodes placed on the forehead. BIS is used to monitor and quantify depth of hypnosis1and to guide anesthetic drug administration during general anesthesia.2Entropy assesses loss of consciousness by the quantification of the degree of spatial and temporal integration of cerebral neuronal activity.3An entropy monitor has been introduced recently; it provides two indices, state entropy and response entropy, that decrease in healthy volunteers receiving propofol with a brief intervening period of wakefulness4and in surgical patients during propofol anesthetic induction.5
We report two cases of perioperative gas embolism encountered during laparoscopic surgery while patients were being monitored simultaneously by BIS (Aspect A-2000 XP®, version 3.11; Aspect Medical Systems, Newton, MA) and entropy of electroencephalogram (S/5™ M-Entropy plug-in Module; Datex-Ohmeda Company, Limonest, France).
In our first case, an 83-yr-old man was scheduled for a laparoscopic hemicolectomy under general anesthesia. Target-controlled infusion of propofol and remifentanil was achieved using a computer-assisted infusion device6while atracurium was administered continuously after a bolus. Standard monitoring was used as was BIS and entropy monitoring. Pneumoperitoneum was achieved with carbon dioxide. The first 90 min of anesthesia and surgery were uneventful. Suddenly, BIS and entropy indices dropped to zero as shown in figure 1. Partial pressure of end-tidal carbon dioxide decreased a few seconds later from 28 mmHg to 19 mmHg and arterial hypotension of 80/45 mmHg was noted (it was previously 149/85 mmHg). The surgeon reported no bleeding. Gas embolism was suspected, and the dramatic change in electroencephalographic-derived indices led to immediate exsufflation and conversion to laparotomy. BIS and entropy remained at low values for approximately 25 min with almost 100% burst suppression even after hemodynamic stability was restored. The colectomy was completed, the anesthetic was discontinued, and the patient awoke. Neurologic examination was performed and was normal. Transesophageal echocardiography performed the day after surgery confirmed a patent foramen ovale.
In our second case, a 46-yr-old woman was scheduled for a laparoscopic cholecystectomy. Anesthesia and monitoring were similar to case 1. Shortly after the onset of carbon dioxide insufflation, partial pressure of end-tidal carbon dioxide suddenly decreased from 32 to 10 mmHg and arterial pressure decreased to less than 60 mmHg. BIS and entropy values decreased to approximately 20 and the burst suppression ratio was 80% within seconds. Laparoscopy showed a tear in the surface of the liver. The pneumoperitoneum was immediately exsufflated, and a laparotomy was performed. BIS and entropy values regained their former values within 5 min, but arterial pressure and partial pressure of end-tidal carbon dioxide remained low for 15 min. Cholecystectomy was performed. Transesophageal echocardiography performed during anesthesia revealed no septal defect. Anesthesia was discontinued at the end of the procedure and the patient awoke. Neurologic examination was normal.
Sudden decreases in BIS have been reported at the onset of clinical deterioration. England was the first to describe the changes in BIS during a hypovolemic cardiac arrest.7An acute decrease in BIS can reflect cerebral hypoperfusion8–10or cerebral embolization.11An alternative explanation for an acute decrease in electroencephalographic-derived indices is an increase in plasma concentration of an anesthetic drug, especially propofol, as a result of rapid alteration of its elimination.12
Our two cases showed simultaneous acute and profound decrease of BIS and entropy indices that forced the anesthesiologist to react quickly. After verification of good signal quality, the low level of electromyogram, the stability of anesthetic drug concentrations and the absence of acute bleeding, the diagnosis of gas embolism was made; this is a known complication of laparoscopic surgery. Using transesophageal echocardiography, a very sensitive method of detection, Derouin et al. reported gas embolism in 11 of 16 patients undergoing laparoscopic cholecystectomy.13The clinical impact of gas embolization can be as serious as cardiac arrest;14however, in most instances there are no lasting effects, probably because of the high solubility of carbon dioxide bubbles. Electroencephalographic monitoring modified the surgical and anesthetic management in our two cases. The chronology of events varied between the cases. In the first case, carbon dioxide bubbles reached the brain very rapidly through the patent foramen ovale; BIS and entropy values decreased before any significant changes in other parameters. Other methods of early detection of paradoxical gas embolism have been reported during laparoscopic cholecystectomy; by transesophageal echocardiography15and by transcranial Doppler.16In our second case, in which a patent foramen ovale was ruled out, the decrease of BIS and entropy was observed after hemodynamic and respiratory parameters changed and was transient, reflecting a decrease in cardiac output as a result of gas embolization.
Finally, anesthesiologists should be aware of the potential for venous gas embolization during routine laparoscopic procedures; BIS or entropy monitoring may play a role in early detection and could complement routine monitoring.
* Foch Hospital, Suresnes, France. firstname.lastname@example.org.