Hemodynamic and respiratory effects of pneumoperitoneum and PEEP during laparoscopic pelvic lymphadenectomy in dogs

Abstract

Extended laparoscopic operations are being performed increasingly in high-risk patients. To assess the effects of increased intraabdominal pressure (IAP) and positive end-expiratory pressure (PEEP) on the hemodynamic and respiratory system during extended procedures a carbon dioxide pneumoperitoneum was artificially induced in 10 dogs undergoing laparoscopic pelvic lymphadenectomy. An increase in IAP up to 15 mmHg had no negative effect on the cardiovascular system. However, the combination of an increased IAP (10-15 mmHg) with PEEP (8 cmH2O) markedly depressed the hemodynamic variables. Measurement of arterial carbon dioxide and fractional end-tidal carbon dioxide revealed significant CO2 retention. We conclude from the results that laparoscopic pelvic lymphadenectomy should be performed in high-risk patients only under general anesthesia with expanded cardiopulmonary monitoring.

Laparoscopic surgery: Pitfalls due to anesthesia, positioning, and pneumoperitoneum

“…However, the anesthesiologist will consider the disadvantages of hypercapnia and acidosis vs the increases in inspiratory peak and plateau pressures that may induce ventilator induced lung injury (VILI). Although positive endexpiratory pressure (PEEP) improves the pulmonary gas exchange during PP [37], it should be realized that PEEP in combination with increased IAP increases the intrathoracic pressure, thus causing a reduction in CO [38]. Because of these pulmonary changes, insufflation with other gases such as argon, xenon, helium, and room air was investigated [39][40][41][42][43][44].…”

Deterioration of Visceral Perfusion Caused by Intra-Abdominal Hypertension in Pigs Ventilated with Positive End-Expiratory Pressure

“…Moreover, PEEP might be especially advantageous to patients whose respiratory mechanism is compromised by an elevation in IAP, as this decreases diaphragmatic excursion, resulting in decreased end-expiratory tidal volume, which may in turn increase CO 2 retention. 3 Studies on the effects of PEEP ventilation on regional vascular beds have yielded conflicting results; however, most of them strongly suggest a decrease in abdominal splanchnic perfusion, caused by a progressive decline in cardiac output, and subsequent abnormalities of its distribution. [4][5][6] These suggestions derived from experimental and clinical studies led us to suspect that the Abstract Experimental studies and clinical experience suggest that the combination of positive end-expiratory pressure (PEEP) ventilation and intra-abdominal hypertension might alter splanchnic hemodynamics to a significantly greater degree than the effect of either of them alone.…”

Circulatory and Respiratory Complications of Carbon Dioxide Insufflation

“…Although ventilation with positive end-expiratory pressure significantly improves pulmonary gas exchange [33, 34]and preserves arterial oxygenation during prolonged pneumoperitoneum [35]it should be noted that positive end-expiratory pressure in the presence of elevated intra-abdominal pressure, increases the intrathoracic pressure and produces marked reduction in cardiac output. Therefore, it should be applied cautiously [36, 37, 38, 39]. A modern ventilation technique is the ‘alveolar recruitment strategy’, consisting of manual ventilation to an airway pressure of 40 cm H 2 O for 10 breaths over 1 min, followed by usual mechanical ventilation with mild positive end-expiratory pressure (5 cm H 2 O).…”