Impairment of Cardiac Performance by Laparoscopy in Patients Receiving Positive End-Expiratory Pressure

Abstract

Background: The cardiopulmonary effects of the combination of abdominal and thoracic pressures in humans have not been well delineated. Objective: To study the cardiopulmonary effects of 15 mm Hg of intra-abdominal pressure in the presence and absence of 10 cm H 2 O of positive end-expiratory pressure (PEEP). Design: Prospective. Setting: University hospital. Methods: Nine patients undergoing laparoscopic cholecystectomy had pulmonary compliance, cardiac output, exhaled carbon dioxide, and preload (left ventricular end-diastolic volume) determined at 4 points while undergoing ventilation with (1) no PEEP before pneumoperitoneum; (2) 10 cm H 2 O of PEEP and no pneumoperitoneum; (3) no PEEP and 15 mm Hg of pneumoperitoneum; and (4) 10 cm H 2 O of PEEP and 15 mm Hg of pneumoperitoneum. Preload and cardiac output were determined by means of transesophageal echocardiog-raphy. Pulmonary compliance and exhaled carbon dioxide were determined by an attachment to the end of the endotracheal tube. Main Outcome Measures: Preload, cardiac output, exhaled carbon dioxide, and pulmonary compliance. Results: There was no significant change from baseline in preload, cardiac output, or pulmonary compliance when either PEEP or pneumoperitoneum was applied separately. However, there was a significant decrease in preload (PϽ.01), cardiac output (P = .01), and exhaled carbon dioxide (P = .04) when PEEP and pneumoperitoneum were applied together. Pulmonary compliance was not significantly affected at any of these points. Conclusions: There was a significant reduction in preload and cardiac output when there was intra-abdominal pressure of 15 mm Hg in the presence of 10 cm H 2 O of PEEP. This combination of pressures may pose a contraindication to laparoscopic surgery.

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).…”

Cardiac function during laparoscopic vs open gastric bypass

“…Several investigators have demonstrated a reduction in CO during pneumoperitoneum [1,7,12,15], whereas others have reported no change [2,4,6,11,13]. McLaughin et al [12] reported a 29.5% decrease in cardiac index in patients undergoing laparoscopic cholecystectomy.…”

“…In addition, others have observed that a 15 mmHg pneumoperitoneum appears to be the threshold for a decrease in cardiac output [2,3,6,11]. In an animal study, Kaklamanos et al [8] also found that prolonged pneumoperitoneum negatively affected cardiac output.…”

Systematic evaluation of different approaches for minimizing hemodynamic changes during pneumoperitoneum

“…These changes are caused by an increase in the intraabdominal pressure (IAP), which is supposed to reduce venous blood return to the heart [4,7,[18][19][20] followed by a decrease in intrathoracic blood volume (ITBV) or left ventricular end diastolic volume (LVEDV) [5,14,16,25]. Either ITBV or LVEDV is useful for assessing cardiac preload.…”