The Beneficial Effects of Positive End Expiratory Pressure on the Circulatory System in a Porcine Model of Carbon DioxidePneumoperitoneum

Authors: Fyntanidou B^1a*,Kotzampassi K^2b, Kazakos G^3c, Apostolopoulou A^4a, Kyparissa M^5d, Palaska E^6d, Lolakos K^7e, Grosomanidis V^5d

¹MD, PhD, MSc Emergency Medicine
²MD, PhD, Surgery
³DVM, PhD, Veterinary Medicine
⁴MD, PhD, Emergency Medicine
⁵MD, PhD, Anesthesiology
⁶MD, PhDc, MSc, Anesthesiology
⁷MD, Anesthesiology

^aEmergency Department, AHEPA Hospital, Thessaloniki, Greece.
^bDepartment of Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
^cCompanion Animal clinic, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece.
^dClinic of Anesthesiology and Intensive Care, School of Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece.
^e1st Department of Cardiac Surgery, Thessaloniki Heart Institute, European Interbalkan Medical Center, Thessaloniki, Greece.

*Corresondence: Kautatzoglou 14A, 54639, Thessaloniki, Greece, Tel: 0030 6977427336, e-mail:

ABSTRACT

Positive End Expiratory Pressure (PEEP) application and Intra-Abdominal Pressure (IAP) increase have individually detrimental effects on the circulatory system. The aim of the present study was to investigate the effects of three different PEEP levels on the circulatory system in a porcine model of carbon dioxide pneumoperitoneum (PNP). PNP at 12mmHg was established by carbon dioxide insufflation in ten pigs after anesthesia induction. PEEP levels were gradually increased from 0 to 15cmH₂O and thereafter pigs were disconnected from the ventilator. The duration of each study phase was 15min (Time Period A). After measurements were obtained, PNP was evacuated and the intra-abdominal cavity was opened. The whole previously described procedure of Time Period A was once more repeated (Time Period B).Appropriate monitoring was used in order to be able to measure Heart Rate (HR), Arterial Pressure (Systolic-SAP, Diastolic-DAP and Mean-MAP), Cardiac Output (CO), Stroke Volume (SV) and Peak Airway Pressures (PIP) at five study phases namely P0: PEEP=0cmH₂O, P1: PEEP=5cmH₂O, P2: PEEP=10cmH₂O, P3: PEEP=15cmH₂O and P4=ventilator disconnection.During Time Period A, gradual PEEP increase caused a raise in CO from 3.8 to 4.7l/min, which returned to baseline values after the ventilator was disconnected. Statistically significant differences compared to baseline values were recorded at P2 and P3. Stroke Volume showed similar alterations. Gradual PEEP increase did not cause any statistically significant alterations regarding HR, SAP, DAP and MAP. On the opposite, during Time Period B, gradual PEEP increase resulted in a decrease of CO from 3.9 to 2.3l/min, which was restored after the ventilator was disconnected. Statistically significant differences compared to baseline values were recorded at P2 and P3. Stroke Volume showed similar alterations. Moreover, at P2 and P3, SAP, DAP and MAP decreased in a statistically significant manner.Comparison between the two study Time Periods at the corresponding Phases revealed statistically significant differences with regard to CO at P2 and P3, to SV at P2, P3 and P4, to HR at P4, to SAP, DAP, MAP at P2 and P3 and to PIP at P0, P1, P2 and P3.PEEP application had beneficial effects on the circulatory system in a porcine model of pneumoperitoneum

 

INTRODUCTION

Cessation of spontaneous breathing and initiation of mechanical ventilation are necessary interventions during general anesthesia, which however have various effects on the cardiovascular system.

Those effects are influenced by several factors such as tidal volume, patients’ volume status and cardiac function^1-5 and are more intense in hypovolemic patients^5,6.

Since heart and lungs are located in the thoracic cavity, a constant heart-lung interaction occurs both during spontaneous breathing and under mechanical ventilation.Immediately after initiation of anesthesia and before any surgical intervention, atelectasis occurs in the majority of patients, which remains for several days after the operation⁷.

The extent of atelectasis is associated with the severity of intrapulmonary shunt and oxygenation impairment.

Positive End Expiratory Pressure (PEEP) application has been used as a method to prevent or eliminate atelectasis during mechanical ventilation^8,9.

PEEP application has an impact on the circulatory system, which is influenced by patients’ heart function and volume status^10-12. Right and left heart might be affected in a different manner by PEEP application¹³ and PEEP could be beneficial in patients with impaired left heart function¹⁴.

Since the beginning of 1980s, laparoscopic surgery has become popular and widely accepted due to its numerous advantages¹⁵. Establishment of pneumoperitoneum (PNP) by carbon dioxide insufflation is an absolute prerequisite for laparoscopic surgery. Intra-Abdominal pressure (IAP) increase has various effects on the respiratory and circulatory system. Haemodynamic alterations after IAP increase have been thoroughly studied since many years. According to experimental and clinical studies, IAP increase causes a CO decline, which initially occurs at IAP level of 10mmHg and becomes really obvious and significant after IAP level of over 20mmHg^17-21.Factors contributing to those alterations are preload decrease and afterload increase. Preload decrease is attributed to Intra-Thoracic Pressure (ITP) increase caused by the cranial displacement of the diaphragm and the subsequent decrease in venous return. Afterload increase is attributed to peripheral vascular resistance increase due to mechanical compression of blood vessels²².

IAP increase induces compression of inferior vena cava (IVC), causing thereby alterations in venous return and vessel resistance²³ which finally result in CO decrease. The degree of decline depends on IAP level, patients’ clinical condition and volume status²¹ and it is more excessive in hypovolemic patients²³.

The individual effects of either PEEP or IAP alone have been thoroughly investigated both in experimental and clinical studies. However, the simultaneous impact of both of those factors has not yet been fully elucidated and there is still debate in the literature^24,25.

The aim of the present study was to investigate the effects of three different PEEP levels on the circulatory system in a porcine model of carbon dioxide PNP.

Material and Methods

This experimental study was conducted in the animal laboratory at AHEPA University Hospital Thessaloniki after obtaining the appropriate approval by the ethics committee for the use of experimental animals of the National Board on Animal Care and Use.

Ten male pigs with an age of 3months and a body weight of 25kg were included in this study.

After premedication (intramuscular injection of ketamine 10mg/kg and dexmedetomidine 10μg/kg) an intravenous catheter was placed on the lateral ear vein via which fluids (Lactated Ringer) and anesthesia inductions agents were administered.

Anesthesia was induced by intravenous administration of thiopental (5mg/kg), rocuronium (1mg/kg), lidocaine (1mg/kg) and fentanyl (0,05mg). Two min after drug administration, laryngoscopy and endotracheal intubation were performed, which were followed by initiation of mechanical ventilation. Siemens Servo C was used for mechanical ventilation and the ventilation settings were:Synchronized intermittent mandatory ventilation with pressure support(SIMV+PS), Tidal Volume (Vt) =10ml/kg, Respiratory Rate(RR): 15/min and Fraction of inspired oxygen (FiO₂)=1. Vt was modified according to the ETCO₂ levels in order to achieve normocapnia

Anesthesia was maintained with sevoflurane (2%) and propofol infusion. Fentanyl was administered for analgesia and intermittent appropriate doses of rocuronium for maintenance of muscle relaxation.

Femoral vessels were surgically exposed and prepared under general anesthesia and mechanical ventilation. A single lumen catheter (20G) was inserted in the femoral artery for invasive arterial pressure monitoring and a sheath was introduced in the femoral vein, which was used both for fluids administration and for the placement of a pulmonary artery catheter-PAC (Swan Ganz-SG). SG was introduced via the sheath and its correct position was recognized and confirmed by the corresponding waveforms. SG was used to measure right atrium pressure, pulmonary artery pressure, mixed venous oxygen saturation and for continuous CO monitoring. The arterial catheter and SG were both connected via transducers to a Datex monitor in order to be able to continuously monitor and record pressures.

Along with invasive direct measurement of the arterial pressure and continuous CO measurement via PAC, monitoring also included ECG (3 leads) and capnography.

Recorded parameters included CO: Cardiac Output, SV: Stroke Volume, HR: Heart Rate, SAP: Systolic Arterial Pressure, DAP: Diastolic Arterial Pressure, MAP: Mean Arterial Pressure and PIP: Peak Inspiratory Pressure.

According to the study protocol, there were two different Time Periods, Time Period A and Time Period B (Table 1).

Time Periods of the study
Time Period A (TP-A)	Time Period B (TP-B)
PNP: establishment by CO2 insufflation (12mmHg)	PNP: evacuation, intra-abdominal cavity was opened

PNP: pneumoperitoneum

Table 1. Time Periods of the study

During Time period A (TP-A)and under hemodynamic and respiratory stability, PNP at 12mmHg was established by carbon dioxide insufflation. Study parameters were recorded at five different phases, namely P0: PEEP=0cmH₂O, P1: PEEP=5cmH₂O, P2: PEEP=10cmH₂O, P3: PEEP=15cmH₂O and P4= ventilator disconnection. During P4 apneic oxygenation was applied to maintain appropriate oxygenation.

Immediately after measurements were obtained, PNP was evacuated and the intra-abdominal cavity was opened(Time Period B, TP-B). Parameters were once more recorded 30min after laparotomy at the five study phases previously described, namely P0: PEEP=0cmH₂O, P1: PEEP=5cmH₂O, P2: PEEP=10cmH₂O, P3: PEEP=15cmH₂O and P4= ventilator disconnection.

After all measurements were obtained (TP-A and TP-B), pigs were euthanized by injection of thiopental (5mg/kg) and potassium chloride 10% (2gr potassium chloride, 26.8mEqK⁺)

For the statistical analysis ANOVA model for repeated measures was employed (SPSS25).

RESULTS

PEEP application caused PIP increase during both study time periods. However, this increase was statistically significant different between the two time periods, TP-A and TP-B, at all study phases (p<0.001).

During TP-A, the gradual PEEP increase from 0 to 15cmH₂O caused a raise in CO, which returned to baseline values after ventilator disconnection. Statistically significant differences compared to baseline values were recorded at P2 (PEEP:10cmH₂O) and P3 (PEEP:15cmH₂O).

Stroke Volume showed similar alterations.Gradual PEEP increase did not cause any statistically significant alterations regarding HR, SAP, DAP and MAP.

On the opposite, during TP-B, the gradual increase of PEEP resulted in CO decrease, which was restored after ventilator disconnection. Statistically significant differences compared to baseline values were recorded at P2 (PEEP: 10cmH₂O) and P3 (PEEP: 15cmH₂O).

Gradual PEEP increase caused a raise in HR, but not in a statistically significant manner. Nevertheless, at the time of ventilator disconnection, HR decreased in a statistically significant manner compared to baseline values.

SV showed a statistically significant decrease compared to baseline values at P2 (PEEP: 10cmH₂O) and P3 (PEEP: 15cmH₂O) and a statistically significant increase at P4 (ventilator disconnection).

All alterations are depicted on Table 2 and Figures 1 to 5.

Comparison between the two study time periods at the corresponding study phases revealed statistically significant differences with regard to CO at P2 and P3, to SV at P2, P3 and P4, to HR at P4, to SAP, DAP, MAP at P1, P2 and P3 and to PIP at P0, P1, P2 and P3.

 

Phases of measurement	TP-A	TP-B	TP–A vs TP-B
	CO
P0	3,8±0,7	3,9±0,7	NS
P1	4,1±0,6	3,4±0,8	NS
P2	4,5±0,6**	2,8±0,8**	p<0,001
P3	4,7±0,5**	2,3±0,8**	p<0,001
P4	3,7±1	4,5±0,9	NS
	SV
P0	36,1±10,9	39,9±15,1	NS
P1	39,1±10,7	35,3±14,3	NS
P2	41,3±9,4*	27,8±13,6**	p<0,01
P3	42,7±8,6**	21,6±11,6**	p<0,001
P4	31,4±7,4*	46,8±16,1**	p<0,001
	HR
P0	109,1±24,8	108,6±29,9	NS
P1	111,2±25,1	112,3±34,6	NS
P2	114±25,8	121,1±36	NS
P3	114,9±24,6	125,4±41	NS
P4	119,2±22,5	99,1±19,6*	p<0,01
	MAP
P0	114,2±14,7	106,8±17,2	NS
P1	117,6±16,4	101,4±14,4	p<0,05
P2	111,8±13,3	92,4±18,1*	p<0,05
P3	108,2±17,8	69,5±20,1**	p<0,01
P4	118,9±13,4	108,5±10,7	NS
	PIP
P0	26,8±2	19,1±2,2	p<0,001
P1	32,9±2,8**	25,5±2,4**	p<0,001
P2	37,6±3,1**	32,4±3,2**	p<0,001
P3	44,5±2,9**	38,6±2,4**	p<0,001

TP: Time Period, CO: Cardiac Output, SV: Stroke Volume, HR: Heart Rate, MAP: Mean Arterial Pressure, PIP: Peak Inspiratory Pressure, *p<0,05, **p<0,01, ***p<0,001. 

Table 2. Mean values±standard deviation, comparison between the two time periods.

 

 

 

 

 

DISCUSSION

According to our protocol design, the aim of this study was to investigate the effects of three different PEEP levels on the circulatory system in a porcine model of carbon dioxide PNP. Measurements were obtained during two time periods, TP-A and TP-B.

During TP-A (PNP: 12mmHg), the gradual PEEP increase from 0 to 15cmH₂O caused a raise in CO but did not cause any statistically significant alterations regarding HR, SAP, DAP and MAP. Ventilator disconnection caused a CO decrease but not in a statistically significant manner. However, this effect might have been more intense and significant if the time duration of the study phase was prolonged for more than 15min.

It is established knowledge that cessation of spontaneous breathing and initiation of mechanical ventilation will cause Intra-Thoracic Pressure (ITP) increase, which will have various effects on the respiratory and cardiovascular system^26,27.

PEEP application is a method used to prevent atelectasis and improve oxygenation, which however causes additional ITP alterations and has an impact on the hemodynamic status of the patients^28,29. All those effects are influenced by patients’ heart function and volume status.

Patients with acute left-sided heart failure might benefit from these effects, which are actually utilized during treatment of pulmonary edema^30,31.

In daily clinical practice these effects are attenuated by advanced mechanical ventilation settings and low tidal volume protective ventilation strategy³².

It is also established knowledge that PNP causes IAP increase which results in CO decline^17,33. This decline is more significant in the hypovolemic patient and is minimized in the hypervolemic one since CO is depended on venous return and preload of the left ventricle^23,34. The impact of IAP increase on the circulatory and respiratory system has been investigated since many years²³.

During TP-A, two factors were present (PEEP and PNP) each of which has an individual negative impact on CO and in general on the circulatory system. Somebody could assume that coexistence of those two factors would have an additive effect. However, this was not recorded in our study and indeed gradual PEEP increase under PNP had altogether a beneficial effect on the circulatory system of study animals.

In their study Fellahi J-L end all, caused an initial IAP increase by means of medical antishock trousers (MAST) and then they applied PEEP of 10cmH₂O via a CPAP Boussignac mask²⁴.  They concluded that application of MAST inflated to 30 cm H₂O in the abdominal compartment caused an increase in the afterload of the left ventricle. Subsequent PEEP application reduced the preceding increase of the afterload of the left ventricle for more than 50% and restored end-systolic diameter of the left ventricle which returned to baseline values.

In another study, Bernard D et al concluded that PEEP application at 10cmH₂O in 20 patients undergoing laparoscopic liver surgery did not cause any decrease in CO²⁵.

Similarly, Russo et al, did not record any cardiovascular alterations after PEEP application at 5 and 10cmH₂O during laparoscopic surgery³⁵.

In a meta-analysis of 21 RCTs (n=1554), Yessenbayeva G end al reported that even high levels of PEEP did not have any detrimental effects on arterial pressure and/or heart rate³⁶.

Our results regarding the impact of PEEP in the setting of PNP are in line with those studies. However, it is not possible to compare results derived from these different studies due to high heterogeneity between protocols with regard to IAP levels, patient positioning, recorded parameters and methods used for measurement (hemodynamic monitoring, ultrasound).

During TP-B (open abdomen), gradual PEEP increase from 0 to 15H₂O caused a decrease in CO, SAP, DAP and MAP. All those anticipated alterations are well documented in recent and previously published literature studies. PEEP application has a beneficial effect on oxygenation but has a negative impact on the cardiovascular system^27,28,37.

About 17% of the total vascular volume is in the vasculature of the thoracic cavity (heart and lungs) and 9% is in the pulmonary circulation. Every condition that has an impact on blood volume has a direct effect on CO and on patients’ hemodynamics³⁷.

Heart chambers and major blood vessels are directly affected by pleural pressure (Ppl) alterations. On the other hand, heart and major blood vessels are surrounded by pericardium, which is acutely inextensible and therefore due to ventricular interdependence every acute volume alteration of one of the two ventricles has an impact on the other via displacement of the interventricular septum³⁷.

Hemodynamic effects of mechanical ventilation are attributed to the fact that heart and lungs are located in the thoracic cavity. Under normal conditions (spontaneous breathing) heart-lung interactions do not have any significant hemodynamic effects. However, Ppl increase by cessation of spontaneous breathing and initiation of mechanical ventilation has a significant impact on the cardiovascular system^1,38.

PEEP application contributes to a further increase in Ppl and right atrium pressure and causes a decrease in venous return, which affects preload and leads to CO decline. The raise of the right ventricular afterload due to the pulmonary vascular resistance increase has an additional contribution to this CO decline³⁹.

Establishment of PNP during laparoscopic surgery increases IAP. According to the guidelines of the World Society of the Abdominal Compartment Syndrome, intra-abdominal hypertension is defined as an increase in IAP of more than 12mmHg⁴⁰.

IAP elevation causes a cranial displacement of the diaphragm and in addition to that abdominal pressure is transmitted at around 50% to the thorax⁴¹. At the same time, IAP increase induces compression of the IVC, aortic compression, decrease in the splanchnic and renal blood flow⁴² and increase in the Systemic Vascular Resistance (SVR) due to compression of the aorta and the rest of the vasculature and in the Pulmonary Vascular Resistance (PVR) due to lung compression⁴³. All those alterations lead to venous return decline.

Hypovolemic patients are experiencing hemodynamic changes at lower levels of IAP. On the other hand, hypervolemic patients are experiencing venous return decrease only at higher levels of IAP, which reflects that fluid administration contributes to avoidance of the detrimental effects of IAP increase¹⁶.

ITP increase due to cranial displacement of the diaphragm causes direct compression of the heart and decline in its compliance and contractility¹⁸.

Previously published old studies suggested that combination of PEEP and PNP had detrimental effects on patients’ hemodynamics^44-46. Those previously reported results have not been confirmed in our own experimental and clinical studies⁴⁷.

It is possible that factors such as IAP level, volume loading, anesthesia depth and patient position might have an influence and contribute to those different results.

PEEP application in the setting of PNP seems to mitigate the negative impact of IAP since the applied PEEP pressure has an opposite direction compared to IAP²⁴. In addition to that, PEEP application mitigates the raise in left ventricular afterload caused by IAP increase²⁴.

When IAP exceeds IVC pressure (P_IVC), IVC gets compressed. IVC compression occurs at the diaphragm level, where IVC enters the thorax. PEEP application can prevent IVC collapse and restore the pressure gradient between CVP and P_IVC^25,48,49.

This beneficial effect is mainly attributed to improvement of the filling function of the heart and decline in the afterload.

Well-designed future clinical studies could reach more clear and definitive conclusions regarding PEEP effects in the PNP setting.

Limitations of the study

This study was conducted in healthy animals in which PNP was established and PEEP was gradually increased from 0 to 15cmH₂O.

In the setting of laparoscopic surgery, applied PEEP rarely exceeds the level of 10cmH₂O and PNP is lower than 10mmHg. On the contrary, in the ICU setting high levels of PEEP are applied on patients suffering from ARDS and multiple organ failure with impaired heart function.

Moreover, all recorded and previously described effects might have been more intense and significant if the time duration of each study phase was prolonged for more than 15min. In addition to that, a prolonged study time period before laparotomy could give even more information.

Conclusion

According to the findings of this experimental study, PEEP application under carbon dioxide PNP improved CO and SV, whereas it did not affect HR, SAP, DAP and MAP.

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Additional materials: No

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Acknowledgements:Not applicable

Authors’ contributions:FB: drafted the paper and is the lead author; KK: contributed to planning and the critical revision of the paper; KG: contributed to planning and the critical revision of the paper; AA: contributed to planning and the critical revision of the paper; KM: contributed to planning and the critical revision of the paper; PE: contributed to planning and the critical revision of the paper; LK: contributed to planning and the critical revision of the paper; GV: contributed to planning and the critical revision of the paper. All authors read and approved the final manuscript.

Funding: Not applicable.

Availability of supporting data:The datasets analyzed during the current article are available fromthe corresponding author on reasonable request.

Ethical approval and consent to participate:Ethics committee approval required.

Competing interests: The authors declare no competing interests.

Received:November 2024, Accepted: December 2024, Published:December 2024

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Citation: Fyntanidou B, Kotzampassi K, Kazakos G, Apostolopoulou A, Kyparissa M, Palaska E, Lolakos K, Grosomanidis V. The beneficial effects of Positive End Expiratory Pressure on the circulatory system in a porcine model of carbon dioxide pneumoperitoneum.Greek e j Perioper Med. 2024;23(d):35-50.

 

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