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Positive end-expiratory pressure during infrarenal aortic clamping limits hemodynamic impairment risk

Giustiniano, Enrico; Cancellieri, Franco; Battistini, Gian M; Dominoni, Cristina; Brancato, Gabriella; Spoto, Maria R

Journal of Cardiovascular Medicine: March 2009 - Volume 10 - Issue 3 - p 282–287
doi: 10.2459/JCM.0b013e3283249b00
Research trial protocol

Background Aortic clamping and unclamping abruptly impact hemodynamic assessment. First, vascular resistance and venous blood return increase, causing a cardiac stress; second, when the clamp has been replaced, vascular resistance falls and hypotension with low perfusion pressure risk occurs. We hypothesized that positive end-expiratory pressure (PEEP) during clamping could limit hemodynamic alterations, then its zeroing just before unclamping could guarantee a more stable blood pressure after restoring total circulation.

Methods Seventy-one patients submitted to aortic infra-renal aneurismectomy were divided into three groups according to PEEP application (0, 5 and 10 cmH2O) during the clamping phase. Just before restoring total circulation, PEEP was zeroed for all patients. Data were collected before clamping, during clamping and after clamp release.

Results After aortic clamping, PEEP of 10 cmH2O significantly limited the mean arterial pressure increase (P = 0.017). The same occurred with a PEEP of 5 cmH2O, but it was not statistically significant (P = 0.341). In group A (PEEP 0 cmH2O), mean and systolic blood pressure did not rise significantly (P = 0.478 and P = 0.403, respectively), but after unclamping, we recorded a significant reduction in mean arterial pressure (from 89.8 ± 10.2 to 80.6 ± 12.7 mmHg; P = 0.002) and systolic blood pressure (from 131.3 ± 14.7 mmHg to 116.8 ± 22.2 mmHg; P = 0.002). It did not occur in the PEEP 5 cmH2O group. In the PEEP 10 cmH2O group, only mean arterial pressure reduced significantly, even if its variation was more limited than in the zero end-expiratory pressure (ZEEP) group (from 86.9 ± 12.1 to 81.4 ± 8.1 mmHg; P = 0.028).

Conclusion PEEP–mechanical ventilation during the clamping phase of infrarenal aortic aneurismectomy can limit blood pressure variation due to clamping and unclamping.

Dipartimento di Anestesia e Terapia Intensiva Generale, Istituto Clinico Humanitas, IRCCS, Rozzano, Milan, Italy

Received 24 July, 2008

Revised 8 November, 2008

Accepted 1 December, 2008

Correspondence to Enrico Giustiniano, Dipartimento di Anestesia e Terapia Intensiva Generale, Istituto Clinico Humanitas, Via Manzoni 56, 20089 Rozzano, Milan, Italy Tel: +39 02 82244115; fax: +39 02 82244190; e-mail:

© 2009 Italian Federation of Cardiology. All rights reserved.