Pulmonary perfusion during anesthesia and mechanical ventilation

Cardiac output and the pulmonary perfusion can be affected by anesthesia and by mechanical ventilation. The changes contribute to impeded oxygenation of the blood. The major determinant of perfusion distribution in the lung is the relation between alveolar and pulmonary capillary pressures. Perfusion increases down the lung, due to hydrostatic forces. Since atelectasis is located in dependent lung regions, perfusion of non-ventilated lung parenchyma is common, producing shunt of around 8-10% of cardiac output. In addition, non-gravitational inhomogeneity of perfusion, that can be greater than the gravitational inhomogeneity, adds to impeded oxygenation of blood. Essentially all anaesthetics exert some, although mild, cardiodepressant action with one exception, ketamine. Ketamine may also increase pulmonary artery pressure, whereas other agents have little effect on pulmonary vascular tone. Mechanical ventilation impedes venous return and pushes blood flow downwards to dependent lung regions, and the effect may be striking with higher levels of PEEP. During one-lung anesthesia, there is shunt blood flow both in the non-ventilated and the ventilated lung, and shunt can be much larger in the ventilated lung than thought of. Recruitment manoeuvres shall be directed to the ventilated lung and other physical and pharmacological measures can be taken to manipulate blood flow in one lung anesthesia.