Anaesthesiology Intensive Therapy, 2011,XLIII,3; 121-125 AAA

The effect of pneumoperitoneum on haemodynamic parameters in morbidly obese patients

*Tomasz Gaszynski

Department of Anaesthesiology an Intensive Therapy, !e i"al #niversity of $% & Background. The type of anaestheti" 'se affe"ts the "ar iovas"'lar f'n"tion in mor(i ly o(ese patients 'ring pne'moperitone'm) In this prospe"tive ran omi*e st' y, +e eval'ate the infl'en"e of inhalation anaesthesia +ith sevofl'rane or intraveno's anaesthesia +ith propofol on haemo ynami" performan"e in o(ese patients 'ring laparos"opy) Methods. ,atients s"he 'le for laparos"opi" (ariatri" pro"e 'res +ere ran omly ivi e into t+o gro'ps- sevofl'rane .gro'p /0 or propofol .gro'p ,0) 1aemo ynami" f'n"tion +as meas're 'sing the transoesophageal Doppler metho after in '"tion of anaesthesia .T10, ins'flation of 232 .T20 an in the anti-Tren elen('rg position +ith pne'moperitone'm .T30) Results. 3ne h'n re patients +ere enrolle in the st' y) The emographi" ata i not iffer (et+een the gro'ps) At T2, the (loo flo+ parameters an ventri"le e4e"tion parameters e"rease in (oth gro'ps +hereas the systemi" vas"'lar resistan"e an mean arterial press're in"rease ) The heart rate +as sta(le) At T3, afterloa parameters an heart rate in"rease in (oth gro'ps yet (loo flo+ parameters e"rease in gro'p ,) The "hanges o(serve +ere not a""ompanie (y any serio's "lini"al signs of "ar iovas"'lar eterioration) Conclusions. ,ne'moperitone'm has an important negative impa"t on haemo ynami" f'n"tion in mor(i ly o(ese patients ('t those "hanges are not a""ompanie (y severe "ar iovas"'lar ist'r(an"es) 5olatile anaesthesia provi es (etter haemo ynami" sta(ility 'ring laparos"opi" (ariatri" s'rgery in s'"h patients) 3(esity is met +hen the (o y mass in e6 .7!I0 is over 30 8g m-2; mor(i o(esity is "hara"teri*e (y 7!I9:0 8g m-2, an s'pero(esity (y 7!I950 8g m-2) In a ition to pro(lems +ith veno's a""ess, patient positioning an air+ay "ontrol, o(esity is asso"iate +ith many "ar iovas"'lar "on itions that have important impli"ations for the a ministration of anaesthesia) Altho'gh there are many papers availa(le on the haemo ynami" effe"t of pne'moperitone'm .,,0 in o(ese patients, they o not "ompare the infl'en"e of ifferent types of anaesthesia an anaestheti"s on the "ar iovas"'lar f'n"tion 'ring laparos"opy) ;rom the anaesthetist<s point of vie+, optimi*ation of

transoperative management represents a real "hallenge that may etermine the s'""ess of s'rgery, the evelopment of "ompli"ations, an the final o't"ome) The type of anaesthesia may re '"e the negative impa"t of ,, on "ar iovas"'lar f'n"tion) The aim of the st' y +as to "ompare the infl'en"e of t+o types of anaesthesia, inhalation .sevofl'rane0 an intraveno's .propofol0, on the hemo ynami" f'n"tion in mor(i ly o(ese patients at t+o important moments of the laparos"opi" pro"e 're- after "reating ,, an after positioning the patient +ith ,, in the anti-Tren elen('rg position) MET !"# After o(taining the approval of the Lo"al =thi"al 2ommittee .,roto"ol no) >??@25A@03@B=0 an +ritten informe "onsent from all s'(4e"ts, patients s"he 'le for ele"tive laparos"opi" a 4'sta(le gastri" (an ing +ere ran omly "hosen for prospe"tive, ran omi*e st' y) The in"l'sion "riteria +ere mor(i o(esity .7!I9:0 8g m20, A/A C II, ?D1A C II, an the e6"l'sion "riteria +ere "oe6isting "ar iovas"'lar iseases, e6"ept for +ell-"ontrolle hypertension) The patients +ere ivi e into t+o gro'ps- half of them +ere anaestheti*e +ith sevofl'rane@32@air .gro'p /0 an half +ith propofol TI5A .gro'p ,0) In (oth gro'ps, anaesthesia +as in '"e +ith propofol 1)5-2)0 mg 8g1 of the "orre"te (o y +eight, fentanyl 100 mg, mi a*olam 3 mg an atra"'ri'm 0)E mg 8g-1 of i eal (o y +eight) In gro'p /, the l'ngs +ere ventilate +ith a mi6t're of o6ygen, air an sevofl'rane in the oses epen ing on age an "lini"al parameters) In gro'p ,, anaesthesia +as maintaine +ith the "ontin'o's intraveno's inf'sion of propofol a""or ing to the >o(ertFs metho .(eginning the inf'sion +ith 10 mg 8g-1min-1 for 10 min, maintaining anaesthesia +ith E-G mg 8g-1min-1, en ing anaesthesia +ith :-E mg 8g-1min-10 In (oth gro'ps, repeate oses of fentanyl 0)005 mg 8g-1 of "orre"te (o y +eight an atra"'ri'm 0)2 8g-1 of i eal (o y +eight +ere a ministrate intraveno'sly) 1aemo ynami" f'n"tion +as meas're (y the transoesophageal Doppler metho 'sing a 1emo/oni" 100 evi"e .Arro+, #/A0) !eas'rements +ere performe at the follo+ing time points- T1 - after in '"tion of anaesthesia, T2 - ins'fflation of the a( omen ."reating ,,0, T3 H in the anti-Tren elen('rg position an ,,) The ,, press're +as set at 15 mm 1g .2 8,a0) The follo$ing parameters $ere recorded% &. real time, a 4'ste every 5 se"- heart rate .1>0, a""eleration .A""0, pea8 velo"ity .,50, left ventri"'lar e4e"tion time .L5=T0, mean aorti" iameter DI; '. estimate - "ar ia" o'tp't .230 an in e6 .2I0, stro8e vol'me ./50 an in e6 ./5I0; an systemi" vas"'lar resistan"e H /5> . yn se"-1"m-50) The meas'rements +ere ta8en "ontin'o'sly an a 4'ste a'tomati"ally (y the evi"e every 5 se") At ea"h time point, 2-: meas'rements +ere re"or e an means "al"'late ) The val'es of parameters at the in ivi 'al time points an the inter-point ifferen"es +ere analyse ) /tatisti"al signifi"an"e +as set at 5I) The istri('tion of ata +as teste +ith the /hapiro-Jil8 test) /tatisti"al analysis +as performe (et+een the s'(gro'ps 'sing

;rie man A?35A; ifferen"es (et+een gro'ps +ere analyse +ith the T'8eyFs post ho" test; the t-test an non-parametri" Jil"o6on test +ere 'se for epen ent samples; finally, "hanges in parameters (et+een the gro'ps +ere "ompare 'sing the t-test an the !ann-Jhitney test +as applie for non-parametri" ata) RE#()T# 2omplete sets of ata +ere "olle"te from :1 patients in gro'p / an from :0 in gro'p ,) ?o "ompli"ations +ere o(serve ) There +as no statisti"al ifferen"e in emographi" "hara"teristi"s (et+een the gro'ps .Ta(le 10) The initial haemo ynami" parameters .T10 +ere similar in (oth gro'ps) At T2, the (loo flo+ parameters an ventri"le e4e"tion parameters signifi"antly e"rease in (oth gro'ps .23, /5, A"", ,5, 2I an /5I0 +hereas /5> an !A, signifi"antly in"rease ) 7oth gro'ps sho+e a re '"tion in L5=T, ho+ever this e"rease +as only signifi"ant in gro'p ,) 1> +as sta(le) In gro'p /, no signifi"ant "hanges in the ma4ority of parameters .23, L5=T, A"", ,5 an 2I0 +ere o(serve at T3) 1o+ever, /5 an /5I e"rease signifi"antly +hereas /5>, !A, an 1> in"rease signifi"antly) In gro'p ,, 23, /5, ,5 an /5I also e"rease signifi"antly) The other parameters .L5=T, A"", 2I, 1>, !A,0 "hange as in gro'p /) Altho'gh the o(serve "hanges +ere signifi"ant, there +as no signifi"ant ifferen"e (et+een the gro'ps for most parameters at in ivi 'al time points, e6"ept for /5 at T3, A"" at T2, ,5 at T2, !A, at T2, an 1> at T3 .Ta(le 20) The analysis of ifferen"es (et+een the val'es at T2 an T3 reveale a signifi"antly higher e"rease in 23, /5, 2I, an /5I in gro'p , "ompare to gro'p / .Ta(le 30) In gro'p /, 23 in"rease at T3 +hile in gro'p , at T2) At T2, a higher !A, in"rease +as fo'n in gro'p / than in gro'p ,; at T3, a higher 1> in"rease +as o(serve in gro'p , "ompare to gro'p /) At T3, there +ere no signifi"ant ifferen"es (et+een the gro'ps for most parameters) 1o+ever, more parameters "hange signifi"antly in gro'p , than in gro'p /) "*#C(##*!+ Laparos"opy represents a mo ern metho of (ariatri" s'rgery, generally asso"iate +ith lo+er mor(i ity an mortality, "ompare +ith the tra itional s'rgi"al approa"h) 1o+ever, in patients +ith impaire "ar iovas"'lar f'n"tion, the laparos"opi" approa"h is limite (y the potential a verse haemo ynami" impa"t) There are many availa(le st' ies sho+ing the impa"t of ,, on the "ar iovas"'lar system in mor(i ly o(ese patients K1, 2L) /ome of them, +ith fin ings similar to o'rs, report signifi"ant haemo ynami" an respiratory "hanges, mostly 'nfavo'ra(le, that o""'rre in o(ese patients +hen "reating ,, for laparos"opy K3L) A""or ing to some other st' ies, parameters li8e 23 in"rease K:L, +hi"h is "ontrary to o'r res'lts, or remaine 'n"hange after ,, K5L .in o'r st' y 23 e"rease signifi"antly after ,,0) !ost a'thors "on"l' e that ,, oes not signifi"antly impair "ar ia" f'n"tion 'ring laparos"opy an is +ell tolerate (y patients) In o'r opinion, the rop (y 20I of the initial 23 val'e after "reating ,, in mor(i ly o(ese patients is signifi"ant an the anaesthesiologist sho'l (e a+are of this pro(lem) In o'r st' y, the ifferen"es (et+een volatile an intraveno's anaesthesia +ere

eval'ate +ith parti"'lar attention fo"'se on their pharma"ologi" effe"ts on the for"evelo"ity relations of the ventri"'lar myo"ar i'm an on the glo(al effe"t on ventri"'lar performan"e) /evofl'rane, li8e other volatile anaestheti"s, has a epressive effe"t on the "ar iovas"'lar system KEL) It e"reases the myo"ar ial "ontra"tility in a ose- epen ent +ay an re '"es the mean arterial press're, "ar ia" in e6 an "ar ia" o'tp't KA, GL) !oreover, sevofl'rane has (een fo'n to in '"e a e"rease in the e4e"tion fra"tion KML) A e"rease in "ar ia" o'tp't res'lts from a e"rease in systemi" vas"'lar resistan"e K10L) /evofl'rane lea s to a ose- epen ent e"rease in en - iastoli" an en -systoli" press're in the left ventri"le K11L, yet its infl'en"e on the "oronary arteries is not so prono'n"e ) /evofl'rane has (een sho+n to have a "ar ioprote"tive effe"t K12L) Altho'gh it oes not "a'se signifi"ant arrhythmias, an important "ommon si e effe"t of high sevofl'rane "on"entrations is oseH epen ent (ra y"ar ia an hypotension) The re"overy of "ar iovas"'lar f'n"tion after sevofl'rane is rapi KML) ,ropofol "a'ses a signifi"ant ose- epen ent e"rease in (loo press're of 'p to :0I K13L) This is 'e to a e"rease in "ar ia" o'tp't, "ar ia" in e6 an systemi" vas"'lar resistan"e .15-25I0) The e"rease in "ar ia" o'tp't is "a'se (y the ire"t epressive effe"t of the r'g on the myo"ar i'm K1:L, +hile the e"rease in systemi" vas"'lar resistan"e res'lts from (oth the e"rease a"tivity of the sympatheti" nervo's system an the ire"t vaso ilatation effe"t on veins an arteries K15L) ,ropofol "a'ses a e"rease in en - iastoli" vol'me in the right ventri"le) The heart rate 's'ally remains 'n"hange (e"a'se propofol has a epressive effe"t on the (arore"eptors rea"ting to e"rease (loo press're in the aorta K1EL) !oreover, propofol e6erts epressive effe"ts on the sinoatrial no e K1AL an the "ar iovas"'lar system, +hi"h may last long after the inf'sion has (een is"ontin'e KML) 3'r st' y "onfirms that ,, has an important negative impa"t on haemo ynami" f'n"tion 'ring general anaesthesia in mor(i ly o(ese patinets) After ins'fflation of the a( omen, (loo flo+ parameters e"rease signifi"antly an afterloa parameters in"rease ) 1o+ever, these "hanges +ere not "lini"ally regar e as serio's "ar iovas"'lar ist'r(an"es) There +as no signifi"ant ifferen"e (et+een the t+o types of anaesthesia as for their infl'en"e on haemo ynami" f'n"tion 'ring laparos"opy) ,ositioning the patient in the anti-Tren elen('rg<s position 'ring ,, ha varying effe"ts on haemo ynami" sta(ility epen ing on the type of anaesthesia 'se ) In patients anaestheti*e +ith propofol, haemo ynami" "hanges +ere more e6presse than in those anaestheti*e +ith sevofl'rane) In gro'p /, the ma4ority of parameters remaine 'n"hange "ompare to the ne'tral s'pine position 'ring ,,) In patients anaestheti*e +ith propofol, positioning the patient in the anti-Tren elen('rg<s position "a'se a signifi"ant e"rease in (l oo flo+ parameters; ho+ever, no other signifi"ant ifferen"es +ere fo'n (et+een the gro'ps) The analysis of ifferen"es re"or e at T2 an T3 reveale that haemo ynami" ist'r(an"es +ere more ynami" an persistent in the propofol gro'p than in the sevofl'rane gro'p) /evofl'rane-(ase anaesthesia provi e (etter haemo ynami" sta(ility than propofolH(ase anaesthesia 'ring laparos"opi" pro"e 'res in the mor(i ly o(ese) In the sevofl'rane gro'p, the re"overy of "ar iovas"'lar f'n"tion +as more rapi ) The organism<s nat'ral efensive me"hanisms against rops in 23, s'"h as

an in"rease in sympatheti" system a"tivity 'ring ,, K1L, are s'ppresse in the "ase of propofol K15L) The vasoa"tive peripheral arterial "ir"'lation, its effe"t on the great veno's "apa"itan"e an on peripheral veno's tone is severely altere +hen propofol is 'se K15L) The epressive effe"t of propofol on vas"'lar tone lasts longer than the (loo propofol "on"entration "an a""o'nt for KML) In "ases of agents s'"h as propofol or sevofl'rane, +hi"h have some vasoa"tive effe"t, the meas'rement of left ventri"le f'n"tion may (e altere (y their infl'en"e on pre- an afterloa K1GL) A""or ing to ,rior an "o-+or8ers K1ML, +ho 'se transoesophageal e"ho"ar iography, the left ventri"'lar en -systoli" +all stress .L5=/J/0 +as high 'ring ,,) /in"e L5=/J/ is a eterminant of myo"ar ial o6ygen eman , more aggressive "ontrol of (loo press're .ventri"'lar afterloa 0 in mor(i ly o(ese patients may (e +arrante to optimise the myo"ar ial o6ygen reN'irements) ;rie an "olleag'es K20L "on"l' e that neither systoli" nor iastoli" performan"e +as signifi"antly affe"te (y the intro '"tion of "apnoperitone'm an positioning of the patient for s'rgery) 2ontrary to o'r res'lts, they o(serve an in"rease in 23 after "reating ,,) 7loo press're meas're (y stan ar means oes not provi e pre"ise information on "ar iovas"'lar haemo ynami" f'n"tion 'ring laparos"opi" pro"e 'res in o(ese patients) 2hanges in haemo ynami" parameters "an only (e estimate (y a van"e haemo ynami" monitoring) Je are a+are that the transoesophageal e"ho-Doppler velo"imetry has signifi"ant limitations) 7a4orat an "o-+or8ers K21L "ompare meas'rements ta8en 'sing the 1emo/oni" 100 +ith ,i223, ?I23 an /+an-Oan* "atheters) The res'lts +ere similar; ho+ever, the 1emo/oni" 100 +as li8ely to sho+ slightly lo+er val'es than thermo il'tion) ."orrelation - 0)G:0), +hi"h, a""or ing to the a'thors, "o'l (e asso"iate +ith the metho of pre i"ting "ar ia" o'tp't (y the 1emo/oni" 100) 23 is a s'm of the (loo flo+ in the es"en ing aorta .A7;0 an in the arteries emerging from the aorti" ar"h, +hi"h "annot (e meas're (y a transoesophageal pro(e) 23 is "al"'late 'sing the form'la- 23P0)EMQ1)226A7;, +hi"h +as "reate 'ring "ar ia" s'rgery) The (loo flo+ in the 'pper part of the (o y, espe"ially thro'gh the "aroti arteries, "hanges epen ing on several fa"tors, e)g) "hanges in A7; "a'se (y "ar ia" s'rgery an the ,a232 infl'en"e on "ere(ral (loo flo+ .27;0 K22L) Jhile 27; is 's'ally 15I of 23 an epen s strongly on ,a232, A7; oes not epen on ,a232 K23L) /a+ai an "o-+or8ers K2:L in i"ate that A7; meas're 'sing the 1emo/oni" 100 metho "an "hange together +ith the "hanges in ,a232 o""'rring 'ring "apnoperitone'm) Another important isa vantage of the 1emo/oni" 100 metho is its sensitivity to the patient<s movements K22, 25L) The a6is (et+een the e"hographi" (eam an aorta iameter sho'l not e6"ee 20 egrees) The re"ommen e trans '"er level is ThE ('t in some patients, e)g) mor(i ly o(ese, it may (e iffi"'lt to estimate) In o'r st' y, the meas'rements +ere fo'n to (e ineffe"tive in 1M o't of 100 patients in"l' e ) /imilar o(servations +ere ma e (y 7ernar in an "olleag'es K2EL) Despite its limitations, the 1emo/oni" 100 transoesophegeal Doppler meas'rement is a non-invasive, easy-toperform metho that "a'ses very fe+ possi(le "ompli"ations +hen "ompare +ith more relia(le metho s s'"h as thermo il'tion)

,erilli an "o-+or8ers K2AL 'se the 1emo/oni" 100 evi"e to estimate haemo ynami" f'n"tion 'ring positive en -e6piratory press're .,==,0 an in the anti-Tren elen('rg position in or er to improve o6ygenation in 20 mor(i ly o(ese patients 'n ergoing (ariatri" s'rgery K2AL) 2ar ia" o'tp't signifi"antly e"rease +ith (oth ,==, an antiTren elen('rg position, +hi"h is similar to o'r res'lts) They "on"l' e that s'"h a position has an important effe"t on 23 that "an eteriorate the (enefits of ,==,) The +ea8nesses of o'r st' y are not only asso"iate +ith the meas'rement metho ) 3(esity itself is "onne"te +ith "hanges in the "ar iovas"'lar system, e)g) in"rease (loo vol'me affe"ting 23 an /5 in those patients) ,5 an A"" are e6N'isitely sensitive to loa ing "on itions) Je trie to stan ar ise them (y transf'sing "rystalloi s 10 mL 8g-1 of i eal (o y +eight at the (eginning of anaesthesia) ;'rther st' ies 'sing more a van"e monitoring may (e reN'ire ) C!+C)(#*!+# &. ,ne'mopositone'm has a signifi"ant negative impa"t on haemo ynami" f'n"tion 'ring general anaesthesia in mor(i ly o(ese patients) Those "hanges, ho+ever, are not "lini"ally "onsi ere as serio's "ar iovas"'lar ist'r(an"es) '. ,ositioning the o(ese patient in the anti-Tren elen('rg mar8e ly e"reases the flo+ parameters in patients anaestheti*e +ith propofol, +hi"h is not so prono'n"e in the sevofl'rane gro'p) ,. 5olatile anaesthesia has more sta(le haemo ynami" performan"e 'ring pne'moperitone'm in mor(i ly o(ese patients) ))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))) ))))))))))))))))) Funding: the work was supported by the government grant [N N403 3755 33]. ))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))) ))))))))))))))))) RE-ERE+CE# 1) Nguyen NT, Wolfe BM: The physiologi" effe"ts of pne'moperitone'm in the mor(i ly o(ese) Ann /'rg 2005; 2:1- 21M-22E) 2) Lamvu G, Zolnoun D, Boggess J, Steege JF: Obesity: physiologi" "hanges an "hallenges 'ring laparos"opy) Am R 3(stetr Oyne"ol 200:; 1M1- EEM-EA:) 3) !tuso D, Wayne M, "assa!o S, "e!abona T, Tei#ei!a J, G!ossi $: 1emo ynami" "hanges 'ring laparos"opi" gastri" (ypass pro"e 'res) Ar"h /'rg 2005; 1:0- 2GM) :) Dumont L, Mattys M, Ma!%i!osoff ", &i'a!% (, lle JL, Massaut J: 1emo ynami" "hanges 'ring laparos"opi" gastroplasty in mor(i ly o(ese patients) 3(es /'rg 1MMA; A- 32E-331)

5) Nguyen NT, )o )S, Fleming NW, Moo!e &, Lee SJ, Gol%man "D, "ole "J, Wolfe BM: 2ar ia" f'n"tion 'ring laparos"opi" vs open gastri" (ypass) /'rg =n os" 2002; 1E- AG-G3) E) MalanT&, DiNa!%o J , *sne! $J, F!in+ ,J J!, Gol%be!g M, Fenste! &,, B!o-n , : 2ar iovas"'lar effe"ts of sevofl'rane "ompare +ith those of vol'nteers) Anesthesiology 1MM5; G3- M1G-M2G) A) )a!+in "&, &agel &S, .e!sten J$: Dire"t negative inotropi" an l'sitropi" effe"ts of sevofl'rane) Anesthesiology 1MM:; G1- 15E-1EA) G) .i+u!a M, *+e%a .: 2omparison of effe"ts of sevoft'rane-nitro's o6i e an enfl'rane-nitro's o6i e on myo"ar ial "ontra"tility in h'mans- loa -in epen ent an noninvasive assessment +ith transesophageal e"ho"ar iography) Anesthesiology 1MM3; AM- 235-2:3) M) $oyse "F, Lie- DF, W!ig/t ",, $oyse G, ngus J : ,ersistent epression of "ontra"tility an vaso ilation +ith propofol ('t not +ith sevofl'rane of esfl'rane in ra((its) Anesthesiology 200G; 10G- GA-M3) 10) *na%a T, *na%a ., .a-a'/i S, Ta+ubo ., Tai M, 0asugi ): 1aemo ynami" "omparison of sevofl'rane an isofl'rane anaesthesia in s'rgi"al patients) 2an R Anaesth 1MMA; ::- 1:0-1:5) 11) Lo-e D, )ett!i'+ D , &agel &S, Wa!ltie! D": Infl'en"e of volatile anestheti"s on left ventri"'lar afterloa in vivo- ifferen"es (et+een esfl'rane an sevofl'rane) Anesthesiology 1MME; G5- 112-120) 12) De )e!t SG, (an %e! Lin%en &J, "!om/ee'+e S, Moelis $, Nelis , (an $eet/ (, ten B!oe'+e &W: 2ar ioprote"tive properties of sevofl'rane in patients 'n ergoing "oronary s'rgery +ith "ar iop'lmonary (ypass are relate to the mo alities of its a ministration) Anesthesiology 200:; 101- 2MM-310) 13) Sato J, Sito S, Jono+os/i ): 2orrelation an linear regression (et+een (loo press're e"reases after a test ose in4e"tion of propofol an that follo+ing anaesthesia in '"tion) Anaesth Intensive 2are 2003; 31- 523-52G) 1:) S1!ung J, Oglet!ee2)ug/es ML, M'"onnell B., Za+/a!y D$, Smols+y SM, Mo!ave' "S: The effe"ts of propofol on the "ontra"tility of failing an nonfailing heart m's"les) Anesth Analg 2001; M3- 550-55M) 15) ,be!t TJ, Mu3i M, Be!ens $, Goff D, .am1ine J&: /ympatheti" responses to in '"tion of anesthesia in h'mans +ith propofol or etomi ate) Anesthesiology 1MM2; AEA25-A33) 1E) ,be!t Tl, Mu3i M, Goff D: Does propofol really preserve (arorefle6 f'n"tion in h'mansS Anesthesiology 1MM2; AA- A 33A) 1A) )o!igu'/i T Nis/i+a-a T: 1eart rate response to intraveno's atropine 'ring

propofol anesthesia) Anesth Analg 2002; M5- 3GM-3M2) 1G) Be%otto JB, ,i'//o!n ,J, G!aybu!n & : =ffe"ts of left ventri"'lar preloa an afterloa on as"en ing aorti" (loo velo"ity an a""eleration in "oronary arteries) Am R 2ar iol 1MGM; E:- G5E-G5M) 1M) &!io! DL, S1!ung J, T/omas JD, W/alley DG, Bou!+e DL: ="ho"ar iographi" an hemo ynami" eval'ation of "ar iovas"'lar performan"e 'ring laparos"opy of mor(i ly o(ese patients) 3(es /'rg 2003; 13- AE1-AEA) 20) F!ie% M, .!s+a Z, Dan3ig (: Does the laparos"opi" approa"h signifi"antly affe"t "ar ia" f'n"tions in laparos"opi" s'rgeryS ,ilot st' y in non-o(ese an mor(i ly o(ese patients) 3(es /'rg 2001; 11- 2M3-2ME) 21) Ba4o!at J, )ofmo'+el $, (agts D , Jan%a M, &o/l B, Be'+ ", Noel%ge2 S'/ombu!g G: 2omparison of invasive an less-invasive te"hniN'es of "ar ia" o'tp't meas'rement 'n er ifferent haemo ynami" "on itions in a pig mo el) ='r R Anaesthesiol 200E; 23- 23-30) 22) "ollins S, Gi!a!% F, Bou%!eault D, "/ouina!% &,No!man%in L,"outu!e &: =sophageal Doppler an thermo il'tion are not inter"hangea(le for etermination of "ar ia" o'tp't) 2an R Anesth 2005; 52- MAG-MG5) 23) "/ong .0, "!aen $ , Mu!+in JM, Lee D, ,lias3i- M, Gelb W: >ate of "hange of "ere(ral (loo flo+ velo"ity +ith hyperventilation 'ring anesthesia in h'mans) 2an R Anaesth 2000; :A- 125-130) 2:) Sa-ai T, No/mi T, O/nis/i 0, Ta+au'/i 0, .u!o M: 2ar ia" o'tp't meas'rement 'sing the transesophageal oppler metho is less a""'rate than the thermo il'tion metho +hen "hanging ,a232) Anesth Analg 2005;101- 15MAH1E01) 25) Lef!ant J0, B!uelle &, ya G, Saissi G,Dau3at M,%e la "oussaye J,: Training is reN'ire to improve the relia(ility of esophageal Doppler to meas're "ar ia" o'tp't in "riti"ally ill patients) Intensive 2are !e 1MMG; 2:- 3:A-352) 2E) Be!na!%in G, Tige! F, Fou'/e $, Mattei M: 2ontin'o's noninvasive meas'rement of aorti" (loo flo+ in "riti"ally ill patients +ith a ne+ esophageal e"ho-Doppler system) R 2rit 2are 1MMG;13- 1AA-1G3) 2A) &e!illi (, Solla33i L, Mo%esti ", nnetta MG, $anie!i $, Ta''/ino $M, &!oietti $: 2omparison of positive en -e6piratory press're +ith reverse Tren elen('rg position in mor(i ly o(ese patients 'n ergoing (ariatri" s'rgery- effe"ts on hemo ynami"s an p'lmonary gas e6"hange) 3(es /'rg 2003; 13- E05-E0M) ))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))) ))))))))))))))))) address% *Tomasz M. Gaszynski

Department of Anaesthesiology an Intensive Therapy, !e i"al #niversity of Lo *, 7arli"8i #niversity 1ospital, 'l) Bop"iTs8iego 22, M0-153 $% &, ,olan tel) Q:G :2 EAG3A:G, email- tomgas*ynUpo"*ta)onet)pl re"eive - 2A)02)2011 a""epte - 1E)05)2011