TEE did not reveal previous heart disease, evidence of segmental wall motion abnormalities, or significant differences in EDA during ARS (Table 1).
The ARS and high levels of PEEP were hemodynamically well tolerated in intravascular volume-loaded morbidly obese patients undergoing laparoscopic surgery. This hemodynamic stability was observed both before and during capnoperitoneum.
The potential hemodynamic repercussions of a reverse Trendelenburg position, capnoperitoneum, and mechanical ventilation depend mainly on their negative effect on venous return.17–21 Thus, the intravascular volume status plays a crucial role in any patient undergoing bariatric surgery, regardless of BMI. Jellinek et al.22 demonstrated the absence of any hemodynamic compromise at high levels of PEEP if CVPs were kept higher than 10 mm Hg. Our data confirm these results: no hemodynamic consequences were observed at higher airway pressures, provided that preload was kept within a normal range, as documented by the unremarkable EDAs and filling pressures. This is not too surprising, because the significantly elevated intraabdominal pressures of morbidly obese patients, particularly during the surgery, reduced the transmural pressure acting on the hemodynamics. The intravascular volume loading with colloid (15 mL/kg of lean body weight) before anesthesia obviously prevented any hemodynamic disturbances in these fasted morbidly obese patients. Our results are also in agreement with those of Erlandsson et al.,17 who found that infusion of 1 L of intravascular volume expanders before applying high levels of PEEP avoided any negative effects in hemodynamics in morbidly obese patients.
Limitations: Because of the particular surgical procedure, we could not assume the intragastric TEE position typically needed for optimal CO measurement. Therefore, we decided to report only values for EDA and the presence or absence of segmental wall motion abnormalities.
After optimization of preload, lung recruitment and high positive airway pressures were hemodynamically well tolerated in morbidly obese patients with or without capnoperitoneum.
The authors thank Stefan Maisch, Clinic of Anesthesiology, University Hospital Hamburg-Eppendorf, Germany, for his help during the conduct of this study and for valuable input during the revision process.
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