Background: The risk of complications, including death, is substantially increased in patients with pulmonary hypertension (PH) undergoing anaesthesia for surgical procedures, especially in those with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH). Sedation also poses a risk to patients with PH. Physiological changes including tachycardia, hypotension, fluid shifts, and an increase in pulmonary vascular resistance (PH crisis) can precipitate acute right ventricular decompensation and death. Methods: A systematic literature review was performed of studies in patients with PH undergoing non-cardiac and nonobstetric surgery. The management of patients with PH requiring sedation for endoscopy was also reviewed. Using a

Intracranial hemorrhage (ICH) is a serious complication in patients receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO) and is associated with high mortality. It is unknown whether ICH may be a consequence of the ECMO or of an underlying disease. The authors first aimed to assess the incidence of ICH at initiation and during the course of VV-ECMO and its associated mortality. The second aim was to identify clinical and laboratory measures that could predict the development of ICH in severe respiratory failure. Data were collected from a total number of 165 patients receiving VV-ECMO from January, 2012 to December, 2016 in a single tertiary center and treated according to a single protocol. Only patients who had a brain computed tomography within 24 hours of initiation of ECMO ( = 149) were included for analysis. The prevalence and incidence of ICH at initiation and during the course of VV-ECMO (at median 9 days) were 10.7% (16/149) and 5.2% (7/133), respectively. Thrombocytopenia and reduced creatinine clearance (CrCL) were independently associated with increased risk of ICH on admission; odds ratio (95% confidence interval): 22.6 (2.6-99.5), and 10.8 (5.6-16.2). Only 30-day (not 180-day) mortality was significantly higher in patients with ICH on admission versus those without (37.5% [6/16] vs 16.4% [22/133]; = 0.03 and 43.7% [7/16] vs 26.3% [35/133]; = 0.15, respectively). Reduced CrCL and thrombocytopenia were associated with ICH at initiation of VV-ECMO. The higher incidence of ICH at initiation suggests it is more closely related to the severity of the underlying lung injury than to the VV-ECMO itself. ICH at VV-ECMO initiation was associated with early mortality.

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Objectives: To ascertain: i) the frequency of thrombocytopenia and heparininduced thrombocytopenia (HIT), ii) positive predictive value (PPV) of the pre-test probability score (PTPS) in identifying HIT iii) clinical outcome of HIT in adult patients receiving veno-venous (VV)-extracorporeal membrane oxygenation (ECMO) or veno-arterial (VA)-ECMO, compared to cardiopulmonary bypass (CPB). Design: A single-centre, retrospective, observational cohort study from January 2016 to April 2018 Setting: Tertiary referral centre for cardiac and respiratory failure Patients: Patients who received ECMO for >48hrs or had CPB during specified period Interventions: None. Measurements and Main Results: Clinical and laboratory data were collected retrospectively. PTPS and HIT testing results were collected prospectively. Mean age (standard deviation) of the EMCO and CPB cohorts were 45.4 (±15.6) and 64.9 (±13), p< 0.00001. Median duration of CPB was 4.6 [2-16.5] hrs compared to 170.4 [70-1008] hrs on ECMO. Moderate and severe thrombocytopenia were more common in ECMO compared to CPB throughout (p<0.0001). Thrombocytopenia increased in CPB patients on day 2 but was 4 normal in 83% compared to 42.3 % of ECMO patients at day 10. Patients on ECMO also followed a similar pattern of platelet recovery following cessation of ECMO. The incidences of HIT in ECMO and CPB were 6.4% (19/298) and 0.6% (18/2998) respectively p<0.0001). There was no difference in prevalence of HIT in patients on VV-ECMO (9/156, 5.7%) vs VA-ECMO (11/142, 7.7%), p=0.81. The PPV of the PTPS in identifying HIT in patients post-CPB and on ECMO were 56.25% (18/32) and 25% (15/60) respectively. Mortality was not different with (6/19, 31.6%) or without (89/279, 32.2%) HIT in patients on ECMO, p=0.79. ConclusionsThrombocytopenia is already common at ECMO initiation. HIT is more frequent in both VVand VA-ECMO compared to CPB. PPV of PTPS in identifying HIT was lower in ECMO patients.HIT had no effect on mortality.